Post on 01-Apr-2015
Surgical NutritionSurgical Nutrition
Raymundo F. Resurreccion, MD, FPCSRaymundo F. Resurreccion, MD, FPCS
ObjectivesObjectives
Differentiate metabolic responses to Differentiate metabolic responses to starvation and starvation and traumatrauma
Explain the energy utilization in Explain the energy utilization in patients undergoing injury and patients undergoing injury and stressstress
Recognize the role of nutritional Recognize the role of nutritional support in patients undergoing support in patients undergoing stress and surgerystress and surgery
ObjectivesObjectives
Determine basic nutritional Determine basic nutritional requirements in the surgical patientrequirements in the surgical patient
Determine the appropriate route for Determine the appropriate route for delivery of nutritiondelivery of nutrition
Recognize the dangers of Recognize the dangers of overfeeding overfeeding
Metabolic Response to InjuryMetabolic Response to Injury
Physiological responses to InjuryPhysiological responses to InjuryInjury, infectionInjury, infection
Diminished intakeDiminished intakeIncreased expenditureIncreased expenditure
Tissues / blood Tissues / blood mononuclear cells, mononuclear cells,
endotheliumendothelium
BrainBrain
SNS HPA
NERCytokines
Metabolicresponse
Inflammatoryresponse
Immuneresponse
Mediators in SIRS/SepsisMediators in SIRS/SepsisMEDIATORMEDIATOR EFFECTSEFFECTS
Interleukin-1Interleukin-1 Fever, proteolysisFever, proteolysis
ProstaglandinsProstaglandins VasodilationVasodilation
CorticosteroidsCorticosteroids HypermetabolismHypermetabolism
GlucagonGlucagon GluconeogenesisGluconeogenesis
NorepinephrineNorepinephrine HypermetabolismHypermetabolism
Growth, thyroid hormonesGrowth, thyroid hormones Acute catabolismAcute catabolism
Complement, anaphylatoxinsComplement, anaphylatoxins Microcirculatory damageMicrocirculatory damage
Kinin system, serotonin histamineKinin system, serotonin histamine VasodilationVasodilation
Oxygen free radicalsOxygen free radicals Membrane damageMembrane damage
Tumor necrosis factorTumor necrosis factor Tissue injury, shockTissue injury, shock
Myocardial depressant factorMyocardial depressant factor Cardiac dysfunctionCardiac dysfunction
Nitric oxideNitric oxide Vasodilation, hypotensionVasodilation, hypotension
Stress Response to InjuryStress Response to Injury
Local Wound1. Cytokines2. Neutrophil products 3. Oxygen radicals4. Prostanoids
Systemic Response1. O2 consumption2. metabolic rate 3. Blood flow maldistribution4. temperature5. Protein catabolism
Endocrine Response1. Catecholamines2. Glucagon3. Cortisol4. HGH
Modulation by CNS1. Pain2. Anxiety3. Hypothermia4. Hyperthermia
SystemicInflammation
AFFERENT ARC
EFFERENT ARC
Neuro-endocrine ResponseNeuro-endocrine Response
Massive receptor stimulus Massive receptor stimulus Hypothalamo–pituitary axis Hypothalamo–pituitary axis CatecholaminesCatecholamines Gluco + mineralo corticoids Gluco + mineralo corticoids GlucagonGlucagon ADHADH InsulinInsulin
Hormonal Response to InjuryHormonal Response to Injury
Hormonal Hormonal LevelsLevels
Glucose Glucose ProductionProduction
ProteolysisProteolysis Protein Protein SynthesisSynthesis
CatecholsCatechols
CortisolCortisol
GlucagonGlucagon
InsulinInsulin
HGHHGH
TestosteroneTestosterone ——
Starvation vs. Severe StressStarvation vs. Severe Stress
Starvation Starvation ContinuumContinuum Stress Stress
Resting energy Resting energy expenditureexpenditure Respiratory Respiratory quotientquotient 0.650.65 0.850.85
Counter regulatory Counter regulatory hormoneshormones ——
Primary fuelPrimary fuel FatFat Fat + amino acidsFat + amino acids
ProteolysisProteolysis ++ ++++++Branched-chain Branched-chain oxidationoxidation ++ ++++++
Starvation vs. Severe StressStarvation vs. Severe Stress
Starvation Starvation ContinuumContinuum Stress Stress
Hepatic protein Hepatic protein synthesissynthesis ++ ++++++
Acute-phase protein Acute-phase protein productionproduction —— ++++++
