Transcript Nutritional Support of the Cacectic Patient

Nutritional Support of
the Cacectic Patient
Recap
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Risk of Malnutrition
Nutritional assessment
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History and examination
Anthropological
Biochemical
Calculation of nutritional needs
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TE = NPE + PE
NPE = CHO and lipids
Study Aims
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Substrate changes
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Acute starvation
Chronic Starvation
Strategy for nutritional support
Enteral access routes
Complications of enteral feeding
Pathophysiology
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Acute Starvation
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Depletion of liver glycogen (rapid)
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Insulin fall, glucagon rise
Hepatic GNG
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Amino-acids from muscle protein
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Alanine and glutamin prefered (75%)
Build up by insulin
Breakdown in absence of insulin
Lipolysis
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Energy for GNG from FFA oxidation
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Insulin fall stimulates lipolysis
Liberates glyserol
Pathophysiology – A. Starvation
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Conservation of substrate
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Glucose to lactate in haemopoetis Sx
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Glyserol (from lipolysis)
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Recycled via glucogenic Cori cycle
Hepatic GNG
Branched chain Amino Acids
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From proteolysis
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Direct oxidation in cardiac tissue and skeletal
muscle
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In Crebs from alanine and glutamine
Stimulates protein synthesis and inhibit
breakdown
Resulting increase in u - N output
Pathophysiology – C. Starvation
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Starvation by above methods
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8 – 12g/day N excretion (340g prot)
35% LBM in 1 month = Fatal
Survival for 2 – 3 months due to
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Decreased energy expenditure
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Altered brain substrate
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Decreased SV and HR (CO)
Voluntary mobilisation decreases due to fatigue
Ketone oxidation
Fall in glucose utilisation
Rise in ketones
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Inhibits hepatic GNG
Pathophysiology - Starvation
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Decrease in EE
Conserving protein
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Catabolism = protein breakdown or
auto-canabalism
Strategy for nutritional support
Nutritional
Assessment
GIT assessment
Non-functional
Functional
•Diarrhoea
•Obstruction
Access
Long term
Short term
•Peritonitis
•Oral
•Oral
•Vomiting
•Gastrostomy
•Naso-gastric
•Ileus
•PEG
•Naso-duodenal
•Short bowel syndrome
•Jejunostomy
•Naso-jejunal
•Jejunostomy
TPN
TEN
Remains
absent
Returns
Normal GIT
Fx
Compromised
GIT Fx
Polymeric
feeds
Semi-elemental
feeds
GIT function
Enteral feeding
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Enteral = in the gut
Needs intact GIT
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Patent
Functional
Needs access
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Oral
Gastric
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All about gastric emptying
Duodenal
Jejunal
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About absorption and volume accomodation
Enteral Access Routes
(other than oral)
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Gastric
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Naso-gastric
Oro-gastric
Via pharingostomy
GAstrostomy
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PEG
Surgical
Duodenal
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Naso and oro-duodenal
Placement
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Blind techniques
Accidental
Endoscopic or PEG extensions
Enteral Access Routes
(other than oral)
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Jejunal
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Naso or oro-jejunal
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At time of open abdomen
Jejunostomy
Enteral formulars
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Semi-elemental
Nutritionally not
balanced
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Polymeric
Nutrtionally
balanced
Low in fat
Proteins in form of
AAS, Peptides and
polypeptied
Easy to digest
Low residue
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Digestion normal
Residue normal
Indications for enteral support
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Basal need not met by intake
Large deficit not net by intake
Increased need (BMR) hypermetabolism
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Burns
Head injury
Partial functioning GIT
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Limitation on volume
Complications
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Tube related / mechanical
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Pulmonary Aspiration
Sinusitis
Misplacement and dislodgement
Erosions and necrosis
Reflux
Blockage
Underfeeding
Complications
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Metabolic
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Diarrhoea
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Hypertonic solutions
Inadequate absorption
Lactose deficiency
Starvation hypoalbunemia
Excess fat
Overfeeding (see previous lecture)
Refeeding
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Severe hypo-phosphatemia and hypo-kalemia
secondary to chronic starvation
To little ATP for absorption