2. Malnutrition
– It can be either:
– Long term-----easy to recognize
– Short term----- dificult to recognize , which occurs frequently with critical illness,
major trauma and burns
–
3. Metabolic response to starvation
– Within 12 hrs most food from the last meal will have been absorbed.
– Plasma insulin decreases and glucagon increases, which facilitate glycogenolysis
in liver
– The glycogen stored in the muscle is broken down to lactate, exported to liver
and converted to glucose there by cori’s cycle.
– With increased duration of fasting (>24 hr) most of the glycogen stores get
depleted and thus glucose production starts de-novo from the amino acids,
process known as gluconeogenesis.
4. Metabolic response to starvation
– With increased fasting, fatty acid oxidation begins.
– This provides glycerol which provides the glucose as the source of energy.
– Similarly the ketones can be produced in liver from the fatty acid generated.
– This can be used by all tissue as source of energy.
– Even the brain adapts to the ketones after 48-72 hrs. of fasting.
– This adaptive ketogenesis helps to reduce the protein breakdown
– Also there is decreased resting energy requirement level due to decline in
conversion from inactive T4 to active T3
7. Nutritional assessment: clinical
techniques
– History: Weight change, dietary intake, other GI symptoms
– Signs: wasting,
– Loss of SC fat,
– Skin elasticity,
– Hand grip strength,
– Edema,
– Alopecia
– Signs of vitamin deficiencies
8. Body weight and anthropometry
– Body weight
– Ideal body weight= (Height in Centimetres -100kg)
– Significant weight loss (10% in 6 month or 5% in 1 month)
– BMI
– BMI<18: indicate significant nutritional impairment
– BMI<15: indicate significant hospital mortality
– MUAC
– Skin fold Thickness
9. Laboratory technique
– Blood glucose
– Fasting lipid profile
– Serum albumin, prealbumin, transferrin, Retinol binding protein
– Lymphocyte count and skin testing for hypersensitivity reaction
– Hemoglobin
10.
11. Types of nutritional supplement
in surgical patients
– Artificial nutrition support
– Indication: any patient who has sustained 5 days of inadPaequate intake or
anticipated to have no intake for this period.
– It can be by:
– Enteral nutrition
– Parenteral nutrition
12. Enteral nutrition
– The term ‘enteral feeding’ means delivery of nutrients into the gastrointestinal
tract.
– The alimentary tract should be used whenever possible.
– This can be achieved with normal food, oral supplements (sip feeding) or
– with a variety of tubefeeding techniques delivering food into the stomach,
duodenum or jejunum.
13.
14. SIP feeding
– used in patients who can drink but whose appetites are impaired or
– In whom adequate intakes cannot be maintained
– These feeds typically provide 200 kcal and 2 g of nitrogen per 200 mL .
– are associated with a significant overall increase in calorie and nitrogen intakes
without detriment to spontaneous nutrition
15. TUBE FEEDING
– can be achieved using conventional nasogastric tubes (Ryle’s),
– fine-bore feeding tubes inserted into the stomach,
– Surgical or percutaneous endoscopic gastrostomy (PEG) or,
– Finally, postpyloric feeding utilising nasojejunal tubes or various types of
jejunostomy
16. Tube feeding
– 20–30 mL are administered per hour initially,
– gradually increasing to goal rates within 48–72 hours.
– In most units, feeding is discontinued for 4–5 hours overnight to allow gastric
pH to return to normal.
17. Fine bore needle
If enteral nutrition required >1 week
Lesser risk of gastric and esophageal
erosion
There is a small risk of malposition
into a bronchus or of causing
pneumothorax
18. PEG
– The placement of a tube through the abdominal wall directly into the stomach
– If patients require enteral nutrition for prolonged periods (4–6 weeks), then
PEG is preferable to an indwelling nasogastric tube;
– This minimises the traumatic complications related to indwelling tubes. PEG
19. JEJUNOSTOMY
– can be achieved using nasojejunal tubes
– or by placement of needle jejunostomy at the time of laparotomy.
– authorities advocate the use of jejunostomies on the basis that :
– postpyloric feeding may be associated with a reduction in aspiration or
enhanced tolerance of enteral nutrition.
20. Contraindications
– Small bowel obstruction
– Proximal intestinal fistula
– Severe Pancreatitis
– UGI bleeding
– GI ischemia
22. Total parenteral nutrition (TPN)
-Provision of all nutritional requirements by means of the intravenousroute and
without the use of the gastrointestinal tract.
– indicated when energy and protein needs cannot be met by the enteral
administration common in :
– those patients who have undergone massive resection of the small intestine,
– who have intestinal fistula or
– who have prolonged intestinal failure for other reasons
23. Route of delivery: peripheral or
central venous access
– In earlier days, the only energy source was hypertonic glucose.
– Being hypertonic, it used to cause thrombophlebitis in peripheral vein, so it
used to be directly given in central venous route
– But nowadays, concept has changed; first energy source should be the mixture
of all carbohydrates, fat, protein and minerals.
– Also relatively non-toxic isotonic preparation of these substrates are available.
– So, nowadays, peripheral parenteral nutrition also exists
24. Peripheral
– Peripheral feeding is appropriate for short-term feeding of upto 2 weeks.
– Access:
– catheter inserted into a peripheral vein and manoeuvred into the central
venous system (peripherally inserted central venous catheter (PICC) line) or
– By using a conventional short cannula in the wrist veins.
– The former method has the advantage of minimising inconvenience to the
patient and clinician
26. Central route
– When the central venous route is chosen, the catheter can
– be inserted via the subclavian or internal or external jugular vein.
– internal or external jugular veins are easily accessible but they suffer the
disadvantage that:
– the exit site is situated inconveniently on the side of the neck, where repeated
movements result in disruption of the dressing with the attendant risk of sepsis.
– The infraclavicular subclavian approach is more suitable for feeding as the
catheter then lies flat on the chest wall, which optimises nursing care
27. HICKMAN line: for longer term parenteral nutrition :
(minimize line dislodgement and reduce the possibility of
line sepsis).
Post-insertion chest X-ray is
essential before feeding is
commenced to confirm the
absence of pneumothorax
and
that the catheter tip lies in
the distal SVC to minimize
the risk of central venous or
cardiac thrombosis
