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به نام خدا

به نام خدا. Patients requiring nutritional support. 1) PATIENTS WITH SEVERELY IMPAIRED GASTROINTESTINAL FUNCTION. 2) PATIENTS WITH INADEQUATE FOOD INTAKE. 3) PATIENTS UNDERGOING MAJOR SURGERY. 4) PATIENTS WITH CANCER. This support had 3 main objectives:. preserve lean body mass.

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به نام خدا

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  1. به نام خدا

  2. Patients requiring nutritional support 1) PATIENTS WITH SEVERELY IMPAIRED GASTROINTESTINAL FUNCTION 2) PATIENTS WITH INADEQUATE FOOD INTAKE 3) PATIENTS UNDERGOING MAJOR SURGERY 4) PATIENTS WITH CANCER

  3. This support had 3 main objectives: • preserve lean body mass • maintain immune function • avert metabolic complications

  4. Recently these goals have become more focused on nutrition therapy • attempting to attenuate the metabolic response to stress • prevent oxidative cellular injury • favorably modulate the immune response

  5. Nutritional modulation of the stress response to critical illness includes: • Early enteral nutrition • appropriate macro- and micronutrient delivery • meticulous glycemic control

  6. 1970s: TPN - separate CH, AAs and Lipids 2500-3000kcals/day: Lactic acidosis, high glucose loads, fatty livers, high insulin Single lumen C/Lines, no pumps Urinary urea measured, N calculated • 1980s: Scientific studies of metabolism: recognition of overfeeding • 1990s: nitrogen limitation: 0.2g/kg/24hr, start of immunonutrition trials

  7. 2010:attenuate the metabolic response to stress 2000s: glucose control, specific nutrients

  8. ICU Nutrition in the 1970

  9. ICU Nutrition through the ages Overfeeding 1980s

  10. What Guidelines are available? CPG :clinical practice guidelines; ASPEN: American Society for Parenteral and Enteral Nutrition ESPEN: The European Society for Clinical Nutrition and Metabolism NICE: National Institute for Health and Clinical Excellence

  11. The four basic components of nutritional assessment include: 1)Anthropometrics 2)Clinical Information 3)Nutrition Intake History 4)Biochemical Data

  12. I. ANTHROPOMETRICS; The most common anthropometrics used in the hospital setting are : • weight (wt), • height (ht) • weight/height (wt/ht)

  13. Weight: 1)Weight is used to assess a patient’s degree of malnutrition A. Percentage of UBW B. Recent weight change

  14. 2)used to consider frame size and muscle mass and to adjust for any edema or excess fluid present. C.WeightAdjustment for Amputation D.WeightAdjustment for Ascites E:Adjusted Body Weight (AdjBW) for Obese Patients

  15. Usual Body Weight • The stable body weight of the person during the past 1-6 months

  16. Percentage of UBW = current weight 100 UBW 85-90% = mild malnutrition 75-84% = moderate malnutrition <74% = severe malnutrition

  17. Ali 80 Kg last time you saw his 3 weeks ago • Today you visit her and he is75kg Percentage of UBW = current weight 100 UBW Percentage of UBW = 75 100 =93.7 80

  18. Recent weight change = UBW – current weight 100 UBW

  19. Ali 80 Kg last time you saw his 3 weeks ago • Today you visit her and he is75kg X 100 Usual Weight 80– Actual Weight 75Usual Weight80

  20. Mary Jane was 80 Kg last time you saw her 3 weeks ago • Today you visit her and she is75kg X 100 Usual Weight 80– Actual Weight 75Usual Weight80

  21. Adjusted Body Weight (AdjBW) for Obese Patients:

  22. Adjusted body weight (ABW) (kg) IBW + 0.4 (actual weight - IBW) Calculate ABW if actual body weight is >30% of IBW (MGH)

  23. Weight Adjustment for Amputation If a patient has loss of a body part or parts, IBW should be adjusted to reflect amputation.

  24. Percentages for adjustments in body weight :

  25. To estimate euvolemic weight, determine degree of ascites and subtract the following amount from actual weight. Mild Ascites ~ 3 kg Moderate Ascites ~ 7-8 kg Severe/tense Ascites ~ 14-15 kg These adjustments were approved by UVA hepatologists.

