Transcript l-arginine

Immunonutrition:
 modulate the immune system
 facilitate wound healing
 reduce oxidative stress
contain certain compounds:




l-glutamine
l-arginine
omega-3 fatty
antioxidants
ASPEN/ESPEN: Immune-modulating enteral
formulations (supplemented with agents
such as arginine, glutamine, nucleic acid,
ω-3 fatty acids, and antioxidants) should
be used for the appropriate
patient population (major elective surgery,
trauma, burns, head and
neck cancer, and critically ill patients on
mechanical ventilation),
with caution in patients with severe sepsis.
To receive optimal therapeutic benefit
from the immune-modulating
formulations, at least 50%–65% of goal
energy requirements should
be delivered daily.
L-ARGININE
 plays fundamental roles in protein metabolism
 polyamine synthesis
 critical substrate for nitricoxide (NO) production
stimulates the release ;
 growth hormone
 insulin growth factor and insulin
 all of which may stimulate protein synthesis
and promote wound healing.
The enzyme, l-arginase, metabolizes l-arginine to l-ornithine,
an amino acid implicated in wound healing.
Guidelines for arginine supplementation can be summarized as follows:
. Normal l-arginine intake is 3 to 5 g/d.
Higher than normal (supraphysiologic) l-arginine
supplementation is necessary
Dietary supplementation with l-arginine
alone should not be used, as only diets
Immunonutrition incorporating
supraphysiologic quantities Of l-arginine
ideally should be started preoperatively as
an oral dietary supplement and continued in
the postoperative
A clear benefit of l-arginine-containing immunonutrition has
not been observed in medical patients, particularly those with
sepsis.
All elective surgical patient populations, including patients
undergoing operations for head and neck cancer and patients
undergoing cardiac or GI surgery, appear to benefit from the
useof immunonutrition formulas containing l-arginine.
OMEGA-3 FATTY ACIDS
incorporated into phospholipids and thereby influence
the structure and function of cellular membranes.
as substrates for the enzymes cyclooxygenase,
lipoxygenase, and cytochrome P450 oxidase
increasing the quantity of omega-3 fatty acids
(found in fish oils) in the diet reduces platelet
aggregation, slows blood clotting, and limits the
production of proinflammatory cytokines.
administration of dietary lipids rich in omega3 fatty acids can modify the lipid profile and
favorably affect clinical outcome a mong
critically ill patients with ARDS
L-GLUTAMINE:
The amino acid, l-glutamine, plays a central role in
nitrogen transport within the body.
used as a fuel by rapidly dividing cells, particularly
lymphocytes and gut epithelial cells.
substrate for synthesis of the important endogenous
antioxidant
translocation of enteric bacteria and endotoxins is
reduced and infective complications less frequent.
l-Glutamine unfortunately is unstable in aqueous
solutions.
To overcome this problem, l-glutamine is added to TPN
solutions as adipeptide (l-alanyl-l-glutamine).
In patients receiving EN, l-glutamine powder can be
dissolved into the nutrition formulation.
Glutamine (enteral):
All: The addition of enteral glutamine
to an EN regimen (not already
containing supplemental glutamine)
should be considered in
thermally injured, trauma, and mixed
ICU patients.
Selenium;
is an essential component of the most important
extra- and intra-cellular antioxidant enzyme
family, the glutathione peroxidases (GPX).
doses of 750–1000 mcg/day should probably not be
exceeded in the critically ill, and aministration of supraphysiological
ddoses should perhaps be administratlimited to 2 weeks.
20-60 mcg
Recommended Daily Intake
Ascorbic acid (C) 200 mg
Vitamin A
3300 IU
Vitamin D
5 mg
Vitamin E
10 IU
Which Nutrient for Which Population?
Elective
Surgery
Critically Ill
General
Septic
Trauma
Burns
Acute Lung
Injury
Arginine
Benefit
No benefit
Harm(?)
