Dr bennet rajmohan mrcs eng mrcs ed consultant general surgeon
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Dr. Bennet Rajmohan , MRCS(Eng), MRCS Ed Consultant General Surgeon. CARE OF NUTRITION IN HOSPITALISED PATIENTS. Introduction. > 30% of in-patients “malnourished” Increased morbidity & mortality Prolonged hospital stay & high costs Especially deleterious in critically ill

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Dr. Bennet Rajmohan , MRCS(Eng), MRCS Ed Consultant General Surgeon

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Dr bennet rajmohan mrcs eng mrcs ed consultant general surgeon

Dr. BennetRajmohan, MRCS(Eng), MRCS EdConsultant General Surgeon

CARE OF NUTRITION IN

HOSPITALISED PATIENTS


Introduction

Introduction

  • > 30% of in-patients “malnourished”

    • Increased morbidity & mortality

    • Prolonged hospital stay & high costs

    • Especially deleterious in critically ill

  • Malnutrition not recognised in most patients

  • Most in-patients lose weight

  • Malnourished lose more weight


  • Standard nutrition

    Standard Nutrition

    • Vast majority recover from illness & can eat normal food within 1–3 days

    • Standard nutrition – Patient’s choice, voluntary, within physician’s orders

    • So, little scope for routine artificial nutrition


    Patients at risk

    Patients at risk

    • Involuntary weight loss > 10%

    • Weight 20% below or above ideal weight

    • Critically ill (acute pancreatitis, burns, sepsis, trauma,

      head injury etc)

    • Unable to eat or swallow (eg: neurological, oropharyngeal or oesophageal disease)

    • Oral diet not anticipated for >7 days

    • Intestinal failure


    Artificial nutrition

    ArtificialNutrition

    • Physician’s responsibility

    • Nutrition support

    • To minimize negative protein balance

    • To maintain muscle, immune & cognitive function

    • To speed up recovery


    Options

    Options

    • Enteral (EN)

      • Via NG / NJ tubes, percutaneous endoscopic gastrostomy (PEG) / jejunostomy (PEJ), surgical jejunostomy

  • Parenteral (PN)

    • Via peripheral or central line

  • EN & PN


  • En vs pn

    ENvs PN

    • EN preferred because

      • Structural & functional integrity of GI tract

        maintained

      • Less septic complications

      • Shorter hospital stay

      • Cheaper

      • Earlier return of cognitive function (head injury)


    Enteral nutrition en

    Enteral Nutrition (EN)

    • Initiate early, within 24 – 48hrs of admission

    • Presence of bowel sounds, passing flatus or stools not mandatory to start feed

    • 70 to 85% EN tolerance achievable, with EN protocol

    • NG vs NJ tubes, both acceptable

    • NJ, if high gastric aspirates or high risk patients, to

      reduce aspiration


    En protocol

    EN protocol

    • Initiate early

    • Avoid stopping EN, if NG aspirate < 500ml. Add

      prokinetics (Metaclopramide, erythromycin)

    • Minimise stopping EN (eg. for investigations, tube displacement etc)

    • Ileus worsened by NPO status

    • Combination of under-ordering & inadequate delivery

       < 50% target calories received


    En dosing

    EN Dosing

    • Energy requirements  25 – 30 kcal/kg ideal body weight/day

    • Aim to achieve at least 50 – 65% of goal calories in

      1st 7 days for clinical benefit

    • Supplement PN, if > 60% energy needs not met by EN alone

    • Protein BMI < 30, 1.2 – 2.0 g/kg(ideal)/day

    • Higher in burns, polytrauma


    Dosing in obese

    Dosing in Obese

    • Permissive underfeeding or hypocaloric feeding

    • Energy, if BMI > 30  11 – 14 kcal/kg actual body weight/day or 22 – 25 kcal/kg ideal body weight

    • Protein  2.0 – 2.5 g/kg ideal body weight/day


    Contraindication for en

    Contraindication for EN

    • Haemodynamically unstable patient

    • On increasing doses of inotropes

    • Avoid EN  1% risk of gut ischaemia


    Complications of en

    Complications of EN

    • Most feared complication of EN – aspiration

    • Intubated ICU patients on EN

      • Head end elevation 30º– 45º

      • Continuous rather than bolus feed

      • Prokinetics

      • Consider NJ tube (or PEG, if feeding needed

        for > 4 – 6weeks)

      • Chlorhexidene mouthwash bd, PPIs to reduce ventilator-associated pneumonia


    Parenteral nutrition pn

    Parenteral Nutrition (PN)

