3. nutrition support


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3. nutrition support

  1. 1. NUTRITION SUPPORTNoraishah Mohamed NorDept Nutrition ScIIUM
  3. 3. CONDITIONS THAT REQUIRE SPECIALIZEDNUTRITION SUPPORT  Enteral —Impaired ingestion —Inability to consume adequate nutrition orally —Impaired digestion, absorption, metabolism —Severe wasting or depressed growth  Parenteral  Gastrointestinal incompetency (diminished intestinal fx)  Hypermetabolic state with poor enteral tolerance or accessibility  Supplement to EN
  4. 4. CONDITIONS IN ENDiminished food intake  Preoperative malnutrition  Coma  Postoperative ileusHypercatabolic states  Polytrauma  Burn  Sepsis  Severe disease condition
  5. 5.  Diminished digestion and absorption  Pyloric stenosis  Pancreatic disease  Biliary disease  Malabsorbtion syndrome  Short bowel syndrome  Radiation enteritis  Ulcerative colitis  Duodenal fistula Chronic disease  Chronic cardiac, hepatic, renal disease  Malignant disease
  6. 6.  Changes in metabolic rate and nitrogen excretion with various types of physiologic stress
  7. 7. INDICATIONS FOR ENTERAL NUTRITIONInadequate amount nutrients and/or calories ingested will lead to malnutrition- associated with an increased incident of:  Poor wound healing  Impaired immune response and response to trauma  Increased risk of sepsis  Altered gut structure/function causing malabsorption and spread of bacteria
  8. 8. Ultimately malnutrition will lead to: Prolong recovery period Increased need for nursing care Increased risk of serious complications Prolong hospital stay Increased medical cost
  9. 9. CONTRAINDICATIONS FOR EN Severe acute pancreatitis High output proximal fistula Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted Inadequate resuscitation or hypotension; hemodynamic instability Ileus Intestinal obstruction Severe G.I. Bleed Expected need less than 5-7 days if malnourished or 7-9 days if normally nourished
  10. 10. ADVANTAGES - ENTERAL VS PN Preserves gut integrity Possibly decreases bacterial translocation Preserves immunological function of gut Reduces costs Fewer infectious complications in critically ill patients Safer and more cost effective in many settings
  11. 11. ADVANTAGES - ENTERAL NUTRITION Intake easily/accurately monitored Provides nutrition when oral is not possible or adequate Supplies readily available Reduces risks associated with disease state
  12. 12. DISADVANTAGES—ENTERAL NUTRITION GI, metabolic, and mechanical complications—tube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax Costs more than oral diets (not necessarily) Less ―palatable/normal‖: patient/family resistance Labor-intensive assessment, administration, tube patency and site care, monitoring
  13. 13. DISADVANTAGES - PN Gut mucosal athropy Overfeeding Hyperglycemia Increased risk of infectious complications Increased mortality in critically ill pt
  14. 14. AIMS OF NUTRITIONAL SUPPORT Preserve lean body mass (protein) Increase protein synthesis Improve immune and muscle function More rapid recovery Shorten hospital stay Reduction of morbidity
  15. 15. ROLES OF NUTRITION SUPPORT DIETITIAN Working with other health care professionals inc. pharmacist, nurse, clinician-to support, restore, maintain optimal nutritional health for individuals with potential or known alterations in nutritional status Assures optimal nutrition support though implementation of nutrition care process related to delivery of EN and PN support (Fuhrman et al 2001)
  16. 16. Nutrition care process Individual nutritional status assessment Indentify nutritional diagnosis Implement appropriate interventions Monitor & reassess an individual’s response to the nutrition care deliveredEvaluate outcomes-incl. the need for transitional feeding care plan or termination of nutr. Support intervention (Lacey & Pritchett, 2003)
  17. 17. ALGORITHM TO CHOOSE NUTRITIONAL SUPPORT Nutritional assessment of the patient Normally nourished but willNormally nourished malnourished develop malnutrition because of disease process if support withheld Normal feeding Nutritional support indicated
