Surgical Nutrition for MS Part 1 Peradeniya March 2007
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Transcript of Surgical Nutrition for MS Part 1 Peradeniya March 2007
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Enteral and Parenteral Nutritionin the Critically Ill patient
MS Part 1 Peradeniya 2007
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Medical Ethics
Obligations of a moral nature which govern
medical practice.
1. Autonomy the right for self determination
2. Avoiding harm (non-maleficence) together with the
aim of providing benefit (beneficence)3. Justice fair and equitable provision of available
medical resources
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Nutrition
Ethics
In most societies food is a symbol of caring
and comfort Provision of food and water to the sick is most
fundamental of all human relationships
It is Unethical and Immoral not to provide
nutritional support for a patient with more
than one week of inadequate intake
The current legal and clinical view
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Metabolic response to trauma (Surgery)
Mediators
Cytokines Paracrine hormones
TNF- Hypermetabolism,
hyperglycaemia, fever, lacticacidosis, shock
Activates hypothalamic-pituitary-adrenal axis
Interleukins
IL-1 Potent H-P-A axisinducer
IL-6 Acute phase response
Neuroendocrine Activated sympathetic
response
Activated hypothalamic-
pituitary hormones
Insulin and glucagon
levels are increased
GH increased
ADH , Renin ,
Aldosterone
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We do have an energy reserve
Protein sparing strategies
Pre-op care Treat sepsis
Avoid starvation
Mobilisation burns fat, spares protein
Nutritional support
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Nutritional Therapy
Patient focused nutritional therapy
is the only way to treat or prevent malnutrition Goal of therapy
is to improve or prevent malnutrition when they
are unable meet the nutritional demands
Minimize wasting Lean body mass
Starvation 2% muscle mass loss per day
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Nutritional Assessment
Why?
Accurately define nutritional status of patient
Define clinically relevant malnutrition Monitor the response to treatment
Research
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Nutritional assessment
How?
Single index
Serum albumin
Limited use long half life, recover with illness not just nutrition
Anthropometry
Skin fold thickness, body wt
Multiple parameters
Prognostic nutritional index (Mullen et al 1979) Serum albumin, transferrin, triceps skin fold, delayed skin
hypersensitivity
Medical history and physical examination
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MalnutritionUnder nutrition, over nutrition, unbalanced intake
Why? Inadequate food intake
e.g. anorexia, dysphagia, vomiting
Malabsorption
Inability to metabolize certain nutrients e.g. renal disease, liver disease, inborn errors of
metabolism Increased requirements
Any one or combination of above
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MalnutritionUnder nutrition, over nutrition, unbalanced intake
Leads to
Immune incompetence
Impaired barrier function, non specific function, specific immunity
Poor wound healing
Impaired vital organ function
Reduced muscle function, lung function, cardiac function, GIT
function
Increased post operative complications
Prolonged hospital stay
Increased mortality
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Weight loss
0-10% Safe zone
10-15% Entering danger zone: Consider artificial nutrition of major
treatment planned
20-25% Danger zone: Nutritional support compulsory if treatment to be
continued
30-35% Risk of death due to cachexia: Immediate nutrition therapy
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Aim of nutritional therapy
Give sufficient energy
25-35 kcal/kg/day Mostly as carbohydrate and not fat
Give sufficient nitrogen
1g/kg/day
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How to give nutritional therapy
correctly
Identify patients at risk
Calculate requirement of specific nutrients Select appropriate route of administration
Monitor intake daily
Monitor effects using objective parameters Watch for adverse reactions or complications
Modify the regimen if necessary
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Goals of nutrition therapy
Improve mental and physical function
Minimize deleterious effects of catabolism Prevent death from starvation
Restore normal body tissue
Accelerate rehabilitation Reduce hospital stay
Improve quality of life
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Routes
Parenteral
Peripheral Central
Enteral
Oral Naso gastric
Naso jejunal
Gastrostomy
Jejunostomy
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When the gut works
Use it
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Range of Enteral formulae
Oral supplements
Usually lactose free, liquid, palatable
Enteral
Polymeric: standard or fibre
Provide 1 kcal/ml or 1.5 kcal/ml
Pre-digested
Semi elemental or elemental Disease specific
Liver, renal or pulmonary failure
Specialized formulae
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Specialized formulae : Rationale