Constitutive protein Constitutive protein productionproduction Urinary nitrogen Urinary nitrogen losseslosses ++ ++++++
GluconeogenesisGluconeogenesis ++ ++++++Ketone body Ketone body productionproduction ++++++++ ++
Metabolic Response to InjuryMetabolic Response to Injury
Rapid glycogenolysis Rapid glycogenolysis HH22O + NaCl retention O + NaCl retention edema edema
Glucose intolerance Glucose intolerance Gluconeogenesis Gluconeogenesis Protein synthesis redirected to acute Protein synthesis redirected to acute
phase proteins + wound healing phase proteins + wound healing Muscle wasting Muscle wasting
Metabolic Response to InjuryMetabolic Response to Injury
Increased energy expenditureIncreased energy expenditure• Pain, anxiety, feverPain, anxiety, fever• Muscular effort-work of breathing, shiveringMuscular effort-work of breathing, shivering
Physiologic stress response: Catabolic Physiologic stress response: Catabolic phasephase• increased caloric needs, inadequate intakeincreased caloric needs, inadequate intake• gluconeogenesis gluconeogenesis wasting of endogenous wasting of endogenous
protein stores, increased urinary nitrogen protein stores, increased urinary nitrogen losseslosses
Energy UtilizationEnergy Utilization
Hypermetabolic state Hypermetabolic state increases demandsincreases demands less efficient use of nutrients for less efficient use of nutrients for
energy energy more nutrients used to meet the more nutrients used to meet the
demands demands Negative energy balance is highly Negative energy balance is highly
correlated to complications in critically ill correlated to complications in critically ill patientspatients
Surgical trauma is Surgical trauma is accompanied by a accompanied by a negative nitrogen negative nitrogen balancebalance
Nitrogen balance is Nitrogen balance is more negative than more negative than during pure fastingduring pure fasting
Effects of Surgical Trauma on Resting Effects of Surgical Trauma on Resting Energy ExpenditureEnergy Expenditure
Long CL, et al. JPEN 1979;3:452-456
Substrate UtilizationSubstrate Utilization
Muscle is metabolized as gluconeogenic substrate to supply the brain, kidney, tumor etc
Glutamine
Weight Loss after Surgical TraumaWeight Loss after Surgical Trauma
Where?Where?• MuscleMuscle• FatFat
Why?Why?• Reduced food intakeReduced food intake• Increased energy expenditureIncreased energy expenditure• Derangements in protein/fat metabolismDerangements in protein/fat metabolism
Oxidation of Carbohydrate and Fat Oxidation of Carbohydrate and Fat in Sepsisin Sepsis
Sepsis score 0
Fatoxidationg/m2/h
8
3
0
Stoner et al Br J Surg 1983
Glucoseoxidationg/m2/h
10 20 30
Sepsis score 0 10 20 30
SurgerySurgery
AnesthesiaAnesthesia
PatientPatientOperativeOperativeRiskRisk
Magnitude of RiskMagnitude of Risk
Risk factors associated with death, Risk factors associated with death, analyzed by a multiple regression modelanalyzed by a multiple regression model
Risk FactorRisk Factor OROR11 Confidence Confidence intervalinterval
MalnutritionMalnutrition22 1.871.87 1.01-3.341.01-3.34
Presence of Presence of cancercancer 2.072.07 1.03-4.151.03-4.15
Age ≥ 60y/oAge ≥ 60y/o 2.302.30 1.26-4.211.26-4.21
Surgical Surgical treatmenttreatment 0.16*0.16* 0.08-0.350.08-0.35
* p < 0.051 OR = odds ratio2 Moderate and severe malnutrition
Correia and Waitzberg, Clin Nutr 2003; 22:235-239
Consequences of MalnutritionConsequences of Malnutrition
Loss of lean body massLoss of lean body mass Poor wound healing, anastomotic Poor wound healing, anastomotic
breakdownbreakdown Compromised immune defenseCompromised immune defense Impaired organ functionImpaired organ function Increased mortality ratesIncreased mortality rates
Predictors of Poor Surgical OutcomePredictors of Poor Surgical Outcome
ParameterParameter PredictorPredictor
AgeAge Increased (>70 years)Increased (>70 years)
Type of SurgeryType of Surgery Emergent, contaminated, open abdominal, thoracic or Emergent, contaminated, open abdominal, thoracic or aortic surgery, prolonged surgeryaortic surgery, prolonged surgery
