Download MBBS Surgery Presentations 42 Nutrition Lecture Notes

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1. To understand the decision-making process for

initiating, maintaining, and terminating

Specialized Nutritional Support (SNS) in surgical

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patients.

2. To understand the decision-making process for

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calculating nutritional requirements, gaining

access for SNS, and monitoring for complications

during SNS.

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Case 1

A 67-year-old man with obstructing esophageal cancer

presents for consideration of surgical therapy. He has lost

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25 pounds (15% of normal body weight) over the past 4

months, is unable to swallow anything except liquids, and

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has near-complete loss of appetite. He has no other past

history of significance and takes medications only for

hypertension. His appearance is gaunt with obvious loss of

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body fat and muscle wasting. There is mild peripheral

edema. The remainder of the physical exam is

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unremarkable. Workup suggests that he is a candidate for

esophageal resection. His albumin is 2.7g/L and his

hemoglobin is 9g/L with microcytic indices. All other

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determinations are normal.

Case 2

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A previously healthy 27-year-old woman is the

restrained driver in a head-on collision. She is

diagnosed with intraabdominal injuries and

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undergoes emergency laparotomy. At operation, a

crush injury to the pancreas and duodenum is

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repaired as is a mesenteric tear and grade II liver

laceration. Appropriate external drainage of the injury

sites is undertaken. She has lost approximately

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1000mL of blood and hasreceived 4000mL of

crystalloid solutions intraoperatively. She will be

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transferred to the intensive care unit (ICU) for initial

postoperative care. No other major injuries are noted.
What?

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Carbohydrate
Lipid
Protein
Trace elements
Vitamins

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Who?

Malnourished (>10% lean body mass)
Incapable of eating (>10 days)

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Why?

Risks of malnutrition including infection, poor healing

and higher mortality

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Malnutrition is exacerbated by physiological stress

When?

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Preoperative?
Early?
Late?
---after initial resuscitation following injury or surgery
How?

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Parenteral
Enteral
Total
Partial

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Issues

Metabolic response to injury
Cytokines, inflammation, hormones

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Biology of substrates
Enteral vs. Parenteral


"Ashen faces, a thready pulse

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and cold clammy

extremities..."The Ebb Phase

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Cuthbertson, Quart. J. Med.25:233,1932

The Ebb Phase

Hypometabolic

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Hypercortisolism

Hypothermic

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Hyperglucagonemia

Hypoinsulinemic

Hyperglycemia

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Hypoperfusion

Hypercatecholemia

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"The patient warms

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up,cardiac output increases

and the surgical team

relaxes..." The Flow Phase

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Cuthbertson. Lancet 1:233, 1942

The Flow Phase

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Hypermetabolic

Hyperinsulinism

Hyperthermic

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Hypercortisolism

Catabolic

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Hyperglucagonemia
High cardiac output


Nutritional Assessment

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Body weight
Body mass index
creatinine height index
Serum proteins:albumin, prealbumin, transferrin

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Immune competence: lymphocytes, DH
Nitrogen balance

NUTRITIONAL

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REQUIREMENTS
PROTEIN

Most important macronutrient.
Normal requirement is 1gm\kg\day

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Doubled in stress, burns, trauma or sepsis
19-20% of protien intake should be EAA, which should

be doubled in stress states.

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Carbohydrates

1 gm of glucose gives 4 kcal.
Liver and skeletal muscle store it as glycogen.
But glycogen stores are exhausted within 24 hrs of

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fasting.

Then?
Gluconeogenesis starts.

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Substrates for gluconeogenesis?
Fats

9kcal\gm.
Body depends on fat for energy in depleted states.

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Hydrolysis of fats depends on hormone sensitive

lipase.

Which hormones increase lipase activity?

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NITROGEN

1 gm = 6.25 gm of proteins.
Obligate nitrogen losses are 56-57mg\kg\day

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How?
37mg\kg- urine
12mg\kg ? stools
5mg\kg ? skin
2-3mg\kg ? evaporation

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Nitrogen balance= N intake- N losses
N loss = 24hr urinary nitrogen+ 4gm\day
+VE N balance= anabolic state
-VE N balance= ?
BEE

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HARRIS- BENEDICT Equation=
Males= 66.47+13.75(W)+5.0(H)- 6.76(A) KCAL\Day
Females= 65.51+ 9.56(W)+1.85(H)- 4.68(A)
REE is the estimation of the pts true energy

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requirements after taking into account activity factor

and injury factor.