(Possible
benefit)
No
benefit
No
benefit
Glutamine
Possible
Benefit
PN
Beneficial
Recommend
…
EN
Possibly
Beneficial:
Consider
EN
Possibly
Beneficial:
Consider
…
Omega 3
FFA
…
…
…
…
…
Recommend
Antioxidants
…
Consider
…
…
…
…
Canadian Clinical Practice Guidelines
ADULT : NUTRITIONAL REQUIREMENTS
The nutritional requirements of each patient will
depend upon a number of factors including:
Age
Activity level
Current nutritional status
Current metabolic and disease states
1)Calorie Requirements:
 Metabolic cart
predictive equations
 If available, indirect calorimetry can be used
to measure energy expenditure using gas
exchange
 When indirect calorimetry is not
possible, there are many possible
predictive equations
 whichever method (indirect calorimetry or
predictive equation) is used, the optimal
energy provision for hospitalized patients
has yet to be determined
Metabolic cart (28, 29):
Indirect calorimetry using a “metabolic cart” measures
actual energy expenditure by collecting, measuring and
analyzing the oxygen consumed (VO2) and the carbon
dioxide (VCO2) expired. From these measurements the
respiratory quotient (RQ) is calculated
a. RQ = VOz/VCOz
b. REE = (3.94 [VOz] + 1.1 [VCOz]) 1.44 - (2.17 [UUN])
Note:
Patient has to be intubated
for the test to be performed
FIO2<60%,
no air leak
chest tube leak.
 PREDICTIVE EQUATIONS
 Harris-Benedict
 Miflin St. Jeor (MSJ)
 Use of Indirect Calorimetry vs. Predictive Equations
PCG:
2013 Recommendation: There are insufficient data to make
a recommendation on the use of indirect calorimetry vs.
predictive equations for determining energy needs for
nutrition or to guide when nutrition is to be supplemented in
critically ill patients.
Conclusions:
The use of indirect calorimetry
compared to predictive equations to
meet enteral nutrition needs has no
effect on mortality.
(A.S.P.E.N)
 Predictive equations should be used with
caution, as they provide a less accurate
measure of energy requirements than indirect
calorimetry in the individual patient.
Calorie Requirements:
CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS
 Resting energy expenditure (REE)—the
energy expenditure while resting in
the supine position with eyes open
 About 10% greater than BEE
 Sleeping energy expenditure (SEE)
It is usually 10% to 15% lower than REE
 Activity energy expenditure (AEE)
During maximum exercise it can be 6to 10-fold greater than the BEE.
 Total energy expenditure (TEE)
the sum of energy expended
during periods of sleep, resting,
and activity.
estimated resting energyeREE = eBEE • stress factor
expenditure;
estimated total energy eTEE = eREE • activity factor
expenditure
 Stress Factors
Major surgery: 15%-25%
Infection: 20%
Long bone fracture: 20%-35%
Malnutrition: Subtract 10%-15%
Burns: Up to 120% depending on extent
Sepsis: 30%-55%
Major trauma: 20%-35%
COPD: 10%-15%
Sedated mechanically ventilated
patients: Subtract 10%-15%.
 Activity Factors
Sedated mechanically ventilated patients: 0-5%
Bedridden, spontaneously breathing nonsedated
patients: 10%-15%
Sitting in chair: 15%-20%
Ambulating patients: 20%-25%
Daily Caloric
Requirements
Sedated mechanically
ventilated patients
Using Measured or
Estimated REE
Using Body Weight
1.0-1.2 • REE
20-24 kcal/kg
Unsedated mechanically
ventilated patients
1.2 • REE
Spontaneously
breathing critically ill
patients
1.2-1.3 • REE
Spontaneously
breathing ward patients
1.3 • REE
(maintenance)
Spontaneously
breathing ward patients
1.5-1.7 • REE
(repletion)
22-24 kcal/kg
24-26 kcal/kg
24-26 kcal/kg
25-30 kcal/kg
University of Kentucky Medical Center
 KCAL/Kg
 HBE or MSJ x Injury factor
University of Kentucky Medical Center
 KCAL/Kg
 Wound Healing: 30-35 kcal/kg, increase to 35-40
kcal/kg if the pt is underweight or losing weight.
 Sepsis and Infection: 30-40 kcal/kg
 Trauma: 25-30 kcal/kg
 Acute Spinal Cord Injury (SCI) 23kcal/kg or HBE w/o
stress factor
 Chronic SCI: 20-23kcal/kg depending on activity
 Stroke: 19-20kcal/kg or (HBE x .95-1.15)
 COPD: 25-30 kcal/kg
 ARF: 25-35 kcal/kg
 Hepatitis: 25-35 kcal/kg if well-nourished
30kcal/kg), 30-40 kcal/kg if malnourished
 Cirrhosis without encephalopathy: 25-35
kcal/kg
 Cirrhosis with encephalopathy: 35 kcal/kg
 Severe Acute Pancreatitis: 35 kcal/kg
 Organ Transplant: 30-35 kcal/kg
 Cancer: Sedentary/normal wt = 25-30 kcal.
