1. Enteral nutrition is preferred over parenteral nutrition for surgical patients who can tolerate enteral feeding as it decreases complications and helps maintain gut function.
2. There are various enteral formula options depending on a patient's needs including standard, immune-enhancing, high calorie/protein, and organ-specific formulas.
3. Enteral access can be achieved through nasogastric/nasojejunal tubes, percutaneous endoscopic gastrostomy, or in some cases parenteral nutrition is required if enteral feeding is not possible. The goal is to meet energy and protein demands to support healing without overfeeding.
Ketone bodies, or simply ketones are substances produced by the liver during gluconeogenesis, a process which creates glucose in times of fasting and starvation. There are three ketone bodies produced by the liver. They are acetoacetate, beta-hydroxybutyrate, and acetone. These compounds are used in healthy individuals to provide energy to the cells of the body when glucose is low or absent in the diet.
Blood glucose regulation, glucose homeostasis, factors regulating and under S...Mohit Adhikary
The slides explain about blood glucose regulation, glucose homeostasis, factors regulating and under Special Circumstances. Factors regulating Blood glucose level include the hormonal and non-hormonal.
In the changing scenario of pharmacy practice in India, for successful practice of
Hospital Pharmacy, the students are required to learn various skills like drug distribution,
drug dispensing, manufacturing of parenteral preparations, drug information, patient
counselling, and therapeutic drug monitoring for improved patient care
Ketone bodies, or simply ketones are substances produced by the liver during gluconeogenesis, a process which creates glucose in times of fasting and starvation. There are three ketone bodies produced by the liver. They are acetoacetate, beta-hydroxybutyrate, and acetone. These compounds are used in healthy individuals to provide energy to the cells of the body when glucose is low or absent in the diet.
Blood glucose regulation, glucose homeostasis, factors regulating and under S...Mohit Adhikary
The slides explain about blood glucose regulation, glucose homeostasis, factors regulating and under Special Circumstances. Factors regulating Blood glucose level include the hormonal and non-hormonal.
In the changing scenario of pharmacy practice in India, for successful practice of
Hospital Pharmacy, the students are required to learn various skills like drug distribution,
drug dispensing, manufacturing of parenteral preparations, drug information, patient
counselling, and therapeutic drug monitoring for improved patient care
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
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Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
6. Majority of surgical patients:
• Well nourished/ Healthy
• Uncomplicated major surgical procedure
• Has sufficient fuel reserve
• Can withstand brief period of catabolic insult and
starvation of 7 days
• Postoperatively:
• Can resume normal oral intake
• Supplemental diet is not needed
7. Surgical patients that needs
nutritional support
• To shorten the postoperative recovery phase and
minimize the number of complications
• Chronically debilitated from their disease or malnutrition.
• Suffered severe trauma, sepsis or surgical complications.
8. Initial hour after Insult:
• Metabolic expenditure of energy
• Urinary nitrogen wasting
• Reprioritization of energy
• Preserve vital organ function
• Support tissue repair
9. DURING FASTING
•Normal healthy adults require ~22-25
kcal/kg per day
•Requirement can be as high as
40kcal/kg in severe stress or burns
11. Short fasting (<5 days)
Healthy adult
Muscle protein fats
Storage of carbs in form of glycogen:
300-400g carbs (glycogen)
75-100g stored in the liver
200-250g stored (SM, cardiac, smooth muscle)