ASAASA > Class 3> Class 3
CardiacCardiac Presence of S3 gallop, jugular venous distention, MI Presence of S3 gallop, jugular venous distention, MI within 6 mos, > 5 PVC, aortic stenosis, unstable angina, within 6 mos, > 5 PVC, aortic stenosis, unstable angina, absence of beta-blockadeabsence of beta-blockade
PulmonaryPulmonary COPD, FEVCOPD, FEV11 , 1.0, L PaO , 1.0, L PaO22 <60 , PCO <60 , PCO22 > 50, fatigue with > 50, fatigue with
walking (steps)walking (steps)
NeurologicNeurologic Impairment, decreased function, nonambulatory statusImpairment, decreased function, nonambulatory status
RenalRenal Decreased creatinine clearance, BUN > 50 mg/dlDecreased creatinine clearance, BUN > 50 mg/dl
NutritionNutrition Hypoalbuminemia, hypokalemiaHypoalbuminemia, hypokalemia
FrailtyFrailty Weakness, early exhaustion, dependencyWeakness, early exhaustion, dependency
American College of Physicians
Loss of Lean Mass and Mortality Loss of Lean Mass and Mortality
*assuming no preexisting loss
Complications Relative to Loss of Lean Body Mass*Complications Relative to Loss of Lean Body Mass*
Lean Body Mass(% loss of total)
Complications(related to lost lean mass)
Associated Mortality (%)
10Impaired immunity, increased infection
10
20Decreased healing,weakness, infection
30
30Too weak to sit, pressure
sores, pneumonia, no healing50
40Death, usually from
pneumonia100
Goals of Surgical Nutritional SupportGoals of Surgical Nutritional Support
Maintain host defenses Maintain host defenses Support metabolic response Support metabolic response Reduce the catabolic state and Reduce the catabolic state and
preserve lean body masspreserve lean body mass Support the depleted patient Support the depleted patient
throughout the catabolic phase of throughout the catabolic phase of recoveryrecovery
Goals of Surgical Nutritional SupportGoals of Surgical Nutritional Support
Improve patient outcomesImprove patient outcomes• Decrease surgical mortality Decrease surgical mortality • Decrease surgical complications and Decrease surgical complications and
infectioninfection Prevent/treat macro/micronutrient Prevent/treat macro/micronutrient
deficienciesdeficiencies Speed the healing / recovery process Speed the healing / recovery process
(Decrease the LOS)(Decrease the LOS)
SurgerySurgery
Full Wound healing
Full Restoration of metabolic and immune homeostasis
Endocrine, metabolic, and immunologic alterations
Nutrition Support in SurgeryNutrition Support in Surgery
Adequate Adequate body reservesbody reserves
food intakefood intake
Nutrition Support in SurgeryNutrition Support in Surgery
Surgery
Wound healing
Restoration of metabolic and immune homeostasis
Endocrine, metabolic, and immunologic alterations
Incomplete restoration of organ functions
Multiple organ dysfunction, failure, and death
Inadequate body reserves
Inadequate food intakeNutrition SupportNutrition Support
Prospective randomized studiesProspective randomized studies
2-3 days: No improvement in outcome2-3 days: No improvement in outcome
5-7 days: Influence in outcome5-7 days: Influence in outcome
7-10 days: Benefits outcome7-10 days: Benefits outcome
Reduction of postop morbidity and mortalityReduction of postop morbidity and mortality
Meguid: Am J Surg 1990; 159:345Meguid: Am J Surg 1990; 159:345
**ENDPOINTS: **ENDPOINTS: Monitor nutrient intake (Calorie Count)Monitor nutrient intake (Calorie Count)Total lymphocyte countTotal lymphocyte count
Necessary Length of Preoperative Nutrition in Necessary Length of Preoperative Nutrition in Malnourished PatientsMalnourished Patients
ASPEN GuidelinesASPEN Guidelines
Preoperative SNSPreoperative SNS should be administered should be administered to to moderately or severely malnourished moderately or severely malnourished patientspatients undergoing major undergoing major gastrointestinal surgery for gastrointestinal surgery for 7 - 14 days7 - 14 days if if the operation can be safely postponed.the operation can be safely postponed.
