The document discusses liver disease and nutrition. It begins by reviewing the functions of the liver and various liver diseases. It then discusses nutritional features of end-stage liver disease and nutritional assessment and management guidelines. Specific topics covered include neurological symptoms associated with liver disease, nutritional assessment tools for patients with end-stage liver disease, daily energy expenditure calculation methods, progression of liver disease, and ESPEN guidelines on enteral and parenteral nutrition for various liver diseases.
http://www.our-diabetic-life.com Intake of large amount of carbohydrates can spike your blood glucose level. Right amount of carbohydrate can make your glucose level under control.
http://www.our-diabetic-life.com Intake of large amount of carbohydrates can spike your blood glucose level. Right amount of carbohydrate can make your glucose level under control.
Nutritional assessment in chronic liver diseaseShaimaa Elkholy
Protein Energy Malnutrition (PEM) is highly prevalent among patients with chronic liver disease. One of the problems is how to assess these patients nutritionally. yet no standard golden rule for their nutritional assessment.
Diet treatment in liver cirrhosis - di Vincenzo Ostilio PalmieriMedOliveOil
Dieta nella cirrosi epatica - di Vincenzo Ostilio Palmieri. 21 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
Nutritional assessment using anthropometric, biochemical, clinical, and dietary methods with a larger understanding of anthropometric methods used in Ethiopia
Liver Transplant India help to choose the best food your liver which is help to make a fit and Healthy liver. http://www.livertransplantindia.com/liver-diet.asp
Nutritional assessment in chronic liver diseaseShaimaa Elkholy
Protein Energy Malnutrition (PEM) is highly prevalent among patients with chronic liver disease. One of the problems is how to assess these patients nutritionally. yet no standard golden rule for their nutritional assessment.
Diet treatment in liver cirrhosis - di Vincenzo Ostilio PalmieriMedOliveOil
Dieta nella cirrosi epatica - di Vincenzo Ostilio Palmieri. 21 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
Nutritional assessment using anthropometric, biochemical, clinical, and dietary methods with a larger understanding of anthropometric methods used in Ethiopia
Liver Transplant India help to choose the best food your liver which is help to make a fit and Healthy liver. http://www.livertransplantindia.com/liver-diet.asp
Hepatitis affects liver cells. it needs proper nutritional support. If proper diet and medicinal treatment given, easy recovery from this disease is possible. As this disease affects your nutritional status, taking care of your nutritional health is equally important.
What exactly is a renal diet is asked by many people as they are concerned about possible kidney disease. Discover 4 important tips and recommended foods to strengthen your kidneys and deter kidney disease
Kidneys are the vital organs in the human body. Its main function is to remove the waste products from our body. At the stages of kidney disease it can’t completely remove toxins, excess salt, water, etc. So these waste products build up in the body and create problems. At the stages of kidney disease we have to follow a healthy renal diet without overloading kidneys. Here we are providing a general diet for kidney disease patients also who are prone to kidney disease. By making simple changes in lifestyle & diet we can improve renal health. Here also provided three simple tests to check for kidney diseases.
protein metabolism
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Proteins are macro-molecules crucial for cell life, which are made up of amino acids (AAs). In healthy people, protein synthesis and degradation are well balanced. However, in the presence of hypercatabolic stimulation (i.e., inflammation), protein breakdown increases as the resulting AAs are consumed for metabolic proposes. Indeed, AAs are biochemical totipotent molecules which, when deaminated, can be transformed into energy, lipids, carbohydrates, and/or biochemical intermediates of fundamental cycles, such as the Krebs’ cycle. The biochemical consequence of hyper-catabolism is protein disarrangement, clinically evident with signs such as sarcopenia, hypalbuminemia, anaemia, infection, and altered fluid compartmentation, etc. Hypercatabolic protein disarrangement (HPD) is often underestimated by clinicians, despite correlating with increased mortality, hospitalization, and morbidity quite independent of the primary disease. Simple, cheap, repeatable measurements can be used to identify HPD. Therefore, identification and treatment of proteins’ metabolic impairment with appropriate measurements and therapy is a clinical strategy that could improve the prognosis of patients with acute/chronic hypercatabolic inflammatory disease. Here, we describe the metabolism of protein and AAs in hypercatabolic syndrome, illustrating the clinical impact of protein disarrangement. We also illustrate simple, cheap, repeatable, and worldwide available measurements to identify these conditions. Finally, we provide scientific evidence for HPD nutritional treatment.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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
