Date post: | 16-Feb-2017 |
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Health & Medicine |
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‘A slender and restricted diet is always dangerous in chronic and in acute diseases’Hippocrates 400 B.C.
Learning Outcomes
• Outline the indications & complications of EN• Outline the indications & complications of TPN• Illustrate with diagrams about Tube-feeding
techniques
Definition
• Nutritional support is the provision of nutrients to patients who cannot meet their nutritional requirements by eating standard diets.
Nutritional Support – Fundamental Goals
• To meet the energy
requirement
for metabolic
processes.
• To maintain a normal
core body
temperature.
• For tissue repair.
Principles of Nutrition• Avoiding of malnutrition• Enteral nutrition – Ideal one•Overfeeding to be avoided• Timing & Type of nutrition•Nutrition therapy protein wasting• Immunomodulators – glutamine, arginine, omega 3 fatty acids – very useful
Nutritional Assessment• No single “ Gold Standard ”• Body wt.loss > 10% - 6mths – prognostic index Body mass index : weight (kg)/ height (m2) [ <18 .5 – nutritional impairment ]• Anthropometric measures – Indirect measures - TSF / MAC – muscle & fat mass • Transport proteins –(Sr.alb.-30mg/dl, prealb.-12g/dl,transferrin-150mmol/L)• Immune incompetence – TLC / Delayed Hypersensitivity• MUST - Tool
Indications for Nutritional Support
Severely Malnourished
Post – op complications
Trauma
Burns
Malignant disease
Renal & Liver failure
Short bowel syndrome
Indications for Nutritional Support• Patient not expected to feed in 7 days Prolonged ileus or intestinal obstruction
Entero - cutaneous fistulas Pancreatitis, U C, Pyloric stenosis
Major bowel surgery• Esophageal replacement• Gastric or colon surgery• Whipple’s procedure
Indications for Nutritional Support
ESOPHAGECTOMY COLON REPLACEMENTCAUSTIC INGESTION, ESOPHAGEAL STRICTURE
Nutritional Requirements • Basic Needs * 25-30 kcal/kg/day• Hospitalized patients -
TER * 1300 - 1800 kcal/day – rough• Basic Nutritional
Requirements * Carbohydrates, fat, proteins, vitamins minerals & trace elements• Feeding regimen –
planned * Standard tables - available
Nutritional Requirements • For Carbohydrates - Glucose
[40-50%] * 100-200 g/day
• For Fat - EFA [30-40%] * 100-200 g/week
• For Protein – N2 [10-15%] * 0.10-0.15g/kg/day (1.25g/kg/day)
• Vitamins / Minerals & Trace elements
Monitoring Feeding Regimes
Nutrition
Daily
Weekly
Fortnightly
Body wt. / Temp CBC / RBS / BUN I-O / electrolytes Plasma proteins LFT/ Acid-base status Ca / Mg / Zn / Po4 U & P osmolality
Sr-Vit B12 / Iron / Folate
Sr-Lactate Trace elements
Enteral Nutrition-Advantages
• More physiological
(liver not bypassed)• Lesser cardiac work • Safer and more efficient• Better tolerated by the patient• More economical
Enteral Nutrition-Access • Sip feeding• NGT/ NDT/ NJT• Gastrostomy• Jejunostomy• PEG (percutaneous endoscopic gastrostomy)
Contraindications of EN• Hemodynamic instability
• Intestinal Obstruction / GI bleed / Ileus
• Intractable vomiting / Diarrhoea
• High output proximal fistula
• Inability to gain access
• Anticipating complications
Complications
Severity
Tube – related
Gastro-intestinal
Metabolic
Infective
Malposition / Displacement
Block / Break / Leakage
Local complications
N V D Aspiration
Constipation Electrolyte disorders Vitamins / minerals
Def. Drug interactions
> Exogenous / Endogenous
Definition
Total parenteral nutrition (TPN) is defined as the provision of all nutritional requirements by means of the I.V route & without the use of GIT.
Indications for TPN
Patient not expected to feed in 7 -10 days
Massive resection of small bowel
High output fistulas
Prolonged intestinal failure – some reasons
Central Access• Central – Catheter is
placed using a needle & guide wire via - • Subclavian approach• Internal jugular approach• External jugular approach
SuperiorVena Cava
Peripheral Access • Peripheral Parenteral
Nutrition
* Through a peripherally
inserted central venous
catheter. [PICC] Catheter.
* Through a formal peripheral
venous line.
Complications
Severity
Nutrition
Over - feeding
Sepsis
Line
Hypoglycaemia/Ca/P/Mg (refeeding syndrome)
Chronic deficiency syndromes (EFA, Zn, mineral and trace elements)
Glucose- Hyperglycaemia, fluid
retention, electrolyte abn. Fat- Hypertriglyceridemia A.A- Aminoacidaemia, uraemia,
metabolic acidosis
Catheter related Systemic sepsis Drug interactions
> On insertion – PT / AE / bleeding > Long-term use - occlusion, VT
Advantages - Enteral v/s PN• Preserves gut integrity
• Possibly decreases bacterial translocation
• Preserves immunological function of gut
• Reduces costs
• Fewer infectious complications in critically ill
patients
• Safer and more cost effective in many settings
Refeeding Syndrome • Is occurrence of severe fluid & electrolyte imbalance in severely
malnourished pts. while starting {RE-FEEDING} EN/TPN. More common in TPN.
• Causes - * ↓ Mg, ↓ Ca, & ↓ Po4 → myocardial dysfn., resp.changes, altered liver fns, convulsions & death.
• Commonly seen → chronic starvation, severe anorexia & alcoholic pts.
• Gradual feeding & correction of Mg, Po4 & ca. & other electrolytes & vitamins is important.
Home Parenteral Nutrition • It is becoming popular in Western countries. • Indicated in Pts. who require nutrients for long term – extensive Crohn’s, mesenteric infarction etc.• Pt. uses the TPN fluids as advised at home. A indweling Silastic catheter is designed for long term use. • Pt. should attend TPN clinic weekly – follow-up or any complications. • Pt. is psychologically comfortable & can attend his job also.