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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

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)
slide17
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

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

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