  18. 18. DIFFERENT WAYS TO PROVIDE NUTRITIONSUPPORT Oral Enteral Parenteral Combined
  20. 20. SIGNS OF FUNCTIONING GIT The present of bowl sound Soft, non-tender abdomen Passage of fistulas/stool Intact appetite
  21. 21. ENTERAL NUTRITION BY MOUTH Common sense  Adequate  Palatable  Varied  Nutritional complete  Provided at regular intervals, more frequentyly than regular meal times if necessary  Progressively increasing in heaviness and complexity
  22. 22.  Cleanliness  In preparation and serving of food and utensils to prevent GIT infection Compassion  Ensuring the patient ingests the preferred food  Putting food in patient’s reach  Conducive eating environment  Involving dietitians in food selection and preparation
  23. 23. ENTERAL NUTRITION BY TUBE Nutrition provided through the gastrointestinal tract via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity Benefits of EN:  Help maintain gut mucosal physiology  May modulate immune response-prevent translocation of bacteria and toxins (maintain gut mucosal integrity)- IgA in EN (IgA prevent absorption of enteric antigents)-less risk for infection  Promote peristalsis  Safer: fewer complication  Lower cost-formula, delivery system and less patient care  Simpler system-care and self-administrator
  24. 24. CLINICAL SETTING IN WHICH ENTERAL NUTRITIONSHOULD BE PART OF ROUTINE CARE PEM with inadequate oral intake of nutrients for the previous 5 days Oral intake <50 % of required needs for the previous 7- 10 days Severe dsyphagia due to strokes, brain tumors, head injuries, multiple sclerosis Major (>30 % of BSA), full thickness burns Short gut due to small bowel resection-enteral nutrition + parenteral nutrition to stimulate regeneration of the remaining intestine
  25. 25.  Clinical conditions in which enteral nutrition usually may be helpful:  Major trauma with functional GIT + inadequate oral intake for 7-10 days  Radiation therapy for cancers of the lungs, head, neck and cervix, and lymphomas  Acute/chronic liver failure + severe anorexia + functioning GIT  Severe renal dysfunction (<5% of normal glomerular filtration) + anorexia + functioning GIT
  26. 26.  Contraindications for enteral feeding:  Mechanical obstruction of GIT  Prolong ileus  Severe GI haemorrhage  Severe diarrhoea  Intractable vomiting  High-output GIT fistula (>500 ml/day)  Severe enterocolitis
  28. 28. TRANSNASAL PASSAGE Transnasal passage of feeding into the stomach/intestine employed when possible  A surgical procedure can be avoided  Generally well tolerated when small-bore feeding tube are used  Disadvantages:  tube can be readily removed by disorientated/uncooperative px.  When larger, stiffer tube used-irritation to nasal passages, pharynx, esophagus & compromise gastroesophageal competency
  29. 29.  Nasogastric  insertion & placement of the tube is easier. Nasogastric, esophagostomy, gastrostomy  feeding allow the digestive process to begin in the stomach-decreasing risk of dumping syndrome.  Disadvantage:  higher risk of aspiration-only gastroesophageal sphincter is operating to prevent reflux
  30. 30.  Nasoduodenal, nasojejunal, jejunostomy:  Advantage:  Posed less risk of regurgitation-advantage of gastroesophageal sphinctar & pyloric sphincters  Disadvantages:  Higher risk of intolerance (nausea, vomiting, diarhea, cramps)-when feeding are not properly selected.  The bactericidal effect of HCL in the stomach is bypassed-need attention for sanitation to formula and equipment
  31. 31. OSTOMIES Require surgical insertion. Indicated when insertion through transnasal is impossible or when long-term feeding is anticipated Advantages:  irritation caused by the feeding tube is eliminated  Ostomies are unobtrusive between feeding time
