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Nutrition Presentation Transcript

  • 1. Surgical Nutritional Support
  • 2. OVERVIEW
    • Artificial Nutrition: Importance and History
      • antibiotics, blood transfusion, critical care monitoring, advances in anesthesia, organ transplantation, and cardiopulmonary bypass
      • hyperalimentation  moderate nutritional supply
      • nutritional pharmacology
      • parenteral  parenteral & enteral
  • 3. OVERVIEW
    • Clinical Sequelae of Impaired Nutrition
      • Impaire the body's ability to heal wounds and to support normal immune function
      • reduced ventilation due to wasting of muscle
      • limiting to all aggressive surgical and medical therapies
    • Incidence of Malnutrition in Hospitalized Patients
      • as many as 50% of hospitalized patients may be malnourished
  • 4.
    • Surgical Nutritional Support : Provide adequate and proper nutrients to support the metabolism of the body, and to maintain the function and structure of the organs, to accelerate the recovery.
  • 5. Questions
    • Why should we provide nutritional support
    • When it is provided
    • What kind and amount of nutrients
    • How to administrate the nutrients
  • 6. METABOLIC ADAPTATIONS IN CATABOLIC STATES AND REGULATION OF NITROGEN BALANCE
  • 7. Regulation of Intracellular Protein Synthesis and Degradation
  • 8. Metabolic Changes in state of starving
    • secretion of insulin declines;
    • secretion of glycagon, growth factor, catecholamine increase;
    • utilization of glucose is accelerated;
    • gluconeogenesis continues
    • proteolysis is initiated to provide energy
      • lipid is oxidized to ketones
      • consume great amount of protein
  • 9.  
  • 10. Metabolic changes in stress (trauma, sepsis)
    • trauma activating the sympathetic nerve
    • utilization of carbohydrates are inhibited, hyperglycemia is produced
      • the secretion of insulin declines
      • the blood level of glycagon, growth factor, catecholamine, thyroid hormone, ACTH, antidiuretic hormone increase
    • The lipolysis is activated, gluconeogenesis and proteolysis is accelerated, large amount of protein are consumed to provide energy supply.
  • 11. FUNDAMENTALS OF ARTIFICIAL NUTRITION
  • 12. General Indications for Nutrition Support and Choice of Route of Administration
    • The pre-morbid state (healthy or otherwise)
    • Poor nutritional status (the current oral intake meets <50% of total energy needs)
    • Significant weight loss (initial body weight less than the usual body weight by ≥10%, or a decrease in inpatient weight by >10% of the admission weight)
    • The duration of starvation (>7 days' inanition)
    • An anticipated duration of artificial nutrition (particularly for total parenteral nutrition [TPN]) of more than 7 days
    • The degree of the anticipated insult, surgical or otherwise
    • A serum albumin value less than 3.0 g/100 mL measured in the absence of an inflammatory state
  • 13. Route of Administration
    • Enteral nutrition (EN)
      • more physiologic, and safe
    • PARENTERAL ROUTE
      • Parenteral nutrition (PN)
      • Total parenteral nutrition (TPN)
  • 14. Mulnutrtion
    • Kwashiorkor (Protein Malnutrition)
      • Adequate fat reserves with significant protein deficits
      • Slight or no weight loss
      • Low visceral proteins (albumin, prealbumin, transferrin)
      • Edema often present
      • Seen in acutely stressed patients
    • Marasmus (Protein—Calorie Malnutrition)
      • Weight loss with fat and muscle wasting
      • Visceral proteins normal or slightly low
      • Seen in chronic malnutrition
  • 15. Nutritional Assessment
    • Clinical History
    • Body Composition Analysis
    • Indirect Calorimetry
    • Anthropomorphic Measurements
    • Functional Studies of Muscle Function
    • Biochemical Measurements
  • 16. Nitrogen Balance
    • total nitrogen intake – nitrogen expiration
    • (most of it are excreted from urine, plus approximately 2~3gm for fecal and others lost of nitrogen)
  • 17. Plasma proteins <1.6 1.6~1.8 1.8~2.0 2.0~2.5 Transferrin (g/L) <21 21~27 28~34 >35 Albumin (g/L) Severe Moderate Light Malnutrition Normal
  • 18. Estimation of Energy Needs
  • 19. Harris-Benedict equation
    • BEE = 66.5 + (13.7 X weight [kg]) + (5.0 X height [cm]) - (6.8 X age [yr] [male])
    • BEE = 655.1 + (9.56 X weight [kg]) + (1.85 X height [cm]) - (4.68 X age [yr] [female])
    • (BEE = basal energy expenditure)
  • 20. Calories Requirements
    • The three major sources of energy are protein, carbohydrate, and fat.
