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Diet supplementation to patient

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  • 1. Prof . M.C. Bansal. MBBS; MS. MICOG. FICOG. Founder principal & Controller ; Jhalawar Medical College And Hospital , Jhalawar. Ex Principal & Controller ; Mahatma Gandhi Medical College And Hospital ; Sitapur., Jaipur.
  • 2. We now need more attention to patient’s diet and dietary habits; but more often we send him away with quick Verbal advice and hastily written prescription .
  • 3. Principles of Nutrition  Avoiding malnutrition is the main goal of nutrition therapy; as mal nutrition is associated with increased morbidity and mortality of any disease or operative procedure done / to be done in near future.  Malnutrition increases chances of sepsis, poor recovery , wound healing , increased respiratory complications and decrease tolerance to many drugs(chemotherapy) and radiotherapy.  Whenever possible GIT ( enteral ) route of nutrition should be used ideally. If it is not possible than only parenteral route is to be used.
  • 4. Principles of Nutrition---  Over feeding should be avoided as it causes hyper glycaemia, Hepatic steatosis , raised BUN and excessive CO2 Production.  Timing and type is also equally important.  Properly planned nutritional therapy reduces protein wasting.  Immunomodulators like glutamin , arginin and mega3 fatty acids are also need supplementation. Glutamin is a non essential amino acid synthesized in skeletal muscles. It is necessary for cell proliferation during tissue repair . Glutamin helps in GI mucosal proliferation , maintains mucosal integrity . Improves immune function and prevent translocation of bacteria.
  • 5. Caloric Requirement  Normal adult = 40 Kcal / KG / Day .  Adult with catabolism = 60Kcal / KG / Day.  It is given as --- > Carbohydrates—50%. > Fat -30 – 40 % . > Protein – 10 – 15 % . Caloric Value --- Carbohydrate—4 Kcal / gm. Fat --- 9 Kcal / gm. Protein --- 3 Kcal / gm.
  • 6. Water requirement  1-1.5 ml / Kcal of energy required., in normal physiological conditions ; to be increased in cicustences like excessive sweating , fever , vomiting , diuresis. Diarrhoea and diseases with water and electrolyte loss.  Calculation of normal water loss =50-100ml in feces + 500-1000ml in exhalation + 1000 ml by kidney depending on solute load +Temperature ( add 100 ml for each centigrade rise in temperature).
  • 7. Indications for Nutritional Support  Preoperative nutritional depletion –to be corrected.  Post operative complications—sepsis, ileus , fistula.  Anorexia nervosa and intractable vomiting .  Malignant disease.  Patient with Renal / hepatic failure.  Post delivery .  Special attention to diabetics , hypertensive PIH ,Obese patients in OB –Gy Floors.
  • 8. Assessment  Body weight .  Mid arm circumference.  Triceps skin Thickness.  Serum Albumin level .  Lymphocyte count . Nutritional Requirements: Carbohydrates, fats, proteins, vitamins, minerals , anti oxidants and trace elements . Water and plenty of fibers in diet .
  • 9. Methods of Feeding Enteral a. Gastro intestinal tract is the best route of feeding. b. Enteral feeding can be given by bolus(oral semisolid/solid / liquid food may need ingestion ,Chewing and deglutination ), By gravity or using mechanical pump to push it down in GI. c. By mouth : requires common sense , cleanliness and compassion . d. By Nasogastric Tube : Nasogastric tube (ryle’s tube ) is put in and its right introduction is confirmed by pushing 5ml of air and auscultation of bubbling sound in stomach area. Feeding rate is 30- 50 ml / hour . %hours gap at night is given to let gastric Ph return to normal . Problems with Tube feeding are  Blockage , nausea and vomiting –Aspiration, Hyperosmolality , Diarrhoea , tube discomfort , Cholestasis , Pull out by patient . e. By Enterostomy  Gastrostomy, Jejunestomy., soluble fiber containing diet with sufficiently required nutrients and calori a re better to prevent diarrhoea.
  • 10. Methods of feeding --Enteral  Complication of tube Feeding  > Aspiration, wound infection and leak—in cases of gastrostomy and jejunostomy. > Diarrhoea due to rapid feeding and Hypo - osmolality. > Hyperglycaemia , hypokalaemia. > Refeeding syndrome due to hypokalaemia and hypophophataemia.