Postoperative SNSPostoperative SNS should be should be administered to patients whom it is administered to patients whom it is anticipated will be unable to meet their anticipated will be unable to meet their nutrient needs orally for a period of 7 to nutrient needs orally for a period of 7 to 10 days.10 days.
A.S.P.E.N. Board of Directors, JPEN 2002
Nutritional AssessmentNutritional Assessment
Body composition (anthropometric Body composition (anthropometric measurements)measurements)
Biochemical dataBiochemical data Clinical assessmentClinical assessment
Subjective Global Assessment (SGA)Subjective Global Assessment (SGA) Indirect calorimetryIndirect calorimetry
Computing Nutritional RequirementComputing Nutritional Requirement
Total caloric requirement (TCR)Total caloric requirement (TCR) Total protein requirement (TPR)Total protein requirement (TPR) Fluid requirementsFluid requirements Micronutrient/Vitamin requirementsMicronutrient/Vitamin requirements
Nutritional RequirementsNutritional Requirements
NutrientsNutrients CarbohydrateCarbohydrate ProteinProtein FatFat VitaminsVitamins MineralsMinerals WaterWater
Calories ProvidedCalories Provided
4 kcal/g4 kcal/g
4 kcal/g4 kcal/g
9 kcal/g9 kcal/g
--
--
--
National Research Council: Recommended Dietary Allowances,10th ed National Academy Press, 1989
Nutritional RequirementsNutritional Requirements
Calculations are based on:Calculations are based on:• ageage• sexsex• weight and heightweight and height• stress factorstress factor• activity levelactivity level
Total Caloric Requirement (kcal/ day)Total Caloric Requirement (kcal/ day)
1. Harris-Benedict Equation (BEE)1. Harris-Benedict Equation (BEE)Male: 66.47 + (13.75 x BW) + (5 x height) - Male: 66.47 + (13.75 x BW) + (5 x height) - (6.76 x Age) x (6.76 x Age) x AFAF x x SFSFFemale: 655.1 + (9.56 x BW) + (1.85 x height) - Female: 655.1 + (9.56 x BW) + (1.85 x height) - (4.67 x age) x (4.67 x age) x AFAF x x SFSF
TCR = BEE x TCR = BEE x AF AF x x SFSF
Nutritional RequirementsNutritional Requirements
Nutritional RequirementsNutritional Requirements
Activity factorsActivity factors• Confined to bed = Confined to bed =
1.21.2• Ambulatory = 1.3Ambulatory = 1.3
Stress FactorsStress Factors• Minor surgery = 1.2Minor surgery = 1.2• Trauma = 1.3 - 1.4Trauma = 1.3 - 1.4• Sepsis = 1.4 - 1.8Sepsis = 1.4 - 1.8• Burns = 2.0 - 2.2Burns = 2.0 - 2.2
2. Short Method2. Short Method• Non stressed: 25 - 30 kcal/kgNon stressed: 25 - 30 kcal/kg• Stressed: 30 - 35 kcal/kgStressed: 30 - 35 kcal/kg
Underweight: Actual BW x 25-35 kcal/kgUnderweight: Actual BW x 25-35 kcal/kg
Overweight: Ideal BW x 25-35 kcal/kgOverweight: Ideal BW x 25-35 kcal/kg
TCR = wt (kg) x 25 - 35 kcalTCR = wt (kg) x 25 - 35 kcal
Nutritional RequirementsNutritional Requirements
Conditions Affecting Caloric NeedsConditions Affecting Caloric Needs
REE ChangeREE Change
Fever (per°C)Fever (per°C) +10 to 15%+10 to 15%
SepsisSepsis +20 to 60%+20 to 60%
TraumaTrauma +20 to 50%+20 to 50%
BurnBurn +40 to 80%+40 to 80%
TreatmentsTreatmentsMech. VentilationMech. Ventilation -25 to -35%-25 to -35%Nutritional supportNutritional support +20%+20%
AgitationAgitation +50 to 100%+50 to 100%
Chiolero R, Nutrition 1997
Drugs Affecting Caloric NeedsDrugs Affecting Caloric Needs
DrugDrug REE ChangeREE Change
OpiatesOpiates -9%-9%
SedationSedation -20 to -55%-20 to -55%
BarbituratesBarbiturates -32%-32%
Muscle relaxantsMuscle relaxants -42%-42%
CatecholaminesCatecholamines +32%+32%
ββ-blockers-blockers -6 to -7%-6 to -7%
+20%+20%
AgitationAgitation +50 to 100%+50 to 100%
Chiolero R, Nutrition 1997
3. Indirect calorimetry3. Indirect calorimetry• Gold standard for measuring REEGold standard for measuring REE
• Calculated by measuring OCalculated by measuring O2 consumption (VO consumption (VO2) )
and COand CO2 production (VCOproduction (VCO2) using the ) using the
abbreviated Weir equation: REE = [3.9 (VOabbreviated Weir equation: REE = [3.9 (VO2) + ) +
1.1 (VCO1.1 (VCO2)] x 1.44.)] x 1.44.
• Performs better than predictive equations with Performs better than predictive equations with added stress factorsadded stress factors
• Measurements made over 20-30 min and 24hr Measurements made over 20-30 min and 24hr EE is extrapolatedEE is extrapolated
Nutritional RequirementsNutritional Requirements
Non-Stressed: 0.8 -1 gm/kg/day Non-Stressed: 0.8 -1 gm/kg/day Mild-Moderately Stressed: 1.2 - 1.5 Mild-Moderately Stressed: 1.2 - 1.5
gm/kg/daygm/kg/day Severely Stressed -Severely Stressed - >1.5-2.5 gm/kg/day>1.5-2.5 gm/kg/day Lefor et al.Critical Care. Lefor et al.Critical Care.