    • Only when GI route is not available

    • Lifesaving

    • Ensures nutrition delivery into blood

    • Higher septic complications,length of stay, cost, morbidity & mortality, compared to EN

    • In dedicated units & expert hands, equally effective as EN


    Indications for pn

    Indications for PN

    • Pre-op PN – malnourished patients, eg. head & neck,

      upper GI cancers (at least 7- 10days, costly)

    • PN in critically ill, if unable to establish EN by 7 days – Supplemental PN & EN

    • Post-op PN – upper GI anastomotic leaks, short bowel syndrome, multiple bowel fistula

    • Home PN – short bowel syndrome


    Types

    Types

    • Peripheral (PPN):

      • Low osmolarity feed (<850 mOsmol/L)

      • Via venflon, add heparin & hydrocortisone

        to feed, GTN patch

  • Central (TPN):

    • Dedicated central venous access

    • High osmolarity (eg: 1450 mOsm/L)


  • Dr bennet rajmohan mrcs eng mrcs ed consultant general surgeon

    PN

    • Permissive underfeed

    • Aim for 80% of energy needs, at least initially

    • Obese – same recommendations as with EN

    • Add parenteral glutamine (0.5g/kg/day)  reduces infections, ICU length of stay & mortality

    • Attempt to restart EN periodically. Stop PN, if EN can provide > 60% of target energy


    Optimal pn

    Optimal PN

    • Protein : fat : glucose caloric ratio20 : 30 : 50

      (Only non protein calories to be counted)

    • Tendency to reduce fat & increase glucose : fat ratio from 50:50 to even 70:30

    • To avoid triglyceridemia, fatty liver, cholestasis & non-alcoholic steato-hepatitis


    Pn administration

    PN administration

    • Bag, with 3 compartments (glucose, amino acids & lipids) mixed just before administering

    • 3-in-1 mixtures, convenient, aseptic

    • Allows continuous & stable administration of all components

    • Antioxidant vitamins (Vit C & E) & trace minerals (Selenium, copper, zinc) must be supplemented daily


    Complications of pn

    Complications of PN

    • Catheter related

      • Insertion related (eg: pneumothorax)

      • Bacterial infections, septicaemia, fungal superinfection

  • Metabolic

    • Insulin resistance & hyperglycemia in critically ill

    • Strict glucose control protocol must – 110 to 150 mg% - to reduce infections

    • Reversible cholestasis, fatty liver

    • Acalculous Cholecystitis


  • Refeeding syndrome

    Refeeding syndrome

    • Metabolic disturbances due to reinstitution of nutrition to starved or severely malnourished patients

    • Fluid & electrolyte disturbances, esp. hypophosphatemia, hypokalemia & hypomagnesemia

    • Sudden shift from fat to carbohydrate metabolism &

      sudden increase in insulin levels after refeeding

    • Neurologic, pulmonary, cardiac, neuromuscular & hematologic complications, confusion, coma, convulsions

      & death


    Special situations

    Special situations


    Acute respiratory failure

    Acute respiratory failure

    • Fluid restricted calorie-dense feed (1.5 – 2.0 kcal/ml), salt restriction

    • ARDS & acute lung injury

      • EN with anti-inflammatory lipids (fish oils) & antioxidants

  • Monitor & replace Phosphate (synthesis of ATP & 2,3 DPG, both critical for diaphragmatic contractility & optimal lung function)


  • Renal failure

    Renal failure

    • ICU patients with ARF

      • Standard EN, standard calorie & protein provision

      • Low K, low PO4 feed, if electrolytes abnormal

  • Haemodialysis or CRRT

    • Amino acid loss 10 – 15 g/day

    • Protein – at least 1.5 – 2.0 g/kg/day, even 2.5g/kg/day suggested


  • Acute pancreatitis

    Acute pancreatitis

    • Mild pancreatitis:

      • Diet within 1-2 days

      • Support only if complication or diet not tolerated by 7days

  • Severe pancreatitis:

    • Early EN, ie, as soon as fluid resuscitation complete

    • PN, if EN not established after 5days


  • References

    References

    • Guidelines for the provision & assessment of nutrition support therapy in the adult critically ill patient:

      Society for Critical Care Medicine(SCCM) and

      American Society for Parenteral and Enteral Nutrition (ASPEN). 2009

    • ESPEN guidelines on Parenteral Nutrition: Surgery.

      2009


    The end

    THE END


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