      • amino acids, 15%
      • fat, 25 to 50%
      • Carbohydrate, 35 to 65%
  • 21. Nutrients
    • Specific Fuels
      • Carbohydrate
      • Lipid
      • Protein
    • Plasma Electrolytes
    • Vitamins and Micronutrients
  • 22. Protein Requirements
    • 70-kg man has between 10 and 11 kg of protein.
    • Daily protein turnover is 250 to 300 g, or 3%
    • the gut , blood system, skin
    • daily requirement 0.8 to 1.0 grams per kg per day, or 150 mg of nitrogen per kg per day
    • 200 to 250 mg of nitrogen per kg of body weight or 1.7 g of protein per kg per day for patients in stress state
  • 23. Calorie-Nitrogen Ratio
    • 150:1 (150 nonpro-tein calories per gram of nitrogen) is required for protein synthesis in healthy persons
      • 100:1 in sepsis
      • 300:1 ~ 400:1 in uremia
  • 24. PRACTICAL APPROACH TO ARTIFICIAL NUTRITION
  • 25. Enteral Nutrtion
    • Indications for Enteral Feeding
    • Routes for Administration of Enteral Feeding
    • Administration
    • Enteral Formulas
  • 26. Indications and Routes of EN
    • Indications
      • Gut works
      • Oral intake not possible—altered mental state, ventilator, oral/pharyngeal/esophageal disorders
      • Oral intake not sufficient for metabolic requirements—anorexia, sepsis, severe trauma/burns
      • Presence of malnutrition and wasting
    • Routes of administration
      • Nasogastric tube, ending in stomach, duodenum or intestine; gastrostomy ; jejunostomy
  • 27.  
  • 28.  
  • 29.  
  • 30.
    • Administration
      • Osmolality , volume , and speed
    • Enteral Formulas
      • All nutrients, degraded products of protein
    • Complications of Enteral Administration
      • Tube, infection, diarriah, dilatation
  • 31. Parenteral Nutrtion
    • Indications for Parenteral Feeding
    • Practical Approach to Calculation of the Ideal Parenteral Formula
    • Catheter Issues in Parenteral Nutrition
    • Metabolic Complications of Long-Term Parenteral Nutrition Administration
  • 32. Indications of PN
      • Enteral feeding not possible—GI obstruction, ileus
      • Enteral intake not sufficient for metabolic requirements—chronic diarrhea/emesis, malabsorption, fistulas, chemotherapy, irradiation therapy
      • Risk of aspiration
      • Adjunctive support necessary for managing disease—pancreatitis, hepatic failure, renal failure, chylothorax
      • Presence of malnutrition and wasting
  • 33. Routes of PN
    • Peripheral Administration
      • Peripheral vein.
    • Central Approach
      • Subclavian vein
      • internal jugular vein
  • 34. Formula
    • Glucose, 35~65% of energy expenditure.
    • Lipid, 25~50% of energy expenditure.
    • Amino acid, non protein energy: nitrogen=150: 1
    • Electrolyte: k, Na, Cl, Ca, Mg, P
    • Vitamin: Vit A, Vit Bs, Vit E
    • Trace metals: Zinc, Copper, Iron
    • Water: 2500~3000ml
  • 35. Complications of Parenteral and Enteral Nutrition
    • Due to improper formula and administration
    • Catheter relative
    • Metabolic complications of long-term PN
      • If the gut can be used, use it.
  • 36. Summary
    • History of artificial nutrition
    • Metabolism
    • Nutritional Assessment and Administration
  • 37. Metabolism
    • Metabolism of protein, carbohydrate, fat and energy production
    • Stress metabolism
  • 38. Nutritional Assessment
    • Types of malnutrition
    • Evaluation of the preexisting deficits
    • Estimation of caloric and protein requirements
  • 39. Administration of nutrition
    • Indications
    • Enteral Nutrition
    • Parenteral Nutrition
  • 40. Complications
    • Due to improper formula and administration
    • Catheter relative
    • Metabolic complications of long-term PN
  • 41.
    • Thank You For Attention