Hypermetabolic, need to gain weight, or anabolic
= 30-35 kcal/kg.
 Hypermetabolic, malabsorption, severe stress: >
35 kcal/kg
 . Obese = 21-25 kcal/kg
Estimated Calorie Needs: HBE or MSJ x Injury factor
Major Elective
HBE x 1.2 - 1.3
Major Non-elective
HBE x 1.3 - 1.5
Minor Elective
HBE x
1.2
Minor Non-elective
HBE x
1.2 - 1.3
Infection w/temp
HBE x 1.2 - 1.3
 Traumatic Brain Injury (CHI) HBE x 1.4
 Multiple trauma & CHI HBE x 1.4 – 1.6
 Pentobarbital coma HBE x 1.0 – 1.2
 Stroke and SAH HBE x 1.0- 1.2
 Pneumonia (or ARDS) HBE x 1.2 - 1.3
 Neuromuscular Blockade HBE x 1
Energy:
ASPEN
 Use 25-30kcal/kg, or predictive
equations, or indirect calorimetry.
 Consider hypocaloric feeding in
critically ill obese (BMI >30kg/m2), e.g.
60-70% of target energy requirements,
or 11-14kcal/kg actual body weight, or
22-25kcal/kg ideal body weight.
ESPEN :
 20-25kcal/kg in acute phase of
critical illness.
 25-30kcal/kg in recovery phase.
Carbohydrates
 provide 4 kcal/g (IV dextrose = 3.4 kcal/g) with an
RQ of 1.0.
 Between 40% and 60% of total caloric needs
(or 70% of nonprotein calories)
Minimum 2g/kg
ESPEN 2009
Maximal glucose oxidation rate is 4-7
mg/kg/minute/24hours.
Ideally keep to ≤5mg/kg/minute/24hours
Protein
1. Normal patient = 0.8 to 1.0 g/kg
2. Postsurgical, mild trauma = 1.25 to 1.5 g/kg
3. Severe trauma, sepsis, organ failure = 1.5 to 2.0 g/k
4. Burn (>20%) or severe head injury ~2.0 g/kg
1.3-1.5g protein/kg.
ESPEN
1.2-2.0g protein/kg if BMI<30kg/m2.
ASPEN
2g/kg ideal weight if BMI 30-40kg/m2.
2.5g/kg ideal weight if BMI >40kg/m2.
Fat
 provides 9 kcal/g with an RQ of 0.7.
 Between 20% and 30% of total
caloric requirements (or 30% of nonprotein calories)
0.7-1.5g/kg.
ESPEN
ENTERAL NUTRITION
INDICATIONS FOR INITIATION OF ENTERAL NUTRITION
1)Oral intake is contraindicated
Examples
Dysphagia, mechanical ventilation, mandibular
fractures, head & neck surgery, neurological
impairment, demyelinating diseases such as
amyotrophic lateral sclerosis, muscular dystrophy,
etc.
2)Inability to meet markedly increased
nutritional needs with oral intake
Examples
Burns, trauma, radiation therapy,
chemotherapy, sepsis/infection, closed
head injury
3)Inability to meet basic nutritional
needs with oral intake alone
Examples
Anorexia, cancer, head
and neck tumors
4)Need to bypass part of the GI tract
to allow enteral nutrition
Examples
Pancreatitis, gastric outlet obstruction,
esophageal cancer, gastroparesis
5)The need for supplemental nutrition due
to decreased absorption
Examples
Short bowel syndrome, inflammatory
bowel disease, fat malabsorption or
other malabsorptive syndromes such as
cystic fibrosis
Benefits of Enteral Nutrition (compared with
Parenteral Nutrition)
Stimulates immune barrier function
Physiologic presentation of nutrients
Maintains gut mucosa
Attenuates hypermetabolic response
Simplifies fluid/electrolyte management
More “complete” nutrition than parenteral nutrition
o iron, fiber, glutamine, etc. are not provided.
Less infectious complications (and costs associated with
these complications)
Stimulates return of bowel function
Less expensive
Delivery Method:
Continuous or cyclic:
Intermittent feeding
Bolus feeding
Continuous or cyclic
18-24 h
25cc/h
8-24h double
125-150cc/h
Intermittent feeding
usually 240-480ml,
over a 45-60 minute
period 5-8 times per day.
