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Pharmaceuticalsession

Hypocaloric,highproteinnutrition
therapyforcriticallyillpatientswith
obesity:clinicalandpharmaceutical
challenges
R. Dickerson (USA)

Hypocaloric, High Protein Nutrition Therapy

for Critically Ill Patients with Obesity:
Clinical and Pharmaceutical Challenges
Roland N. Dickerson, Pharm.D., BCNSP, FASHP, FCCP
Professor of Clinical Pharmacy
University of Tennessee Health Science Center
and
Clinical Pharmacist and Clinical Coordinator
Nutrition Support Service
Regional Medical Center at Memphis
USA

Obesity Compounds the Metabolic

Response to Critical Illness and the
Adverse Effects of Overfeeding
Increased incidence of diabetes mellitus
Increased incidence of hyperlipidemia
Decreased VC, TLC, and FRV with
morbid obesity; increased difficulty with
ventilator weaning
Decreased LV contractility and EF; LV
hypertrophy and increased LVEDP
Increased incidence of fatty liver

Hospitalized Obese Patients Exhibit

Wide and Unpredictable Variability in
Energy Expenditure

Feurer ID et al. Ann Surg.1983;197:17-21.

Clinical Challenges:
Nutrition Therapy of the Critically Ill
Patient with Obesity
Achieve net protein anabolism
Avoid worsening pre-morbid
complications of obesity especially
hyperglycemia
Avoid development of new complications
of overfeeding
Avoid further fat weight gain

Influence of Caloric and Protein

Intake Upon Nitrogen Balance
2.2

1.6

0.9
0.9
0.9
0.9

0.5

Adapted from Elwyn DH et al. Crit Care Med.1981;8:9-20.

Impact of Calories and Protein

Upon Body Composition
Nitrogen-Protein conversion

350 mg/kg/d = 2.2 g/kg/d

300 mg/kg/d = 1.9 g/kg/d
250 mg/kg/d = 1.6 g/kg/d
200 mg/kg/d = 1.3 g/kg/d
150 mg/kg/d = 0.9 g/kg/d

Hill GL et al. Br J Surg.1984;71:1-9.

Shaw JHF et al. Surgery.1988;103:148-155

The Impact of Energy Balance Upon

Nitrogen Loss After Traumatic Injury
N
Energy in
(% of REE)
Protein in
(% of REE)
Nit Bal g/d

Hypercal

Eucaloric

Hypocal

10

10

10

148 + 19

118 + 20

82 + 16

22 + 3

22 + 4

22 + 5

-8.3 + 5.7

-7.5 + 5.2

-7.9 + 5.5

422 + 180
347 + 147
Urine 3-meH
375 + 95
umol/d
Frankenfield DC et al. JPEN.1997;21:324-329.

Excessive Caloric Delivery Increases Fat

Mass Without Changes in Lean Body Mass in
Thermally Injured Patients

Change in Fat Mass

Change in Lean Body Mass

Hart DW et al. Ann Surg.2002;235:152-161.

Summary of Clinical Studies

Route
PN

PN

PN

PN

PN

EN

Dickerson RN. Curr Opin Clin Nutr Metab Care.2005;8:189-196.

Nutrient Composition of Eucaloric

and Hypocaloric Feeding Formulas
Regimen
Protein suppl.
Kcals/L
Protein (g/L)
NPC: N2

Eucaloric
1.0
62
77:1

Hypocaloric
+ 25 g/L
1.1
87
54:1

Dickerson RN et al. Nutrition.2002;18:241-246.

Nutritional Outcome: Nitrogen Balance

Dickerson RN et al. Nutrition.2002;18:241-246.

Clinical Outcomes
Eucaloric
Hypocaloric
(30 kcal/kg*/d) (22 kcal/kg*/d)
Survival
11/12
28/28
29.6 + 14.0
LOS (d)
37.2 + 22.7
18.6 + 9.9
ICU stay (d)
28.5 + 16.1
Antibiotics (d) 24.7 + 17.3
16.6 + 11.7
Vent days
23.7 + 16.6
15.9 + 10.8
*ideal body weight
p < 0.05, p<0.09
Dickerson RN et al. Nutrition.2002;18:241-246.

Impact of Hypocaloric Feeding Upon

Glycemic Control in Obese Patients

Choban PS et al. Am J Clin Nutr.1997;66:546-50.

Hypocaloric EN in Critically Ill

Older Patients with Obesity
Variable
N
Age, yrs
ISS
DM, n (%)
Alb, g/dL
sCr, mg/dL
mCrCl, mL/min
BMI, kg/m2

60+ yrs
33
69 + 6
27 + 10
11 (33%)
2.9 + 0.8
0.9 + 0.3
101 + 38
35 + 6

< 60 yrs
41
42 + 12*
29 + 13
5 (12%)*
3.4 + 0.8*
0.8 + 0.2
157 + 70*
35 + 5

Dickerson RN et al. Submitted for consideration of publication.

Hypocaloric EN in Critically Ill

Older Patients with Obesity

Dickerson RN et al. Submitted for consideration of publication.

Hypocaloric EN in Critically Ill

Older Patients with Obesity

Dickerson RN et al. Submitted for consideration of publication.

Benefits of Hypocaloric High Protein

Nutrition Support for Critically Ill
Obese Patients

Decreased potential for overfeeding

Positive nutritional outcomes
Assists with glycemic control
Fat weight loss
Positive clinical outcomes

Designing a Hypocaloric Regimen

in Obese Stressed Patients
If REE cannot be measured, give < 21
total kcals/kg adj wt/d (or < ~ 25 kcal/kg
IBW/d).
Meet obligatory glucose requirements
(~120 g/d and ~80 to 150 g/d for wound
healing).
Use a mixed fuel system particularly if
patient is diabetic

Designing a Hypocaloric Regimen

in Obese Stressed Patients
Design initial protein intake for ~ 2 g/kg
IBW/d if BMI < 40; 2.5 g/kg/d if BMI > 40;
adjust based on nitrogen balance and serum
protein response
Contraindicated in patients with renal or
hepatic disease; use with caution if hx DKA
Monitor clinical response, accuchecks,
triglycerides, serum proteins, nitrogen
balance, LFTs, ABGS, EF/EDVI, etc.

Designing a Hypocaloric, High Protein

Regimen in Obese Stressed Patients
Pharmaceutical Challenges for
Parenteral Nutrition
Requires use of concentrated macronutrient
ingredients for compounding
Initial concentrations of macronutrients:
dextrose 70%, amino acids 15 or 20%,
lipids 30%
Glucose: Lipid ratio may alter during
hospital course

Designing a Hypocaloric, High Protein

Regimen in Obese Stressed Patients
Pharmaceutical Challenges for
Enteral Nutrition
If high protein, low calorie (e.g., 93 g/L and 1
kcal/mL) formula not available
Avoidance of Enteral Feeding Contamination
Clean environment and blenderizing of
protein powder with enteral feeding
Intermittent liquid protein doses (may need to
be diluted to strength for viscous solutions)

Questions?