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How do we calculate REE?
REE = BEE *activity factor* injury factor

ACTIVITY FACTOR:
Bed rest = 1.2

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Ambulatory = 1.3
INJURY FACTOR =
Minor surgery = 1.2
Trauma = 1.35
Sepsis = 1.6

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Burns = 2.1
30 Kcal\kg\d adequately meets the requirement in

postsurgical cases.

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During catabolic phase calorie requirement is 1.2- 2.0

times greater than BEE.

Calorie to nitrogen ratio should be between 100 and

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150 to 1 in normal states and in sepsis 100:1.

Causes of Inadequate Nutrition

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Poor oral intake
Catabolic states
Malabsorption
Increased losses
Drug and alcoholabuse

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Depression
Isolation
Poverty
NUTRITIONAL ASSESMENT

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Components of Nutrition Assessment
Medical and social history
Diet history and intake
Clinical examination
Anthropometrics

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Biochemical data

Medical and Social History

Gathered from chart review and patient interview

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Medical history: diagnosis, past medical and surgical

history, pertinent medications, alcohol and drug use,

bowel habits

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Psychosocial data: economic status, occupation,

education level, living and cooking arrangements,

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mental status

Other: age, sex, level of physical activity, daily living

activities

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Dietary History and Intake

Appetite and intake: taste changes, dentition,

dysphagia, feeding independence, vitamin/mineral

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supplements

Eating patterns: daily and weekend, diet restrictions,

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ethnicity, eating away from home, fad diets

Estimation of typical calorie and nutrient intake: RDAs,

Food Guide Pyramid

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Obtain diet intake from 24-hour recall, food frequency

questionnaire, food diary, observation of food intake

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Diet Assessment

Evaluate what and how much person is eating, as well

as habits, beliefs and social conditions that may put

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person at risk

Usual intake

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24 hr recall: retrospective, easy
Food logs: prospective, requires motivation
Food frequency questionnaire: general idea of how

often foods are consumed

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Compare to estimation of needs
Nutritional Questions for

the Review of Systems

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General

Usual adult weight
Current weight

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Maximum, minimum weights
Weight change 1 and 5 years prior
Recent changes in weight and time period
Recent changes in appetite or food tolerance
Presence of weakness, fatigue, fever, chills, night sweats

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Recent changes in sleep habits, daytime sleepiness
Edema and/or abnormal swelling

Nutritional Questions for

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the Review of Systems

Alimentary

Abdominal pain, nausea, vomiting

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Changes in bowel pattern (normal or baseline)
Diarrhea (consistency, frequency, volume, color, presence of

cramps, food particles, fat drops)

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Difficulty swallowing (solids vs. liquids, intermittent vs.

continuous)

Early satiety

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Indigestion or heartburn
Food intolerance or preferences
Mouth sores (ulcers, tooth decay)
Pain in swallowing
Sore tongue or gums

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Nutritional Questions for

the Review of Systems

Neurologic

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Confusion or memory loss
Difficulty with night vision
Gait disturbance
Loss of position sense

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Numbness and/or weakness

Skin

Appearance of a diagnostic rash

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Breaking of nails
Dry skin
Hair loss, recent change in texture

Clinical Examination

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Identifies the physical signs of malnutrition
Signs do not appear unless severe deficiencies exist
Most signs/symptoms indicate two or more

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deficiencies

Examples:

Head and Neck: hair loss, bitemporal wasting, conjunctival

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pallor, xerosis, glossitis, bleeding/sore gums, angular

cheliosis, stomatitis, poor dentition, thyromegaly

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Extremities: edema, muscle wasting, loss of s/c fat
Neurologic: evidence of peripheral neuropathy, reflexes,

tetany, decreased mental status

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Skin: ecchymosis, petechie, pallor, pressure ulcers, wound

problems/infection
Characteristics of Nutritional

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Status

Good

Poor

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Alert expression

Apathy

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Shiny hair

Dull, lifeless hair

Clear complexion

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Greasy, blemished

complexion

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Good color

Poor color

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Characteristics of Nutritional