Hepatic glycogen will sustain at only 16 hours of
fasting
Most abundant
source energy
17. Short-term Fasting
• Lactate - not enough
• Daily protein degradation – 75g/day for a 70kg adult
• Provide AA substrate for gluconeogenesis
• Proteolysis during starvation:
• Decrease insulin
• Increase cortisol
• Increase urinary nitrogen excretion (N- 7 to 10/day up to 30g/day)
18. Prolonged starvation
• Systemic proteolysis
• 20g/day
• Urinary excretion stabilizes:
• 2 to 5 g/day
• ADOPTATION:
• Myocardium
• Renal cortex
• Skeletal muscle
• Brain
• after 2 days-gradually become principal fuel source by
24 days
Uses:
Ketone bodies
Fuel source
19. Prolonged starvation
• Kidney – participate in gluconeogenesis
• Uses Glutamine and Glutamate
• ½ of systemic glucose production
21. Prolonged starvation
• Lipid – in adipose tissue
• Provide 40% or more caloric expenditure
• Energy requirement for basal enzymatic and
muscular function are met
• 160g FFA and glycerol per day
• FFA release is stimulated by
• Insulin level
• Glucagon
• Catecholamine
22. Metabolism after INJURY
• Injury or infection
• neuroendocrine
• immunologic response
Breakdown of
protein and stored
fats
GLUCOSE FUEL
24. LIPID METABOLISM AFTER INJURY
• Adipose tissue
• Triglycerides
• 50 – 80% energy source after an injury or during critical
illness
• Fat mobilization ( Lipolysis); response to
• Catecholamine
• ACTH
• Thyroid hormone
• Cortisol
• Growth hormone (GH)
• Decrease insulin
Oxidation produce
1g Fat = 9 kcal energy
25. Absorption of
Dietary TAGs
Major source
Hydrolyze TAG – FFA+
Monoglyceride
FFA,
Monoglyceride
absorb
Resynthesize
Esterification
LCT = 12C or>
Shorter FA Directly enter to
portal circulation-liver
carried by albumin
26. LIPID metabolism
• Hepatocytes:
• Use FA as fuel source during stress
• Synthesize phospholipids or triglyceride (Fed state)
• Systemic tissue: (Muscle, Heart)
• Use Chylomicron and triglyceride as fuel
• Lipolysis is Mediated by TNF( during stress and injury)
27. Period of energy DEMAND
• Lipolysis and FA oxidation
• Mediate by hormonal influences such as:
• Catecholamine
• ACTH
• Thyroid hormones
• Growth hormone
• Glucagon
30. • LCTs (Long-chain Triglyceride)
• Need carnitine shuttle to be transported to mitochondria
• MCTs (Medium-chain triglyceride)
• 6-12 carbons
• Readily cross the mitochondria
• Exclusive use associated with higher metabolic demands, toxicity
and essential fatty acid deficiency
31. • TCA (Tricarboxylic Acid cycle)
• 1 acetyl-CoA molecule =
• 12 ATP
• Carbon dioxide (CO2)
• Water (H2O)
• Excess Acetyl-CoA
• Precursor of ketogenesis
32. KETOGENESIS
• Carbohydrate depletion Acetyl-CoA
TCA cycle
lipolysis
carbohydrate
KETOSIS- Hepatic ketone production exceeds
extrahepatic utilization
HAPATIC KETOGENESIS
Ketogenesis rate = inversely related
severity of the injury
34. CARBOHYDRATE METABOLISM
• Refers to the utilization of glucose
• Oxidation of 1g CARBS= 4 kcal
• Parenteral = 3.4kcal/g of dextrose
Starvation:
Glucose production Expense Protein(Skeletal Muscle)
Primary Goal : Minimize muscle wasting
Glucose 50g/d will reduce ketosis
Sepsis & severe trauma exogenous glucose
administration = never suppress AA degradation to
gluconeogenesis
37. Injury and severe infection
• Hypermetabolic state
• Peripheral glucose intolerance
• Gluconeogenesis – liver (Lactate & pyruvate)
• Increase splanchnic glucose production
• 50-60% in sepsis
• 50-100% in burn
• Hepatic gluconeogenesis (alanine &Glutamine)
• Nervous system
• Wounds
• erythrocytes
Cannot be suppress by
giving exogenous
glucose
Provide fuel
38. GLUCOSE TRANSPORT &
SIGNALING
• Hydrophobic cell membrane – impermeable to
hydrophilic glucose molecules
• 2 classes of glucose membrane transporter
1. GLUT (glucose transporter)
• Facilitated diffusion transport of glucose down a concentration
gradient
2. SGLT (Na glucose transporter)
• transports glucose molecules against concentration gradient by
active transport
39.
