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Dr. Bennet Rajmohan , MRCS(Eng), MRCS Ed Consultant General Surgeon

Dr. Bennet Rajmohan , MRCS(Eng), MRCS Ed Consultant General Surgeon. CARE OF NUTRITION IN HOSPITALISED PATIENTS. Introduction. > 30% of in-patients “malnourished” Increased morbidity & mortality Prolonged hospital stay & high costs Especially deleterious in critically ill

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Dr. Bennet Rajmohan , MRCS(Eng), MRCS Ed Consultant General Surgeon

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  1. Dr. BennetRajmohan, MRCS(Eng), MRCS EdConsultant General Surgeon CARE OF NUTRITION IN HOSPITALISED PATIENTS

  2. Introduction • > 30% of in-patients “malnourished” • Increased morbidity & mortality • Prolonged hospital stay & high costs • Especially deleterious in critically ill • Malnutrition not recognised in most patients • Most in-patients lose weight • Malnourished lose more weight

  3. Standard Nutrition • Vast majority recover from illness & can eat normal food within 1–3 days • Standard nutrition – Patient’s choice, voluntary, within physician’s orders • So, little scope for routine artificial nutrition

  4. Patients at risk • Involuntary weight loss > 10% • Weight 20% below or above ideal weight • Critically ill (acute pancreatitis, burns, sepsis, trauma, head injury etc) • Unable to eat or swallow (eg: neurological, oropharyngeal or oesophageal disease) • Oral diet not anticipated for >7 days • Intestinal failure

  5. ArtificialNutrition • Physician’s responsibility • Nutrition support • To minimize negative protein balance • To maintain muscle, immune & cognitive function • To speed up recovery

  6. Options • Enteral (EN) • Via NG / NJ tubes, percutaneous endoscopic gastrostomy (PEG) / jejunostomy (PEJ), surgical jejunostomy • Parenteral (PN) • Via peripheral or central line • EN & PN

  7. ENvs PN • EN preferred because • Structural & functional integrity of GI tract maintained • Less septic complications • Shorter hospital stay • Cheaper • Earlier return of cognitive function (head injury)

  8. Enteral Nutrition (EN) • Initiate early, within 24 – 48hrs of admission • Presence of bowel sounds, passing flatus or stools not mandatory to start feed • 70 to 85% EN tolerance achievable, with EN protocol • NG vs NJ tubes, both acceptable • NJ, if high gastric aspirates or high risk patients, to reduce aspiration

  9. EN protocol • Initiate early • Avoid stopping EN, if NG aspirate < 500ml. Add prokinetics (Metaclopramide, erythromycin) • Minimise stopping EN (eg. for investigations, tube displacement etc) • Ileus worsened by NPO status • Combination of under-ordering & inadequate delivery  < 50% target calories received

  10. EN Dosing • Energy requirements  25 – 30 kcal/kg ideal body weight/day • Aim to achieve at least 50 – 65% of goal calories in 1st 7 days for clinical benefit • Supplement PN, if > 60% energy needs not met by EN alone • Protein BMI < 30, 1.2 – 2.0 g/kg(ideal)/day • Higher in burns, polytrauma

  11. Dosing in Obese • Permissive underfeeding or hypocaloric feeding • Energy, if BMI > 30  11 – 14 kcal/kg actual body weight/day or 22 – 25 kcal/kg ideal body weight • Protein  2.0 – 2.5 g/kg ideal body weight/day

  12. Contraindication for EN • Haemodynamically unstable patient • On increasing doses of inotropes • Avoid EN  1% risk of gut ischaemia

  13. Complications of EN • Most feared complication of EN – aspiration • Intubated ICU patients on EN • Head end elevation 30º– 45º • Continuous rather than bolus feed • Prokinetics • Consider NJ tube (or PEG, if feeding needed for > 4 – 6weeks) • Chlorhexidene mouthwash bd, PPIs to reduce ventilator-associated pneumonia

  14. Parenteral Nutrition (PN) • Only when GI route is not available • Lifesaving • Ensures nutrition delivery into blood • Higher septic complications,length of stay, cost, morbidity & mortality, compared to EN • In dedicated units & expert hands, equally effective as EN

  15. Indications for PN • Pre-op PN – malnourished patients, eg. head & neck, upper GI cancers (at least 7- 10days, costly) • PN in critically ill, if unable to establish EN by 7 days – Supplemental PN & EN • Post-op PN – upper GI anastomotic leaks, short bowel syndrome, multiple bowel fistula • Home PN – short bowel syndrome

  16. Types • Peripheral (PPN): • Low osmolarity feed (<850 mOsmol/L) • Via venflon, add heparin & hydrocortisone to feed, GTN patch • Central (TPN): • Dedicated central venous access • High osmolarity (eg: 1450 mOsm/L)

  17. PN • Permissive underfeed • Aim for 80% of energy needs, at least initially • Obese – same recommendations as with EN • Add parenteral glutamine (0.5g/kg/day)  reduces infections, ICU length of stay & mortality • Attempt to restart EN periodically. Stop PN, if EN can provide > 60% of target energy

  18. Optimal PN • Protein : fat : glucose caloric ratio20 : 30 : 50 (Only non protein calories to be counted) • Tendency to reduce fat & increase glucose : fat ratio from 50:50 to even 70:30 • To avoid triglyceridemia, fatty liver, cholestasis & non-alcoholic steato-hepatitis

  19. PN administration • Bag, with 3 compartments (glucose, amino acids & lipids) mixed just before administering • 3-in-1 mixtures, convenient, aseptic • Allows continuous & stable administration of all components • Antioxidant vitamins (Vit C & E) & trace minerals (Selenium, copper, zinc) must be supplemented daily

  20. Complications of PN • Catheter related • Insertion related (eg: pneumothorax) • Bacterial infections, septicaemia, fungal superinfection • Metabolic • Insulin resistance & hyperglycemia in critically ill • Strict glucose control protocol must – 110 to 150 mg% - to reduce infections • Reversible cholestasis, fatty liver • Acalculous Cholecystitis

  21. Refeeding syndrome • Metabolic disturbances due to reinstitution of nutrition to starved or severely malnourished patients • Fluid & electrolyte disturbances, esp. hypophosphatemia, hypokalemia & hypomagnesemia • Sudden shift from fat to carbohydrate metabolism & sudden increase in insulin levels after refeeding • Neurologic, pulmonary, cardiac, neuromuscular & hematologic complications, confusion, coma, convulsions & death

  22. Special situations

  23. Acute respiratory failure • Fluid restricted calorie-dense feed (1.5 – 2.0 kcal/ml), salt restriction • ARDS & acute lung injury • EN with anti-inflammatory lipids (fish oils) & antioxidants • Monitor & replace Phosphate (synthesis of ATP & 2,3 DPG, both critical for diaphragmatic contractility & optimal lung function)

  24. Renal failure • ICU patients with ARF • Standard EN, standard calorie & protein provision • Low K, low PO4 feed, if electrolytes abnormal • Haemodialysis or CRRT • Amino acid loss 10 – 15 g/day • Protein – at least 1.5 – 2.0 g/kg/day, even 2.5g/kg/day suggested

  25. Acute pancreatitis • Mild pancreatitis: • Diet within 1-2 days • Support only if complication or diet not tolerated by 7days • Severe pancreatitis: • Early EN, ie, as soon as fluid resuscitation complete • PN, if EN not established after 5days

  26. References • Guidelines for the provision & assessment of nutrition support therapy in the adult critically ill patient: Society for Critical Care Medicine(SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). 2009 • ESPEN guidelines on Parenteral Nutrition: Surgery. 2009

  27. THE END

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