  26. Height/Weight • BMI

  27. BMI = weight (kg)/height (m)2 BMI = weight (lbs)/height (in)2 x 703

  28. WHO BMI classifications Underweight: BMI<18.5 kg/m2 Healthy weight: 18.5 - 24.9 kg/m2 Overweight: 25-29.9 kg/m2 Obese: > 30 kg/m2

  29. Height-Weight- Age • Harris-Benedict equation • MiflinSt. Jeor (MSJ)

  30. Harris-Benedict equation. BMR in men (kcal/d) = 66 + 13.7 (weight) + 5 (height) - 6.8 (age) BMR in women (kcal/d) = 665 + 9.6 (weight) + 1.8 (height) - 4.7 (age)

  31.  Miflin St. Jeor (MSJ) Formulas: BEE – Basal Energy Expenditure Males: BEE= 10 x weight (kg) + 6.25 X height (cm) – 5 x age (y) +5 Females: BEE= 10 x weight (kg) + 6.25 X height (cm) – 5 x age (y) – 161

  32. Hamwi Method Ideal body weight

  33. HamwiMethod Males: 106 # for the first 5 feet of ht plus 6 # for each additional inch (+/- 10%) Females: 100 # for the first 5 feet of ht plus 5 # for each additional inch (+/- 10%)

  34. Ideal weight can be calculated using the Hamwiequation: Males: 48.1kg for the first 152.4cm of height, + 2.72kg for each additional 2.54cm Females: 45.4kg for the first 152.4cm of height, + 2.27kg for each additional 2.54cm.

  35. Ideal body weight IBW in men (kg) = 50 + 2.3 [height (inches) - 60] IBW in women (kg) = 45.5 + 2.3 [height (inches) - 60]

  36. II. CLINICAL INFORMATION Medical record Physician and other health care professionals Patient or patient family interviews General observations of the patient’s physical appearance Evaluation of psychosocial background

  37. III. NUTRITIONAL INTAKE HISTORY: 24 hour recall 3 day food record

  38. Data collection should include:  Food habits  Quality and quantity of ingested nutrients  Appetite and changes in appetite  Food intolerance and allergies  Chewing or swallowing problems

  39. Risk factors identified may include: • (1) Current anorexia or major changes in appetite within last 3 mo • (2) Diet orders that nths are inadequate in meeting patient nutritional requirements • NPO or clear liquid >5 days without enteral/parenteral nutrition • (3) Problems with chewing, swallowing, • (4) Past or present need for enteral or parenteral nutrition

  40. 4)BIOCHEMICAL DATA ASSOCIATED WITH NUTRITIONAL STATUS : • Although these lab values are helpful in the assessment of nutritional status, they should be used in combination with other clinical data

  41. TOTAL URINARY NITROGEN ( TUN)* • URINARY UREA NITROGEN (UUN)*

  42. TUN is preferred • UUN is used to estimate nitrogen balance, it does take into account 2 g for the dermal and fecal losses of nitrogen and 2 g for the non-urea components of the urine (e.g. ammonia, uric acid, and creatinine). • the unmeasured nitrogen losses from burns, fistulas and drainage devices need to be considered and used in the interpretation of a nitrogen balance.

  43. N2 Balance = N2 Intake - N2 Loss, intake = gms protein consumed/24 hours/ 6.25 N2loss = gms urine urea nitrogen + 4 (non-urinary urea losses*)

  44. 24 hr. protein intake – TUN (gm) + 2 gm 6.25 +4 to + 6: Net anabolism +1 to - 1: Homeostasis -2 to – 1: Net catabolism

  45. Potential causes Potential causes for for high values low values Inadequate calorie or protein intake Growth increased catabolism Pregnancy Athletic training Trauma Surgery Poor quality protein intake Critical Illness Recovery from illness

  46. 24 hr. protein intake –UUN (gm) + 4 gm] 6.25 +4 to + 6: Net anabolism +1 to - 1: Homeostasis -2 to – 1: Net catabolism

  47. Potential causes Potential causes for for high values low values Inadequate calorie or protein intake Growth increased catabolism Pregnancy Athletic training Trauma Surgery Poor quality protein intake Recovery from illness

  48. Hepatic Proteins Albumin, Prealbumin and Transferrin are not listed in the previous section as research has shown that these hepatic proteins are not reliable indicators of nutritional status and are negative acute phase reactants.

  49. Albumin, prealbumin, and transferrin should not be used as indicators of nutritional status in hospitalized patients due to the effects of stress and inflammation on these parameters .

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