م بسم اهلل الرحمن الرحي

Nutritional Screening

Can physically

eat food?

Can patient

tolerate food?

Previous diet2

) (

.

.

Objectives in

Nutritional Screening

Weight, height,

Ask ideal weight

Lab (Alb, Hct, hgb,

FBS)

Appearance (edema,

skin tregor, cachexia,

ulcer,..)

3

.

-

Weight :bed-scale

(Seca 984- Germany)

Malnourished people NICE guideline (2006) describes people

who are malnourished, as defined by any of the following:

a body mass index (BMI) of less than 18.5 kg/m2

unintentional weight loss greater than 10% within the last 3–6 months

a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.

People at risk of malnutrition

those who have:

eaten little or nothing for more than 5 days

and/or are likely to eat little or nothing for 5

days or longer

a poor absorptive capacity and / or high

nutrient losses and/or increased nutritional

needs from causes such as catabolism

Important tipIt is of important to consider

nutrition support for people who

are

either malnourished

or

at risk of malnutrition.

Who needs Nutrition Support?

Those with poor

nutritional status

Weight loss (>2.5

kg/month-

unintentionally)

Albumin < 3.5 g/dl)8

–

.

-

- ) (

.

What’s Nutrition Support?

9

Methods to improve or maintain

nutritional intake are known

as nutrition support.

What’s Nutrition Support?

1- Oral (for example, fortified food, additional snacks and / or sip feeds)

10

What’s Nutrition Support?

2- Enteral – the delivery of a

nutritionally complete feed directly into

the gut via a tube

11

What’s Nutrition Support?

3- Parenteral – the delivery of nutrition

intravenously.

12

When select Enteral way?

If got still works,

But for 5 to 7 days did

not take enough food

13

تغذیه روده ای زمانی در بیماران

استفاده می شود که عملکرد

دستگاه گوارش درست بوده اما

روز و حتی 7تا 5بیمار به مدت

ته بیشتر دربافت غذائی کافی نداش

ولذا نیازمندیهای غذائی وی از

.طریق خوراکی تامین نشده است

Short term Enteral feeding?

ه موارد استفاده کوتاه مدت از تغذ ی(:هفته4کمتر از )روده ای

می برای بیمارانی بکار:نازوگاستریک

رود که می توان از معده بطور کامل

استفاده کرد و نگرانی از جهت تهوع،

.استفراغ و آسپیراسیون وجود ندارد

ت برای بیمارانی که نیاز اس: نازوژژونال

ب معده و دئودنوم بای پس شود، مثال آسی

معده با اسید، بیمارانی که در معرض

ه آسپیراسیون هستند، و یا بیمارانی ک

.تهوع و استفراغ مداوم دارند

14

< 4 weeks

Nasogastric

Nasojejunal

Short term Enteral feeding:

15

Long term Enteral feeding?

ه موارد استفاده بلند مدت از تغذ ی(:هفته4کمتر از )روده ای

ا به طریق جراحی ب: گاستروستومی

بیهوشی عمومی و یا از طریق زیر

، با یک تسکین داروئی،(PEG)پوستی

تحت کنترل اندوسکپی و با کیت

(.2)مخصوص این کار انجام می شود

ه می برای بیمارانی تعبی: ژژنوستومی

شود که الزم است بمدت بیش از چهار

(.2)هفته معده و دئودنوم بای پس شود16

> 4 weeks

Gastrostomy

Jejunustomy

Gastrostomy (PEG)

17

The role of GI tract Immune competence and prevention of acute

phase reactions.

Metabolic function in amino acid metabolism

As a mechanical barrier for bacterial

translocation.

Its importance for infectious complications such

as nosocomial pneumonia.

Jejunustomy

19

Indication of Enteral Feeding:

20

Dysphasia, coma, demencia

Those with depression, not

reluctant to eat food

) (

Main indication for EN

• is prevention and

treatment of

malnutrition

in order to improve outcome;

Enteral Nutrition

“If the gut works, use it!”

An important consideration

NPO should be withhold as soon as possible.