Status

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Good

Poor

Bright, clear eyes

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Dull, red-rimmed eyes

Pink, firm gums and

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Red, puffy, receding

well-developed teeth

gums, and missing or

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cavity-prone teeth

Firm abdomen

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Swollen abdomen

Firm, well-developed Underdeveloped, flabby

muscles

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muscles

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Characteristics of Nutritional

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Status

Good

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Poor

Well-developed bone

Bowed legs, "pigeon

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structure

breast"

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Normal weight for

Over- or underweight

height

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Erect posture

Slumped posture

Emotional stability

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Easily irritated,

depressed, poor

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attention span

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Characteristics of Nutritional

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Status

Good

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Poor

Good stamina

Easily fatigued

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Seldom ill

Frequently ill

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Healthy appetite

Excessive or poor

appetite

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Healthy, normal sleep Insomnia at night,

habits

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fatigued during the day

Normal elimination

Constipation or diarrhea

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42
Stop and Share

Identify at least 5

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signs of

malnutrition

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present in this

child.

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Anthropometrics

Inexpensive, noninvasive, easy to obtain, valuable

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with other parameters

Height, weight and weight changes
Segmental lengths, fat folds and various body

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circumferences and areas

Repeated periodically to note changes
Individuals serve as own standard
Anthropometric Measurements

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Height

Weight

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Anthropometric Measurements

Head

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Triceps skinfold

circumference
Disadvantages of Anthropometrics

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Intra and interobserver error
Changes in composition of patient's tissues
Inaccurate application of raw data
Measurements are evaluated by comparing them with

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predetermined reference limits that allow for

classification into risk categories

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Anthropometrics

Ideal body weight

Males: 106 lbs + 6 lbs per inch over 5 ft

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Females: 100 lbs + 5 lbs per inch over 5 ft
Add 10% for large-framed and subtract 10% for small-

framed

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%IBW = (current wt/IBW) X 100

80-90% mild malnutrition
70-79% moderate malnutrition
60-69% severe malnutrition

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<60% non-survival
Anthropometrics

%UBW: usual body weight

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= (current wt/UBW) X 100
85-95% mild malnutrition
75-84% moderate malnutrition
0-74% severe malnutrition

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% weight change = usual weight ? present

weight/usual weight X 100

Significant weight loss

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>5% in 1 month
>10% in 6 months

Body Mass Index = BMI

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Evaluation of body weight independent of height
BMI = weight (kg)/height2 (m)

>40

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obesity III

30-40

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obesity II

25-30

overweight

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18.5-25

normal

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17-18.4

PEM I

16-16.9

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PEM II

<16

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PEM III
Frame Size

Determined using wrist circumference and elbow

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breadth

Determines the optimal weight for height to be

adjusted to a more accurate estimate

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Wrist circumference: measures the smallest part

of the wrist distal to the styloid process of the ulna

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and radius

Elbow breadth: measures the distance between

the two prominent bones on either side of the

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elbow

Skinfold Thickness

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Estimates subcutaneous fat stores to estimate total

body fat

Triceps, biceps, subscapular, and suprailiac using

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calipers are most commonly used

Disadvantages: total body fluid overload, caliper

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calibration, inter-individual variability
Body Circumferences and Areas

Estimates skeletal muscle mass (somatic protein stores and

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body fat stores

Midarm or upper arm circumference (MAC): on the upper arm

at the midpoint between the tip of the acromial process of the

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scapula and the olecranon process of the ulna

Midarm muscle or arm muscle circumference (MAMC):

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determined from the MAC and triceps skinfold (TSF)

MAMC = MAC ? (3.14 X TSF)
Total upper arm area: determines upper arm fat stores
Upper arm muscle mass provides a good indication of lean body

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mass, used in the calculation of upper arm fat area

Upper arm fat area: calculation may be a better indicator of

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changes in fat stores than TSF

Bioelectrical Impedance Analysis (BIA)

Measures electrical conductivity through water in

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difference body compartments

Uses regression equations to determine fat and LBM
Serial measures can track changes in body

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composition

Obesity treatments
DEXA: dual-energy X-ray absorptiometry

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Whole body scan with 2 x-rays of different intensity
Computer programs estimate

