Friday 21 December 2012
Wednesday 19 December 2012
Nutritional diseases , nutrition 1 , last part
•Provide a life sustained therapy for the patient who can not take adequate food by mouth who consequently at risk for malnutrition and its complication
Benefits of Nutritional Support
•Preservation of nutritional status
•Prevention of complications of protein malnutrition
• Post-operative complications
•Preservation of nutritional status
•Prevention of complications of protein malnutrition
• Post-operative complications
Nutritional therapy given when
•1. improve the quality of life.
•2. improve the ability to recover from the disease.
Don’t forget it depend : disease outcome
severity of the malnutrition
any additional stress
•1. improve the quality of life.
•2. improve the ability to recover from the disease.
Don’t forget it depend : disease outcome
severity of the malnutrition
any additional stress
Who Requires Nutritional Support?
•Patients already with malnutrition – surgery / trauma/sepsis
•Patients at risk of malnutrition
•Patients already with malnutrition – surgery / trauma/sepsis
•Patients at risk of malnutrition
Patients at Risk of Malnutrition
Cannot eat for >9 days
Vomiting : acute pancreatitis ,hperemesis gravidarum GIT obstruction: malignancy neurological : coma , swallowing dis. Abdominal pain : A. pancreatitis
Can not absorb: intestinal fistula ,short bowel syndrome
Should not eat: bowel rest in
Cannot eat for >9 days
Vomiting : acute pancreatitis ,hperemesis gravidarum GIT obstruction: malignancy neurological : coma , swallowing dis. Abdominal pain : A. pancreatitis
Can not absorb: intestinal fistula ,short bowel syndrome
Should not eat: bowel rest in
•Others
nutritional support in patient with malignancy
nutritional support in malnourished patient before surgery
nutritional support in patient with malignancy
nutritional support in malnourished patient before surgery
Type of the nutritional rehabilitation
•Normal diet mild malnutrition and treatable disease
•Supplement high energy and protein content used if normal diet cant give sufficient nutrition
•Specific Nutritional support
Enteral feeding
•Normal diet mild malnutrition and treatable disease
•Supplement high energy and protein content used if normal diet cant give sufficient nutrition
•Specific Nutritional support
Enteral feeding
Types of Nutritional Support
Enteral Nutrition
Parenteral Nutrition
Enteral Nutrition
Parenteral Nutrition
Enteral Feeding Is Best
•More physiologic
•Less complications
•Gut mucosa preserved
•No bacterial infection
•Cheaper
•More physiologic
•Less complications
•Gut mucosa preserved
•No bacterial infection
•Cheaper
Enteral Feeding Is Indicated
•When nutritional support is needed
•Functioning gut present
•No contra-indications
–no ileus, no recent anastomosis, no fistula
•When nutritional support is needed
•Functioning gut present
•No contra-indications
–no ileus, no recent anastomosis, no fistula
Types of Feeding Tubes
•Naso-gastric tubes
•Naso-duodenal tubes
•Naso-jejunal tubes
Tubes inserted down the upper GIT,
following normal anatomy
•Naso-gastric tubes
•Naso-duodenal tubes
•Naso-jejunal tubes
Tubes inserted down the upper GIT,
following normal anatomy
Types of Feeding Tubes
•Gastrostomy tubes
–Percutaneous Endoscopic Gastrostomy (PEG)
–Open Gastrostomy
•Jejunostomy tubes Tubes that require an invasive procedure for insertion(feeding for long time
•Gastrostomy tubes
–Percutaneous Endoscopic Gastrostomy (PEG)
–Open Gastrostomy
•Jejunostomy tubes Tubes that require an invasive procedure for insertion(feeding for long time
What Can We Give in Tube Feeding?