  32. 32.  Jejunostomies:  Advantage:  permits early post operative feeding (unlike stomach & colon)-the small bowel is not affected by postoperative ileus.  Relatively safe, comfortable, potential for long-term use  Disadvantage:  Possibility of infection is high like other ostomy procedure
  33. 33. EN ADMINISTRATION Administration of EN should be guided by:  Px’s age  Underlying disease  Enteral access device  Condition of GI
  34. 34.  When the patient should be started with EN?  Eary initiation of EN is beneficial if px is hemodynamically stable  In ICU, when EN was initiated within 24-48 hrs of admission:  Lower rates of infection  Shorter hospital stay (Bar et a. 2004)
  35. 35. METHODS OF DELIVERYBased on: Nutrient needs Feeding site Formula selection Current medical status3 methods of delivery: 1. Bolus feeding 2. Intermittent bolus feeding 3. Continuous feeding
  36. 36.  Bolus feeding:  Administered using a syringe/feeding reservoir  Infused over a period of time  Tolerance is dependent on the functional ability of the gut  Generally, the px is fed a vol of 250-400ml of formula- 5-8x/day  Allow px greater freedom/movement between feeding times  Associated with high incidence of complications:  Nausea  Vomiting  Diarrhoea  Abdominal distension & cramps  Aspiration
  37. 37.  Intermittent bolus feeding:  Administered by slow gravity drip  Each feeding is given over 30 min every 3-4 hrs  Tolerance is dependent in the functional ability of the gut  Initiation of feeding with 50 ml of isotonic formula (<30ml/min) every 3-4 hrs  Progression of feeding regime with additional 50 ml every 8-12 hrs as tolerated  Generally, prescribed vol of formula 250-400 ml infused over a 20-30 min period 5-8x/day  Allow px greater freedom/movement between feeding times.  Complications can be similar to bolus feeding
  38. 38.  Continuous feeding  Utilised when bolus/intermittent feedings are not tolerate/in critical ill patients/small bowel feeding  Usually pump assisted  Associated with reduced incidence of high gastric residual, GER and aspiration  Restricts px movement
  39. 39.  Continuous tube feeding i. Initiation of tube feeding range from 20-50ml/hr ii. Progression of tube feeding range from 10-20ml/hr every 8-24 hrs until the desired volume is attained iii. the strength can be increased as tolerated. iv. If feeding is not tolerated-reduce the rate & strength to previously tolerated level-gradually increase the rate & strength again v. Avoid altering rate & strength at the same time
  41. 41. ENERGY REQUIREMENT1. Haris Benedict EquationMale REE = 66.47+13.75W+5.0H-6.76AFemale REE = 665.10+9.56W+1.85H-4.68A W= wt in kg H = ht in cm A= age in years2. Formula FAO/WHO/UNU (1985) Male 18 – 30 REE = 15.32W+679 30 – 60 REE = 11.2W+879 >60 REE = 13.5W+987 Female 18 – 30 REE = 14.7W+496 30 – 60 REE = 8.7W+829 >60 REE = 10.5W+596
  42. 42. 3. Ismail et al.(1998)Men 18 – 30 years:BMR=0.0550(W)+2.480 MJ/d 30 – 60 years:BMR=0.0432(W)+3.112 MJ/dWomen 18 – 30 years:BMR=0.0535(W)+1.994 MJ/d 30 – 60 years:BMR=0.0539(W)+2.147 MJ/d
  43. 43. ACTIVITY AND STRESS FACTORS Activity Factor =1.0 – 1.1 (bed rest) = 1.2 – 1.3 (very light) =1.4 – 1.5 (light) = 1.6 – 1.7 (moderate activity) =1.9 – 2.1 (highly active) = 2.2 – 2.4 (strenuous)
  44. 44.  Stress Factor : =1.1(mild malnutrition, postoperate no complication =1.2(mild illness confined to bed) =1.3(mild illness ambulatory) =1.2-1.3 (surgery major) =1.3-1.4 (trauma skeletal) =1.2 – 1.3(mild infection and stress) =1.4 – 1.5(moderate infection and stress) =1.6 – 1.8(severe hypercatabolic) =2.0 – 2.2(sepsis) =1.2 – 1.4(<20%BSA) =1.5 – 1.7(20 – 40%BSA) =1.8 – 2.0(>40%BSA) =1.2 – 1.3(Fracture) =1.4 – 1.5(respiratory or renal failure) =1.4 – 1.8(COPD) =1.5 – 1.6(Cancer with chemo or radiation,cardiac cachexis)
  45. 45. TYPES OF ENTERAL PRODUCTS Standard/polymeric formulas Elemental Modular (Supplements) Condition Specific