20042004
Protein should comprise approximately Protein should comprise approximately
20% of the total calories during stress20% of the total calories during stress
Protein RequirementsProtein Requirements
Non-Protein CaloriesNon-Protein Calories
CarbohydrateCarbohydrate FatsFats
• NPC combinationsNPC combinations• acute stress: 70% carbo 30% fat• usual: 60% carbo 40% fat• infections: 50% carbo 50% fat• pulmonary: 40% carbo 60% fat
HYPERGLYCEMIA
(Effects in stressed patients)
Impaired wound healing Insulin resistance
Risk of LBM loss
Skeletal muscle proteolysis
Risk of infection Oxidative stress
(proinflammatory)
Supplying Large Amounts of Supplying Large Amounts of Carbohydrates Leads to HyperglycemiaCarbohydrates Leads to Hyperglycemia
VitaminsVitamins
Fat SolubleFat Soluble• Vitamin AVitamin A • Vitamin DVitamin D
Water SolubleWater Soluble • Folic AcidFolic Acid• Pantothenic AcidPantothenic Acid• BiotinBiotin• Niacin Niacin • RiboflavinRiboflavin
• Vitamin EVitamin E• Vitamin KVitamin K
• ThiamineThiamine
• Vitamin BVitamin B66
• Vitamin BVitamin B1212
• Vitamin CVitamin C
ElectrolytesElectrolytes
Sodium
Potassium
Chloride
Calcium
Phosphorus
Magnesium
ZincZinc
CopperCopper
ChromiumChromium
ManganeseManganese
SeleniumSelenium
IodineIodine
IronIron
Fluid RequirementsFluid Requirements
How much volume to give?How much volume to give? Cater for maintenance & on going Cater for maintenance & on going
losses losses Normal maintenance requirements Normal maintenance requirements
• By body weightBy body weight• Alternatively, 30 to 50 ml/kg/dayAlternatively, 30 to 50 ml/kg/day
Maintenance Water RequirementsMaintenance Water Requirements
Weight (kg)Weight (kg) mL/kg/hrmL/kg/hr mL/kg/daymL/kg/day
1 – 101 – 10 44 100100
11 – 2011 – 20 22 5050
21 – n21 – n 11 2020
ChildrenChildren
Adults 30 ml/kg/dayAdults 30 ml/kg/day
Water lossesWater losses
Add on-going losses based on I/O chartAdd on-going losses based on I/O chart• Urine: 800 to 1500 ml/dayUrine: 800 to 1500 ml/day• Stool: 250 ml/dayStool: 250 ml/day
Consider insensible fluid losses alsoConsider insensible fluid losses also• 8-12 ml/kg/day8-12 ml/kg/day• Cutaneous insensible losses increase by 10% Cutaneous insensible losses increase by 10%
for every 1°C above >37°Cfor every 1°C above >37°C
Maintenance Water RequirementsMaintenance Water Requirements
Change in Fluid RequirementsChange in Fluid Requirements
IncreasedIncreased DecreasedDecreased
FeverFever Renal failureRenal failure
FistulasFistulas Congestive heart failureCongestive heart failure
DiarrheaDiarrhea Cirrhotic ascitesCirrhotic ascites