  • 11. Advantages of Enteral Feeding  Enteral feeding preserves mucosal proteins , digestive enzymes , IgA secretion ; prevents mucosal atrophy and bacterial translocation.  It is more physiological as nutrients absorbed in jejunum and ileum pass through liver first before processing / storage. Gallstone formation is prevented as gall bladder maintains its contractility.  It is cost effective with minimal problems and complications even after long term feeding.  It supplies glutamine and short chain fatty acids to gut .
  • 12. Contra Indication of Entreat feeding  Intestinal obstruction , GI bleed, paralytic ileums , severe diarrhea and high out put fistula.  Low cardiac out put / aerodynamically unstable patient.  If safe assess to entreat feeding is not available . Complications are anticipitated.
  • 13. Total Pareteral Nutrition ( TPN)  All nutrition requirements are given through intravenous route.  About 5% hospitalized patient need TPN.  Central venous catheter ---Put in Subclavian , internal jugular where tip of venous catheter reaches at distal part of superior vena cava.  It can be peripheralPerenteral nutrition ---Through a peripherally inserted venous catheter / canula/ butter fly or vene section
  • 14. Technique Of TNP  Using a needle or guide wire a subclavian vein catheter is passed just below clavicle and fixed to skin with micropore adhesive tap .  TPN is better given through central vein and not through peripheral vein( butterfly , small canola/ needle of 22/ 24 gaze ) . Peripherally inserted central vein catheter(as in Femoral Vein—inferior vena cava) can also be used .
  • 15. Indication Of TPN  Failure or any contra indication for enteral nutrition for 7- 10 days.  High out put abdominal fistula, duodenal , biliary / pancreatic fistula.  Major abdominal surgery .  Septicaemia.  Multiple trauma.  peritonitis , paralytic Ileus.  Massive GI bleed / unstable haemodynamics.  High risk of aspiration .  Hyper emesis Gravidorum .  MODS , head injury , coma. Severe burns.
  • 16. Goal Factors For TPN  To decrease adverse effects of catabolism.  To increase protein synthesis, to reduce protein break down and to prevent weight loss.  To support on going metabolism .  To improve immune function.  To improve cardiac and respiratory function.  To maintain glycogen reserve in cardiac and skeletal muscles.  To maintain acid –base and electrolyte metabolism .
  • 17. Assessment in TPN  Age, morbid state, muscle mass and weight should be noted.  Underlying disease, its severity, therapies given / continued till date , GI function is to be assessed.  Biochemical tests  > serum albumin level , Serum electrolytes, p02.pco2. ph , Blood sugar , Blood urea, serum retaining , SGOT and SGPT other enzyme study as per individual case. > CBP, Platelet count , BT, CT and clot retraction time and coagulation / fibrinolysis as per need of case. > urine analysis –Ph , Na+ , urea , Protein ,casts and hourly output. (a) Assessment of fluid requirement  1500 ml for 20 kg body weight + 20 ml / kg for additional weight. (b) Energy requirement assessment  Resting Energy expenditure ( REE) .1. by simple calculation : REE in Kcal /day = 25 X Wt in KG. 2. Herris Benedict equation : REE in woman =655+ (9.6 X weight ) + (1.8 X ht)- ( 4.7X Age ) Physical activity / disease / body temperature are also added. 3. Indirect Calorimettry : it is more accurate method. , done by using special instrument . REE =(3.9 X Vo2 ) + (1.1 X Vco2 ) – 61. Note VCo2 means--- Vo2 Means ------
  • 18. Component Used in TPN  Carbohydrates –  Fat—  Amino acids ---  Vitamins---  Trace Elements ---  Electrolytes ---  Minerals ---  Fluids– as vehicle and to meet its daily requirement as calculated .
  • 19. Components in TPN----Carbohydrates  Dextrose is less costly and provide 3.4 Kcal / gm , can be used in 50-70% concentration through central venous catheter/ per oral .  It supplies 50- 60 % of require calories, stimulate insulin release and aerobic oxidation of glucose, prevents neo glucogenesis, there by prevents muscle protein breakdown and thus has nitrogen sparing ability and prevention of metabolic acidosis.  Problems : 1. low caloric value as compared to fats. 2.Require large fluid volume to infuse . 3. Hyperglycemia if develops causes more CO2 production 4. High osmolality in High concentration( > 10% solution ) causes thrombophlebitis. 5.Rate of dextrose infusion is 5mg / kg / min.
