Nutritional Support

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Nutritional Support

• M Ballal

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ISCP objectives

• Objective
• Recognise the need for artificial nutritional
  support and arrange enteral nutrition.
• Knowledge
• 3 Effects of malnutrition, both excess and
  depletion3 Methods of screening and assessment 
• Clinical Skills
• 3 Arrange access to suitable artificial
  nutritional support, preferably via a nutrition
  team Dietary supplements 2 Arrange access to
  suitable artificial nutritional support,
  preferably via a nutrition team Enteral
  nutrition 1 Arrange access to suitable
  artificial nutritional support, preferably via a
  nutrition team Parenteral nutrition

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Up to 40 of hospital admissions are malnourished
and continue to lose weight
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Who is malnourished

• the patient has not eaten or is very unlikely to
  be eating for more than 5 days (whatever their
  current nutritional status and BMI), or
• the patients BMI is lt18.5, or
• the patient has unintentionally lost gt10 body
  weight over the previous 3-6 months, or
• the patient has a BMI lt20 with unintentional
  weight loss gt5

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Malnutrition Universal Screening ToolMUST
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The goal

• Promote wound healing
• Promote resistance to infection
• Prevent muscle protein loss
• Treatment is a multidisciplinary approach

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Components determining Response to injury

• Tissue damage
• Size and mechanism determine amount of cytokines
  (IL, TNF IFN) released and counter regulatory
  hormone release
• Controlled( surgery ) vs uncontrolled injury(
  trauma, burn)
• Volume
• Hypoperfusion and blood loss increase tissue and
  organ damage
• Pain and fear
• Increase counter regulatory hormones ( cortisol,
  Catecholamines, Glucagon)
• Infections
• Cytokines, and endotoxins

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Phases of response

• Ebb phase( shock ) 24hr
• Metabolic activity decrease
• Catabolic (Flow) phase
• depends on length and severity of insult
• Increase metabolic rate and water and salt
  retention
• All mechanism aim to mobilise nutrients to area
  of injury( glucose and amino acids)
• Glycogenolyis, gluconeogensis lead to increase
  glucose
• Proteolysis and Negative N Balance lead to
  muscle wasitng , decreased immunity and organ
  dysfunction if gt 15 BW loss
• Insulin resistance
• Anabolic (Convalescent) phase
• up to 4-6 weeks post
• Glycogen and Protein synthesis
• Lipogenesis
• Sodium diuresis

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Energy metabolism

• ATP is generated from breakdown of the carbon-
  hydrogen bond

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Energy Requirement

• Needed for work( metabolism, mechanical,
  synthesis)
• Basal Metabolic rate basal energy requirement at
  rest for metabolism
• Can be measured using indirect calorimetry
• Estimated using nomogram charts, Harris Benedict
  formula, Schofileds Equations

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Estimating energy requirements

• Harris-Benedict Equation

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Estimating energy requirements
BMR 38 kcal / m2 / hour X BSA m2 X 24 hours
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Examples of energy requirements
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Estimating energy requirements

• Resting Energy Requirement(REE)
• Is the actual energy required accounting for
  activity and stress(e.g surgery , infection,
  trauma)
• REEBMR x Activity factor x Injury factor
• Activity factor 1.2 bed rest
• 1.3 ambulatory
• Injury factor 1.2 minor surgery
• 1.35 trauma
• 1.6 Sepsis
• 2.1 Burns
• e.g. 70 kg man with trauma nursed in bed
• REE 1449 x 1.2x1.352347kcal/day

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Body composition

• TBW55-60 of body weight ( in 70 kg 40L)

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Nitrogen balance

• 1 gr of Nitrogen 6.25 gr of protein
• Protein synthesis and metabolism is measured by
  nitrogen balance
• N balance N in-N Out
• N anabolic
• N- Catabolism, starvation
• N balance (total protein(gr)/6.25 ) (UUN4gr)
• It estimated prot requirement 1.5gr/kg/day
  adjusted to protein requirement e.g burn increase
  to 2.5
• Ratio of kcal to protein is 150kcl to 1gr
  N(6.25gr pr)

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Substrate vs Energy Generated

• 1 cal energy needed to raise the temp of 1 g of
  water from 14.5 to 15.5oCat 1 atm
• 1gr of Glucose 4 kcal
• 1gr protein 4 kcal
• 1gr Fat 9 kcal
• 1gr Dextrose(hydrated glucose)3.4kcal
• 1 lt of 5 Dextrose 170kcal

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Requirements

• Energy 30-35kcal/kg/day
• Fluid 30ml/kg/day
• Protein 1.5gr/kg/day
• Carbohydrate Lipid 7030
• Max lipid 1.5gr/kg/day
• Glucose limit preferred 5g/kg/day

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Who to treat

• Well nourished pt lt 5 days of starvation
• Elective surgery
• Malnourished without severe catabolism

• Post surgery unable to eat for gt 7 days
• Severe catabolism regardless of pre nutritional
  status
• Intestinal failure

• Start Nutrition support perioperative or ASAP
  with Oral supplemental nutrition e.g. Enhanced
  Recovery

• Immediate enteral or Parenteral Nutriotional
  support

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Modalities of Nutrition support

