Enteral Parenteral Nutrition in acute care

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Enteral Parenteral Nutrition in acute care
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Enteral Nutrition- Why?

• Favours villus trophicity
• Promotes gut motility
• Avoids infectious complications
• Is less costly
• Reduces translocation of bacteria?

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Assessment

• Patient history
• Disease status
• Recent severe body weight loss gt5 in 3 weeks or
  gt 10 in 3 months
• History of chronic low food intake, alcoholism,
  chronic psychiatric disorders

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Assessment 2

• Assess present condition
• Diseases associated hypermetabolism, burns,
  sepsis, multi organ failure
• Signs of malnutrition on examination
• Body Mass Index lt20kg/m2

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Energy and protein requirement

• Calculate!
• Pragmatic approach 20-25kcal/kg body weight(25-30
  Male) non protein
• Protein 1.2 - 1.5 g/kg body weight, no more than
  1.8g/kg. Caution with renal disease

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Nutrients

• Carbohydrates 60-70
• Polysaccharides most common but require
  pancreatic enzymes
• Disaccharides (sucrose,lactose) require
  disaccharidases
• Monosaccharides (glucose/fructose tolerance may
  limit use

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• High osmolality diets in patients with vagotomy,
  gastrectomy and intestinal dysfunction may lead
  to rapid transit
• Diabetic patients may develop hyperosmolar non
  ketotic coma, glucose load will need to be
  reduced with insulin titrated accordingly
• Carbohydrates yield more carbon dioxide, this may
  be an issue

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Fibres

• Insoluble fibres in moderation may regulate
  transit time
• Soluble fibres provide source of short chain
  fatty acids by fermentation
• Soy polysaccharide commonly used

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Lipids

• Essential fatty acids
• Long chain fatty acids (corn oil- soy oil)
• Mediumchain fatty acids (palm oil)
• MCT do not stimulate pancreatic action, rapidly
  hydrolysed and may be beneficial if fat digestion
  is a problem
• N3 fatty acids may be of use to modulate immune
  response

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Proteins

• proteins (polymeric diets)
• pre-digested nutrients (semi elemental)
• amino acids (elemental)
• Intact proteins require pancreatic function
• peptide are well absorbed

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Glutamine

• Energy substrate for rapidly dividing cells
• Influences immune system via T-cells
• Influences DNA/RNA synthesis, prevents gut
  deterioration, protects mucosal barrier
• Limited clinical application or research in EN

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Indications for enteral feeding

• Evidence based
• Actual malnutrition
• prolonged fasting
• supplementation of insufficient oral intake

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• Pragmatic
• severely stressed patients unable to eat 5-7 days
• severe trauma and burns
• maintenance of gut mucosa
• opening of digestive tract and preparation for
  oral feeding

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Contra indications

• Non functioning gut
• peritonitis - generalised
• severe shock states
• short bowel - less than 30cms

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Parenteral Nutrition

• Central Line - jugular, sub clavian, PICC,
  vascuport
• Peripheral Line - mid line, rotating venflon

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Complications

• Early - Pneumothorax, bleeding, nerve damage,pain
  air embolus, arrythmia/tamponade
• Late - Sepsis,thrombosis, displacement

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Nutrients in TPN

• Macronutrients- Protein, carbohydrate, fat
• Micronutrients - fat soluble A,D,E,K Water
  soluble B group C etc
• Electrolytes Na, K, Ca, Mg, phosphate
• Elements Iron, Zn,Se,Cu,Mn

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Predicting Energy Requirements

• Initial re-feeding or ongoing stress cover
  20kcal/kg
• Black et al 1996
• Head Injury - 8MJ/Day
• Liver transplant - 7MJ/Day
• Elderly Mentally Ill - 5MJ/day

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Nutrient Content

• Carbohydrate - provide 50 of energy requirement,
  may be less in ventilatory failure due to oxygen
  demand of carbohydrate
• Protein- Nitrogen balance cannot be corrected
  during acute illness, 1.25g/kg/day advised
  special consideration for Renal/Liver disease

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• Fat - remainder of energy requirement
• Increase of fat if volume restriction due to
  fluid overload
• Reduce fat if lipaemic or liver function test
  abnormal

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Clinical chemistry

• Na/K
• Glucose
• Creatinine and urea
• Liver function tests
• Phosphate/Calcium/Magnesium
• Iron
• Vitaminsand trace elements

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Over prescription in early parenteral feeding

• Metabloic instability
• Insulin Resistance
• Essential/conditional nutrient deficiencies
• refeeding syndrome
• Liver dysfunction
• Immunosuppression
• The need to dispose of excess nutrients and by
  products of catabolism

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Re-feeding Syndrome

• Due to concentration of feed, directly into
  plasma, levels of Mg, phosphate, K and Ca fall
  very quickly. As a result there is a concurrent
  increase in sodium and water leading to oedema