Preferred by ambulatory patients.
Disadvantage includes:
poor tolerance since a larger
feeding volume is administered
over a short time.
Bolus feeding
Bolus feeding is discouraged in the ICU.
rapid infusion via syringe through a
gastrostomy tube
may result in nausea, diarrhea, distention, cramps, or
aspiration
300-500cc
3-5h
5-10min
Carbohydrate (CHO):
 Concentration & form of CHO constitute
major differences between formulas
 Forms of CHO include:
 Simple sugars and monosaccharides
(glucose and fructose).
 Disaccharides
(sucrose, lactose, and maltose)
require enzymatic conversion to
monosaccharides in the intestinalbrush
border prior to absorption.
 Polysaccharides and oligosaccharides
, produced from hydrolysis of starch, result
in glucose polymers of intermediate chain
lengths.
Starch hydrolysis
increases the solubility and osmolality of the product
Protein:
 Three major categories are classified
by degree of digestion required:
 Intact protein, found in whole foods,
requires complete digestion.
 Crystalline amino acids –
theoretically require minimal digestion.
The small particle size increases the
osmolality
 Hydrolyzed protein –enzymatically hydrolyzed to
smaller peptide fragments and free amino acids,
partially hydrolyzed protein requires digestion
while di and tri-peptides are absorbed directly.
Useful in conditions such as:
short bowel and Crohn's disease and pancreatic
insufficiency.
Fat:
 Increases the caloric density but does not
contribute to the osmolality.
 Most formulas contain long chain triglycerides (LCT)
with variable amounts of medium-chain
triglycerides (MCT) and mono and diglycerides.
MCT are transported via the portal system directly
into the blood stream
they are oxidized to ketones and carbon dioxide.
MCT does not require emulsification for absorption
their use is indicated with CF, liver disease, pancreatitis,
and other disorders where fat absorption may be
impaired.
Timing of enteral nutrition
 All: EN should be started within the
first 24–48 hours following
admission
PCG
2013 Recommendation:
Based on 16 studies, we recommend early enteral
nutrition (within 24-48 hours following admission to
ICU) in critically ill patients.
Conclusions:
1) Early enteral nutrition, when compared to delayed
nutrient intake is associated with a trend towards a
reduction in mortality in critically ill patients.
2) Early enteral nutrition, when compared to
delayed nutrient intake is associated with a
significant reduction in infectious complications
3) Early enteral nutrition, when compared to
delayed nutrient intake has no effect on ICU or
hospital length of stay.
4) Early enteral nutrition, when compared to
delayed nutrient intake improves nutritional
intake
Achieving Target Dose of Enteral Nutrition
PCG
 There were no new randomized controlled trials since
the 2009 update and hence there are no changes to
the following summary of evidence.
Dosage of enteral feeding
 ASPEN: The feedings should be
advanced toward the patient’s goal
over the next 48–72 hours
 Efforts to provide > 50%–65% of goal
energy should be made in
order to achieve the clinical benefit of EN
over the first week of hospitalisation.
ESPEN:
No general amount can be
recommended as EN therapy has
to be adjusted according to the
progression/course of the disease
and to gut tolerance
 ASPEN/CCPG: If unable to meet energy requirements (100%
of target goal energy) after 7–10 days by the enteral route
alone, consider initiating supplemental parenteral nutrition
 ESPEN: All patients who do not meet their nutritional needs
after 2 days should receive supplemental PN.
Haemodynamically unstable patients
ASPEN: In the setting of haemodynamic compromise :
patients requiring significant haemodynamic support
including high dose catecholamine agents, alone
in combination with large volume
fluid or blood product resuscitation to maintain
cellular perfusion),
EN should be withheld until the patient is fully
resuscitated and/or stable.
