David Bihari is an Intensivist from Prince of Wales Hospital in Sydney. He is particularly interested and passionate about nutrition in the critically ill, and has been involved in research in this area for many years. Here he talks about how we feed in ICU.
3. Conflicts
of
Interest
• “TPN
Czar”
of
Prince
of
Wales
Hospital
• Medical
representaGve
on
the
TPN
Forum
• In
a
previous
life,
performed
and
published
research
in
the
area
of
“immunonutriGon”
• Tendency
to
believe
in
“one’s
own
bull
shit”!
4. You
Are
What
You
Eat
• The
noGon
that
to
be
fit
and
healthy
you
need
to
eat
GOOD
FOOD!
• “Dis
moi
ce
que
tu
manges,
je
te
dirai
ce
que
tu
es”
Anthelme
Brillat-‐Savarin
1826
• 1942
Lindahr
–
You
are
what
you
eat:
how
to
win
and
keep
healthy
with
diet
• More
Catholic
than
catabolic?
– TransubstanGaGon!
5. Things
Your
Mother
Taught
You
• Eat
your
greens
….not
too
many
Mars
bars
…
because
you
are
what
you
eat!
– Avoid
the
“Cambridge
diet”
of
beer
and
crisps
16. Things
Your
Mother
Taught
You
• Eat
your
greens
….not
too
many
Mars
bars
…
because
you
are
what
you
eat!
– Avoid
the
“Cambridge
diet”
of
beer
and
crisps
• Don’t
go
swimming
on
a
full
stomach!
–
Nutrients
in
the
lumen
of
the
bowel
promote
splanchnic
blood
flow
– “Trophic
enteral
feeding”
:
10
–
30
mL/hour
19. 1909 - British lady “suffragette” (fighting for the
rights of women) put in prison and on hunger strike
The Intensivist?
“more intensive than caring”
The Dietician?
“obsessing about calories”
20. NutriGonal
Support
2014
• Energy
intake
may
not
be
so
important
– Hypocaloric
enteral
feeding
is
widespread
– Trophic
feeding
• ResurrecGon
of
TPN
through
meta-‐analysis
(2005)
since
its
crucifixion
by
meta-‐analysis
(1998)
• IntroducGon
of
glutamine
containing
TPN
by
meta-‐analysis
21. NutriGonal
Support
2014
• Crucifixion
of
TPN
–
EPaNIC
study
– Not
enough
protein!
• Crucifixion
of
glutamine
–
the
REDOX
study
– Too
much
nitrogen
given
to
paGents
too
sick
to
uGlise
– Not
enough
nutriGon!
• New
intravenous
lipid
soluGons
available
• Crucifixion
of
enteral
immune
modulaGng
nutriGon
(specifically
arginine
containing
feeds
eg.
“Impact”)
by
meta-‐analysis
(2003)
26. Lessons
from
Northern
Ireland
“Hunger”
Bobby Sands 61 days
Francis Hughes 59 days
Raymond McCreesh 61 days
Patsy O’Hara 61 days
Joseph McDonnell 61 days
Martin Hurson 44 days
Kevin Lynch 71 days
Kieran Doherty 73 days
Thomas McElwee 62 days
Micky Devine 61 days
Cause of death - infection
27. StarvaGon
in
hospital
is
unacceptable
• Nutrients
-‐
unlike
drugs
-‐
are
required
for
the
maintenance
of
good
health,
survival
• 10
IRA
hunger
strikers
fasted
to
death
over
a
mean
of
62
+
3
days
– Died
from
infecGon
• Australian
medical
student
lost
in
Nepal
lived
for
42
days
eaGng
only
snow
(Ann
Int
Med
1997)
:
lost
19
kg,
80
to
61
kg
• StarvaGon
is
not
the
same
as
criGcal
illness
• Malnourished
paGents
form
a
special
group
– Li-le
/me
to
waste
before
ins/tu/ng
support
28. TreaGng
MalnutriGon
Learning
from
the
Past
The Refeeding Syndrome – death from
hypophosphataemia (plus hypomagnesaemia)
29. The
Refeeding
Syndrome
• First
described
in
Far
East
Japanese
prisoners
amer
2nd
World
War
• Schnitker
et
al
Ann
Inter
Med
1951
• StarGng
to
eat
associated
with
development
of
cardiac
failure
– DepleGon
of
intracellular
PO4,
Mg
&
K
• Decreased
secreGon
of
insulin
– Refeeding
with
CHO
results
in
increased
insulin
secreGon,
cellular
uptake
of
PO4,
Mg
and
K
• First
4
days
of
refeeding
• Arrhythmias,
sudden
death,
heart
failure,
rhabdomyolysis,
seizures
41. The
REDOX
Study
–
4
arms
" 0.35
Gm/kg/day
iv
glutamine
plus
30
Gm
enteral
glutamine
" 0.5
Gm/kg/day
of
iv
dipepGde
alanyl-‐glyutamine
" 42.5
Gm
of
enteral
alanyl-‐glutamine
and
glycine-‐glutamine
• AnGoxidants
– 500
mcg
selenium
iv,
300
mcg
enterally
– 20
mg
zinc,
10
mg
beta-‐carotene
enterally
– 500
mg
vitamin
E,
1500
mg
vitamin
C
enterally
42.