Blenderised feeds
Commercially prepared feeds
Blenderised feeds
Commercially prepared feeds
Complications of Enteral Feeding
12% overall complication rate
•Gastrointestinal complications
•Mechanical complications
•Metabolic complications
•Infectious complications
12% overall complication rate
•Gastrointestinal complications
•Mechanical complications
•Metabolic complications
•Infectious complications
Complications of Enteral Feeding
Gastrointestinal
•Distension
•Nausea and vomiting
•Diarrhoea
•Constipation
Gastrointestinal
•Distension
•Nausea and vomiting
•Diarrhoea
•Constipation
Complications of Enteral Feeding
Infectious
•Aspiration pneumonia
•Bacterial contamination
Infectious
•Aspiration pneumonia
•Bacterial contamination
Complications of Enteral Feeding
Mechanical
•Malposition of feeding tube
•Sinusitis
•Ulcerations / erosions of nasal and esoph
•Blockage of tubes
Mechanical
•Malposition of feeding tube
•Sinusitis
•Ulcerations / erosions of nasal and esoph
•Blockage of tubes
Parenteral Nutrition
Parenteral Nutrition
Allows greater caloric intake
BUT
•Is more expensive
•Has more complications
•Needs more technical expertise
Allows greater caloric intake
BUT
•Is more expensive
•Has more complications
•Needs more technical expertise
Who Will Benefit From Parenteral Nutrition?
Patients with/who
–Abnormal gut function
–Cannot consume adequate amounts of nutrients by enteral feeding
–Are anticipated to not be able to eat orally by 5 days
–Prognosis warrants aggressive nutritional support
Patients with/who
–Abnormal gut function
–Cannot consume adequate amounts of nutrients by enteral feeding
–Are anticipated to not be able to eat orally by 5 days
–Prognosis warrants aggressive nutritional support
Two Main Forms of Parenteral Nutrition
•Peripheral Parenteral Nutrition
•Central (Total) Parenteral Nutrition
•Peripheral Parenteral Nutrition
•Central (Total) Parenteral Nutrition
Peripheral Parenteral Nutrition
Given through peripheral vein
•Short term use
•Mildly stressed patients
•Low caloric requirements
•Needs large amounts of fluid
•Contraindications to central TPN
Given through peripheral vein
•Short term use
•Mildly stressed patients
•Low caloric requirements
•Needs large amounts of fluid
•Contraindications to central TPN
What to Do Before Starting TPN
•Nutritional Assessment
•Venous access evaluation
•Baseline weight
•Baseline lab investigations
•Nutritional Assessment
•Venous access evaluation
•Baseline weight
•Baseline lab investigations
Baseline Lab Investigations
•Daily : urea , electrolytes, glucose
•Twice weekly : LFT, calcium, phosphate, magnesium
•Weekly: CBC, zinc, triglycerides
•Monthly: copper, selenium, manganese
•Daily : urea , electrolytes, glucose
•Twice weekly : LFT, calcium, phosphate, magnesium
•Weekly: CBC, zinc, triglycerides
•Monthly: copper, selenium, manganese
Formula of the TPN
•Dextrose 10% ,20% glucose
•Intralipid 10%, 20% fatty acid
•Vamine ( amino acid) 8%, 14%
•Vitamins
•Minerals
•Trace elements
•Dextrose 10% ,20% glucose
•Intralipid 10%, 20% fatty acid
•Vamine ( amino acid) 8%, 14%
•Vitamins
•Minerals
•Trace elements
Complications Related to TPN
•Mechanical Complications
•Metabolic Complications
•Infectious Complications
•Mechanical Complications
•Metabolic Complications
•Infectious Complications
Mechanical Complications Related to vascular access technique
•pneumothorax
•air embolism
•arterial injury
•bleeding
•brachial plexus injury
•thoracic duct injury
•pneumothorax
•air embolism
•arterial injury
•bleeding
•brachial plexus injury
•thoracic duct injury
Mechanical Complications
Venous thrombosis
Catheter occlusion Related to catheter in situ
Venous thrombosis
Catheter occlusion Related to catheter in situ
Metabolic Complications
Abnormalities related to excessive or inadequate administration
–hyper / hypoglycemia
–Fluid and electrolyte: Refeeding syndrome
hypomagnesemia, hypokalemia, hypophosph
Congestive heart failure
–acid-base disorders
Abnormalities related to excessive or inadequate administration
–hyper / hypoglycemia
–Fluid and electrolyte: Refeeding syndrome
hypomagnesemia, hypokalemia, hypophosph
Congestive heart failure
–acid-base disorders
Hepatic complications
•Biochemical abnormalities
•Cholestatic jaundice
•Hepatic steatosis
•Gall stones
•Acalculous cholecystitis
Infectious Complications
◦Insertion site contamination
◦improper insertion technique
◦use of catheter for non-feeding purposes
◦contaminated TPN solution
◦contaminated tubing
•Secondary contamination
–septicaemia
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