  46. 46.  Polymeric formula  Composed of intact proteins, disaccharides,polysaccharides, variable amounts of fat and residue  Require a functioning GIT for absorption and digestionCategory Characteristic Indication ProductsStandard •Nutritionally Normal digestive & Ensure/Nutren complete absorptive capacity Optimum/Osmolite •Provide 1 kcal/ml •Distribution: 50-60 % CHO 10-15 % Protein 25-30 % fatFiber- •Similar to standard Constipation, Jevity/ Nutrensuplemented formula except for diarrhoea Fibre/Nutren fibre content Diabetic •4 – 20g of dietary fibre/l
  47. 47. Category Characteristic Indication ProductsConcentrated Similar to standard Fluid restriction Ensure Plus, formula except Enercal Plus provide 1.5 – 2.0 kcal/ml
  48. 48.  Elemental formula  Partially hydrolyzed proteinCharacteristic Indication ProductsNutritionally complete Reduced digestive & absorption Peptamen/AlitraQ,Usually provide 1 kcal/ml capacity e.g. Crohn’s Disease, Short Elementum Bowel Syndrome, long term fasting with gut atrophy, post operativeMay contain glutamine patients
  49. 49.  Modular Formulas Single nutrient supplement, nutritionally incomplete, usually low in electrolytes Examples :  Fat-MCT oil (Medium Chain Triglyceride)  CHO- Carborie, Polycose (Glucose polymer)  Protein- Myotein
  50. 50.  Condition specific productsCondition Characteristic Indications ProductMetabolically •Nutritionally complete Polytrauma /post Perativestress •Provides 1.5 kcal/ml operative period •High in protein: >20% kcal (following major surgeries) •May contain: arginine,nucleotides, omega-3 fatty acidsHepatic •Protein content: high in BCAA, Hepatic FalkaminEncephalopathy low in Aromatic Amino Acids EncephalopathyProtein, •Provides 2.0 kcal/ml Acute or chronic Suplenaelectrolyte and •Low in protein kidney disease not (NA)fluid restriction •Low in phosphorous on dialysisGlucose •Nutritionally complete Hyperglycaemia :> Glucerna/Intelorance •Provides 1.0kcal/ml 10mmol/L Nutren •Low in CHO: 35% of kcal Diabetik/ Nutricomp® •High in fat: 40-50% of kcal Diabetic •Fibre supplemented
  51. 51. Condition Characteristic Indications ProductCO2 retention •Nutritionally complete Chronic obstructive Pulmocare pulmonary disease •Provides 1.5 kcal/ml with CO2 retention •High in fat: 55% kcal & •Low in CHO: 30% kcalElectrolyte •Provides 2.0 kcal/ml Acute or chronic Nepro/and Fluid •Moderate in protein renal failure Nutricomp®restriction •Low in phosphorous requiring dialysis Renal
  52. 52. IMMUNE-ENHANCING FORMULAS Have added ―immune-enhancing‖ nutrients (arginine, glutamine, omega-3 fatty acids, nucleotides) Results of research have been mixed Multiplicity of active ingredients makes it difficult to control variables Meta-analysis suggests that they might be most beneficial in surgical patients Some evidence of harm in septic patients
  53. 53. EVIDENCE- BASED Glutamine should be added to standard formula in:  Burn & trauma patients In Burns pt, the trace elements (Cu, Zn, Se) should be supplemented in higher dose For the trauma patient, it is not recommended to routinely use immune-enhancing EN, as its use is not associated with reduced mortality, reduced LOS, reduced infectious complications or fewer days on mechanical ventilation. Diet supplemented with arginine should not be used for critically ill pts.
  54. 54. FORMULAS FOR IMPAIRED GI FX:INFANT/CHILDREN Protein Hydrolysate  Pregestimil  Alimentum Peptide/ Elemental  Neocate  Peptamen Jr.  Vivonex Pediatric  Neocate advance
  55. 55. INITIATION OF FEEDING Choose full strength, isotonic formulas for initial feeding regimen. Initiation and advancement of enteral formula in pediatric patients is best done over several days in a hospital setting using a flexible nutrition plan.
  56. 56. INITIATION OF FEEDING- PAEDIATRICContinuous feeding Generally children are started  isotonic formula at a rate of 1-2 mL/kg/h for smaller children  1mL/kg/h for larger children over 35-40 kg.  The rate is advanced based on tolerance by the child  the goal of providing 25% of the total calorie needs on day 1.Bolus feeding  2.5-5 mL/kg can be given 5-8 times per day with gradual increases in this volume to decrease the number of feedings to closer to 5 times daily.
