Clinical Nutrition. part II

Transcription

1 Clinical Nutrition part II Jacek Szopinski MD. PhD Department of General Surgery and Transplantology Collegium Medicum in Bydgoszczy, Nicolaus Copernicus University in Torun, Poland

2 How much energy? 35 kcal/kg IBW 30 kcal/kg IBW 25 kcal/kg IBW 20 kcal/kg IBW Obesity Perioperatively Burns Sepsis Repeted surgery GI fistula Severe malnutrition

3 What is nutrition support? An alternate means of providing nutrients to people who cannot eat any or enough food When is it needed? Illness resulting in inability to take in adequate nutrients by mouth Illness or surgery that results in malfunctioning gastrointestinal tract Two types: Enteral nutrition Parenteral nutrition

4 Nutrition route ENTERAL route always preferable unless contraindications: mechanical ileus, severe shock (non-stabilized), bowel ischemia (even suspected only) IF the enteral route NOT POSSIBLE or at least 60% of daily energy intake can not be acheived -> MIXED ENTERAL AND PARENTERAL NUTRITION PARENTERAL route alone

5 Methods of enteral feeding Sip feeding Tube feeding Nasoenteral tube Tube enterostomy Percuteneous endoscopic jejunostomy (PEG) Fine catheter needle jejunostomy

6 Sip feeding / oral nutritional supplements (ONS)

7 Oral nutritional supplements protein rich (ie. Nutridrink Protein 125 ml) before major non cancer surgery (2x daily/ 5 x days) with immunonutrition (i.e. Cubitan, Impact Enteral) contain: ARG, GLU, nucleotides (2x daily / 5-7 days)

8 Enteral feeding If the gut works use it Nasogastric (NG) Nasojejunal (NJ) Percutaneous Endoscopic Gastrostomy (PEG) Percutaneous Endoscopic Jejunostomy (PEJ) Radiologically Inserted Gastrostomy (RIG) Surgical Gastrostomy Surgical Jejunostomy (JEJ)

9 Nasoenteric tube

10 PEG or G-tube

11 PEG (Percutaneous Endoscopic Gastrostomy)

12 G-tube (gastric tube)

13 Microjejunostomy

14 1. Whole protein formulae (polymeric) - contain intact proteins, and usually include lipids in the form of long chain triglycerides (LCTs), and carbohydrates predominantly as maltodextrins; - require relatively normal gastrointestinal function for digestion and absorption, but can be used successfully in up to 95% of patients on artificial enteral nutrition; - nutrients are not hydrolysed - osmolality reasonably close to the physiological level (about 200 to 350 mosmol/kg). 2. Peptide based formulae (oligomeric) - partially "pre-digested" and are thus more easily absorbed than whole protein formulae. - contain nitrogen predominantly in peptide form (chains of 2-50 amino acids). - lipids are provided at least in part as MCTs, since these also are more readily digested and absorbed. 3. Free amino acid formulae (monomeric) contain single amino acids as the nitrogen source; very few indications for their use, since oligopeptides are generally better absorbed than free amino acids and combine this with lower osmolality.

15 EN Standard formula standard energy kcal / ml low energy < 0. 9 high energy > 1. 2

16 Indications for monomeric formulae Some forms of congenital metabolic disease, Severe allergy to dietary protein, Nutritional treatment of Crohn's disease

17 Enteral formulae Protein sources for the whole protein formulae are mostly milk proteins such as casein, often together with soy proteins. In peptide-based formulae hydrolysates of soy, lactalbumin, gelatine and/or whey are used. Amino acid-based formulae contain free amino acids, and accordingly do not contain glutamine, because this amino acid is not stable in its free state. Fat sources in standard formulae are predominantly mixtures of oils that are high in polyunsaturated ω-6 fatty acids, such as sunflower, soy, safflower and corn oils. Recently, with increasing awareness of the positive effects of the ω-3 fatty acids, canola oil has been added to many formulae, and sometimes fish oils are added. Medium chain triglycerides (MCT) derived from coconut oil form part of several formulae. Peptide-based and elemental preparations often contain dominant amounts of MCTs, on the basis that they do not require bile salts or pancreatic lipase prior to absorption, and that they bypass the lymphatic system with direct uptake into the portal circulation. Self-evidently the MCTs do not contain any essential fatty acids, and a minimum of 5% polyunsaturated fatty acids is added to any such mixture in order to ensure that the formula is nutritionally complete.

18 Carbohydrate sources are predominantly partial enzymatic hydrolysates of corn starch (maltodextrins with at least 10 glucose molecules). Some formulae, especially those intended for oral use, may contain small amounts of sucrose as this increases palatability. Some whole protein formulae may also contain starch. Minerals, vitamins and trace elements are added, usually to meet 100% of each RDA in the volume of the formula required to yield 1500 kcal.

