Post on 25-Aug-2019
transcript
Metabolic response to stress
Pierre Singer, MD Institute for Nutrition Research
Critical Care Medicine Rabin Medical Center
Tel Aviv University
Disclosures
• Speaker fees from Abbott, GE, Cosmed,
B Braun, Baxter and Fresenius-Kabi
• Grants from Abbott, Baxter, B Braun and
Fresenius-Kabi
Main messages
• Acute phase modifies energy expenditure and
substrate utilization
• Anabolic resistance and protein breakdown
are leading to significant muscle loss
• Persistent Inflammation-Immunosuppression
Catabolism Syndrome (PICS) is secondary to
significant nutritional changes
Stress:
Trauma –
Infection -
Surgery
Epinephrine Norepinephrine Sympathic drive
Cytokines Inflammatory mediators
Adipokines
GIT hormones?
Anabolic
resistance Uncontrolled
catabolism
CHANGES IN: ENERGY EXPENDITURE BODY COMPOSITION
Adapted from JC Preiser
7
High ATP is associated with better
outcome
Stress:
Trauma –
Infection -
Surgery
Epinephrine Norepinephrine Sympathic drive
Cytokines Imflammatory mediators
Adipokines
GIT hormones?
Anabolic
resistance Uncontrolled
catabolism
CHANGES IN: ENERGY EXPENDITURE BODY COMPOSITION
Adapted from JC Preiser
Dead Trauma
Day Weeks ------ months
Anabolic Phase
0
EBB Phase FLOW Phase
En
erg
y, h
ea
t, O
2 c
on
sum
pti
on
Late
Anabolism
Turning
point
Injury
Phase
Phases of the response to injury: REE
(Resting Energy Expenditure) is increased after the injury
phase
.
Catabolism
Hypermetabolic period
Energy consumption increase
Elective surgery 10 %
Trauma 25 %
Peritonitis, sepsis 75 %
Burn 100 %
9
?
Resting energy expenditure, calorie and protein consumption in
critically ill patients: a retrospective cohort study. Zusman O, Theilla M, Cohen J, Kagan I, Bendavid I, Singer P.
Today the REE increase is less marked
Crit Care. 2016 Nov 10;20(1):367
Changes in the hypermetabolic period
Hemodynamic Hormonal Protein Carbohydrate Fat
CO Cortisol Catabolism Gluconeogenesis Lypolysis
SVR Glucagon Protein
degradation Lactate Lipogenesis
AV O2 Insuline
Liver acute
phase protein
syntesis Insulin resistance Ketone
bodies
Adrenaline Urea FFA usage of
myocard
.
Stress response - Carbohydrate metabolism: Substrate endogenous production
Splancnic glucose production
m/min/sq.m
Takala J.Baillieres Clin Endocrinol Metab 1997;11:617-27
Lipolysis during feeding is
increased in injury or sepsis Elwyn DH: Clin Nutr 1993
Muscle catabolism mechanisms
Nitrogen balance
-35
-30
-25
-20
-15
-10
-5
0
Burns Injury
Cyst
ectomy Sepsis
Hip
repl.
Malnour-
ished Normal
Normal
fasted
gra
ms
N
p
er 7
0 k
g
0
-100
-300
-400
-200
mg
N p
er k
g
(Surgical) trauma is accompanied by a negative nitrogen balance
Nitrogen balance is more negative than during pure fasting
The graded nature of the response
to the surgical trauma
15
Elwyn et al Crit Care Clin 1987; 3:57
From admission: loss of muscle mass in biopsy and Protein/DNA
Breakdown> Synthesis
TRACERS SHOW AN INCREASE IN SYNTHESIS AND A HIGHER INCREASE IN BREAKDOWN, LEADING TO NEGATIVE NITROGEN BALANCE
Intensive Care Department
The effects
of bed
rest... Decrease in muscle mass
Crit Care Med 2015
County
Autophagy cleans cell debris, but
releases nutrients and is inhibited by
feeding
Substrate utilization Weissman C, Crit Care Clinics 1999
CCM 2015
Qualitative US can evaluate muscle wasting
CT Scan can evalute fat mass and lean body mass of ICU patients
JPEN 2014; 38:880
Phase angle obtained by bio-
impedance is assessing
malnutrition
Phase angle is
predictive of
survival and
malnutrition
Conclusions
• In the acute phase:
– Energy expenditure is increased in a moderate way
– mobilization of substrates to provide glucose,
– obligatory lipolysis,
– Obligatory proteolysis.
• In the stabilized phase, body composition should
be preserved and nutritional support can be
adapted to the patie t’s eeds to preve t fro PICS.