Metabolic considerations in critical illness : : 1. (ebb phase):
2. ; (Catabolism): (1)stress hormne,, (2)cortisol.catecholamines, insulin resistant (3) cytokines( IL-1. IL-6. TNF),
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1. AGEs
AGEs.advanced glycation end products
? 1. <220 mg/dl 2. <200mg/dl 3. <110mg/dl( DM) 4. <180mg/dl 5. <150mg/dl 6. <120mg/dl( 100mg/dl.AACE ADA 2003 80-110 mg/dl 2004 (D) <150mg/dl
1. 2. 3. (cortisol.glucagon.catacholamine) IL-1 IL-6 TNF- 4. 5.
ADA 14-18 Kcal/kg (60-70% calorie needs) 25-30 Kcal/kg (1.2-1.3 REE)
Kcal/kg) --.
. 1. (???) 2..
24 (UUN) 24 uun =(uun+4)x6.25 = +10
Nitrogen Balance = -( +4) 90%~95% = 0 = < 0 < > 0 > 24,
Metabolic considerations in critical illness 3. :(anabolism)
(Kwashiorkor) (Marasmus) (Marasmic- Kwashiorkor) 2.8 g/dl 3 mm 15 mm
PCM ( Protein-Caloric Malnutrition ) Marasmas Kwashiorkor Marasmas Kwashiorkor
Kwashiorkor Marasmus
1.Early feeding 2.refeeding symdrome 3.overfeeding
Early feeding Improve blood flow maintain gut integrity and barrier function stabilized villus structure 48-72hrs( ) NG or ND or NJ or ostomy 10-20cc/hr D5W
Hemodynamic instability Should not started enteral feeding until stable blood flow to gut is diminished further stressing gut with enteral feeding bowel ischemia : <1000 / PPN Support
Refeeding syndrome& Overfeeding Malnourished patients at risk for refeeding syndrome should have serum phosphorus,magnesium,potassium and glucose levels monitored closely at intiated of SNS.(special nutrition support) Upon initiation of SNS in patients with anorexia nervosa,frequent fluid,electrolyte,and acid-base monitoring must be undertaken to avoid sequelae of the refeeding syndrome..
. 1. 2.24 uun<=5 / : 3., 4. 5.
. 1. 2.24 uun >10 / 3. 4., 5. 24-36
. 1. 2.
:..
1. 2.
1. 2. 3. --- 4.
(refeeding syndrome)--- Refeeding syndrome hypophosphatemia hypomagnesium acute respiratory failure arterial hypotention tachycardia peralbumin dextrose 100mg/L K Na P
(overfeeding)--- Azotemia 65 Ccr BUN 2g/kg BUN ( 30mg/dl) BUN/Cr 15 / hydration
Fat-overload syndrome Repiratory distress hypertriglyceridemia prothrombin and partial thromboplastin times bilirubin Bleeding from orifices 3g/kg/day lipids propofol C-reactive protein acutephase response TG TG 300mg/dl cytokine
Hepatic steaosis Hepatomegaly with/without right upper quadrant pain or tenderness Abnormal, hight fat live glucose TG
Hpercapnia PaO2 minute ventilation PaO2 40mmHg ph 7.4 PaO250~60mmHg, bicarbonate 24mmol/L and ph 7.4 RQ overfeeding CO2 dextrose (PaCO2 PH)
Hyperglycemia glucose 200mg/dl insulin adminstration dextrose 4kg/min systemic inflammatory response syndrome pancreatitis on steroids peritoneal dialysis contain dextrose hydration dextrose
HHNK hight CHO load severe burns glucose 600mg/dl pancreatitis reneal function CVP pulmonary capillary wedge pressure intravascular vloume plasma cardiopulmonary 350mOsm/L bypass insulin type 2 DM K
Hypertonic dehydration hypernatremia hematocrit azotemia Na protein rehydration water intoxication minerals
Hpertriglyceridemia TG 300mg/dl lipid ( TG propofol 300~400mg/dL 6mg/kg/hr) lipids lipid 2g/kg/hr 10% 500ml emulsion gram-negative TG 500mg/dl sepsis lipid EFA energy fat dextrose
Metabolic acidosis blood ph 7.35 bicarbonate 21mEq/L energy to nitrogen ratio(90:1) hydration renal function ph bicarbonate K BUN
Thanks for your attention