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Nutrition

Nutrition. Who. Starvation induced malnutrition Reduced Intake Defective absorption Physiological Stress / Expenditure Burn Malignancy / Surgery Trauma Patient in ICU … CAVH / CAVHD (dialysis) Short term / Long term. Nutritional Status Assessment. No Gold Standard

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Nutrition

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  1. Nutrition

  2. Who • Starvation induced malnutrition • Reduced Intake • Defective absorption • Physiological Stress / Expenditure • Burn • Malignancy / Surgery • Trauma • Patient in ICU… • CAVH / CAVHD (dialysis) • Short term / Long term

  3. Nutritional Status Assessment No Gold Standard History & Examination

  4. Parameters • Weight lost • Subjective / objective • 5-10%, 1 month • 10-20%, 6 months • Weakness • Central muscle wasting • Clothing / Photos • Lost of muscle bulk

  5. Indirect assessment • Anthropometry • Triceps bulk • Skinfold thickness • Midarm muscle circumference • Problems • Inter observer variability • Affected by the patient’s hydration status • Patients own factors (jobs, activities, habits)

  6. Indirect assessment • Creatine-height index • Urinary collection (patient need to have meat-free diets) • Muscle function • Grip strength • Respiratory status • Response to electrical stimulation • Delayed hypersensitivity • Test the immunity respond

  7. ParametersOthers • Albumin • Prealbumin • Immune competence • Delayed cutaneous hypersensitivity • Total lymphocyte count

  8. Biochemical markers • Albumin (T1/2=21days) • Transferrin (T1/2=8days) • Prealbumin (T1/2=2-3days) • Need to consider : • Synthesis rate • Degradation rates • Vascular losses Veterans Affairs Total Parental Nutrition Cooperative Study Group (1991) Perioperative total parental nutrition in surgical patients. N Engl J Med 325, 525-532 Grant,JP. (1986) Nutritional assessment in clinical practice. Nutr Clin Pract 1, 3-11 Fleck,A (1988) Acute phase response: implications for nutrition and recovery. Nutrition 4, 109-117

  9. International Classification of Disease Ninth revision • Recommendations for assessment of malnutrition • Percent weight loss from usual weight, percent IBW (ideal body weight) • Serum albumin level • Inability to eat for ≥7 days Stack JA, Babineau TJ, Bistrian BP (1996) Assessment of nutritional status in clinical practice. Gastroenterologist 4, S8-S15

  10. Prognostic Nutritional Index • PNI(%)=158-16.6(Alb)-0.78(Tsf)-0.20(Tfn)-5.8(Dh) Alb: Albumin (g/dL) Tsf: Triceps folds thickness (mm) Tfn: Serum transferrin (mg/dL) Dh: Delayed hypersensitivity (0-2) none, <5mm, >5mm Surgery, Basic Science and Clinical Evidence, 2000 pp 123-176

  11. Prognostic Inflammatory Nutrition Index PINI=(CRP)(AAG)/(PA)(ALB) CRP: C reactive protein AAG: α1 acid-glycoprotein PA: prealbumin ALB: albumin Surgery, Basic Science and Clinical Evidence, 2000 pp 123-176

  12. Caloric requirements • Harris-Benedict Equation • Male 66+(13.7 x wt.kg) + (5 x ht.cm) – (6.8 x age) • Female 665 + (9.6 x wt.kg) + (1.7 x ht.cm) – (4.7 x age) • Roughly • 22 to 25 Kcal/kg of actual body weight/day

  13. Nutrition Support • Enteral Feeding • Parental Feeding • Total Parental Feeding (TPN) • Partial Parental Feeding

  14. Enteral Feeding • More physiological • Less access complication • Less metabolic complication • Less volume complication • More economical

  15. Enteral Feeding • Prevent intestinal mucosal atrophy • Maintain gut mucosal barrier • Decrease translocation of bacteria from GIT to circulation / peritoneum • Important mechanism for second phase of systemic inflammatory response syndrome (SRS) & later multiorgan failure syndrome (MOF) • Retain normal gut flora distribution

  16. Enteral Feeding • Nasogastric tube • Gastrostomy tube • Nasojejunal tube • Jejunostomy tube Bolus feeding Continuous feeding Feeding ideally should bypass or placed distal to the segment of disease / obstruction

