Nutritional Support of the Cacectic Patient

1. Nutritional Support of the Cacectic Patient

2. Recap • Risk of Malnutrition • Nutritional assessment • History and examination • Anthropological • Biochemical • Calculation of nutritional needs • TE = NPE + PE • NPE = CHO and lipids

3. Study Aims • Substrate changes • Acute starvation • Chronic Starvation • Strategy for nutritional support • Enteral access routes • Complications of enteral feeding

4. Pathophysiology • Acute Starvation • Depletion of liver glycogen (rapid) • Insulin fall, glucagon rise • Hepatic GNG • Amino-acids from muscle protein • Alanine and glutamin prefered (75%) • Build up by insulin • Breakdown in absence of insulin • Lipolysis • Energy for GNG from FFA oxidation • Insulin fall stimulates lipolysis • Liberates glyserol

5. Pathophysiology – A. Starvation • Conservation of substrate • Glucose to lactate in haemopoetis Sx • Recycled via glucogenic Cori cycle • Glyserol (from lipolysis) • Hepatic GNG • Branched chain Amino Acids • From proteolysis • In Crebs from alanine and glutamine • Direct oxidation in cardiac tissue and skeletal muscle • Stimulates protein synthesis and inhibit breakdown • Resulting increase in u - N output

6. Pathophysiology – C. Starvation • Starvation by above methods • 8 – 12g/day N excretion (340g prot) • 35% LBM in 1 month = Fatal • Survival for 2 – 3 months due to • Decreased energy expenditure • Decreased SV and HR (CO) • Voluntary mobilisation decreases due to fatigue • Altered brain substrate • Ketone oxidation • Fall in glucose utilisation • Rise in ketones • Inhibits hepatic GNG

7. Pathophysiology - Starvation • Decrease in EE • Conserving protein • Catabolism = protein breakdown or auto-canabalism

8. Strategy for nutritional support Nutritional Assessment GIT assessment • Non-functional • Diarrhoea • Obstruction • Peritonitis • Vomiting • Ileus • Short bowel syndrome Functional Access • Long term • Oral • Gastrostomy • PEG • Jejunostomy • Short term • Oral • Naso-gastric • Naso-duodenal • Naso-jejunal • Jejunostomy TPN TEN Remains absent Returns GIT function Normal GIT Fx Compromised GIT Fx Polymeric feeds Semi-elemental feeds

9. Enteral feeding • Enteral = in the gut • Needs intact GIT • Patent • Functional • Needs access • Oral • Gastric • All about gastric emptying • Duodenal • Jejunal • About absorption and volume accomodation

10. Enteral Access Routes (other than oral) • Gastric • Naso-gastric • Oro-gastric • Via pharingostomy • GAstrostomy • PEG • Surgical • Duodenal • Naso and oro-duodenal • Placement • Blind techniques • Accidental • Endoscopic or PEG extensions

11. Enteral Access Routes (other than oral) • Jejunal • Naso or oro-jejunal • At time of open abdomen • Jejunostomy

12. Semi-elemental Nutritionally not balanced Low in fat Proteins in form of AAS, Peptides and polypeptied Easy to digest Low residue Polymeric Nutrtionally balanced Digestion normal Residue normal Enteral formulars

13. Indications for enteral support • Basal need not met by intake • Large deficit not net by intake • Increased need (BMR) - hypermetabolism • Burns • Head injury • Partial functioning GIT • Limitation on volume

14. Complications • Tube related / mechanical • Pulmonary Aspiration • Sinusitis • Misplacement and dislodgement • Erosions and necrosis • Reflux • Blockage • Underfeeding

15. Complications • Metabolic • Diarrhoea • Hypertonic solutions • Inadequate absorption • Lactose deficiency • Starvation hypoalbunemia • Excess fat • Overfeeding (see previous lecture) • Refeeding • Severe hypo-phosphatemia and hypo-kalemia secondary to chronic starvation • To little ATP for absorption