• Enteral
• Oral supplement Solution
• Ensure
• NG /NJ feeding
• PEG(Percutaneous Endoscopic Gastrostomy)
• Feeding Jejunostomy

• Parenteral
• Peripheral TPN
• PICC TPN
• Central Venous Catheter
• Tunnelled CVC(Hickman Line)

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Enteral Feeding (EF)

• Physiologic
• Gut mucosal integrity maintained
• It is even effective with lower calories
• Permissive underfeeding 60-70 of caloric intake
• Use of prokinetics increased success rate of EF
  in ICU
• Side effects Diarrhoea, Pain, wind, danger of
  over feeding

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Routes of Enteral

• Oral
• Long term nutrition
• Allows cephalic phase
• Antibacterial effect of saliva

• NG /NJ feeding
• Allow high calory delivery
• Risk of aspiration
• Start slow then increase
• Aspirate lt 300ml /4hrs

• PEG(Percutaneous Endoscopic Gastrostomy)
• Long term nutrition
• Relatively invasive

• Feeding Jejunostomy
• Bypasses gastric emptying
• Long term and avoids aspiration risk
• Surgically placed

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TPN

• Satnley dudreick 1968 ( surgical resident yr 5)
• Allows for delivery of high calories when GIT
  function is impaired
• Allow for delivery of all essential nutrition
  elements

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Routes of Parenteral

• Peripheral
• Easy and avoids central complications
• Only low osmol TPN (high vol)
• Phlebitis

• PICC
• Relatively easy to insert and maintain
• Allow concentrated TPN
• Blocks easy

• Central Venous Catheter
• Needs to be dedicated
• Invasive and complications
• Short term lt 14 days

• Tunnelled CVC
• surgically placed
• Long term TPN
• Same risks as CVC but less colonisation

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Complication of TPN

• Mechanical
• Pnemothorax, vascular injury, thrombosis
• Infective
• Line sepsis
• Metabolic
• Liver dysfunction
• Hyperglu, Lipi, Hypo P, K, Mg, c
• Gut atrophy
• Bacterial translocation
• Endotoxemia prone(Fong et al ann surg 1989 )

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Sandstrom R, Drott C, Hyltander A, et al. The
effect of postoperative intravenous feeding (TPN)
on outcome following major surgery evaluated in a
randomized study. Ann Surg 19932171925.)
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Re feeding syndrome

• Cardiac failure, pulmonary oedema and
  dysarrhythmias
• Acute circulatory fluid overload or circulatory
  fluid depletion
• hypophosphataemia
• hypokalaemia
• hypomagnesaemia and occasionally hypocalcaemia
• hyperglycaemia

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The Wernike-Korsakoff syndrome

• Acute thiamine deficiency
• apathy and disorientation
• nystagmus, opthgalmoplegia or other eye movement
  disorders
• ataxia
• severe impairment of short-term memory often with
  confabulation.

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Overfeeding

• Inability of body to cope with high fuel load
• Allow for 60-70 of requirement at early stage is
  as effective

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Over feeding side effects
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Other type Supplements

• Elemental
• Fistula output lt 2L/day
• Fibre
• Vitamin complex
• Glutamine
• Immune enhancing diet(IED)
• Arginin, omega3FA and Nucleic acid

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• Why you need to know about it

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Requirements

• Energy 30-35kcal/kg/day
• Fluid 30ml/kg/day
• (421)
• Protein 1.5gr/kg/day
• Carbohydrate Lipid 7030
• Max lipid 1.5gr/kg/day
• Glucose limit preferred 5g/kg/day

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Substrate vs Energy Generated

• 1 cal energy needed to raise the temp of 1 g of
  water from 14.5 to 15.5oCat 1 atm
• 1gr of Glucose 4 kcal
• 1gr protein 4 kcal
• 1gr Fat 9 kcal
• 1gr Dextrose(hydrated glucose)3.4kcal
• 1 lt of 5 Dextrose 170kcal

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Example

• 180cm and 85kg man BSA 2.1 m2
• femur
• BMR 38 kcal / m2 / hour X 2.1 m2 X 24 hours
• BMR 1,915 kcals / day
• EER1915x 1.3x 1.353361kcal/day
• Protein 1.5 x 85127.5gr/day
• Route PO

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Example 2

• 84 yr female, 45kg . 2 days of abdo pain ,
  Vomiting, peritonitis . Laparotomy, pus and free
  bile pre pyloric large ulcer.

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Example 3

• 56yr male. 60 kg. BMI 18. Gastric Cancer stage 1.

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Example 4

• 72yr male, 70kg, in ITU Post op perf DU on CPAP.
  Leaked at day 6. re laparotomy free bile and pus.
  Dense adhesions. Unable to free small bowel.
  Washout drain and laparostomy. Post op wound
  fistula 1500 ml/day.

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Reference

• Surgery Scientific Principles and Practice(3rd
  ed)
• Critical care for the Surgeon, clinics of North
  America. Dec 2006
• Critical Care for Postgraduate Trainees
• http//www.nice.org.uk/nicemedia/pdf/nutrition_adu
  lts_1stcons_full_guideline.pdf
• http//www.bapen.org.uk/pdfs/must/must_full.pdf