19 EN formulae generally do not contain lactose, cholesterol, purines, or gluten This is achieved by careful choice of the base materials rather than through technical elimination processes. Cholesterol, for example, is avoided by the selection of plant oils as the predominant lipid sources. Purines are absent from the principal macro-ingredients (such as milk and soy). Gluten content is minimised by the choice of corn-derived carbohydrates. The protein component of most enteral products is added in highly concentrated powder form, usually with a protein fraction of about 85%; this helps to ensure that only negligible amounts of lactose remain despite the use of milk. Enteral formulae are therefore safe for patients with primary or secondary lactose intolerance, coeliac disease, and appropriate for use in those with gout or hypercholesterolaemia. Despite their use of manipulated products, enteral formulae are still based on natural components mainly using common high quality staples. Emphasising their artificiality is no more logical than in respect of regular supermarket foods (such as milk desserts), and may be counterproductive when encouraging their use by patients.

20 Short-Term vs. Long-Term Tube Feeding Access No standard of care for cut-off time between short-term and long-term access However, if patient is expected to require nutrition support longer than 6-8 weeks, longterm access should be considered

21 Complications of Enteral Nutrition Support Aspiration Nausea and vomiting (delayed gastric emptying) Malabsorption (hyperosmolarity) steatorrhea, diarrhea (most frequent)

22 Parenteral Nutrition This is administering nutrients through the vein AIO ( All in One method) Two types: Peripheral Central

23 Indications for Total Parenteral Nutrition (TPN) All severely ill patients where GIT is not available for feeding. Protein calorie malnutrition Intra-abdominal sepsis Sever trauma It is used when the GIT is blocked, short, fistulated, inflamed or cannot cope with demands.

24 Indications for Total Parenteral Nutrition (TPN) GIT is: Blocked - Gastric outlet obstruction Short - Short bowel syndrom Fistulated - proximal enterocutaneous fistula. Inflamed inflammatory bowel disease Unable to cope severe trauma

25 Central vein access

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27 Central vein access The end of the catheter lower 1/3 vena cava upper 1/3 right atrium X-ray!

28 CVC port Ceramic base Silicone membrane (up to 2000 injections)

29 Proteins amino acids always 8 obligatory amino acids: (izo, leu, liz, met, fen, tre, try, wal) + non obligatory amino acids total amount: g/l daily requirement for healthy adults: 0.75 /kg BW daily requirement for patients: / kg BW

30 Carbohydrates Glucose one of 2 main energy sources (4 kcal/g) usually % of energy lowers the level of gluconeogenesis, regulates metabolism of amino acids and lipids Max dose 5 mg/kg/min produced CO2 RQ (Respiratory Quotient) = used O2 RQ glucose = 1.0 RQ lipids = 0.7 Maintain plasma glucose < 150 mg/dl

31 Lipids soybean fatty acids (LCT) source of energy (1 g = 9 kcal) and obligatory fatty acids (linoleic acid, alpha-linolenic acid) phospholipids structure of the cell membrane % energy 0.1 g/kg/h (LCT) or 0.15 g/ kg/ h (MCT/LCT) stop infusion if hipertrigliceridemia (> 350 mg/dl) able to modify inflammation: MCT, olive oil, fish oil

32 Vitamins 9 water soluable vitamins + 4 lipid soluable obligatory for metabolism of proteins, lipids and carbohydrates coenzymes, regulatory functions, antioxidants for free radicals ALL vitamins should be given from the very begining (50% pts shortage of vitamins D, folic acid, E, A, H) administration of some vitamins modifies the need for others (ie. C -- B2 i B12) Solutions: Soluvit, Cernevit (water sol.) Vitalipid (lipid sol.)

33 Electrolytes All electrolytes should be administered to fulfil daily requirements and losts The amino acids solutions contain electrolytes Can be added separately if necessary NaCl, KCl, CaCl2, Ca gluconate, Phosphate Solutions: Glycophos, Addiphos Limitted amout in the All in One bags!!!

34 AIO ( All in One bags)

35 AIO 1+ ions: Na + K < 130 mmol/l 2+ ions: Ca + Mg < 8 mmol/l CAN (Critical Aggregation Number a maximal concentration of cations above which the aggregation of lipid particles can occur 1+ ions + 64 x 2+ ions x 3+ ions < 600 /l CaHPO4 - unsoluable Ca3PO4 - unsoluable 2+ ions => 60x more destabilizing effect of a monovalent ions

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37 Precipitation of Calcium Hydrogen Phosphate. The sediment is deposited when the product of concentration of Ca2+ and ions is above 72 mmol2/l. Many other factors such as ph and the content of the mixture, the way it was prepared, and storage conditions may affect the solubility of CaHPO4. Currently, the risk of precipitation of CaHPO4 can be eliminated by the use of organic calcium salts such as gluconates and glycerophosphate which do not dissociate in aqueous solutions Inactivation of Vitamins, as They Are Highly Susceptible to Degradation. Parenteral nutrition generally contains vitamins at the minimal concentrations necessary for the body function. Sometimes the clinical state of the patient requires additional supplementation with high doses of some vitamins: vitamin B1 in severe malnutrition or vitamin C in patients with increased cell catabolism. Inactivation of vitamins may follow many mechanisms: photolysis of vitamin A and B1, oxidation of vitamin C, reduction of vitamin B1, or adsorption of vitamin A onto the surface of the container

