Sepsis is a life-threatening condition that arises when the body's response to an infection spirals out of control, damaging vital organs and potentially leading to death. Surviving sepsis is a significant accomplishment, but the road to full recovery can be long and challenging. The last thing that may be on your mind post sepsis might be the idea of eating a healthy diet. But it is essential to eat well after a hospital stay. This article provides a detailed guide to nutrition post-sepsis, focusing on the importance of diet in rebuilding strength, restoring muscle mass, and supporting overall well-being.
Understanding Sepsis and Its Impact on the Body
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock, a subset of sepsis, involves profound circulatory, cellular, and metabolic abnormalities. The pathogenesis of sepsis involves several molecular mechanisms, including immune-inflammatory dysfunction, complement deactivation, mitochondrial damage, and endoplasmic reticulum stress.
The dysregulated host response to pathogens in sepsis results in a combination of neuronal, endocrine, and immune-inflammatory abnormalities leading to profound micro- and macro-hemodynamic and metabolic consequences. These abnormalities result in cellular dysfunction and varying degrees of organ dysfunction. Glucose becomes the primary substrate, as glycolysis has the advantage of not requiring oxygen, although energy production is significantly lower than in the Krebs cycle. Hepatic ketogenesis is suppressed by increased insulin levels. This allows peripheral tissues to utilize glucose as a primary energy source. Hepatic glycogenolysis provides glucose for a short time. This is followed by intensive endogenous glucose production (gluconeogenesis) in the liver from lactate, amino acids derived from increased protein catabolism, and glycerol derived from increased lipolysis.
Sepsis can lead to prolonged hospital stays and affect patients who are elderly, frail, have multiple comorbidities, or suffer from chronic end-stage disease. Modern hospital care enables even septic patients with frailty and multimorbidity to survive.
The Importance of Nutrition After Sepsis
After a serious illness like sepsis or septic shock, it takes time for your body to heal and for you to regain your strength. Weight loss and loss of muscle mass can occur quickly when someone is in an intensive care unit (ICU). People who have been in bed for an extended period lose muscle mass. Your body, including your muscles, is made up of cells. Those muscles need nutrition to rebuild themselves when they break down or refurbish themselves if there’s weight loss or dehydration. Food helps rebuild what we need to build that muscle mass and bring back that lost weight. Good nutrition also helps our brain and our cognitive function. Keeping all this in mind, it’s not surprising to learn that the first step in recovery post sepsis is to help rebuild muscle strength and mass.
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Eating a healthy diet helps reduce the risk of some illnesses, while eating a diet full of junk food and processed foods, as well as foods that are high in fat and sugar, can increase your risk of developing certain medical conditions. Eating healthy foods, with an emphasis on protein can help sepsis and septic shock survivors rebuild some of that lost muscle mass.
Rehabilitation and Recovery
Rehabilitation usually starts in the hospital by slowly helping you to move around and look after yourself: sitting up, standing, walking, taking yourself to the restroom, bathing and other activities. The purpose of rehabilitation is to restore you back to your previous level of health or as close to it as possible. Begin your rehabilitation by building up your activities slowly and rest when you are tired. Talk with a healthcare provider if you or your caregivers are concerned about any physical symptoms or feelings you are experiencing. Work with a healthcare provider to determine the most appropriate rehabilitation plan and what activities are safe for you.
Many people who survive sepsis recover completely and their lives return to normal. However, as with some other illnesses requiring intensive medical care, some patients have long-term effects. Generally, the effects of sepsis improve with time. Some hospitals have follow-up clinics or staff to help patients and their families or caregivers. If you feel that you are not getting better, finding it difficult to cope, are continuing to be exhausted, or want more information, call a healthcare professional.
Nutritional Strategies for Recovery
Consulting a Dietitian
Dieticians are the food experts. It would be a good idea for anyone recovering from a serious illness or who has any dietary issues to consult with a dietician. During the first visit, the dietitian would do an interview, asking what you like to eat, how you get and prepare your food, and the difficulties you may have in consuming a healthy diet. What health issues do you have? What medications are you currently taking? What was your diet like before you became ill? Check to see if your insurance policy allows for dietary consultations. Your doctor’s office may have a dietitian on staff.