Contraindication of

oral and Enteral Feeding:

26

) (

) (

.

(

)

-

-BUN

-

-

-

Methods of Enteral Feeding:

27

( Bolus feeding)

.

.

.

.

.

( Gravity feeding))

.

.

.

.

Indication of Parenteral Feeding:

28

-

- .

- :

(

)

- .

-

.

1 Peripheral Parenteral Nutrition 2 Multiorgan failure 3 Centeral Line Parenteral Nutrition

• Not working gut

• Peripheral veins

• Central veins

30

Parenteral Nutrition (PN)

Consider oral nutrition support

and

stop when the patient is established on adequate

oral intake from normal food

if patient malnourished/at risk of malnutrition

can swallow safely and gastrointestinal tract is working

Consider Enteral Nutrition

and

use the most appropriate route of access and mode

of delivery

stop when the patient is established on adequate

oral intake from normal food

has a functional and accessible gastrointestinal

tract

if patient malnourished/at risk of malnutrition

despite the use of oral interventions

Consider parenteral nutrition

use the most appropriate route of access and mode of delivery

stop when the patient is established on adequate

oral intake from normal food or enteral tube feeding

and has either

introduce progressively and

monitor closely

if patient malnourished/at risk of malnutrition

a non-functional,

inaccessible or perforated

gastrointestinal tract

inadequate or unsafe oral

or enteral nutritional intake

When to start feeding following

placement?1.After surgery: no need for flatus or BM

2. PEG tube may be utilized for feedings within 2 hours in

adults and 6 hours in infants and children. (B)

feeding can be initiated within 24-48 hours. (A)

Malnutrition is still exist

in hospitalized patients.

Key messages

Patients

Benefit from Nutrition Support.

Key messages

Hospital discharge

با تشکر

40

Thanks for your attention.

NematyM@mums.ac.ir

مرخصي از بیمارستان

با تشکر

The editorial of the 2006 ESPEN

guidelines on Enteral Nutrition

it is worth mentioning

“Although nutritional support is therapy in

most cases it is exactly what it says –

supportive rather than specific treatment

of the underlying disease.” (Lochs H, 2006)

Acknowledgment

• ICU patients

• MUMS

• Colleauges:

• Drs: Ghayour, Safarian, Norouzy, Azarpajooh, Alamdari.

• Mrs Siadat, Firouzy, and Tavallae

• Ms Shahsavan, Ghavami, Momenzadeh

• Mr Mohajery SAR

46

Nutritional risk screening (NRS 2002)

In this study NRS 2002 method, a system for screening of nutritional risk was used to assess malnutrition [20]. It is based on the concept that nutritional support is indicated in patients who are severely ill with increased nutritional requirements, or who are severely undernourished, or who have certain degrees of severity of disease in combination with certain degrees of undernutrition. Patients were scored in each of the two components; undernutrition and disease severity, according to whether they were absent, mild, moderate or severe, giving a total score 0–6. If patient was more than 70 years, one point was added to the total score. Patients with a total score of ≥3 were classified as nutritionally at-risk. Undernutrition was estimated using three variables used in most screening tools: BMI, percent recent weight loss and change in food intake, since these have reasonable evidence base in the literature, correlating with changes in function and clinical outcome.

Hospital Malnutrition

Effectiveness of nutritional

supplements in hospitals varies,

probably due to the influence of poor

appetite (Miline et al. 2005)

Mechanism ?

The mechanism of cachexia in hospitalised

patients remains largely unclear.

Appetite Regulation

Mechanism? Findings from Imperial's college's metabolic medicine lab suggested that

peptide hormones released from the gut, such as ghrelin and peptide YY

(PYY), which stimulate and inhibit the appetite, respectively, might play a role

in the altered eating behaviour of patients, particularly intensive care patients

because the anorexia in hospitalised patients is often characterised by a

premature feeling of fullness and loss of hunger.

Nematy, M. 2005

Batterham R, 2004

Nematy, M. 2007

Nematy, M 2006

Methodology: Bio-Impedance analyzer (BIA)

(Body stat 1500 MDD, England)