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Inflammatory bowel disease(IBD)-ulcerative colitis and Crohn’s

Inflammatory bowel disease(IBD)-ulcerative colitis and Crohn’s alterations in microbiome play a role in IBD 1)different oxidative pathways in the altered microbiome 2)more aggressive nutrient uptake by altered microbiome-this favours the altered microbiome

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Inflammatory bowel disease(IBD)-ulcerative colitis and Crohn’s

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  1. Inflammatory bowel disease(IBD)-ulcerative colitis and Crohn’s alterations in microbiome play a role in IBD 1)different oxidative pathways in the altered microbiome 2)more aggressive nutrient uptake by altered microbiome-this favours the altered microbiome 3) altered microbiome is more virulent

  2. Exam 180 minutes 120 multiple choice questions-120 points -4 short answer question-60 points multiple choice-lecture 7a-12c inclusive short answer-whole Nutr2105 course

  3. Note Nutrition 2106-Fall 2014- Principles of Nutrition in Metabolism Nutrition 2101-Nutritional Assessment-Theory-Fall 2014 Nutrition 2107- Introduction to Sports Nutrition-Winter 2015

  4. Note Nova Scotia now spends 47 cents of every budget dollar on healthcare(10 years ago it was 40 cents) -is the publically funded healthcare system in its present form sustainable?

  5. Note Email sent today to first year and senior students. Email is regarding completion of NSEE survey (first year and senior students) . Please complete to help CBU better help you!

  6. Lecture 10a 17 March 2014 Enteral and Parenteral Feeding

  7. Enteral Feeding -refers to use of intestine (uses oral or tube feeding to direct nutrients to intestine) -called complete enteral feeding if formula is primary source of nutrients -complete formulas can be used in smaller quantities to supplement table foods -complete formulas required if patient is on tube feeding or oral liquid diet for more than a few days

  8. Types of enteral formulations -standardised -hydrolysed -modular -characterised by type of protein in the formulation

  9. Types of enteral formulations Standardised Appropriate for people who are able to digest and absorb Contain complete proteins (complete refers to whole proteins or combination of protein isolates(purified proteins)) Blenderised formulas contain protein from pureed foods (e.g. blenderised meats)

  10. Types of enteral formulations • Hydrolysed • Pre-digested protein- so only get small peptides or just free amino acids • Some have medium chain triglycerides or are very low in fat

  11. Types of enteral formulation Modular Provide a single nutrient Modules can be combined with other modules or with minerals and/or vitamins to address the specific needs of a patient

  12. Candidates for tube feeding • Anybody who: • can not get food down orally or • has mental incapacitation • are malnourished or • has high nutrient requirements or extensive intestinal resections or is on a ventilator • gastrointestinal obstructions or fistulas • in short anyone who cannot access or utilise GI • tract on their own

  13. Distinguishing characteristics of enteral formulations • Nutrient density • 1.0  kcal/ml- standard • 1.2 – 2.0 kcal/ml for nutrient dense formulas -nutrient dense formulations are given in smaller volumes to persons with fluid • balance issue- e.g. congestive heart patients

  14. Distinguishing characteristics of enteral formulations 2) Fibre if administered over short time - low to moderate fibre - otherwise gas and distension can be an issue if long term administration -then higher amounts of fibre

  15. Distinguishing characteristics of enteral formulations • 3) Osmolality- measure of concentration of molecular and ionic particles in solution • -serum is 300 milliosmoles/kg of solution • -isotonic solution is 300 milliosmoles/kg • -hypertonic is greater than 300 milliosmoles/kg of solution • -hypertonic can induce diarrhea in intestine so a slow introduction of hypertonic solution for intestinal route is essential

  16. Tube placement-1) transnasal or 2) direct catheter  1)Transnasal Nasogastric-children and adults-larger nose than infants so nasogastric is used in children and adults Orogastric-infants- smaller nose than adults and children so orogastric is used Nasoduodenal-nose to duodenum Nasojejunal placement-nose to jejunum

  17. Tube placement 2) Catheter direct to stomach or jejunum Enterostomies- surgical placement of catheter -Gastrostomy- direct to stomach -Jejunostomy-direct to jejunum

  18. Safehandling of formulations Open and closed systems Open- exposed to air Closed-not exposed to air Keep your fingers out of the soup for open systems

  19. Initiating and progressing a tube feeding • Formula delivery techniques-Intermittent feeding • Best to stomach • No more than 250-400 ml over 30 minutes • Use- depends on tolerance • Bolus feeding included here (300-400 ml) in 10 minutes

  20. Initiating and progressing a tube feeding   Formula delivery techniques Continuous feeding Delivered slowly over 8-24 hours Good for people who have received nothing though GI tract for a long time, hypermetabolising persons and those receiving intestinal feedings Formula volume and strength institutionally based- standard operating procedures (sops)

  21. Initiating and progressing a tube feeding   Additional matters Supplemental water -standard formulas contain about 850 ml of water/per formula -most people need about 2 L of water per day Gastric residual volume -amount left over from previous feedings-significance of this?