  57. 57. INITIATION OF FEEDING-CHILDREN Bolus feedings & gravity-controlled feedings  started with 25% of the goal volume divided into the desired number of daily feedings.  Formula volume may be increased by 25% per day as tolerated, divided equally between feedings Pump-assisted feedings  A full-strength, isotonic formula can be started at 1-2 mL/kg/h and advanced by 0.5-1 mL/kg/h every 6-24 hrs until the goal volume is achieved
  58. 58. For preterm, critically ill, or malnourished children  Use pump  initial volume : 0.5-1 mL/kg/hour  Advancing to 10-20 ml/kg/day
  59. 59. INITIATION OF FEEDING-ADULTS Bolus feedings & gravity-controlled feedings  full-strength formula  3-8 times per day  increases of 60-120 mL every 8-12 hours as tolerated up to the goal volume. Pump-assisted feedings  initiated at full strength at 10-40 mL/h and advanced to the goal rate in increments of 10-20 mL/h every 8-12 hours as tolerated
  60. 60. PATIENT POSITIONING Elevatethe backrest to a minimum of 30º-45º, for all patients receiving EN unless a medical contraindication exists.  Eg.unstable supine, hemodynamic instability, prone position If necessary to lower the Head-to-bed (HOB) for a procedure or a medical contraindication, return the patient to HOB elevated position as soon as feasible.
  61. 61. FLUSHES-PRACTICE RECOMMENDATIONS Flush feeding tubes with 30 mL of water every 4 hours during continuous feeding or before and after intermittent feedings in an adult patient flushthe feeding tube with 30 mL of water after residual volume measurements in an adult patient Flushing of feeding tubes in neonatal and pediatric patients should be accomplished with the lowest volume necessary to clear the tube
  62. 62. MEDICATION ADMINISTRATION Do not add medication directly to an enteral feeding formula. Avoid mixing together medications intended for administration through an enteral feeding tube to reduce risks of:  physical and chemical incompatibilities,  tube obstruction  altered therapeutic drug responses Dilute medication appropriately prior to administration.
  63. 63. REFEEDING SYNDROME Severefluid and electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding. These complications are often worsened by overfeeding or by use of aggressive repletion.
  64. 64. PHYSIOLOGIC CHANGES OCCUR DURINGREFEEDING Intracellular mineral depletion  Hypophosphatemia  hypomagnesemia,  Hypokalemia  body fluid disturbances (―refeeding edema‖)  vitamin deficiencies (eg, thiamine) lifethreatening  cardiac arrythmias  respiratory arrest  Congestive heart failure
  65. 65. CONSEQUENCES OF ELECTROLYTE ABNORMALITIESElectrolytes Consequence PO4 Acute ventilatory failure Arrythmias Confusion Congesive heart failure Lethargy, weakness Rhabdomyolysis K+ Arrythmias Cardiac arrest Constipation / ileus Polyuria / polydipsia Respiratory depression Weakness Mg2+ Anorexia Arrythmias Confusion Diarrhoea / constipation Weakness
  66. 66. PATIENTS AT HIGH RISK OF REFEEDING Patients with any of the following:  BMI < 16 kg/m2  Unintentional weight loss >15% within the last 3-6 months  Very little or no nutrition for >10 days  Low levels of potassium, magnesium or phosphate prior to feeding
  67. 67.  Patients with 2 or more of the following:  BMI < 18.5 kg/m2  Unintentional weight loss >10% within the last 3-6 months  Very little or no nutrition for >5 days  A history or alcohol abuse or some drugs including insulin, chemotherapy, antacids or diuretics
  68. 68. MONITORING FOR REFEEDING SYNDROME Monitoring metabolic parameters prior to the initiation of EN feedings and periodically during EN therapy should be based on protocols Prevention of refeeding syndrome is of utmost importance Pxat high risk for refeeding syndrome and other metabolic complications should be followed closely, and depleted minerals and electrolytes should be replaced prior to initiating feedings.