Immune-modulating enteral formulations
ASPEN/ESPEN: Immune-modulating enteral
formulations supplementaed with agents such s
arginine, glutamine, nucleic acid, ω-3 fatty acids,
and antioxidants) should be used for the appropriate
patient population (major elective surgery, trauma,
burns, head and neck cancer, and critically ill
patients on mechanical ventilation),
with caution in patients with severe sepsis
Complications of overfeeding include (but not limited to):
. Hyperglycemia
. Lipogenesis
Fluid and fat gain rather than lean body mass gain
Fatty liver
Immunosuppression (with excessive lipid and linoleic acid intake)
Increased minute ventilation (VE)
Excessive CO2 production impairing pulmonary status/vent
wean
 DRUG NUTRIENT INTERACTIONS WITH ENTERAL PRODUCTS
Only administer sucralfate
(CarafateR), omeprazole,
antacids, iron salts, and
ketoconazole (NizoralR) into
the stomach
Stop continuous tube feedings for 1 hour
before and 1 hour after each phenytoin
(DilantinR) dose to maximize the drug
absorption.
When diarrhea occurs, determine if any medication
contains excessive quantities of sorbitol. Examples
include:
acetaminophen elixir, codeine solution, diazepam
solution, LomotilR, furosemide solution, guaifenesin
syrup, lithium citrate
syrup, metoclopramide syrup, morphine sulfate
solution potassium chloride elixirs, and some
theophylline solutions.
GENERAL GUIDELINES FOR ADMINISTERING
MEDICATIONS WITH ENTERAL FEEDINGS:
1)Stop the tube feeding prior to administration of
meds.
2)Flush the feeding tube with 20-30 ml of
warm water or appropriate volume before and
after giving medication through the tube.
3)If more than one medication is being given
at the same time, give each medication
separately and flush the tube with 5-15 ml
of warm water between medications.
4)Use liquid preparation if possible (if
patient does not have diarrhea).
5)If a tablet form must be used, be sure it is
finely crushed and dispersed in warm water.
6)Do not crush enteric-coated, sublingual, or
sustained-release tablets, if in doubt check with
PharmD.
7)tube feeding when done giving medications.
7)Most liquid medications are hypertonic and
should be diluted with 30-60ml of water prior
to administration
8)tube feeding when done giving medications.
Categories of Enteral Formulas
 Return up to 250 ml gastric
residuals to the patient.
 Notify physician if feedings
held twice in 24 hours.
ASPEN
-500ml
Holding EN for gastric residual volumes
< 500 mL in the absence of other signs of
intolerance should be
avoided.
 For high-risk patients or those shown to be
intolerant to gastric feeding, delivery of EN
should be switched to continuous infusion.
 Agents to promote motility such as prokinetic
drugs (metoclopramide and erythromycin)
or narcotic antagonists (naloxone and alvimopan)
should be initiated where clinically
feasible.
 Diverting the level of feeding by post-pyloric
tube placement should be considered.
 Use of chlorhexidine mouthwash twice a day should
be considered to reduce risk of ventilator-associated
pneumonia.
In the ICU setting, evidence of bowel motility
(resolution of clinical ileus) is not required in
order toinitiate EN in the ICU.
Critically ill patients should be fed
via an enteral access tube placed in the
small bowel if at high risk for aspiration
or after showing intoleranceto gastric
feeding.
 Parenteral nutrition is usually
indicated in the following
situations:
1)Documented inability to absorb adequate
nutrients via the gastrointestinal tract
Massive small-bowel resection / Short bowel
syndrome (at least initially)
Radiation enteritis
Severe diarrhea
2)Complete bowel obstruction
3)Severe catabolism with or without
malnutrition when gastrointestinal tract
is not usable within 5-7 days
4)Inability to obtain enteral access
5)Inability to provide sufficient
nutrients/fluids enterally
6) Pancreatitis in the setting of
intolerance to jejunal delivery of nutrients
7) Persistent GI hemorrhage
8) Acute abdomen/ileus
9)High output enterocutaneous fistula and EN
access cannot be obtained distal to the site.
10) Trauma requiring repeat surgical
procedures / NPO status
 Parenteral nutrition may be indicated in
the following situations:
 Enterocutaneous fistula as above
 Inflammatory bowel disease unresponsive to
medical therapy
 Hyperemesis gravidarum when nausea and
vomiting persist longer than 5 -7 days and
enteral nutrition is not possible
 Partial small bowel obstruction
 Intensive chemotherapy /
Contraindications for Parenteral
Nutrition:
1)Functioning gastrointestinal tract
2)Treatment anticipated for less than 5 days in
patients without severe malnutrition
3)Inability to obtain venous access
4)A prognosis that does not warrant
aggressive nutrition support
5)When the risks of PN are judged to exceed
the potential benefits
COMPONENTS OF PARENTERAL NUTRITION:
A. MACRONUTRIENTS
1)CARBOHYDRATE
2. PROTEIN
3)FAT
CARBOHYDRATE
Dextrose contains 3.4 kcal/g (CHO is
given as a dextrose monohydrate)
Requirements:
Minimum: 1 mg/kg/minute 1440
mg/kg/24hrs
Maximum: 5 mg/kg/minute
7200mg/kg/24hrs OR 7 g/kg/day OR
24 dextrose kcal/kg/day.