38 Immunonutrition Recently - some advantages of specific components for patients survival and lowering the number of complications (several trials, some still ongoing) glutamine, arginine, nukcleotydes, ώ- 3 fatty acids GLUTAMINE (Dipeptiven) elevating the number and activity of limphocytes and the cytotoxic activity of mononuclears; obligatory AA for fast proliferating cells strong indications (grade A) in severe burn and trauma daily dose in critically ill: 0,3-0,6 g/kg OMEGA 3 FATTY ACIDS (Omegaven) immunosupresive effect (lower cytokine production, lower the expression of Tcell activating receptors) lower inflammatory response (support CARS) max 30 % of daily lipid

39 PPN vs. TPN TPN (total parenteral nutrition) High glucose concentration (15%-25% final dextrose concentration) Provides a hyperosmolar formulation ( mosm/l) Must be delivered into a large-diameter vein through central line. PPN (peripheral parenteral nutrition) Similar nutrient components as TPN, but lower concentration (5%-10% final dextrose concentration) Osmolarity < 900 mosm/l (maximum tolerated by a peripheral vein) May be delivered into a peripheral vein Because of lower concentration, large fluid volumes are needed to provide a comparable calorie and protein dose as TPN (practically up to 2000 kcal/24h)

40 Administration of the Nutrient Solution The hypertonic solution is given at a constant rate per day (usually 1-1.5liters in 1st 24hrs then 1liter 12hourly x 48hrs increasing up to 2.5liters/day gradually to avoid hyperosmolarity problems.

41 Parenteral Nutrition Monitoring Check daily electrolytes and adjust TPN/PPN electrolyte additives accordingly Check accu-check glucose q 6 hours (regular insulin may be added to TPN/PPN bag for glucose control as needed) Non-diabetics or NIDDM: start with half of the previous day s sliding scale insulin requirement in TPN/PPN bag and increase daily in the same manner until target glucose is reached IDDM: start with 0.1 units regular insulin per gram of dextrose in TPN/PPN, then increase daily by half of the previous day s sliding scale insulin requirement Check triglyceride level within 24 hours of starting TPN/PPN If TG > mg/dl, lipid infusion should be significantly reduced or discontinued Consider adding carnitine 1 gram daily to TPN/PPN to improve lipid metabolism ~100 grams fat per week is needed to prevent essential fatty acid deficiency

42 Parenteral Nutrition Monitoring (continued) Acid/base balance Adjust TPN/PPN anion concentration to maintain proper acid/base balance Increase/decrease chloride content as needed Since bicarbonate is unstable in TPN/PPN preparations, the precursor acetate is used; adjust acetate content as needed

43 Complications of Parenteral Nutrition Hepatic steatosis (PNALD) May occur within 1-2 weeks after starting PN May be associated with fatty liver infiltration Usually is benign, transient, and reversible in patients on short-term PN and typically resolves in days Limiting fat content of PN and cycling PN over 12 hours is needed to control steatosis in long-term PN patients

44 Complications of Parenteral Nutrition Support (continued) Cholestasis May occur 2-6 weeks after starting PN Indicated by progressive increase in TBili and an elevated serum alkaline phosphatase Occurs because there are no intestinal nutrients to stimulate hepatic bile flow Trophic enteral feeding to stimulate the gallbladder can be helpful in reducing/preventing cholestasis Gastrointestinal atrophy Lack of enteral stimulation is associated with villus hypoplasia, colonic mucosal atrophy, decreased gastric function, impaired GI immunity, bacterial overgrowth, and bacterial translocation Trophic enteral feeding to minimize/prevent GI atrophy

45 Benefits of Enteral Nutrition Over Parenteral Nutrition Cost Tube feeding cost ~ $10-20 per day TPN costs up to $100 or more per day! Maintains integrity of the gut Tube feeding preserves intestinal function; it is more physiologic TPN may be associated with gut atrophy Less infection Enteral feeding very small risk of infection and may prevent bacterial translocation across the gut wall TPN high risk/incidence of infection and sepsis

46 Refeeding Syndrome the metabolic and physiologic consequences of depletion, repletion, compartmental shifts, and interrelationships of phosphorus, potassium, and magnesium Severe drop in serum electrolyte levels resulting from intracellular electrolyte movement when energy is provided after a period of starvation (usually > 7-10 days) Physiologic and metabolic sequelae may include: EKG changes, hypotension, arrhythmia, cardiac arrest Weakness, paralysis Respiratory depression Ketoacidosis / metabolic acidosis

47 Refeeding Syndrome (continued) Prevention and Therapy Correct electrolyte abnormalities before starting nutrition support Continue to monitor serum electrolytes after nutrition support begins and replete aggressively Initiate nutrition support at low rate/concentration (~ 50% of estimated needs) and advance to goal slowly in patients who are at high risk

48 Consequences of Over-feeding Risks associated with over-feeding: Hyperglycemia Hepatic dysfunction from fatty infiltration Respiratory acidosis from increased CO2 production Difficulty weaning from the ventilator Risks associated with under-feeding: Depressed ventilatory drive Decreased respiratory muscle function Impaired immune function Increased infection

49 Thank you