  69. 69.  Patientsat risk of developing refeeding syndrome should be identified, electrolyte abnormalities should be corrected prior to the initiation of nutrition support. Nutrition support should be initiated at approximately 25% of the estimated goal and advanced over 3-5 days to the goal rate. Serumelectrolytes and vital signs should be monitored carefully after nutrition support is started
  70. 70. CHALLENGES IN NUTRITIONAL SUPPORT1. Caloric requirement not met  Under ordering by physician  Reduced delivery  Slow advancements2. Gut dysfunction  High residual volume (GRV)  Nausea  Vommiting  Absent of bowel sound  Diarrhea  Aspiration
  71. 71. 3. Procedure and diagnostic test  require fasting4. Lack of enthusiasm, personal bias and individual practice
  72. 72. THE RISK FACTORS FOR ASPIRATION Sedation supine patient positioning the presence and size of a nasogastric tube malposition of the feeding tube mechanical ventilation, vomiting bolus feeding delivery methods poor oral health nursing staffing level advanced patient age
  73. 73. STRATEGIES TO OPTIMIZED DELIVERY& MINIMIZED RISK1. Use feeding protocol2. Motility agent (eg. Prokinetic)3. Small bowel vs gastric feeding4. Body position5. Nutrition support practice
  74. 74. FEEDING PROTOCOLe.g.Prospective evaluation before and after evidence based protocol introduction of EN in surgical pt.. Within 24 – 48 hr  With the protocol: Inceased delivery of nutirents Shortened duration of mechanical ventilation Decrease mortality
  75. 75. PROKINETIC AGENT: METOCLOPRAMIDE IVadministration of metoclopramide or erythromycin should be consider in pt with intolerance to EF  E.g with high gastric volume
  76. 76. LEVELS OF GRVSeverity Definition TreatmentMild <200 ml •Return GRV •Continue feedingModerate 200 – 500 ml •1st episode continue •2nd episode start prokinetic agent • 3rd episode reduce EN by half • 4th episode: •Stop feeding •Place NJ tube •Start EN protocol againSevere > 500 ml •Stop gastric feeding •Place NJ tube •Start EN protocolRefer MNT pg 10 other assessment of tolerance
  77. 77. SMALL BOWEL FEEDINGSmall bowel fed pt have improved energy delivery in some studiesDuodenal vs gastric feeding in ventilated blunt trauma pt  Improved tolerance ofEN and consequent faster achievement of desired calories Kortbreek JB J Trauma
  78. 78.  Small bowel vs gastric feeding  Maybe associated with a reduction in pneumonia in critically ill pt  No different in mortality or ventilation days  Small bowel feeding improves cal & prot intake and is associated with less time taken to reach target rate of enteral nutrition.
  79. 79. NUTRITION SUPPORT PRACTICESHow should pt be tube fed aftersurgery?  TF should be initiated within 24 hr after surgery  Sholud satrt with low flow rate (e.g 10 - 20 (max) ml/hr)due to limited intestinal tolerance  May take 5 – 7 days to reach the target intake  Not consider harmful
  80. 80. NUTRITION SUPPORT PRACTICES DO NOT…………..:1. Assemble feeding system on the pt’s bed2. Top up fresh formula until the formula hanging in the feeding bag has finished3. Overfed patients:  High calorie density formula  1.3 kcal/ml  Perative  1.5 kcal/ml  Pulmocare  2.0 kcal/ml  nepro/enercal plus
  81. 81. OPEN VS CLOSED SYSTEM Open System:  Product is decanted into a feeding bag  Allows modulars such as protein and fiber to be added to feeding formulas  Less waste in unstable patients (maybe)  Shortens hang time  Increases nursing time  Increased risk of contamination
  82. 82.  Closed System or Ready to Hang:  Containers sterile until spiked for hanging  Can be used for continuous or bolus delivery  No flexibility in formula additives  Less nursing time  Increases safe hang time  Less risk of contamination  More expensive than canned formula
  83. 83. Open System Closed System Hangtime 8 hours for  Hang time 24-48 hours decanted formula; 4 based on mfr hours for formula mixtures recommendations Feeding bag and  Y port can be used to tubing should be deliver additional fluid rinsed each time and modulars formula replenished  May result in less formula Contaminated waste as open system feedings are formula should be associated with pt discarded p 8 hours morbidity
  84. 84. CONCLUSIONo Practice early enteral feedingo Use strict protocolso Modify preoperative preparationo Identify & rectify tube displacemento Consider tube placement post pylorico Alter method of feeding (routine cycling, smallero volume, concentrated feeds)o Works as Nutrition Support Teamo Continuous Nutrition Education
  85. 85. THANK YOU….Q???
  86. 86. TUTORIAL1. Male, age 39, 189 cm tall. 91 kg body weight, confined to bed and having burn of 40% TBSA and body temp is 39°. Calculate calorie req and plan a EN regimen.2. Female, age 41, 160 cm tall. 67 kg body wt. confined to bed and ventilated. Diagnosed with COPD. Calculate cal req and plan for EN regimen through pump feeding3. Pt with TPN, Patient on Nutriflex (peripheral) for three days after operation (75 ml/hr) 1. Calculate the calorie from the TPN 2. How to manage the pt if dr plan to change to EN