40. GLUT SGLT
GLUT 1
– transporter in human
erythrocytes
- Part of the endothelium in the
BBB (BRAIN)
SGLT 1
- Prevalent on brush borders of the small
intestine enterocytes
- Primarily mediates the active uptake of
luminal glucose
- Enhances gut retention of water through
osmotic absorption
GLUT 2
- major glucose transporter in
Hepatocytes
- Important in glucose uptake and
and release
GLUT 3
- Neuronal tissues
SGLT 1 and 2
- Associated with glucose reabsorption at
proximal renal tubules
GLUT 4
- Primary glucose transporter of
insulin-sensitive tissues
- Implications in insulin resistant
DM
GLUT 5
- Fructose transporters
Adipose tissue, skeletal muscle &
cardiac muscle
41. PROTEIN & AA METABOLISM
• Average protein intake: 80-120 g/day
• 1 g protein = 4 kcal energy
• 6 g protein = 1 g nitrogen
• Urinary nitrogen excretion
• Excess of 30g/g = 1.5 lean body mass lost
• Injured individual who does not received nutrition for 10
days 15% lean body mass lost
• Excessive lean body mass lost of 25-30% DEATH
42. PROTEIN & AA METABOLISM
• After injury
• Mediated by glucocorticoid
• Increase urinary nitrogen excretion and negative
nitrogen balance (CHON Catabolism)
• Protein catabolism- gluconeogenesis
• Mainly in skeletal muscle (Preserve Liver & Kidney)
• Excretion of intracellular elements
• Creatinine
• Sulfur
• Phosphorus
• Potassium
• magnesium
Rapid Utilization of this elements
Indicative of HEALING during
recovery
After injury- peak 7Days
Persist – 3to 7 weeks
Response to:
1. Tissue hypoxia
2. Acidosis
3. Insulin resistance
4. Elevated glucocorticoid
47. GOALS
(1) meet the energy requirements for metabolism
(2) meet the substrate requirements for protein
synthesis
48. First goal: Estimation of
energy requirements
1. Physical examination
• Muscle
• Adipose tissue
• Organ dysfunction
• Skin
• Hair
• Neuromuscular function
2. Anthropometric data
• Weight change
• Skinfold thickness
• Arm circumference muscle area
3. Biochemical
determination
• Creatinine
• Albumin level
• Prealbumin
• TLC
• Transferrin
49. SURGICAL NUTRITION
• Estimate of energy requirements:
basal energy expenditure (BEE) using the Harris-
Benedict equation
Estimate: 30kcal/kg/day will adequately meet the requirements in most
post surgical patient
50. 2nd goal: meet substrate
requirement for CHON synthesis
Nonprotein-calorie:nitrogen ratio = 150:1
Evidence= 80:1 to 100:1 benefit healing
Vitamins and minerals: ensure that adequate
replacement is available in diet or by
supplementation.
Essential fatty acid supplementation: patients with
depletion of adipose tissue
51. Overfeeding
• Result from overestimation of caloric needs
• Contribute to clinical deterioration
1. Increase in oxygen consumption
2. Increase carbon dioxide production
3. Prolonged ventilatory support
4. Fatty liver
5. Hyperglycemia
6. Decrease immune response
7. Increase infection risk
52. ENTERAL NUTRITION
• Rationale:
1. low cost
2. Decrease intestinal mucosal atrophy
3. Less infection (Vascular access complication)
4. Consequence of GI tract disuse
• IgA production
• Cytokine production
• Bacterial overgrowth
• Altered mucosal defense
Enteral over Parenteral
feeding
53. Indication for Enteral feeding
• Hemodynamically stable
• Functional GI tract
• Early enteral feeding (24-48 hours) ICU stay
• Preoperative patient with protein caloric
malnutrition
10 days partial starvation: in patient undergoing
elective surgery (IV dextrose only)
54. Initiation of feeding
• Patient must have adequate urine output
• Presence of bowel sound and flatus or passage of stool are
not absolute.