Bone mineral density

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Lean body mass
Fat mass
"Best estimate" for body composition of clinically

available methods

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Biochemical Data

Used to assess body stores
Altered by lack of nutrients, medications, metabolic

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changes during illness or stress

Interpret results carefully
Fluid status distorts results

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"Stressed" states (infection, surgery) effects results
Use reference values established by individual lab
Visceral Proteins

Produced by the liver

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Affected by protein deficiency, but also renal and

hepatic disease, wounds and burns, infections, zinc

and energy deficiency, cancer, inflammation,

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hydration status, and stress

Albumin

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Half life 14-21 days
Normal value 3.5-5.0 g/DL
Most widely used indicator of nutritional status
Acute phase response: levels decrease in response to

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stress (infection, injury)

Affected by volume

Increases with dehydration, decreases with edema and

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overhydration
Prealbumin

Better measure of nutritional status due to shorter

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half-life, ~2 days

Normal value: 18-40 mg/DL
Responds within days to nutritional repletion

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Levels affected by trauma, acute infections, liver and

kidney disease; highly sensitive to minor stress and

inflammation

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Creatinine Height Index

Estimates LBM
= actual creat excretion (24 hour urine collection)

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expected creat excretion
Males: IBW X 23 mg/kg
Females: IBW X 18 mg/kg
>80% normal

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60-80% moderately depleted
<60% severely depleted
Accurate 24-hr urine collection is difficult to

obtain in acute-care setting

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Hematological Indices

Determine nutritional anemias
Transferrin: Fe transport protein
TIBC: total Fe binding capacity

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Indicates number of free binding cites on transferrin

Fe deficiency: increased transferrin levels, decreased

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saturation

Ferritin: Fe storage protein, increases during

inflammation

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Depressed hemoglobin is an indicator of Fe deficiency

anemia

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Indirect calorimetry/Metabolic Cart

Measures CO2 produced and O2 consumed in critically

ill patients on ventilators

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Calculates resting metabolic rate based on gas

exchange

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Respiratory quotient calculated

Corresponds to oxidation of nutrients
CHO: 1:1 ratio of CO2 produced/O2 consumed
Lipid: 0.7:1 ratio

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Protein: 0.82:1 ratio
Mixed diet: 0.85:1 ratio
Overfeeding/lipogenesis: >1.0
Case 1

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55yo male with Crohn's disease has failed Remicade

and needs an ileocolic resection.

What are the surgical nutritional issues?

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Nutritional Support

Fundamental goal of nutritional support:
1.

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To meet the energy requirement for metabolic

processes

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2. To maintain a normal core body temperature
3. For tissue repair
Conditions That Require

Specialized

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Nutrition Support

Enteral

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--Impaired ingestion
--Inability to consume adequate nutrition orally
--Impaired digestion, absorption, metabolism
--Severe wasting or depressed growth

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Parenteral

--Gastrointestinal incompetency
--Hypermetabolic state with poor enteral

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tolerance or accessibility

ENTERAL NUTRITION

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Enteral Nutrition

Nutrition delivered via the gut
Includes oral feedings and tube feedings

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Enteral Tube Feeding

Nutritional support via tube

placement through the nose,

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esophagus, stomach, or intestines

(duodenum or jejunum)

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--Must have functioning GI tract
--IF THE GUT WORKS, USE IT!
--Exhaust all oral diet methods first.

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Oral Supplements

Between meals
Added to foods
Added into liquids for medication pass

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by nursing

Enhances otherwise poor intake
May be needed by children or teens to support

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growth

Diagram of enteral tube placement.

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Copyright ? 2000 by W. B. Saunders Company. Al rights reserved.

Fig. 22-2. p. 468.
Indications for Enteral

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Nutrition

Malnourished patient expected to be unable to

eat >5-7 days

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Normally nourished patient expected to be

unable to eat >7-9 days

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Adaptive phase of short bowel syndrome
Increased needs that cannot be met through

oral intake (burns, trauma)

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Inadequate oral intake resulting in

deterioration of nutritional status or delayed

recovery from illness

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ASPEN. The science and practice of nutrition

support. A case-Based Core curriculum. 2001; 143

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Contraindications for EN

Severe acute pancreatitis
High output proximal fistula
Inability to gain access

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Intractable vomiting or diarrhea
Aggressive therapy not warranted

ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001;

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143
Contraindications for EN

Inadequate resuscitation or

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hypotension; hemodynamic instability

Ileus
Intestinal obstruction
Severe G.I. Bleed

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Expected need less than 5-7 days if

malnourished or 7-9 days if normally

nourished

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Severe diarrhea
Protracted Vomiting Are Not

Contraindications

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Intestinal dysmotility
Do Not Feed a Necrotic Bowel !!

