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METABOLISM
IN= ingested nitrogen
I. REVIEW
UN= 24-hr urine nitrogen
Nutrients RNL= remaining nitrogen loss
- Proteins = 3.1 (constant)
o 4 kcal/ g
- Carbohydrates 0 NB= normal
o 4 kcal/g (oral) + NB= pregnant women
o 3.4kcal/g (parenteral) - NB = stressed individuals
- Lipids
o 9 kcal/g
- water Respiratory Quotient (RQ)
- vitamins
- minerals RQ = VC02 / V02
Lipogenesis
Fatty Acid Metabolism - RQ > 1.0 – 8.0
- Should be avoided in nutrition
Triglycerides in circulation
↓
Fatty Acid + glycerol Nutrient Utilization
↓
Can enter cell for metabolism Regulation
OR - nutrient availability
Remain in circulation (hypertriglyceredemia) - stress
NB = IN – (UN + RNL)
SURGERY METABOLISM 1
will yield approximately same
Excess Fatty Acids value
Fatty acids in the circulation go inside the mitochondria For Healthy individuals = 0.8- 1.0
where it undergoes beta oxidation. AcetylCoa is For Stressed = 1.0- 2.0
produced which moves into the cytoplasm. It is
converted to Ketones during low insulin states or
Triglycerides during high insulin states. Carbohydrate Requirements
TNF and IL-1 inhibit carnitine, which metabolizes fatty Catabolic State
acids in the mitochondria. Thus FA are converted back to CHO= 45%
triglycerides and are brought back into the circulation. Fat = 30%
CHON= 25%
↑TNF, ↑IL-1 = ↓carnitine = hypertriglyceridemia
Vitamins and Minerals
Obesity
Early Fasting
- energy expenditure must be calculated based on IBW - energy comes from muscles
- using ABW will over-feed the patient resulting in - ↑ gluconeogenesis
↑triglycerides, ↑FA
Late Fasting
- energy from ketones
Calculating Basal Energy Expenditure
Metabolic Reaction to Starvation
Harris Benedict Equation
variables: age, weight, height, gender, activity levels, Hormone Source
etc Norepi Sympathetic ↓
NS
“Rule of Thumb” Method Norepi Adrenals ↑
calorie requirement: Epi Adrenals ↑
25-30 kcal/ kg/ day T4 Thyroid ↓
SURGERY METABOLISM 2
↑ hyperglycemia
*There is less energy expenditure in starvation! ↑ gypertriglyceridemia
↑ hypercapnia
↑ fatty liver
Metabolic Response to Trauma ↑ hyperphosphatemia
↑ hypermagnesemia
Ebb Phase
- hypovolemic shock
- ↓ Cardiac output Macronutrients During Stress
- ↓ O2 consumption
- ↓ Blood pressure Carbohydrates
- ↓ Tissue perfusion - at least 100g/day to prevent
- ↓ Body temperature k-sis? (sorry can’t understand my
- ↓ Metabolic rate handwriting)
- CHO intake 30%- 90% of total
Flow Phase Calories
- ↑ catecholamines
- ↑ glucocorticoids Fat
- ↑ glucagon - provide 20%- 35% of total
- ↑ cytokines, lipid mediators calories
- ↑ acute CHON production from muscle = loss of - intravenous: 1.0- 1.5
body mass
Protein
Endocrine Response - 20%- 30% of total calories
- FA from FA deposits
- Glucose from liver/ muscle glycogen
- AA from muscle No Stress
Cal: Nitogen >150:1
*There is increased energy expenditure in trauma! %CHON/ total calories 45% CHON
CHON/ kg body weight 0.8g/kg/day
Nutrient Intervention
Nutritional Evaluation
- Nutrient counseling
SGA: Subjective Global - Oral supplements
Assessment - Enteral tube feeding
- Parenteral
History
- weight change in the past 3-6 months or 2 *Rule: if the patient’s GIT is functional, use oral
weeks supplements and enteral tube feeding. Only of the GIT is
- dietary intake compared to usual non-functional will parenteral methods be used!
- GI symptoms
- functional capacity * refer to Clinical Decision Making Algorithm for
- Metabolic needs of diseases Nutritional Support
Physical Examination
- loss of subcutaneous fat Summary
- muscle wasting
- ankle edema - nutrient utilization depends on availability
- sacral edema (fasting) and inflammatory response (stress)
- ascites - Nutritional requirements ↑ during trauma
Anthropometrics Measures
TSF
MAC
BMI Nomogram
Underweight <18.5
Normal 18.5-25
Overweight 25- 30
Obese >30
SURGERY METABOLISM 4