• < 200ml in 4-6hours gastric residual
• Low output enterocutaneous fistula (<500ml/day)
• Enteral feeding: short bowel syndrome, clinical
malabsorption( necessary calories, essential minerals &
vitamins= parenteral)
• Trophic feeding= no additional benefits
Gastroparesis= feeding should be distal to pylorus
55. Feeding formula consideration
1. GI-tolerance promoting
2. Anti-inflammatory
3. Immune modulating
4. Organ supportive
5. Standard enteral nutrition
Each physician must use his or her own clinical
judgment = what best formula for the patients need
56. Factors that influence the
choice of formula
1. Extent of organ dysfunction
2. Nutrients needed to restore optimal
function and healing
3. Cost
There are no conclusive data to
recommend one category of product
over the other
57. Immunonutrients
• Glutamine- Nonessential AA
• Most abundant
• 2/3 of the free intracellular AA pool
• 75% within skeletal muscle
• Synthesize in SM and Lung
• Major fuel in enterocytes, immunocytes
• Precursor of glutathione
During stress= peripheral glutamine are rapidly depleted and
AA use primarily for fuel source toward the visceral organs and
tumor
58. •Arginine
• Nonessential AA
• Immunoenhancing property
• Wound-healing benefits
• Led net nitrogen retention and protein synthesis
Omega-3 PUFA, Omega-6 PUFA
• Reduces proinflammatory response from prostaglandin
production
59. ENTERAL FORMULAS
LOW RESIDUE ISOTONIC
• Provide a caloric density of 1 kcal/mL
• Approx. 1500-1800 ml
• Nonprotein-calorie: nitrogen ratio: 150:1
• Standard or first-line formulas for stable patients
with intact gastrointestinal tract
60. ISOTONIC W/ FIBER
• Reduce diarrhea (delay intestinal transit time)
• Contain soluble and insoluble fiber (most often soy-
based
IMMUNE-ENHANCING
• Contains: glutamine, omega-3 fatty acids, Arginine and
nucleotides
No additional benefit for critically ill except for burn
and trauma patients that are already stabilize
61. CALORIE-DENSE
• Calorie-dense (greater caloric value for the same
volume)
• Suitable for patient requiring fluid restriction
• Provide 1.5-2.0 kcal/ml, suitable for patients
requiring fluid restriction
• Have higher osmolality than standard formulas and
are suitable for intragastric feedings
62. HIGH PROTEIN
• Available in isotonic and non-isotonic mixtures and
proposed for critically ill or trauma patients with high
protein requirements
• 80-120:1 nonprotein-calorie:nitrogen ratio
63. ELEMENTAL
• Contain predigested nutrients and provide proteins
in the form of small peptides, limited complex
carbohydrates, minimal fat content
• Easily absorbed
• Trace elements limits its long-term use
• Used mostly in patient with malabsorption, gut
impairment, and pancreatitis
64. RENAL-FAILURE FORMULA
Lower concentration of K,P, Mg
Contains essential amino acids
Lack vitamins and trace elements
PULMONARY FAILURE FORMULA
Fat content increased to 50% or total calories to reduce
CO2 production
HEPATIC FAILURE FORMULA
50% of proteins and branched chain amino acids (reduce
aromatic amino acids)
Goal is to reduce aromatic AA levels
68. C. PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY (PEG)
Endoscopy skills required
may be used for gastric decompression or bolus
bolus feeds
aspiration risks
can last 12–24 months
slightly higher complication rates with
placement and site leaks
69.
70.
71. D. SURGICAL GASTROSTOMY
Requires general anesthesia and small
laparotomy
procedure may allow placement of extended
duodenal/jejunal feeding ports
laparoscopic placement possible
72. E.FLUOROSCOPIC GASTROSTOMY
Blind placement using needle and T-
prongs to anchor to stomach;
can thread smaller catheter through
gastrostomy into duodenum/jejunum
under fluoroscopy
73. F. PEG-JEJUNAL TUBE
two-stage procedure with PEG
placement, followed by fluoroscopic
conversion with jejunal feeding tube
through PEG
74. G. DIRECT PERCUTANEOUS ENDOSCOPIC
JEJUNOSTOMY (DPEJ)
Direct endoscopic tube placement with
enteroscope
placement challenges
greater injury risks
77. PARENTERAL NUTRITION
• Continuous infusion of a hyperosmolar solution
containing carbohydrates, proteins, fat and other
necessary nutrients through an indwelling catheter
inserted into the superior vena cava
• To obtain the maximum benefit, the calorie:protein
ratio must be adequate (at least 100 to 150 kcal/g
nitrogen) and both carbohydrates and proteins must
be infused simultaneously
79. CENTRAL
PARENTERAL
NUTRITION
PERIPHERAL
PARENTERAL
NUTRITION
Central vein Peripheral vein
Dextrose content of the
solution is high (15% to
25%)
Reduced levels of dextrose (5%
to 10%) and protein (3%)
macronutrients and
micronutrients
Amount of Macronutrients
and micronutrients.
Appropriate for severe
malnutrition
*used when central routes not
available
*only used for less than 2 wks
82. “Students, you do not
study to pass the test. You
study to prepare for the
day when you are the only
thing between a patient
and the grave”
Mark Ried
Editor's Notes
Army into battlefield
They need these for energy
Imagine these are your army.
Initial hours following surgical or traumatic injury are metabolically associated with a reduced total body energy expenditure and urinary nitrogen wasting.