INSTEAD FEED EARLY TO

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PREVENT A NECROTIC

BOWEL

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Advantages - Enteral vs PN

Preserves gut integrity
Possibly decreases bacterial translocation
Preserves immunological function of gut

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Reduces costs
Fewer infectious complications in critically

ill patients

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Safer and more cost effective in many

settings

ASPEN. The science and practice of nutrition support. A case-based core curriculum.

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2001; 147
ADA EAL, Critical Illness, accessed 8-07
Advantages--Enteral Nutrition

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Intake easily/accurately monitored
Provides nutrition when oral is not possible or

adequate

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Supplies readily available
Reduces risks associated with

disease state

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Disadvantages--Enteral

Nutrition

GI, metabolic, and mechanical

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complications--tube migration; increased

risk of bacterial contamination; tube

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obstruction; pneumothorax

Costs more than oral diets (not necessarily)
Less "palatable/normal": patient/family

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resistance

Labor-intensive assessment,

administration, tube patency and site care,

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monitoring
Enteral Formulas

Liquid diets intended for oral use or for tube

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feeding

Ready-to-use or powdered form
Designed to meet variety of medical and

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nutrition needs

Can be used alone or given with foods

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Enteral Formulas

Determine best choice by medical and

nutrition assessment

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Meet specific nutrition needs


Enteral Formula Categories

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Polymeric
Monomeric
Fiber-containing
Disease-specific

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Rehydration
Modular

Route For Feeding Access

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Short Term access (for 4-6wk)---

Use Nasal Access :naso-gastric/jejunal tubes
Nasogastric tubes:
?Allow use of hypertonic feeds

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higher feeding rates
bolus/Intermittent feeding
?Fine bore 8-10 F NG tubes

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Access Techniques.....cont

Nasojejunal NJ tubes
Indicated--gastric reflux
--delayed gastric emptying

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--unconcious patient
Fine bore 6-10 F
Insertion same as NG, but once reached stomach,

patient is turned onto the right side advance tube

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10cm

To assist postpyloric placement of NJ tube :
10mg Metoclopramide iv 10 min

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200mg

Erythromycin iv 30min prior placement

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Access Techniques.....cont

Long Term access > 4-6wk----Feeding Ostomies

(Enterostomies)

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Percutaneous Endoscopic Enterostomy
Surgical Enterostomy

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Percutaneous Endoscopic

Enterostomy

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1- Percutaneous Endoscopic Gastrostomy
PEG: Method of choice
Considered in pat. with normal gastric emptying

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Percutaneous Endoscopic Gastrostomy

Contraindications:

Gastric cancer

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Gastric ulcer
Ascitis
Coagulation disorders

(Source: Kudsk KA, Jacobs DO. Nutrition. In: Surgery: Basic Science and Clinical Medicine.

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Norton JA, et al., eds. New York: Springer-Verlag, 2001(2) Part 7, Section 91:136)


Feeding Ostomies (Enterostomies)

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Percutaneous Endoscopic Jejunostomy

2- PEJ
New--

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Technically difficult
Indicated if postpyloric feeding is needed
Allows concomittent jejunal feeding and gastric

decompression

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Administration of EN

Bolus
Continuous

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Intermittent
Cyclic
Bo

Ad lu

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mi s

n iF

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stee

er di

20n

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0 gs

-400 ml of

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enteral formula into the

stomach over 5 to 20

minutes, usually by gravity

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with a large-bore syringe

Indications:

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-Recommended for gastric

feedings

-Requires intact gag reflex

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-Normal gastric function

Continuous Feedings

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Administration into the GIT via pump or gravity,

usually over 8 to 24 hours per day

Indications:

