Post on 22-Nov-2014
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Parenteral Nutrition in Obstructive Colon Cancer
Gardian Lukman Hakim
What :
“Provide adjunctive therapy to support thestress response, provide exogenous nutrientsto reduce drain on endogenous stores and thedepletion of lean body mass, and prevent theconsequences of protein malnutrition”
• “provision of early enteral feeding”
• Attaining access and initiating enteral feeding is considered part of basic resuscitation
Cancer Patient (CxPt) : Metabolic Point of View
• CxPt are frequently malnourished
• Cause :
1. Nutritional Status Before Cx
2. Tumor itself
3. Cancer therapy
CxPt :
• Tend to be immunosupressed
• The benefits of nutrition support may outweigh concern about nutrition effect on tumor growth
• The value of nutrition support in CxPt : provide exogenous substrates to meet protein and energy requirements.
Metabolic Changes in CxPt :
• Glucose intolerance, increased fat depletion, and protein turnover.
• Unable to conserve energy because of inefficient metabolisms.
• A lot of mediators such as hormones, cytokines, and growth factors nutritional derangements.
• Negative energy balance.
Protein Carbohydrate Lipid
TNF-α Muscle Proteolysis Glycogenolysis DecreasedLipogenesis
Protein Oxidation DecreasedGlycogenesis
Decreased LPL in fat tissue
Hepatic Protein synthesis
Gluconeogenesis
Glucose Clearence
Lactate Production
IL-1 4 Hepatic Protein Synthesis
Gluconeogenesis Lypolysis
GlucoseClearence Decreased LPL Synthesis
Fatty Acid Synthesis
IL-6 Hepatic Protein Synthesis
Lypolysis
Fatty Acid Synthesis
IFN-α IncrreaseLypolysis
Decreased LPL Activity
Starvation vs Stress Metabolisms
Characteristi Starvation Hypermetabolism
Energy Expenditure Decreased Increased
Respiratory Quotient Low (0,7) High (0,85)
Response to Feeding +++ +
Mediator Activation + +++
Primary Fuels Fat Mixed
Gluconeogenesis + +++
Proteolysis + +++
Protein Synthesis + +++
Ureagenesis + +++
Ketone Formation ++++ +
When :
• Nutrition support should be considered once hemorrhage has been controlled, devitalized tissue debrided, fractures stabilized, and the patient rescuscitated from shock.
• Nutrition intervention is appropriate in the catabolic phase when hemodynamic stability is attained.
Why :
• It seems logical that nutrition related morbidity and mortality can be prevented or ameliorated by appropriate and timely nutrition intervention.
Where :
Nutritional Assessment and Monitoring :
• History and Physical Exam remain mainstaymore useful in ambulatory setting or in chronic patient.
• Skin Fold Thickness (SFT) & Mid Arm Circumference (MAC) Not Practical in Recumbent Position
Nutritional Assessment and Monitoring :
• Albumin :
Half-life 20 days
Insensitive in acute changes
Useful in predicting surgical mortality and monitoring status over long term
• Transferin : half-life 8-10 days. Inverse by serum iron.
• Retinol-binding protein : 12 hours half-life
• Thyroxin-binding prealbumin :
Half-life 2-3 days
Fall early in catabolic illness, rise early in subsequen decrease in acute phase reactant.
Nitrogen Balance :
• Most consistently associated with improve outcome.
• Ideally positive balance is the goal.
• Nitrogen Balance : Intake-Output
• Intake : Protein or AA /6,25
• Output : Urinary nitrogen losses + 2 g
• Urinary Nitrogen Losses : UUN+ 20% UUN
Nitrogen Balance :
• Classically involve 24-hour measuring, but 12 or 6 hour urine collection can be obtained.
• Usually calculated weekly
Another Laboratoy Data :
• CBC
• Serum Electrolyte (Na/K/Cl/HCO3/Ca/Mg/PO4)
• Blood Glucose
• Liver Function , Renal Function.
How :
• Target of Calories : 25-30 kcal/kg/day
• Obesity is adjusted :
IBW+0,25(ABW-IBW)
Obesity adjusted X 25-30.
Carbohydrate Requirements :
• 60-70% of non protein calories
• Excess of glucose administration :
1. Hyperglicemia
2. Excess of carbon dioxide production
Fat Requirements :
• 15-40% total calorie requirements
• Not exceed 1-1,5 g/day
• Complication due to excess of fat
1. hyperlipidemia
2. immunosuppression
3. hypoxemia impaired oxygen diffusion and v/q mismatch.
Protein Requirement :
• Protein demands are markedly increaseed.
• Protein synthesis is responsive to amino acid infusions.
• Protein requirement is between 1,2-2 g/kg/day
Electrolyte, vitamin, and so on
• Must be maintain between normal limit.
Enteral vs Parenteral Nutrition
• General consideration is the works of gut
• Enteral route is prefered
• Advantage of enteral route :
1. Easy administration
2. Good tolerance
3. Promotion of mucosal growth and development.
4. Maintaning the barrier function of the GI tract.
• Mechanical obstruction is contraindicated to enteral nutrition.
• In this case total parenteral nutrition is prefered.
Terima Kasih