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
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. • Review the functions of the liver
• Review diseases of the liver
• Understanding neuro-psychological
symptoms associated with liver disease
• Nutritional features of end stage liver
disease
• Nutritional assement of end stage liver
disease
• Nutritional management –ESPEN
GUIDELINES IN LIVER DISEASE
3. Functions of the Liver:
• Largest organ in body, integral to most
metabolic functions of body,
• Only 10-20% of functioning liver is
required to sustain life
• Removal of liver will result in death within
24 hours
4. • Main functions include:
– Metabolism of CARBOHYDRATE, protein, fat
– Storage/activation vitamins and minerals
– Formation/excretion of bile
– Steroid metabolism, detoxifier of drugs/alcohol
– Action as (bacteria) filter and fluid chamber
– Conversion of ammonia to urea
• Gastrointestinal tract significant source of ammonia
• Generated from ingested protein substances that are
deaminated by colonic bacteria
• Ammonia enters circulation via portal vein
• Converted to urea by liver for excretion
9. Understanding neuro-psychological symptoms
associated with liver disease
All neurological and psychological symptoms in patients with liver
disease that cannot be explained by presence of other
pathologies
• Brain and nervous system damage secondary to severe
liver dysfunction (most often chronic disease) resulting
from failure of liver to remove toxins
• Multifactorial pathogenesis with exact cause unknown
• Symptoms vary from nearly undetectable, to coma with
decerebration
– Characterized by various neurologic symptoms
• Cognitive impairment
• Neuromuscular disturbance
• Altered consciousness
• Reversible syndrome
10. Pathogenesis Theories
• Endogenous Neurotoxins
– Ammonia
– Mercaptans
– Phenols
• Increased Permeability of Blood-Brain Barrier
• Change in Neurotransmitters and Receptors
– GABA
– Altered BCAA/AAA ratio
• Other
– Zinc defficiency
11. Neurotoxic Action of Ammonia
• Readily crosses blood-brain barrier
• Increased NH3 = increased glutamate
– α-ketoglutarate+NH3+NADH→glutamate+NAD
– glutamate+NH3+ATP→glutamine+ADP+Pi
• As a-ketoglutarate is depleted TCA cycle activity halted
• Increased glutamine formation depletes glutamate stores
which are needed by neural tissue
– Irrepairable cell damage and neural cell death ensue.
– In liver disease, conversion of ammonia to urea and
glutamine can be reduced up to 80%
12. False Neurotransmitter Hypothesis
• Liver cirrhosis characterized by altered
amino acid metabolism
• Increased Aromatic Amino Acids in plasma and
influx in brain
• Decrease in plasma Branched Chain Amino Acids
• Share a common carrier at blood-brain barrier
• DECREASE BCAAs in blood may result in
INCREASE AAA transport to brain
13. • AAA are precursors to neurotransmitters
and elevated levels result in shunting to
secondary pathways
14. Change In Neurotransmitters and Receptors
• BRANCH CHAIN AMINOACID.
• Fischer and colleagues, published their
‘‘unifiedhypothesis on the pathogenesis of
HE’’ based on the observation that during
hepatic failure, plasma levels of BCAA
decreased and the AAA increased, DUE
TO increased BCAA catabolism in muscle
and decreased AAA breakdown in the
failing liver.
15. • A reduction in the insulin/glucagon ratio
was hypothesized to play a key role in
disturbing the balance between anabolism
and catabolism.
• Give rise to a decrease in the BCAA/AAA
ratio, which was called the Fischer-ratio
(BCAA/AAA ratio).
16. The increase in plasma AAA incombination
with an increased blood brain barrier
permeability for neutral amino acids has
been suggested to contribute to an
increased influx of AAA in the brain,
because they compete for the same
transporter (large neutral amino acid
transporter). This, inturn, would lead to
imbalances in neurotransmitter synthesis
and accumulation of falsneurotransmitters,
such as octopamine in thebrain, which
may contribute to HE
17. • hyperammonemia during liverfailure, ammonia is
detoxified by alternative pathways, the most
important of which, although essentially
temporary, is the formation of glutamine from
ammonia and glutamate maInly in muscle &
brain.
• In muscle BCAA transaminate with a-
ketoglutarate in the BCAA transferasereactions ,
yielding glutamate, explaining why
hyperammonemia may contribute to low plasma
BCAA
18. • coupling of ammonia to glutamate in the
glutaminsynthetase reaction as an alternative
ammonia detoxification route,
• glutamine is exported from muscle and
brain.The increased cerebral release of
glutamine in this hypothesis was thought to
facilitate the rapid exchange of glutamine for
neutral amino acids, notably the AAA, by the
large neutral amino acid carrier- This increased
influx of AAA in the brain would raise the
availability of precursors for neutrotransmitters.
19. • BCAA levels are crucially determined by
nutritional factors, whereas AAA levels
appear to depend much more upon intact
hepatic metabolism.
