ACUTE AND LONG TERM NUTRITION SUPPORT

1
ACUTE AND LONG TERM NUTRITION SUPPORT

• FOR THE PERSON WITH BRAIN INJURY
• KAREN KOPPY, MPH, RD, LD
• HCMC

2
3 TOPICS

• Critical Care
• Rehabilitation Process
• New Research (micronutrients and neutroceuticals

3
TYPES OF BRAIN INJURIES

• Traumatic Brain Injury (TBI)
• Stroke
• Anoxic Injury
• Combinations

4
STAGES OF DAMAGE

• Primary at the injury site
• Secondary response to injury
• Increased intracranial pressure (IP)
• Endocrine disturbances
• Sodium and fluid balance disturbance

5
TREATMENT FOCUS

• Resuscitation of blood pressure and oxygenation
  to brain
• Treat ICP
• Provide nutrition

6
CHALLENGES TO NUTRITION SUPPORT

• Intubation
• Sedation
• Confusion, agitation
• Delayed gastric emptying
• Glucose intolerance
• Fluid and electrolyte imbalance

7
METABOLIC AND PHYSIOLOGIC CONSEQUENCES

• Hypermetabolism
• Stress hormone release
• BEE
• Caloric needs
• Catabolism
• Muscle breakdown
• Nitrogen (N2) losses

8
INFLAMMATORY RESPONSE

• Reactive Oxygen Species (ROS)
• Systemic Inflammatory Response Syndrome (SIRS)
• Consequences
• Mediators

9
PROCESS OF INFLAMMATION
10
(No Transcript)
11
INTERVENTIONS FOR INFLAMMATION

• Nutrition Support
• Anti-inflammatory Medications
• Anti-cytokines (anti-TNF)
• Probiotics
• Glycemic Control
• Nutrition Modulators
• Omega-3 fatty acids
• Antioxidants

12
IMMUNOLOGICAL RESPONSE

• Molecular, cellular and chemical mediators
• Improved with adequate nutrition

13
FLUID IMBALANCE

• Common Disturbances of Sodium and Fluid
• Diabetes Insipidus (DI)
• Syndrome of Inappropriate Antidiuretic Hormone
  (SIADH
• Cerebral Salt Wasting Syndrome (CSWS)

14
INCREASES IN NUTRITIONAL NEEDS AFTER INJURY

• Calorie needs
• Increase initially
• May decrease later due to decreased physical
  activity
• Protein needs
• Increase initially
• Taper back to normal needs 1 year after injury
• Vitamin needs
• Increase initially
• Mineral needs
• Increase initially
• Fluid needs
• Increase initially

15
NUTRITIONAL REQUIREMENTS

• Calories
• Calculating needs
• Indirective Calorimetry
• Predictive Equations (Harris-Benedict Equation,
  Frankenfield Equation)
• Standard 140 of BEE
• Permissive underfeeding
• For the critically ill patient
• Variables
• Induced coma
• Respirator
• Fever
• Sepsis

16
MACRONUTRIENTS

• Carbohydrates
• 40-50 calories
• Hyperglycemia
• Protein
• 15-20 calories
• Nitrogen losses
• Fat
• 30-40 calories
• High proportion Omega 3 Fatty Acids

17
MICRONUTRIENTS

• Definition measure in mg or less
• Vitamins, trace elements
• Components of enzymes, coenzymes, substrates,
  hormones
• Difficult to assess status
• Injury causes derangements
• Deficiencies

18
IMPORTANT NUTRIENTS FOR CRITICALLY INJURED
PATIENTS

• Zinc
• Antioxidant action
• Losses during injury
• Recommendations
• Dangers of excessive intake inhibits Copper
  absorption

19
IMPORTANT NUTRIENTS

• Iron (Fe)
• Carrier of oxygen generates ROS
• Contributes to micro-organism proliferation
• How the body compensates during SIRS
• Supplements not recommended during inflammatory
  process

20
IMPORTANT NUTRIENTS

• Vitamin E (tocopherol)
• Antioxidant actions
• Dangers of excessive intake
• Vitamin D
• Recently discovered receptors on immune cell
  types
• Inhibitor of proinflammatory cytokines

21
IMPORTANT NUTRIENTS

• Vitamin C (ascorbic acid)
• Antioxidant properties
• Wound healing
• Iron absorption
• Recommendations
• Consequences of excessive intake

22
IMPORTANT NUTRIENTS

• Selenium
• Antioxidant action
• Low levels in trauma patients
• Copper and Manganese
• Elevated levels in SIRS
• Supplementation not warranted unless deficient
  (losses with diarrhea)

23
ENTERAL NUTRITION SUPPORT

• Post-pyloric placement for feeding tubes
• Tight glucose control
• High protein formula (immune-enhanced formulas
  not shown to improve outcomes in brain injured
  patients)

24
PARENTERAL NUTRITION SUPPORT

• Rarely indicated
• Necessary when gut is non-fuctional (ileus, bowel
  obstruction, malabsorption)
• Some evidence supporting use for patients on high
  dose pressors
• Encourage simultaneous trophic enteral feedings

25
IMPROVED OUTCOMES
26
REHABILITATION

• Hospital rehabilitation
• Discharge planning
• Home or Facility

27
GOALS FOR CARE

• 5.3 million Americans with TBI disabilities
• 700,000 strokes per year
• Nutrition goals
• To improve the individuals well being and
  ability to meet his/her nutritional requirements
• To support life and healthy function

28
COMMON NUTRITION CHALLENGESAFTER BRAIN INJURY

• Dysphagia (swallowing difficulty)
• Depression (decreased appetite)
• Weakness
• Cognitive changes
• Bowel changes (constipation/diarrhea)

