Trauma and Critical Care

things that cause hypermetabolic response

sepsis, trauma, burns, major surgery, stress, fractures

ebb phase

shorter period of time right after insult, survival instinct, decreases blood flow

hypovolemia(low blood circulating), shock, tissue hypoxia(insufficient oxygen at tissue level)

-decreased cardiac output, O2 consumption, body temp

flow phase

acute phase proteins, hormonal response, immune response

increased: cardiac output, O2 consumption, body temperature, energy expenditure, protein catabolism

body tries to use a lot of energy to fight off offenders, prioritizing pos acute phase proteins (reduce serum albumin)

what is common in acute and critically ill pts

hyperglycemia, typically 140-180mg/dL

circulating BG is acceptable in critically ill

body weight changes in critical illness

most can be attributed to shifts in body water

4.73L on avg at end of hemodynamic instability for trauma

12.5L on avg post sepsis

capillaries become more permeable leading to edema and fluid leaks

when is EN not appropriate in trauma

ASPEN says pts at low nutritional risk with normal baseline nutrition and low disease severity who can’t maintain volitional intake do not require specialized nutrition therapy over first week in ICU

when is EN appropriate in trauma

trophic or full nutrition by EN is appropriate for pts with acute respiratory distress syndrome/Acute lung injury and those expected to be on ventilation >72hours

aspiration risk

recommended to divert the level of feeding by post pyloric enteral access device placement in patients deemed at high risk of aspiration (age, experience/history of reflux, inability to protect airway)

pts at high risk of aspiration should have agents promoting utility initiated when feasible

reperfusion injury

sepsis and critical injury can lead to decreased blood flow to GI tract

nonocclusive bowel necrosis incidence of 0.3% in ICU patients

rate should be kept low until hemodynamically stable

ASPEN rec EN held in hemodynamic compromise until pt fully stable

changes to skeletal protein

pts can lose around 5% of their total body protein during first 2 weeks following major surgery

neg acute phase proteins decrease

protein losses through urine and wound exudate

stress and burn pt protein needs

burns may need 3-4g/kg/d

stress may need 1.5-2g/kg/d

determining calorie needs in trauma

indirect calorimetry = gold standard

very $$ not many places have it, not accurate if pt has chest tube/gas exchange tube

calorie needs trauma

no one formula is best

25-30kcal/kg/d

in pts with edema, use dry weight/usual body weight

***account for kcal from propofol/dex

enhanced recovery after surgery ERAS

pre and post operative care program that recommends carbohydrate consumption before surgery

-avoid preoperative fast, solid meals 6 hours before surgery, 800mL carb rich clear liquid midnight b4 and 400mL 2 hours before

-early oral nutrition post surgery

-shows decrease in complications, reduced length of stay, etc

benefit of CHO before surgery

decreases insulin resistance seen with long periods of fasting, provides energy shift from catabolic state

spares proteins

results of physiologic trauma

hyperglycemia, hyperinsulinemia