20. Increase Permeability of Blood-
Brain Barrier
• Astrocyte (glial cell) volume is controlled by
intracellular organic osmolyte
• Organic osmolyte is glutamine.
• glutamine levels in the brain result in volume
of fluid within astrocytes resulting in cerebral
edema (enlarged glial cells)
• Neurological impairment
– N=Normal Astrocytes
– A=Alzheimer type II astrocytes
– Pale, enlarged nuclei
– characterisic of HE
21. Nutritional Assessment of
patients with ESLD
Weight?
Weight history?
Protein markers of nutritional status?
Descriptive history of wasting?
Skinfolds?
Intake?
Appetite?
22. Assement…
SGA for patients with liver disease ..
Anthropometry
Food history
Nausea
Anorexia
Taste changes
Diarrhoea
Early satiety
Functional capacity
Grip strength
23. Daily energy expenditure
1) predictive equation;-harris benedict
equation( based on sex,ideal body wt,
height).
• Men: BMR = 66 + ( 13.7 x wt,kg ) + ( 5 x ht inch ) - ( 6.7
x age in year )
• Women: BMR = 655 + ( 9.6 x wt,kg ) + ( 1.8 x ht inch )
- ( 4.7 x age in years )
24. • BEE(KCAL/DAY)- 25 x WT IN KG
• To allow the thermal effect of food intake
the BEE multiplied by 1.2 to derive the
resting energy expenditure-is in resting
tate but not on fasted state.
• In hypermetabolic condition –
• Mild stress-BEEx1.2
• Mod stress-BEEx1.4
• Severe stress –BEEx1.6
25. • 2) indirect calorimetry.
It is impossibel to mesure metabolic heat
production in clinical practise, the
metabolic energy expenditure is mesured
indirectly by mesuring whole body vo2 and
vco2,technique called indirect calorimetry.
27. ;NUTRION IN ALCOHOLIC HEPATITIS
subject recommendation grade
general Use simple bedside methods such as the
SubjectiveGlobal Assessment (SGA) or anthropometry
to identify patients at risk of undernutrition.
Recommended energy intake: 35–40 kcal/kg BW/d
Recommended protein intake: 1.2–1.5 g/kgBW/d
C
c
c
application Use supplementary enteral nutrition when patients
cannot meet their caloric requirements through
normal food.
In general, oral nutritional supplements are
recommended.
A
28. subject recommendation gerad
route Use tube feeding if patients are not able to maintain
adequate oral intake (even when oesophageal
varices are present)
PEG placement is associated with a higher risk of
complications and is not recommended
A
C
Type of
formula
Whole protein formulae are generally
Recommended.
Consider using more concentrated high-energy
formulae in patients with ascites.
Use BCAA-enriched formulae in patients with
hepatic encephalopathy arising during enteral
nutrition.
C
C
A
29. nutrition in liver cirrhosis
subject recommendation grade
General Use simple bedside methods such as the Subjective
Global Assessment (SGA) or anthropometry to
identify patients at risk of undernutrition.
Recommended energy intake: 35–40 kcal/kgBW/d
Recommended protein intake: 1.2–1.5 g/kgBW/d
C
C
C
application Use supplementary enteral nutrition when patients
cannot meet their caloric requirements through
normal food.
In general, oral nutritional supplements are
recommended.
A
A
30. route Use tube feeding if patients are not able to maintain
adequate oral intake (even when oesophageal
varices are present)
PEG placement is associated with a higher risk of
complications and is not recommended
A
c
Type of
formula
Whole protein formulae are generally
recommended.
Consider using more concentrated high-energy
formulae in patients with ascites.
Use BCAA-enriched formulae in patients with
hepatic encephalopathy arising during enteral
nutrition.
The use of oral BCAA supplementation can improve
clinical outcome in advanced cirrhosis
C
C
A
B
31. Nutrition in transplantation AND
SURGERY .surgerySUBJ RECOMME.. GRADE
preoperative Follow recommendations for cirrhosis. B
postoperative Initiate normal food/enteral nutrition within
12–24 h postoperatively.
Initiate early normal food or enteral nutrition after
other surgical procedures
B
route
preop Follow recommendations for cirrhosis.
postop Use nasogastric tubes or catheter jejunostomy for
early enteral nutrition.
b
FORMULA-
PREOP
Follow recommendations for cirrhosis.
POSTOP Whole protein formulae are generally
recommended.
In patients with ascites prefer concentrated high
energy formulae for reasons of fluid balance.
Use BCAA-enriched formulae in patients with
hepatic encephalopathy arising during enteral
nutrition.
C
C
A
32. OUTCOME-
PREOP
An improvement of perioperative mortality or
complication rate by preoperative tube feeding or
oral nutritional supplements has not yet been
showN.