43.
44.
45. Arginine
as
an
Immunonutrient
• Arginine
(C6H14N4O2,
mw
174.20)
– EssenGal
amino
acid
during
childhood
– CondiGonally
essenGal
in
adults
– Incorporated
into
protein
at
4.7%
per
mole
– Found
in
meat,
fish,
dairy
products,
brown
rice,
nuts,
raisons,
whole
wheat
– Glutamine,
glutamate
and
citrulline
are
also
dietry
sources
of
arginine
• IntesGnal
conversion
to
citrulline
• Renal
and
hepaGc
conversion
to
arginine
46. Watermelon
ConsumpGon
and
Plasma
Arginine
Levels
• Collins
et
al
NutriGon
2007;
23:
261-‐266
• Watermelon
is
a
rich
source
of
citrulline
• Controlled
diet
plus
0
/
780
g
/
1560
g
of
watermelon
juice
– Equivalent
to
1
g
and
2
g
citrulline
/
day
• Amer
3
weeks,
fasGng
plasma
arginine
levels
increased
by
12
and
22%
respecGvely
• No
change
in
citrulline
levels
• 18%
increase
in
ornithine
levels
47. Arginine
as
an
Immunonutrient
• Number
of
supposed
beneficial
effects
– Anabolic
secretagogue
sGmulaGng
the
secreGon
of
growth
hormone,
glucagon,
insulin
and
IGF-‐1
– UGlized
in
the
synthesis
of
creaGne
in
skeletal
muscle
• Important
for
high
energy
creaGne
phosphate
– Enhances
wound
healing
– Enhances
cell
mediated
immunity
in
elecGve
surgical
paGents
– Substrate
for
the
formaGon
of
NO
48. Metabolism of L-arginine by nitric oxide synthase
(NOS) and arginase
Nitric oxide synthase oxidatively degrades L-arginine into L-citrulline
and nitric oxide (NO), whereas arginase hydrolyses L-arginine to urea
and L-ornithine
<5%
>95%
49. Arginine
in
Sepsis
• Role
of
nitric
oxide
(NO)
in
sepsis
– Key
mediator
of
the
vasodilataGon
• Appropriate
release
maintains
microvascular
blood
flow
• Excessive
release
associated
with
hypotension
– Key
mediator
in
macrophages
and
white
cells
for
killing
of
invading
microorganisms
• Excessive
release
associated
with
Gssue
injury?
– Splanchnic
mucosal
injury
– Myocardial
dysfuncGon
– Skeletal
muscle
mitochondrial
dysfuncGon
50. Arginine
in
Sepsis
• The
Heyland
Hypothesis
– Arginine
in
sepsis
may
be
contra-‐indicated
since
it
may
enhance
the
producGon
of
NO
and
worsen
any
associated
Gssue
injury
– Signal
of
detrimental
effect
obtained
from
studies
of
arginine
containing
enteral
nutriGon
– Ignores
the
evidence
of
the
detrimental
effects
of
blocking
the
synthesis
of
NO
in
sepGc
shock
using
N-‐
methyl-‐L-‐arginine
(546C88)
52. 2/22 = 9%
3/31 = 10%
0/37 = 0%
3/98 = 3%
36/296 = 12%
2/33 = 6%
28/170 = 16%
12/36 = 33%
2/43 = 5%
3/30 = 10%
6/29 = 21%
180/390 = 46%
45/176 = 26%
Heyland DK et al. Should Immunonutrition become
routine in critically ill patients? A systematic
review of the evidence. JAMA 2001; 286: 944-953
1391 “critically ill” patients studied with 322 deaths (23%)
13 studies included
Relative risk 1.18; 95%CI 0.88-1.58
53.
54. A
Convert
to
Heylandism
• The
paGent
must
be
fed
early
• The
paGent
must
go
on
TPN
• The
paGent
must
receive
glutamine
• The
“Maya”
factor!
55. • A
Killer
Penis
in
Minutes
– www.libidus-‐pill.com
• Penis
Enlargement
Chart
– www.Penis-‐
Enlargement-‐Chart.com
56.
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• L-Arginine 500mg
• May assist with male infertility
• May assist wound healing and immune
function
• May assist cardiovascular health
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