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Promote tolerance
Compromised gastric function
Feeding into small bowel
Intolerance to other feeding techniques

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Intermittent Feedings

Administration of 200-300 ml over 30-60 minutes q 4-

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6 hours

Indications:
Intolerance to bolus administration
Initiation of support without pump

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Open vs Closed System


Open System

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Product is decanted

into a feeding bag

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Allows modulars such

as protein and fiber to

be added to feeding

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formulas

Less waste in unstable

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patients (maybe)

Shortens hang time
Increases nursing time
Increased risk of

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contamination

Closed System or Ready to

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Hang

Containers sterile until

spiked for hanging

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Can be used for

continuous or bolus

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delivery

No flexibility in

formula additives

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Less nursing time
Increases safe hang

time

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Less risk of

contamination

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More expensive than

canned formula
Closed vs Open System

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Open System

Closed System

Hang time 8 hours

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for decanted formula; Hang time 24-48

4 hours for formula

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hours based on mfr

mixtures

recommendations

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Feeding bag and

Y port can be used to

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tubing should be

rinsed each time

deliver additional

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formula replenished

fluid and modulars

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Contaminated

May result in less

feedings are

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formula waste as

associated with pt

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morbidity

open system formula

should be discarded

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p 8 hours

Closed vs Open System

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In a survey of nurses at MetroHealth, only

28% were aware of the 8 hour hang time for

open system formulas written into nursing

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policy

55% recommended adding new formula to

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old, in violation of existing nursing protocol

66% could state the 24 hang time for closed

system formulas

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The cost of wasted formula is minimal

compared to the cost of nursing time and

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risk of illness in patients

Luther H, Barco K, Chima CS, Yowler CJ. Comparative study of two systems of

delivering supplemental protein with standardized tube feedings. J Burn Care

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Rehabil 2003;24:167-172.
What are the major problems

associated with tube feeding?

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1- Aspiration----Most Important

Prevalence range from 2% - 95%
Several issues should be considered:

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1-Tube Size and Position
Large bore vs small bore
Gastric vs Jejunal
2-Body Position Supine vs Semi recumbent
3-Underlying Disease Gastroparesis/ Atony

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4-Feeding Regimen
Intermittent or Continuous vs Bolus
To Limit the Risk of Aspiration

1- Raise head of bed 30-400 during feeding and 1 hr

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after

2-Use intermittent / continuous feeding regimens

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rather than------ bolus method

3-Check gastric residual regularly
4-Consider jejunal access--------

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-recurrent tube feeding aspiration
-high risk of gastric motility dysfunction

2-Diarrhea----Most Common

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Incidence 2.3% - 68%
Critically ill are more prone
Multiple aetiologies:
1-Medications:
Antibiotics-----overgrowth of C.difficile / Candida

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Sorbitol base liquids---Theophylline
Meds containing Magnesium
2-Altered bacterial flora
H2-blockers/ PPI---permit bacterial overgrowth
Bacteria colonize---Gastric pH exceeds 4

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2-Diarrhea----Most Common

3-Formula Composition

?Osmolality & Rate

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incidence of diarrhea in critically ill
mechanically vent patients----receiving hyperosmolar feeds

at high infusion rates

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2-Diarrhea----Most Common

4-Hypoalbuminemia
---Reduces osmotic pr & causes intestinal mucosal

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oedema

Critically ill with s.Alb < 2.6g/dl diarrhea with

standard EN

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5-Formula Contamination
Altered Drug absorption & Metabolism

Phenytoin

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Binds to NG tubing at pH of enteral
formulation----less drug delivery
Warfarin
Resistance 2ndry to Vit K in Enteral feedings

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Stop enteral feeding 2 hrs before and 2

hrs after

Metabolic Complications

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Less frequent compared to TPN
Hyperglycemia: 2ndry to High CHO load in specific

formula esp critically ill / elderly--------insulin

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resistance

Electrolyte imbalance:
Use of high osmolar formulation esp: Pat on fluid

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restriction/ renal concentrating difficulties are at risk of

-----Dehydration & Hypernatremia
Mechanical

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Feeding tube obstruction
Feeding tube dislodged
Nasal irritation
Skin irritation/excoriation at ostomy site