OUTCOME-
POSTOP
Early normal food or enteral nutrition is
recommended for transplant and surgery patients
with LC in order to minimise perioperative—in
particular infectious—complications.
34. NUTRTION IN ALCOHOLIC
STETOHEPATITIS
SUBJECT RECOMMEN.. GRADE
GENERAL Use simple bedside methods such as the Subjective
Global Assessment (SGA) or anthropometry to identify
patients at risk of undernutrition.
Start PN immediately in moderately or severely
malnourished ASH patients, who cannot be fed
sufficiently either orally or enterally.
Give i.v. glucose (2–3 g kg1 d1) when patients have to
abstain from food for more than 12 h.
Give PN when the fasting period lasts longer than 72 h.
C
A
C
C
ENERGY Provide energy to cover 1.3REE .
Give glucose to cover 50–60 % of non-protein energy
requirements.
Use lipid emulsions with a content of n-6 unsaturated
fatty acids ..
C
C
C
35. AMINOACID
S
Provide amino acids at 1.2–1.5 g kg1 d C
MICRONUTR
IENT
Give water soluble vitamins and trace elements daily
from the first day of PN.
Administer vitamin B1 prior to starting glucose infusion
to reduce the risk of Wernicke’s encephalopathy
C
C
MONITORIN
G
Employ repeat blood sugar determinations in order to
detect hypoglycemia and to avoid PN related
hyperglycemia.
Monitor phosphate, potassium and magnesium levels
when refeeding malnourished patients.
C
C
36. IN LIVER CIRRHOSIS
SUBJECT RECOMMEN.. GRAD
E
GENERAL Start PN immediately in moderately or severely
malnourished cirrhotic patients, who cannot be fed
sufficiently eitherorally or enterally.
Give i.v. glucose (2–3 g kg1 d1) when patients have
to abstain from food for more than 12 h.
Give PN when the fasting period lasts longer than
72 h.
Consider PN in patients with unprotected airways
and encephalopathy when cough and swallow
reflexes are compromised.
Use early postoperative PN if patients cannot be
nourished sufficiently by either oral or enteral route.
After liver transplantation, use early postoperative
nutrition; PN is second choice to EN.
C
A
C
C
C
A
37. ENERGY Provide energy to cover 1.3 x REE
Give glucose to cover 50 % - 60 % of non-protein
energy requirements.
Reduce glucose infusion rate to 2–3 g kg1 d1 in case
of hyperglycemia and use consider the use of i.v.
insulin.
Use lipid emulsions with a content of n-6 unsaturated
fatty acids lower than in traditional pure soybean oil
emulsions
C
C
C
AMINOACID
S
Provide amino acids at 1.2–1.5 g kg
In encephalopathy III or IV, consider the use of
solutions rich in BCAA and low in AAA, methionine
and tryptophane
C
A
38. MICRONUTR
IENT
Give water soluble vitamins and trace elements daily
from the first day of PN.
In alcoholic liver disease, administer vitamin B1 prior
to starting glucose infusion to reduce the risk of
Wernicke’sencephalopathy
C
C
MONITORIN
G
Employ repeat blood sugar determinations in order to
avoid PN related hyperglycemia.
Monitor phosphate, potassium and magnesium levels
when refeeding malnourished patients
A
C
39. IN ACUTE LIVER FAILURE
GENERAL Commence artificial nutrition when patient is unlikely to
resume normal oral nutrition within the next 5–7 days.
Use PN when patients cannot be fed adequately by
EN.
C
C
ENERGY Provide energy to cover 1.3 REE.
Consider using indirect calorimetry to measure
individual energy expenditure.
Give i.v. glucose (2–3 g kg1 d1) for prophylaxis or
treatment of hypoglycaemia.
In case of hyperglycaemia, reduce glucose infusion
rate to 2–3 g kg1 d1 and consider the use of i.v.
insulin.
Consider using lipid (0.8 – 1.2 g kg1 d1) together with
glucose to cover energy needs in the presence of
insulin resistance
C
C
C
C
C
40. IN ACUTE LIVER FAILURE
SUBJ RECOMMEN GRAD
E
AMINOACID In acute or subacute liver failure, provide amino acids
at 0.8–1.2 g kg1 d1.
C
MONITORIN
G
Employ repeat blood sugar determinations in order to
detect hypoglycaemia and to avoid PN related
hyperglycaemia.
Employ repeat blood ammonia determinations in order
to adjust amino acid provision.
C
C
41. References
• Cornelis H. C. Dejong,4* Marcel C. G. van de Poll,4
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43. • NEUROTRANSMITTERS IN HEPATIC
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Thank you.