This phase of recovery also characterized by functions that participate in the restoration of hemostasis such as augmented metabolic rates and oxygen consumption, enzymatic preference for readily oxidizable substrate such as glucose and stimulation of immune system
A Normal healthy adults require ~22-25 kcal/kg per day (drawn from carbohydrates, lipids and protein sources) to maintain basal metabolic needs
Fuel utilization in a 70-kg man during short-term fasting with an approximate basal energy expenditure of 1800 kcal. During
starvation, muscle proteins and fat stores provide fuel for the host, with the latter being most abundant.
In the healthy adult, principal sources of fuel during short-term fasting (<5 days) are derived from muscle protein and body fat, with fat being the most abundant source of energy
Glycogen in the muscle are not readily available therefore hepatic glycogen are rapidly and preferentially depleted and fall in glucose serum in <16 hours
This table shows that the fat is the most abundant source of energy and followed by protein
Below is the substrate and its equivalent energy kcal/g and its daily requirement
During fasting, a healthy 70-kg adult will use 180 g of
glucose per day to support the metabolism of obligate glycolytic
cells such as neurons, leukocytes, erythrocytes, and the renal
medullae.
What promotes glycogenolysis? Breakdown of glycogen into glucose
Gluconeogenesis: Produce glucose
Glycolysis is defined as breakdown of glucose molecule into lactate & pyruvate to produce high free energy (ATP, NADPH)
The recycling of
peripheral lactate and pyruvate for
hepatic gluconeogenesis is accomplished by the Cori cycle. Alanine within skeletal muscles can also be
used as a precursor for hepatic gluconeogenesis. During starvation, such fatty acid provides fuel sources
for basal hepatic enzymatic function
Lactate production from skeletal muscle is insufficient during short-term fasting
(simple starvation). Therefore, Protein degraded daily (75 g/d for a 70-kg adult) to provide the
amino acid substrate for hepatic gluconeogenesis. Although proteolysis during starvation
occurs mainly within skeletal muscles, protein degradation
in solid organs also occurs.
This reduction in proteolysis reflects
the adaptation by vital organs (e.g., myocardium, brain, renal
cortex, and skeletal muscle) to using ketone bodies as their principal
fuel source. In extended fasting, ketone bodies become an
important fuel source for the brain after 2 days and gradually
become the principal fuel source by 24 days.
Energy requirement for basal enzymatic and muscular function are met from mobilization of triglyceride from adipose tissue
The magnitude of metabolic
expenditure appears to be directly proportional to the severity
of insult, with thermal injuries and severe infections having the
highest energy demands
REE (Resting energy expenditure)
Exogenous and dietary provide a major source of triglycerides. Dietary lipids are not readily absorb require pancreatic lipase and phospholipase to hydrolize trigly to FFA MONOgly
Fig 12. Fat mobilization in adipose tissue. TAGs are serially hydrolyzed with resultant FFA release every step. The FFAs diffuse readily into the capillary bed for transport
FFA absorbed in the cell conjugate with acyl=CoA within the cytoplasm.
Fatty acyl-CoA cannot enter the inner mil mitochondrial membrane and require carnitine as a carrier protein
Carbohydrate depletion slows the entry of acetyl-CoA into
the TCA cycle secondary to depleted TCA intermediates and
enzyme activity. Increased lipolysis and reduced systemic carbohydrate
availability during starvation diverts excess acetyl-
CoA toward hepatic ketogenesis.
Starvation in healthy adult:
The primary goal for maintenance glucose administration in surgical patients is
to minimize muscle wasting. The exogenous administration of
small amounts of glucose (approximately 50 g/d) facilitates fat
entry into the TCA cycle and reduces ketosis.
Fig 13. Simplified schema of glucose metabolism through the pentose monophosphate pathway or by breakdown into pyruvate. Glucose-6- phosphate is an important “cross road” for glucose metabolism.
Deleterious to the patient
Amino acids cannot be considered a long-term fuel reserve
Indeed excessive protein depletion (25% to 30% of lean body weight) is not compatible with sustaining life.
Elective operations and minor injuries result in lower protein synthesis
and moderate protein breakdown. Severe trauma, burns, and
sepsis are associated with increased protein catabolism.
Estimate: low risk of over feeding
Ideal body weight should be calculated from BEE to avoid overfeeding
(esp. obese and px with anasarca)
Enteral feeding is preferred than parenteral
Mostly patient undergoing elective surgery can tolerate 10 days of partial starvation
Options for enteral feeding
Intravenous access methods: 16-gauge catheter inserted into a subclavian or internal jugular vein and threaded into the superior vena cava