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Lecture Outline
Energy Sources Nutrition Requirements Diet Advancement Micronutrients for wound healing Enteral versus Parenteral Nutrition
Case studies
Energy Sources
Carbohydrates
Limited storage capacity, needed for CNS function Yields 3.4 kcal/gram Pitfall: too much=lipogenesis and increased CO2 production
Fats
Major endogenous fuel source in healthy adults Yields 9 kcal/gm Pitfall: too little=essential fatty acid (linoleic acid deficiency-dermatitis and increased risk of infections
Protein
Needed to maintain anabolic state (match catabolism) Yields: 4 kcal/gm Pitfall: must adjust in patient with renal and hepatic failure
Elevated creatinine, BUN, and/or ammonia
Nutrition Requirements
Healthy Adults
Calories: 25-35 kcals/kg Protein: 0.8-1 gm/kg Fluids: 30 mls/kg
Pre-hospital/pre-surgical nutrition
Nutrition
The surgical patient
Extraordinary stressors (hypovolemia, hypervolemia, bacteremia, medications) Wound Healing
Anabolic state, appropriate vitamins (A, C, Zinc), and adequate kcals/protein.
Protein:
Increase to 1-1.8 grams/kg
Fluids:
Individualized
Diet Advancement
Traditional Method:
Start clear liquids when signs of bowel function returns. Rationale: Clear liquid diets supply fluid and electrolytes in a form that require minimal digestion and little stimulation of the GI tract. Clear liquids are intended for short-term use due to inadequacy
Diet Advancement
Recent Evidence:
Suggests that liquid diets and slow diet progression may not be warranted!!
Clinical study:
Looked at early post-operative feeding using regular diets or very fast progression vs. traditional methods of NPO until bowel function with slow diet progression and found no difference in postoperative complications. (emesis, distention, NGT reinsertion, LOS,)
Keep in Mind
Per SLP
When using liquid diets, patients must have adequate swallowing functions. Even patients with mild dysphagia often require thickened liquids. Therefore, be specific in writing liquid diet orders for patients with dysphagia
No vitamin A with renal failure due to greater potent ional for toxicity. (Can exceed the binding capacity of retinol binding protein leading to elevated circulating levels.)
No vitamin C with renal failure due to risk for renal oxalate stone formation.
Malnourished patient expected to eat within 5-7 days Severe acute pancreatitis High output enteric fistula distal to feeding tube Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted Expected need less than 5-7 days if malnourished or 7-9 days if normally nourished
Jejunostomy
PEJ (percutaneous endoscopic jejunostomy) Surgical or open jejunostomy
Transgastric Jejunostomy
PEG-J (percutaneous endoscopic gastro-jejunostomy) Surgical or open gastro-jejunostomy
Bolus feeding:
Start with 100-120 mL bolus Increase by 60 mL q bolus to goal volume Typical bolus frequency every 3-8 hours
Aspiration Precautions
To prevent aspiration of tube feeding, keep HOB > 30 at all times Do not use methylene blue to test for aspiration; regular blue food dye OK but not proven effective method of detecting aspiration
Complications of Enteral Nutrition Support Nausea and vomiting / delayed gastric emptying Malabsorption
Common manifestations include unexplained weight loss, steatorrhea, diarrhea Potential causes include gluten sensitive enteropathy, Crohns disease, radiation enteritis, HIV/AIDS-related enteropathy, pancreatic insufficiency, short gut syndrome
no weight change
1475-1770 kcal (25-30 kcal/kg) 59-71g protein (1-1.2 g/kg) 1770 mL fluid (30 mL/kg)
Determine electrolyte needs Determine acid/base status Check to make sure desired formulation will fit in the total volume indicated
Non-diabetics or NIDDM: start with half of the previous days sliding scale insulin requirement in TPN/PPN bag and increase daily in the same manner until target glucose is reached IDDM: start with 0.1 units regular insulin per gram of dextrose in TPN/PPN, then increase daily by half of the previous days sliding scale insulin requirement
Acid/base balance
Adjust TPN/PPN anion concentration to maintain proper acid/base balance Increase/decrease chloride content as needed Since bicarbonate is unstable in TPN/PPN preparations, the precursoracetateis used; adjust acetate content as needed
Cholestasis
May occur 2-6 weeks after starting PN Indicated by progressive increase in TBili and an elevated serum alkaline phosphatase Occurs because there are no intestinal nutrients to stimulate hepatic bile flow Trophic enteral feeding to stimulate the gallbladder can be helpful in reducing/preventing cholestasis
Gastrointestinal atrophy
Lack of enteral stimulation is associated with villus hypoplasia, colonic mucosal atrophy, decreased gastric function, impaired GI immunity, bacterial overgrowth, and bacterial translocation Trophic enteral feeding to minimize/prevent GI atrophy
Height: 60 Weight: 155# / 70kg BMI: 21 Usual wt: 175# Estimated needs:
2100-2450 kcal (30-35 kcal/kg) 84-98g protein (1.2-1.4 g/kg) 2100-2450 mL fluid (30-35 mL/kg)
Above will provide 2275 kcal, 99g protein, DIR=(385 g dex/ 70 kg /1440 minute in a day)*1000= 3.8mg/kg/min LIR= (285 mls lipid * 20%)/ 70 kg=0.8 g/kg/day
Initiate TPN at ~ of goal rate/concentration and gradually increase to goal over 2-3 days to optimize serum glucose control
Less infection Enteral feedingvery small risk of infection and may prevent bacterial translocation across the gut wall
TPNhigh risk/incidence of infection and sepsis
Refeeding Syndrome
the metabolic and physiologic consequences of depletion, repletion, compartmental shifts, and interrelationships of phosphorus, potassium, and magnesium Severe drop in serum electrolyte levels resulting from intracellular electrolyte movement when energy is provided after a period of starvation (usually > 7-10 days) Physiologic and metabolic sequelae may include:
EKG changes, hypotension, arrhythmia, cardiac arrest Weakness, paralysis Respiratory depression Ketoacidosis / metabolic acidosis
Consequences of Over-feeding
Risks associated with over-feeding:
Hyperglycemia Hepatic dysfunction from fatty infiltration Respiratory acidosis from increased CO2 production Difficulty weaning from the ventilator
Questions
Reference:
American Society for Parenteral and Enteral Nutrition. The Science and Practice of Nutrition Support. 2001. Han-Geurts, I.J, Jeekel,J.,Tilanus H.W, Brouwer,K.J., Randomized clinical trial of patientcontrolled versus fixed regimen feeding after elective abdominal surgery. British Journal of Surgery. 2001, Dec;88(12):1578-82 Jeffery K.M., Harkins B., Cresci, G.A., Marindale, R.G., The clear liquid diet is no longer a necessity in the routine postoperative management of surgical patients. American Journal of Surgery.1996 Mar; 62(3):167-70 Reissman.P., Teoh, T.A., Cohen S.M., Weiss, E.G., Nogueras, J.J., Wexner, S.D. Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial. Annals of Surgery. 1995 July;222(1):73-7. Ross, R. Micronutrient recommendations for wound healing. Support Line. 2004(4): 4.