 Consequences of excess CHO
administration:
Hyperglycemia
Glucosuria
Synthesis and storage of fat
Hepatic steatosis
Increased carbon dioxide production impairing
pulmonary status/vent wean
Requirements:
Approximately 16% of protein or amino acids are
nitrogen.
The goal should be to provide adequate protein
to maintain a positive (2 to 4 g)
Requirements range from 0.8 g/kg/day to 2.5 g/kg/day.
Generally 15 – 20% of the daily caloric intake should
come from protein.
PROTEIN
 Amino acid = 4 kcal/g
 Protein calories should be
included when calculating total
caloric requirements
FAT
 Minimum: To prevent essential fatty acid
deficiency (EFAD), 2% to 4% of the total caloric
requirement should come from linoleic acid (25 to
100 mg/kg/day)
 Maximum: Maximal fat dosage should not exceed
60% of calories OR 1.0 - 2.5 g/kg/day
Lipids should be used with caution
in patients with serum triglycerides
(TG) > 400mg/dl.
 Use with caution in patients
allergic to eggs.
Lipids are generally administered
over a 24 hour period
 Guidelines for rate of infusion are <
0.11 g / kg / hr
Consequences of excess lipid administration:
 Fat overload syndrome with neurologic, cardiac,
pulmonary, hepatic and renal dysfunction
 Thrombocyte adhesiveness
 Accumulation of lipid in the reticuloendothelial
system (RES), leading to RES dysfunction
 Impaired immune response
MICRONUTRIENTS:
PARENTERAL NUTRITION CALCULATIONS:
CUSTOM PN:
Step 1 – Determine protein and calorie needs
Step 2 – Subtract protein calories (grams protein x 4) from
total calories
Step 3 – Subtract lipid calories* from remaining calories
Step 4 – remaining will be dextrose calories
Minimum flow rates:
Dex/50 + g Pro/215 + 5 = minimum flow rate
Central:
[(Dextrose kcals X 0.42) + (grams of protein X 10)]
÷ 24 = minimum hourly flow rate. Add
5 ml/hour for MVI, trace elements, etc. Round up to
nearest increment of 5.
Peripheral: [(Dextrose kcals x 0.15) + grams of
protein] ÷ 2.1 = minimum hourly flow rate. Add 5
ml/hour for MVI, trace elements, etc. Round up to
nearest increment of 5.
COMPLICATIONS ASSOCIATED WITH
PARENTERAL NUTRITION :
 Metabolic complications; hyperglycemia is the most
common – tight blood glucose control is optimal.
 Gastrointestinal complications: steatohepatitis,
cholestasis
 Pharmacological complications
 Manganese toxicity is possible with prolonged use of
PN
 Infection / sepsis
 Metabolic bone disease
Nutritional modifications in disease
A. Diabetes. Low simple sugar. high fiber. and high fat to minimize
hyperglycemia.
B. Renal failure. High calorie. low protein. and low electrolytes
(phosphorus.
potassium) to prevent volume overload. hyperammonemia. and
electrolyte
imbalance. However, in patients on dialysis. protein requirements
may actually increase.
C. Liver failure. Low protein. high branch chain amino acids to prevent
encephalopathy.
D. Respiratory failure. High calorie, high fat (low carbohydrate) to
prevent CO2
accumulation.
E. Pancreatitis. Enteral. postpyloric (nasojejunal) feeding is superior to
TPN.
F. Other GI diseases. If nonfunctional GI tract, may require TPN.
G. Trauma. Consider immune-enhancing diet.
Grade 1 ascites Mild ascites only detectable by ultrasound No
treatment
Grade 2 ascites Moderate ascites evident by moderate symmetrical
distension of abdomen Restriction of sodium intake and diuretics
Grade 3 ascites Large or gross ascites with marked abdominal
distension
Large-volume paracentesis followed by restriction of sodium intake
and diuretics (unless
patients have refractory ascites)