Enteral Nutrition and Role of Milk
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Enteral Nutrition and Role of Milk

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    Enteral Nutrition and Role of Milk Enteral Nutrition and Role of Milk Presentation Transcript

    • Enteral Nutrition & Role of Milk
    • The Total Enteral Nutrition (TN) DEFINED : Delivery of all the necessary substrates (Amino acids + Carbohydrates + Lipids) via an access either through the natural anatomical GI route or surgically created one
    • Benefits of Enteral Nutrition Therapy • Maintains GIT structure, integrity and function • Easier, more Physiological • Enhances intestinal immune function • Reduces bacterial translocation • Decreases risk of sepsis • Fewer complications than with parenteral nutrition • Lower costs, Less expensive
    • Benefits of Enteral Nutrition Therapy Improved Patient Outcomes Improved wound healing Decreased risk of complications Decreased length of stay Decreased healthcare costs
    • Benefits of Enteral Nutrition Therapy Early Intervention as Part of Initial Care Enteral Nutrition • Oral supplements • Tube feeding Parenteral Nutrition • Central • Peripheral If the gut works, use it!”
    • Conditions That Often Require Nutritional Support
    • Factors to be taken into consideration: ►Preoperative fasting status/ level of starvation before ICU admittance, ►Number of days anticipated on ventilator and any associated systemic problems.
    • Techniques of Access
    • Nutrition : Basic Principles 1. Critically ill : Prone for high energy expenditure and rapid protein breakdown. E N initiated within 24 hours of admission significantly reduces morbidity. 2. Parenteral support to be administered to all patients who cannot tolerate enteral regimen within 5 to 7 days of starvation.
    • Nutrition : Basic Principles 4. Appropriate electrolyte supplementation like vitamins and minerals. 5. Critical monitoring essential. 6. Immunonutriton is still a contentious issue, especially in terms of final outcome!
    • Nutritional Requirement ►Energy requirements ►Can be calculated from Harris Benedicts equation ►In clinical settings: 25 – 30 Kcals / kg / day ►Average of 1500 – 2000Kcal or it can vary as per the patients requirement / condition ►Protein requirements ►Critical patients: 0.8 to 2 gm / kg of IBW, this range can vary depending upon patient’s conditions
    • Considerations in Enteral Nutrition 1. Applicable 2. Site placement 3. Formula selection 4. Nutritional/medical requirements 5. Rate and method of delivery 6. Tolerance
    • Complications of TEN Complications of GI access • Dislodgements • Small bowel volvulus, infarction • Catheter/tube occlusion • Leakage/skin breakdown • Tube malposition Gastric distention & aspiration
    • Complications of TEN And Diarrhea Where milk become the primary source for the cause of Diarrhea. Main Causes : • Drugs like certain antibiotics, • Enema, • Therapy line (Chemo therapy or Radiation), • High speed feeding, • Mishandling of milk & Milk related causes
    • Milk specific causes for Diarrhea among patients who are on EN • Feed is not prepared in a hygienic way • Quality of milk is in-determinant • Commonly loose milk is used which is supposed to be boiled first before consumption and for preparing the feed the milk should be at room temperature. • Temperature changes happening during transportation of feed. • Delays in administration of feeds.