29
BRAIN FUNCTIONS
30
FEEDING OPTIONS

• Oral feedings
• Self feedings
• Assisted feedings
• Tube Feedings
• Total nutrition support
• Supplemental nutrition support
• Parenteral Feedings
• Only utilized when the gut is not functional

31
CALORIC NEEDS DURING REHABILITATION

• Affected by
• Activity level
• Age
• Medications
• May decrease with increased risk of weight gain
  (fat tissue) increased risk of decubitus ulcers

32
PROTEIN NEEDS

• Very high after injury
• 2x normal needs (1.5 2 gram/kg)
• Increased metabolic rate
• Increased muscle breakdown
• During rehab state
• Continues to be elevated for up to 1 year
• Long-term
• 0.8 gram/kg

33
DYSPHAGIA

• Difficulty chewing, swallowing
• 40 60 after stroke
• Neurological damage after TBI

34
DYSPHAGIA
35
DYSPHAGIA FEEDING INTERVENTIONS

• Swallow evaluation (Speech Pathologist)
• Dysphagia Diet (food and fluids)
• Adaptive equipment
• Tube Feedings

36
NATIONAL DYSPHAGIA DIET

• Level 1
• Smooth pureed, homogenous, cohesive
• Pudding-like
• Level 2
• Moist, soft textured
• Easily form a bolus
• Level 3
• Nearly regular textures
• No hard, sticky or crunchy foods

37
LIQUID CONSISTENCY

• Spoon Thick
• Honey-like
• Nectar-like
• Thin (includes all liquids)

38
THICKENED WATER
39
EXAMPLES OF MEALS

• Dysphagia Level 1 (dinner)
• Pureed chicken
• Mashed potatoes with gravy
• Pureed carrots with butter
• Applesauce
• Chocolate pudding

40
EXAMPLES OF MEALS

• Dysphagia Level 2 (Breakfast)
• Scrambled egg
• Pancake moistened with syrup and butter
• Wheaties moistened with milk
• Banana
• Orange juice (correct consistency)

41
EXAMPLES OF MEALS

• Dysphagia Level 3 (lunch)
• Shredded lettuce with dressing
• Vegetable soup (consider consistency)
• Turkey sandwich with mayonnaise
• Fresh ripe melon
• Cookie (no nuts)

42
PUREED BREAD PRODUCT
43
NUTRITIONAL SUPPLEMENTS

• High Calorie, High Protein
• High Protein
• Liquid Consistency
• Thickeners

44
LIQUID SUPPLEMENTS
45
PROTEIN SUPPLEMENTS
46
THICKENERS
47
TUBE FEEDINGS

• During hospitalization
• Longer term (PEG Tubes)
• Intermittent feedings
• Transitioning to oral diet

48
TYPES OF FEEDING TUBES

• Post-Pyloric feeding tube (e.g. Corpak)
• Used initially reduced risk of aspiration
• Usually continuous or nocturnal
• Maximum length of use 4 weeks
• Gastric feeding tube (e.g. PEG)
• Used for longer term nutrition support
• Usually intermittent feeding schedule
• Often use syringe for bolus feeding

49
ETHICAL CONSIDERATIONS IN PEG PLACEMENT

• Nutrition support is effective therapy
• Motor and cognitive improvements
• Emotional aspects of nourishment
• Palliative care
• Decisions made with patient and family
  involvement
• Benefits/risks

50
NASOGASTRIC FEEDING
51
FEEDING PUMP
52
PORTABLE FEEDING
53
PEG TUBES
54
PEG FEEDING TUBE
55
PEG FEEDING TUBE
56
SYRINGE FEEDING
57
TUBE FEEDINGS
58
COGNITIVE CHANGES

• Level of alertness
• Orientation
• Cooperativeness
• Sustained attention
• Cognition
• Physical endurance
• Depression/Poor appetite

59
TRANSITIONING TO ORAL FEEDING

• Safe oral bolus
• Intermittent tube feeds
• Meal before tube feeding
• Normal meal routine
• Calorie Counts
• Food Preferences
• Monitor fluid intake

60
ADAPTIVE EQUIPMENT

• Dinnerware
• Silverware

61
EASY GRIP CUP
62
NOSEY CUP
63
DRINKING AIDS
64
HIGH SIDED DISH
65
FOOD BUMPER
66
CURVED UTENSILS
67
(No Transcript)
68
AIDS TO DAILY LIVING CUFF
69
BOWEL CHANGES

• Diarrhea
• Medication related
• Probiotics
• Tube feeding related
• Constipation
• Decreased activity
• Inadequate fiber/fluids
• Medications

70
HOME MONITORING

• Weight
• Record intakes
• Improvement in swallowing
• Ongoing swallow evaluations
• Bowel habits
• Fluid status
• Adequate diet
• Variation
• Multivitamin/mineral supplementation

71
STROKE PREVENTION

• Sodium restricted diets
• Promote normal blood pressure
• Cholesterol lowering diets
• Reduce risk of cholesterol emboli stroke

72
COMPLEMENTARY ALTERNATIVE MEDICINE (CAM)

• gt30 of western population uses some for of CAM
• Chronicity of neurological problems
• Most common for brain injury patients herbal
  remedies, antioxidants
• Few studies available showing effectiveness

73
NEW RESEARCH

• Antioxidants
• Amino Acids
• Omega 3 fatty acids
• Probiotics

74
WEBSITES

• US Dept of Health and Human Services
• www.healthfinder.gov
• Medline
• www.nlm.nih.gov/medlineplus/nutrition.html
• National Institute of Neurological Disorders and
  Stroke
• www.ninds.nih.gov