NG suctionNG suction Pulmonary diseasePulmonary disease
NUTRITIONAL ASSESSMENT
Functioning GI Tract?
YES NO
ENTERAL NUTRITION PARENTERAL NUTRITION
Tube feeding for more than 6 weeks?
YES NO
Nasoenteric TubeEnterostomy
Risk for pulmonary aspiration?
YESYES NO NO
Nasogastric Tube
Nasoduodenal or Nasojejunal Tube
Gastrostomy
Jejeunostomy
Clinical Decision Making Algorithm for Nutritional SupportClinical Decision Making Algorithm for Nutritional Support
GI FUNCTION
NORMAL COMPROMISED
Standard Formula Specialty Formula
FORMULA TOLERANCE
PN for more than 4 weeks?
YES NO
Central PN Peripheral PN
GI FUNCTION RETURNS?
YESNO
Adequate
Inadequate
Progress to More Complex Diet and Oral Feedings as Tolerated
PN Supplementation
Progress to Total Enteral Feedings
Oral FormulaSupplements
Preferential Use of Enteral NutritionPreferential Use of Enteral Nutrition
EN delivery has two main routes: EN delivery has two main routes: gastric and post-pyloric gastric and post-pyloric
Use of the gut stimulates GALT & Use of the gut stimulates GALT & MALT MALT →→ enhanced immune responseenhanced immune response
Early feeding can trigger gut Early feeding can trigger gut immunity and thereby improve immunity and thereby improve outcomesoutcomes
McClave, J Clin Gastro, Sept 2002McClave, J Clin Gastro, Sept 2002
Preferential Use of Enteral NutritionPreferential Use of Enteral Nutrition
Delay or failure may promote a Delay or failure may promote a proinflammatory state with proinflammatory state with ↑↑ disease disease severity & morbidityseverity & morbidity
Early EN in the post-operative period is a Early EN in the post-operative period is a viable option to address recuperation viable option to address recuperation needs, malnutrition and its complicationsneeds, malnutrition and its complications
Reduce morbidity and cost compared with Reduce morbidity and cost compared with parenteral nutritionparenteral nutrition
Limitations Of EN DeliveryLimitations Of EN Delivery
Deranged motilityDeranged motility
Reduced exocrine Reduced exocrine
pancreatic functionpancreatic function
Intestinal Intestinal
hypoperfusion/ hypoperfusion/
bowel ischemiabowel ischemia
Gastric refluxGastric reflux
AspirationAspiration
Nausea, vomiting Nausea, vomiting
Abdominal Abdominal distention and distention and crampscramps
DiarrheaDiarrhea
MalabsorptionMalabsorption
Parenteral NutritionParenteral Nutrition
Essential form of sustenance for Essential form of sustenance for patients who cannot tolerate the oral patients who cannot tolerate the oral or tube feeding administered or tube feeding administered intravenously. intravenously.