Addressing Loss of Appetite
Loss of appetite isn’t uncommon post sepsis. First, you’re not as physically active, so you may not be working up an appetite. Foods may taste funny. The idea of eating may make you feel nauseous. Or, you may be too fatigued to want to eat. If this is the case, usually grazing is your best bet, rather than a few large meals. Grazing means picking at healthy foods or having small meals whenever you’re hungry throughout the day. Facing the idea of eating can be difficult. If you’re not tempted to eat because the food doesn’t taste good, experiment with flavors - herbs and mild spices can make a big difference in how something tastes. Pain can also affect your appetite. In this case, try timing your meals for about a half-hour or so after you take your pain reliever.
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Macronutrient Balance
Ensure you have a good combination of nutrients in your food and drink. This is not the time to follow special diets that eliminate carbs or other food groups. Healthy fats, such as those from olives, nuts, fatty fish (like salmon, tuna, mackerel), soy, and tofu, are essential in providing your body with protein, which is a building block for muscle mass.
As much as dietitians want their clients to eat as healthy as possible, moderation is key. If you’re not terribly hungry and you crave food that may not be considered beneficial, a small amount now and then should not hurt. This, of course, is unless you have a medical issue that prevents you from consuming it.
The Catabolic and Anabolic Phases
After a very early phase of abnormal response to the infection, which lasts hours and is characterized by a “metabolic shock”, the body rapidly enters the so-called acute catabolic phase. A combination of cytokine storm, neurohormonal stress response (involving catecholamines, corticosteroids, and glucagon), and insulin resistance play an important role in the acute phase. Fasting is common as voluntary food intake ceases, contributing to the metabolic response we will discuss shortly.
During the catabolic phase, one of the most critical responses is the provision of energy substrates to the tissues, despite the sepsis-induced mitochondrial dysfunction and overactivation of the immune-inflammatory response. Glucose becomes the main substrate because glycolysis has the advantage of not requiring oxygen, although it is associated with significantly lower energy production than the Krebs cycle/oxidative phosphorylation even when fasting because insulin levels are elevated. Hepatic glycogenolysis supplies glucose for a few hours in times of high demand, as occurs in critical illnesses such as sepsis. As a result, intensive endogenous production of glucose (gluconeogenesis) begins in the liver. The most important substrates for “de novo” glucose production in the liver are glycerol from increased lipolysis in adipose tissue and amino acids from increased protein catabolism, particularly in muscle.
The anabolic phase begins once sepsis has resolved and the stress response subsides. Only then can nutrition effectively counteract the negative protein (and energy) balance, so that the damaged tissue can rebuild.
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Nutritional Assessment and Monitoring
The profound metabolic changes that occur in the various phases of sepsis require quantitative and qualitative adaptation of nutritional support during the course of the disease. A tailored nutritional program for these patients must always be preceded by a thorough nutritional assessment. Close monitoring is also required to adjust the program according to metabolic changes and resumption of oral feeding. On admission, it is important to check for pre-existing malnutrition and to assess the risk of malnutrition. For this purpose, the combination of general clinical assessment, laboratory parameters, and validated scores is useful to predict the clinical outcome.
Among the laboratory parameters, nutritional biomarkers such as albumin and TTR deserve special mention. Due to its long half-life (about 14-20 days), albumin is not considered useful in assessing acute changes in nutritional status but remains a good marker of chronic malnutrition. However, neither molecule is a reliable marker of malnutrition in patients affected by inflammatory diseases. Outside the ICU, TTR values > 0.16 g/L are associated with a good prognosis. It has also been shown to be a reliable nutritional marker for refeeding follow-up. Among the scores, CONUT, PNI, and NRS-2002 are the most commonly used. The NRS-2002 score seems to be the most accurate.