  17. Enteral Feeding • Different Formulary • (cost Vs medical need) • Polymeric formula • Osmolite / Jevity • Elemental formula • Contains low molecular weight polypeptide, free fatty acids • Partially digested form for better absorption • Modulate formula • Specially chemically prepared formula • Medium / short chain fatty acids • eg. COAD – less carbohydrate (H-CO load)

  18. Enteral Feeding • Complications: • Diarrhea • Electrolytes / Fluid imbalance • Access complication • Dislodgement • Blockage • Breakage • Aspiration

  19. Parental Nutrition • Venous access • Central • Peripheral • Osmolarity of formula • Most of them hyperosmolar in order to achieve the caloric requirement in relation to volume • thus Central venous access preferred

  20. Parental Nutrition • 3 in 1 solution

  21. Parental Nutrition • Additive • Electrolytes • Na, K, Mg, Ca, PO4 … • Trace elements • Copper, zinc, selenium … • Medications • Insulin … • Vitamin

  22. Daily requirement Anabolism = ingested > excreted protein Catabolism= ingested < excreted protein • Protein • 0.8 – 1.0 gm/kd/day • in stress up to 2.5gm/kg/day • liver encephalopathy limited to 0.8gm/kg/day • Measure the nitrogen balance 24 hour urine • nitrogen (gm) x 6.25 = protein (gm) • protein is 16% nitrogen • Fat • at least 3 – 5 % of calories as fat is needed to prevent essential fatty acid deficiency • Limited to 25-40% total calories • too much… adverse effects on immunity and gas exchange, increase risk of sepsis • monitor serum triglycerides • rate < 0.1 gm/kg/hr • continuous lipid infusion promotes improved triglyceride clearance • 10% lipid = 1.1 kcal/ml • 20% lipid = 2 kcal/ml • CHO • minimum of 100gm/day for brain and RBCs metabolism • stressed patient limited to < 5mg CHO/kg/min

  23. Overfeeding • Increased CO2 production • Increased Lipogenesis / fatty liver • Slower recovery • Energy requirement increased • Specific energy • Impaired immune function

  24. Parental Nutrition • Complications • Access complication • Pneumothorax • Line infection • Deep vein thrombosis • Metabolic disturbance • Refeeding syndrome • Decreased PO4 if started with excess carbohydrate formula in severe malnourished patients • Cholestasis • Hyperglycaemia • Hepatic dysfunction • Sepsis • Fluid / electrolytes imbalance

  25. Refeeding Syndrome • Intracellular movement of potassium, magnesium and phosphorus, as well as sodium and fluid retention associated with administration of glucose in poorly nourished patients • Potentially fatal • At risk groups • Severe malnourished patients with • Chronic alcoholism • Prolonged fasting patients • Prolonged IV hydration without nutrition

  26. Evidence • Enteral Feeding • Long term rehabilitation • Mortality 8% vs 21.7% (Fracture Hip) • Bastow MD, Rawlings J, Allison SP (1983) Benefits of supplementary tube feeding after fractured neck of femur: a randomized controlled trial. BMJ 287, 1589-1592 • Delmi M, Rapin CH, Bengoa JM (1990) Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 335, 1013-1016 • Lower incidence of sepsis (26% vs 4%; P<0.05) • Moore, EE, Jones TN(1986) Benefits of immediate jejunostomy feeding after major abdominal trauma-a prospective, randomized study. J Trauma 26,874-88

  27. Evidence • Parenteral Nutrition • More post operative complications • (? Benefit in severely malnourished group) • Veterans Affairs Total Parenteral Nutrition Cooperative Study Group (1991) Perioperative total parenteral nutrition in surgical patients. N Engl J Med 325, 525-532 • Brennan MF, Pisters PWT, Posner M et al (1994) A prospective randomized trial of total parenteral nutrition after major pancreatic resection for malignancy. Ann Surg 220, 436-444 • 7 days Pre-Operative TPN (HCC) • Morbidity 34%vs 55% P=0.02 • Fan ST, Lo CM, Lai ECS et al (1994) Perioperative nutritional support in patients undergoing hepatectomy for hepatocellular carcinoma, N Engl J Med 331, 1547-1552

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