  • 20. Components In TPN –Fats  Fats give high calorie (1gm = 9 Kcal.)  Essential fatty acids – given as emulsion containing Triglycerides---Emulsion is prepared from Sunflower/soybean oil with egg phospholipids (emulsifying factor) and Glycerin (isotonic ).  Fat has low osmolality (260m mol /L); It is available as 10%, 20% ,30% emulsion .  Advantage of fat in TPN : high calorie input , prevents hyperglycemia, Lees CO2 and insulin production , prevents essential Fatty acid’s deficiency ; if given 3times a week and reduces thrombophlebitis i.e. prevention of problems which may develop with high concentration dextrose therapy.  Problems with Fats IN TPN : Hypertrigyceraemia, sepsis , fat embolism , fat over load , hepatic dysfunction, delayed gastric emptying and Pancreatitis,  Lipid emulsion is good culture media for bacteria and fungi -- > chances of development of sepsis.  Triglyceride levels should be monitored weekly ; if > than 400mg% , infusion should be discontinued .  Mixture of long and medium chain fatty acids is better tolerated and more efficient .  Lipid emulsions are avoided in in hyperlipidaemia, obesity , anaemia and acidosis.
  • 21. Components In TPN--- Amino acids  They are source of proteins.  Caloric Value 1gm=3-4 Kcal ; ^.25 gm protein contains 1 gm Nitrogen.  IN TPN 20% calories are provided by proteins ; daily need is 0.8 -1.5 gm/ Kg .  Less protein is given in cases of chronic live and renal disease as blood urea and serum creatinin levels are high .  It is used in more ratio in cases of burns , trauma, sepsis, enteropathy.  Protein supplement should not exceed 1.7 gm/ Kg/day, if so it will cause raise blood urea .  Uses of amino acids in TPN ---in protein anabolism , prevents catabolism .  Monitoring --- by doing BUN / ammonia level .
  • 22. Vitamins,electrolyts minerals trace elements :  Electrolytes like Na+, K=, Cl-, Mg++, Ca++, HCO3 phosphates .  Fat soluble Vitamins: Vitamin A , D , E, K.  Water soluble vitamins : B 1, 2,6,12,Methyl cholamin,Folic acid and C.  Trace elements : iodine , zinc , Copper , chromium , iron, manganese and selenium.  Anti Oxidants : Vat: C,A, Zinc, selenium etc.
  • 23. Monitoring The Patient On TPN  Body weight recording .  Fluid balance ( input and out put recording ).  Biochemical tests done on alternate day or twice awake : blood sugar , urea, Electrolytes(Na, K, Magma and Phosphates ),Triglycerides , serum creatinin , Total proteins and AG ratio , LFT.  Weight gain > 1 KG / day signifies Fluid over load ; to be avoided.
  • 24. Complication Of TPN A. Technical Air embolism , pneumothorax , bleeding , Venous Catheter (displacement , sepsis , block)., infection and thrombosis. B. Biochemical electrolyte imbalance , hyper / hypo osmolality , hyperglycaesmia, dehydration / fluid over loading . Altered immunological and reticulo- endothelial function., azotaemia. C . Others Dermatitis , anaemia, increased capillary permeability , Cholestatic Jaundice; severe hepatic statuses, metabolic acidosis, candidasis, staphylo cocal infection ( 10-15% cases ).
  • 25. Contra Indications For TPN  Cardiac Failure .  Blood dyscrasias.  Altered fat metabolism. Anabolic steroid Durabolin( 25mg) Injection is given weekly to improve nitrogen balance.
  • 26. Home Parenteral TPN  It is becoming popular .  It is common in western countries.  It is indicate in short bowel syndrome or any condition where enteral therapy is not feasible .  Pt himself uses the TPN fluid as advise at his home; he is permitted to go home with TPN catheter. Patient should attend TPN clinic weekly for follow-up , monitoring and admission if any problem / complication is suspected.  Patient will have better psychology, comfortable and can attend his job.  It decreases hospital bed load .  It is cost effective.
  • 27. Re Feeding Syndrome  Re feeding syndrome is occurrence of severe fluid and electrolyte imbalance in severely malnourished patient while starting the proper feeding enteral or parenteral nutrition  It is more common in TPN .  It causes hypomagnesaemia, hypocalcaemia and hypo phosphataemia leading to cardiac dysfunction, altered level of consciousness, convulsion and often death.  Gradual feeding and correction of Mg ,Ca, phosphorus deficiency and other electrolyte imbalance.  Condition is more common in chronic starvation , severe anorexia and chronic alcoholics. s