Pulmonary disease Reduce CO2 production
High fat, low CHO
Liver disease Prevent encephalopathy
Low fat, high CHO, more branched chain AA
Renal disease To minimize renal load
Low mineral, high calorie, moderate protein
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Indications for parenteral nutrition
Temporary or permanent intestinal failuremajor trauma, abdominal surgery,pancreatitis,inflammatory bowel disease
Inadequate oral intake for one week or more
Severely malnourished unable to meet his or
her requirements enteraly
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Sites of central venous access for parenteral nutrition
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Parenteral Nutrition supplies
Energy
Amino acids Electrolytes
Vitamins
Water Trace elements
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Parenteral nutritionstandard regimens
Amino acids 1.5g/kg/day
Energy 30 kcal/kg/day (CHO + fat) Electrolytes basal amounts
Vitamins and trace elements basal amounts
Above are maintenance requirements. Additional fluid
and electrolytes may be required
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Adult parenteral nutrition
on a single slide
3000 ml water
3000 Cals (12,800 Kj) 100 Grams L-amino acids
100 mmol Sodium
100 mmol Potassium Phosphate and Magnesium
Vitamins and trace elements
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Parenteral Nutrition
1. Catheter-related complications Pneumothorax
Air embolism
Catheter embolisation
Venous thrombosis
Catheter occlusion
Improper tip location Phlebitis
Catheter-related sepsis
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Parenteral nutrition
2. Gastrointestinal complications Liver dysfunction
Hepatic steatosis Intra hepatic cholestasis
Gastrointestinal atrophy
Translocation of bacteria
Gastric hyperacidity
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Parenteral Nutrition
3. Metabolic and Electrolyte Complications Hyperchloraemic metabolic acidosis
Due to high Chloride intake
Electrolyte disturbances Hypokalemia, Hypernatraemia
Rebound Hypoglycemia TPN should be weaned not abruptly stopped
Refeeding syndrome when TPN given after a period of starvation
increased insulin lead to severe hypophosphatemia,hypokalemia, hypomagnesaemia
Deficiencies
Trace elements, vitamins (thiamine, folic acid, vitamin K)
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Enteral Nutrition?
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Early enteral nutrition
in the acutely ill
Reduces septic and non septic complications
Improve outcome of the critically ill and injuredpatient
Small bowel function and the ability to absorb
nutrients remains intact despite critical illness ,even in the presence of gastro paresis and
absent bowel sounds
Consider trans-pyloric feeding even in this state
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How does early enteral nutrition help?(Crit Care Med 2001; 29: 2264-70)
Improves nitrogen balance
wound healing host immune function
Augment cellular antioxidant mechanisms
Decrease hyper metabolic response to tissue injury
Preserve intestinal mucosal integrity maintain mucosal immunity
prevent increase in mucosal permeability
decrease bacterial translocation)
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Nutrition in specific diseases
Acute renal failure With CRRT no need to
restrict volume
Normal nutritional supportappropriate
Liver disease Use lipids in caution
Restrict proteins 0.5g/kg/day
Risk of hypoglycemia Inhibitory neurotransmitters
Branched chain AA ifdeficient may contribute toencephalopathy
Respiratory failure Oxidation of fat produce less
CO2 than CHO
Acute pancreatitis Enteral feeding useful
jejunal feeds lessstimulation
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Adjunctive nutrition Glutamine
An oxidative fuel
Nucleotide precursor for enterocytesand immune cells
Large amounts released by muscle incatabolic states
Branched chain amino acids Benefit no evidence yet
Omega-3 fatty acids Less cytokine production
Anti-inflammatory
ARDS - ?benefit
Arginine Precursor of nitric oxide
Enhanced cell mediated immunity
Nucleotides DNA, RNA precursors
If deficient immunity affected
Immuno-nutrition Enriched diets with Omega 3 +
Arginine + nucleotides and Glutamine
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Enteral vs ParenteralParenteralguaranteed intake
never rejected
can be used with short gut or absent gutfunction
Less nutritionally effective than EN
Hyperglycaemia
Electrolyte imbalance
HyperlipidemiaConstant supervision
Needs long term CVC
Sterility and infection considerations
Costly
Enteralcan be capricious
can be vomited
Requires functional gutDiarrhoea
Can be used to continue oral meds
More effective on-line to portal system
Encourages gut motility
Normalises gut flora
Electrolyte imbalance unusualLess supervision
Less infection
Cheap(er)
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Wherever possible resort toEnteral feeding
Use parenteral nutrition to
supplement above and only if
essential for total nutritional
support
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Summary
Nutrition is essential not an option
Move towards enteral feeding
Control sepsis
Early mobilisation
Remember the vitamins