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Refeeding Syndrome

At risk: when refeeding those with marginal body

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nutrient stores, stressed, depleted patients, those who

have been unfed for 7-10 days, persons with anorexia

nervosa, chronic alcoholism, weight loss

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Symptoms: Hypokalemia, hypophosphatemia and

hypomagnesemia; cardiac arrhythmias, heart failure;

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acute respiratory failure
Refeeding Syndrome

Correct electrolyte abnormalities (via oral, enteral,

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parenteral route) before initiating nutrition support

Administer volume and energy slowly
Monitor pulse rate, intake and output, and electrolyte

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levels

Provide appropriate vitamin supplementation
Avoid overfeeding

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Monitoring of Patients on EN

Electrolytes
BUN/Cr
Albumin/prealbumin

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Ca++, PO4, Mg++
Weight
Input/output
Vital signs
Stool frequency/consistency

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Abdominal examination
Routes of Parenteral Nutrition

Central access

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--TPN both long- and short-term placement

Peripheral or PPN

--New catheters allow longer support via

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this method limited to 800 to 900 mOsm/kg

due to thrombophlebitis

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<2000 kcal required or <10 days

Advantages--Parenteral Nutrition

Provides nutrients when less than

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2 to 3 feet of small intestine remains

Allows nutrition support when GI intolerance

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prevents oral or enteral support
Indications for Total

Parenteral Nutrition

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GI non functioning
NPO >5 days
GI fistula
Acute pancreatitis
Short bowel syndrome

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Malnutrition with >10% to 15 % weight loss
Nutritional needs not met; patient refuses food

Contraindications

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GI tract works
Terminally ill
Only needed briefly (<14 days)
Administration

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Start slowly

(1 L 1st day; 2 L 2nd day)

Stop slowly

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(reduce rate by half every 1 to 2 hrs

or switch to dextrose IV)

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Cyclic give 12 to 18 hours per day

Monitor

Weight

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(daily)

Blood

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Daily

Electrolytes (Na+, K+, Cl-)

Glucose

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Acid-base status

3 times/week

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BUN

Ca+, P

Plasma transaminases

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Monitor--cont'd

Blood

Twice/week

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Ammonia

Mg

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Plasma transaminases

Weekly

Hgb

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Prothrombin time

Zn

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Cu

Triglycerides

Monitor--cont'd

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Urine:

Glucose and ketones (4-6/day)

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Specific gravity or osmolarity (2-4/day)

Urinary urea nitrogen (weekly)

Other:

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Volume infusate (daily)

Oral intake (daily) if applicable

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Urinary output (daily)

Activity, temperature, respiration (daily)

WBC and differential (as needed)

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Cultures (as needed)
Problems

PPN

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Site irritation

TPN

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1. Catheter sepsis

2. Placement problems

3. Metabolic

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Q. A young man weighting 65 kg was admitted to the

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hospital with severe burns in a severe catabolic state.

An individual in this state requires 40 kcal per kg

body weight per day and 2 gms of protein/kg body

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weight/day. This young man was given a solution

containing 20% glucose and 4.25% protein. If 3000 ml

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of solution is infused per day -

The patient would not be getting sufficient protein
The calories supplied would be inadequate
Both protein and calories would be adequate

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Too much protein is being infused
Q. One is not the indication of total parenteral

nutrition -

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Acute pancreatitis
Enterocolic fistula
Chronic liver disease
Faecal fistula

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Q. TPN is indicated in all except -
Short bowel syndrome
Burn
Sepsis
Enterocutaneous fistula

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Q. A patient on total parenteral nutrition for 20 days

presents with weakness, vertigo and convulsions.

Diagnosis is :

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Hypomagnesemia
Hyperammonemia
Hypercalcemia
Hyperkalemia

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Q. Ramesh met and accident with a car and has been

in `deep coma' for the last 15 days. The most suitable

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route for the administration of protein and calories is

by :

Jejunostomy tube feeding

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Gagstrostomy tube feeding
Nasogastric tube feeding
Central venous hyperalimetation
Q. A patient undergoes a prolonged and complicated

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pancreatic surgery for chronic pancreatitis. Most

preferred route for supplementary nutrition in this

patient would be :

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Total Parentral Nutrition
Feeding Gastrostomy
Feeding Jejunostomy
Oral feeding

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