    • Route taken • Most of the time Enteral feed is stopped in such condition OR • Feed is prepared milk free
    • Consequences of Stopping Milk In Enteral Feed Less calories and less protein per ml of the feed
    • However Protein is Critical Critical illness dramatically increases muscle proteolysis and more than doubles the dietary protein requirement. Yet surprisingly, most critically ill patients receive less than half the recommended amount of protein during their stay in a modern intensive care unit. Reference: Why Critically Ill Patients Are Protein Deprived. Journal of Parenteral & Enteral Nutrition
    • Why Protein is Important? Muscle proteolysis dramatically increases in critical illness, making free amino acids available for new protein synthesis at sites of tissue injury and at other locations in the body to regulate inflammatory and immune responses. Reference: Why Critically Ill Patients Are Protein Deprived. Journal of Parenteral & Enteral Nutrition
    • Why Protein is Important? Amino acid uptake by the rapidly turning-over central proteins is constrained by the rate at which amino acids are released from muscle, suggesting that exogenous protein replacement could beneficially increase central protein synthesis, possibly moderate the intensity of systemic inflammation, and improve clinical outcomes in many situations. Reference: • Nutrition and traumatic brain injury: a perspective from the Institute of Medicine report. JPEN J Parenter Enteral Nutr. 2011 • Metabolic vs nutrition support: a hypothesis.JPEN J Parenter Enteral Nutr. 2010
    • Why Protein is Important? There is strong support in the critical care literature for early and adequate protein provision Reference: Why Critically Ill Patients Are Protein Deprived. Journal of Parenteral & Enteral Nutrition
    • Why Milk? Milk is universally considered a nearly perfect food. In particular, dairy products are excellent protein sources. However, researchers have learned that dairy foods provide more than just essential nutrients (like protein). Indeed, they contain other “biologically active” components that may affect overall health. Reference: The American Journal of Clinical Nutrition. 2013
    • Milk- The Wonder Protein Source Some milk components may modulate intestinal bacteria, whereas others may influence the nervous system. Reference: The American Journal of Clinical Nutrition. 2013
    • Milk- The Wonder Protein Source In a recent article published in the June 2013 issue of The American Journal of Clinical Nutrition, states that many of these proteins might very well be active in regions of the small intestine. This article is accompanied by an editorial by Paul Ross and colleagues, who argue that the “black box” of human protein digestion has clearly now been opened.
    • Then arises the issues concerning milk quality
    • Issues concerning milk quality  Contamination  Adulteration  Addition of Preservatives  Wrong boiling practices
    • The technology breakthrough What are the attributes a consumer looks for in milk  Quality  Hygiene  Nutrition  Non – adulterated  Free from preservatives  Convenient
    • So Why to stop milk when we have safer options available – UHT MILK
    • UHT Milk – Safer option for Enteral feeds • Doesn’t require boiling • Preservatives, adulterants free • Convenience i.e. easy to prepare the Enteral feed using UHT milk • Administration of the feed will be easier (feed can even be prepared at patient’s bedside) • Reduce chances of infection as it is bacteria free
    • Case study ►26yrs male admitted in causality with pneumonia and high grade fever. Nutritional Assessment Height – 180cm Weight – 65kg BMI (kg/m2) – 20.06 IBW – 80kg Clinical Parameters Serum Albumin – 2.7g/dl Nutritional Requirement – 30 * 65 = 1980 ~ 2000Kcal Protein requirement – 1.2 * 65 = 78gm Fat – 30% of total calories
    • ►Ryle’s Tube Feeding started @ 50 ml / hr, then increased to 100ml / hr. ►Target was to provide atleast 1 Kcal / ml of the feed and to meet the current protein requirement as calculated. ►But then suddenly the patient started with few of the Gastrointestinal problems due to which the feed was stopped for a day as per the doctor’s instructions. ►Checked the patient record for all possible causes but nothing can be ruled out, then tracked the possibilities of mishandling of the feed during preparation till the time it is given to the patient.
    • Gaps in feeding ►Then found the following gaps: • Milk was not boiled by the kitchen staff, and cold milk from the refrigerator was used for the feed preparation • There was 15 mins. delay in feeding the patient by the ICU staff as per their chart • To overcome the above challenges, we have started preparing the enteral feeds in UHT milk and all the problems related to feed preparation resorted automatically. • The patient was able to handle the feed well. • The feed frequency was then increased further to 120ml per hour.
    • ► Aseptic processing ensures that everything in the production chain is commercially sterile including the food, packaging materials, machinery and the environment in which the packaging takes place. ► It removes all micro-organisms from milk including bacterial spores. ► Ultra Heat Treatment (UHT) is given to milk and the heating period is so brief, it causes less damage to nutrients and flavour compounds. ► Aseptic packaging involves transferring the UHT-treated milk into pre-sterilized packages in a sterile environment. ► Because of the sterile packaging, there is no risk of contamination. ► Aseptic packaged milk has unparalleled hygienic quality offering intact nutrients necessary for child’s growth and development. If Technology Has a Solution Then Why Not Adopt It …
    • Thank you