Energy Expenditure
Activity-induced energy expenditure should be assessed in recovering patients who resume physical activity. Metabolic changes due to sepsis and common therapies administered to septic patients, such as steroids and vasopressors, are not considered in PE and can only be measured by indirect calorimetry. The Harris-Benedict and Schofield equations are the most commonly used PE for estimating energy expenditure. Basal metabolism does not increase by more than 30% compared to normal and decreases more the more severe the sepsis. Endogenous energy production occurs through massive mobilization of caloric reserves (adipose tissue, muscle, glycogen).
Macronutrient Recommendations
The recommended amounts of lipids and glucose are 0.7-1.5 g/kg/day and 1-1.5 g/kg/day, respectively. Protein loss is considerable from the first day of illness, and supplementation is often inadequate compared to actual requirements. The recommended protein intake is about 1.0 g/kg/day (ranging between 0.8 and 1.3 g/kg/day) and should be administered as soon as possible after admission. We recommend administration of 0.8 g/kg/day during sepsis and a gradual increase up to 1.3 g/kg/day when shock resolves.
Enteral vs. Parenteral Nutrition
Enteral nutrition (EN) is less costly than parenteral nutrition (PN) and theoretically represents the most physiological way of feeding. EN improves gastrointestinal blood flow, preserves the intestinal mucosal structure, stimulates enzymatic processes, and enhances the systemic immune response. An immediate clinical benefit of EN in septic patients could be the prevention of bacterial translocation and stress ulcerations. EN is considered to be safer than PN because no central venous access is required, and undesirable effects of PN (hyperglycemia, hyperlipidemia, fatty liver, etc.) are avoided. However, EN is not without drawbacks. Feeding may be suboptimal due to irregular absorption. Gastric content may not pass beyond the pylorus (slow gastric emptying, ileus, etc.) which increases the aspiration risk. EN may also be hampered by transit problems (vomiting, diarrhea) and is contraindicated when the gut is ischemic, injured, or obstructed.
Addressing Common Post-Sepsis Symptoms
Your sepsis experience may continue to affect you physically and emotionally when you return home. Regardless of your age, prior health, or activity level, recovery can take time. Around 40% of people who develop sepsis are estimated to experience physical, cognitive, and/or psychological after effects. Recovery time varies for each person. Generally, it can take a few weeks to a few months, but for some it can take longer.
Physical Symptoms
Sepsis can cause widespread inflammation and changes in blood flow in the smallest of our blood vessels. This can affect the function of organs and body tissues in different parts of our body.
Enhancing Recovery
There are several ways sepsis survivors can support their recovery process:
- Time: Recovery takes time, and there is no standard timeline.
- Pacing: Physical recovery can be gradual. Survivors should pace their activities and avoid rushing themselves.
- Space to talk: Sharing thoughts and feelings about the experience can significantly benefit recovery.
- Self-Care: Prioritising self-care is essential. Survivors should aim to eat a balanced diet rich in fresh fruit, vegetables, and plenty of water.
- Sleep: Regular sleep is crucial for health.
- Managing stress and anxiety: As survivors recover, they may encounter new challenges, including accepting their illness and focusing on recovery.
- Diary: Keeping a daily diary can be both therapeutic and practical.
- Light exercise: Maintaining mobility is beneficial, though survivors might not have the same energy levels or muscle tone as before.
Post Sepsis Syndrome (PSS)
Typically, most people with PSS will get better with time. Tell your family and friends about PSS, explain how you feel and give them information to read so they can understand what you’re going through - as you may look well, but feel unwell. Each case of PSS is different. Cases commonly last between 6-18 months, but for a minority recovery can take much longer.
Seeking Help and Support
- Family and friends: Loved ones play a crucial role in supporting sepsis survivors during their recovery.
- GP: Keeping the GP informed about progress is important, especially after an extended stay in critical care.
- Critical Care follow-up: Some critical care units offer follow-up services, which can vary depending on the hospital.