Indications: Parenteral NutritionIndications: Parenteral Nutrition
General IndicationsGeneral Indications• Patients requiring long-term (>10 days) Patients requiring long-term (>10 days)
supplemental nutrition because they are supplemental nutrition because they are unable to receive all of their daily unable to receive all of their daily energy, protein, and other nutrient energy, protein, and other nutrient requirements through oral or enteral requirements through oral or enteral feedingfeeding
• Severe gut dysfunction or inability to Severe gut dysfunction or inability to tolerate enteral feedingstolerate enteral feedings
Indications: Parenteral NutritionIndications: Parenteral Nutrition
Inability to use the gastrointestinal tractInability to use the gastrointestinal tract• intestinal obstructionintestinal obstruction• peritonitisperitonitis• intractable vomitingintractable vomiting• severe diarrheasevere diarrhea• high-output enterocutaneous fistulahigh-output enterocutaneous fistula• short bowel syndromeshort bowel syndrome• severe malabsorption. severe malabsorption.
Need for bowel rest Need for bowel rest Palliative use in terminal patients is controversialPalliative use in terminal patients is controversial
ASPEN Board of Directors. JPEN 2002; 26 Suppl 1: 83SA
Composition of FormulasComposition of Formulas
Aminoacids
Water
VitaminsTrace
Elements
Electrolytes
Lipids
Dextrose
Parenteral Nutrition
Parenteral Access Parenteral Access
Nutrition Care PlanNutrition Care Plan
Computed calorie and protein Computed calorie and protein requirements based on disease, labs, requirements based on disease, labs, current complicationscurrent complications
Determine form & route of feedingDetermine form & route of feeding• Type of feedingType of feeding
• Oral • Enteral - NGT, PEG, Surgical tubes• Parenteral - peripheral, central
• Delivery method (pump or bolus)Delivery method (pump or bolus)
Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press, 1992
MonitoringMonitoring
MetabolicMetabolic GlucoseGlucose Fluid and Fluid and
electrolyte balanceelectrolyte balance Renal and hepatic Renal and hepatic
functionfunction Triglycerides and Triglycerides and
cholesterolcholesterol
AssessmentAssessment Body weightBody weight Nitrogen balanceNitrogen balance Plasma proteinPlasma protein
MonitoringMonitoring
FLUID BALANCES CALORIE COUNT
Dangers of OverfeedingDangers of Overfeeding
Secretory diarrhea (with EN)Secretory diarrhea (with EN) Volume overload, CHFVolume overload, CHF COCO2 production: ventilatory CO2 production: ventilatory
demanddemand O2 consumptionO2 consumption
Dangers of OverfeedingDangers of Overfeeding
Electrolyte problems: PO4 , K, MgElectrolyte problems: PO4 , K, Mg Hyperglycemia, glycosuria, Hyperglycemia, glycosuria,
dehydration, lipogenesis, fatty liver, dehydration, lipogenesis, fatty liver, liver dysfunctionliver dysfunction
Increased mortality (in adult studies)Increased mortality (in adult studies)
Thank you for your attention.Thank you for your attention.