  22. 2 Youtubes- enteral feeding https://www.youtube.com/watch?v=EWtqxJeyCMA https://www.youtube.com/watch?v=hploKHe-V4U

  23. Class activity • Design an enteral feeding for the pathology/problem of your choice that meets the dietary principles of adequacy, variety, moderation, nutrient density, energy control, and balance

  24. Lecture 10b 17 March 2014 Parenteral Feeding

  25. Parenteral Feeding (going around ie circumventing the intestine) Nutrients go directly into blood stream bypassing gastrointestinal tract-this is done by intravenous needle or catheter Used when a patient cannot, due to physical or psychological impairment, consume sufficient nutrients enterally Used when patients gi system will not adequately process food for body Actual infusion depends on site of infusion and patient’s fluid and nutrient requirements

  26. Types of Parenteral Nutrition Peripheral parenteral nutrition (PPN)- peripheral vein used Total parenteral nutrition (TPN)-superior vena cava used Basic difference between the two is the concentration of nutrients infused (higher concentration is used for TPN due to more rapid dilution in superior vena cava)

  27. Parenteral Feeding Usual fluid volume is 1.5-2.5 L over a 24 hour period for most people

  28. Parenteral Feeding Composition of ingredients in bag for intravenous delivery Dextrose Amino acids Lipid emulsion Sterile water Electrolytes Vitamins

  29. Carbohydrate Dextrose- provides 3.4 kcal/g and not 4 kcal/g -difference is due to what? Concentration is 12.5 % (max for peripheral introduction) to 25 % (total parenteral nutrition) Restricted in ventilator patients because oxidation of glucose produces more carbon dioxide than does oxidation of fat

  30. Protein Mixture of essential and non-essential amino acids Concentration 3.5-15 % Quantity of amino acids depends on patients estimated requirements and hepatic and renal function-why?

  31. Lipid emulsions Safflower and soybean oil with egg lecithin used as an emulsifier (why the emulsifier and how does it work?) Isotonic Significant source of calories

  32. Lipid emulsions Available in 10, 20, 30 % concentrations supplying 0.9 and 1.8 and 2.7 kcal/ml respectively-Do the math Usual dose is 0.5 to 1 g/kg/day to supply 20-30 % of total kcal requirement IV fat contradicted for severe hepatic pathology, hyperlipidemia or severe egg allergies Used cautiously with atherosclerosis, blood coagulation disorders

  33. Electrolytes Dictated by patients blood chemistry values and physical assessment findings

  34. Standard multivitamin and trace mineral preparations added to parenteral solutions to meet micronutrient needs

  35. PPN -must be isotonic and therefore low in dextrose and amino acids to prevent phlebitis and increased risk of thrombus formation -need to maintain isotonic solutions of dextrose and amino acids while avoiding fluid overload limits the caloric and nutritional value of PPN

  36. PPN delivers complete but limited nutrition the final concentration cannot exceed 12.5 % dextrose-also uses lower concentrations of amino acids vitamins and minerals are added lipid emulsion may be added to supplement calories depending on the patients tolerance

  37. PPN -provides temporary nutritional support -short term- 7-10 days and do not require more than 2000 to 2500 kcal per day

  38. PPN -may be used for a post surgical ileus or anastomotic leak or for patients who require nutritional support but are unable to use TPN because of limited accessibility to a central vein -sometimes used to supplement an oral diet or tube feeding or transition from TPN to enteral intake

  39. TPN Hypertonic solutions provide more dextrose and/or protein but they must be delivered centrally in a large diameter vein so that they can be quickly diluted

  40. TPN TPN is used when nutritional requirements are high and anticipated need is relatively long 3 litres of 10 % dextrose provides only 1020 kcal -calculation

  41. TPN -traditionally-catheter to superior vena cava figure 21-2

  42. TPN • Indications: • severe malnutrition • GI abnormalities : due to obstruction, peritonitis, severe acute pancreatitis • after surgery or trauma especially that involving extensive burns, sepsis • need for supplementation of inadequate oral uptake in patients who are being treated aggressively for cancer • bone marrow transplantation

  43. TPN • cyclic • -constant infusion for 8-12 hours • -used for home patients • -used to support inadequate oral intake • -allows insulin and glucose to drop when infusion is not taking place • -switch from continuous TPN to cyclic TPN should be gradually decreased by several hours per day and signs of glucose overload and fluid imbalance should be monitored

  44. Note

  45. Lecture 10c 17 March 2014 Surgery and Burns

  46. Surgery -patient should be well nourished prior to surgery-this gives better recovery -however, surgical patients are often malnourished due to anorexia, nausea, vomiting, burns, fever, malabsorption, and blood loss -surgical prep- range of actions include: -high calorie protein diet -enteral feeding -parenteral feeding

  47. Surgery -nothing by mouth (NPO) for a least 8 hours prior to general anesthesia due to risk of aspiration -oral intake is resumed after bowel sounds return- usually 24-48 hours after surgery -start with clear liquids to full liquids to soft or regular diet as tolerated post-op -usually a high protein high calorie diet is appropriate-this helps with healing

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