A-Nutritional A-Nutritional requirementsrequirements

The nutritional requirements of any The nutritional requirements of any human are divided into 3 broad human are divided into 3 broad categories:categories:

1.Energy requirements:1.Energy requirements:

2.Build-up requirements.2.Build-up requirements.

3.Vitality requirements3.Vitality requirements

1.Energy requirements1.Energy requirements

adult needs 30-50 KCal/Kg/dayadult needs 30-50 KCal/Kg/day growing child needs up to 100-120 growing child needs up to 100-120

KCal/Kg/dayKCal/Kg/day Provided mainly by carbohydrates(1gm Provided mainly by carbohydrates(1gm

leads to 4 KCaL) and fat (1gb leads to leads to 4 KCaL) and fat (1gb leads to 9 KCaL). 9 KCaL).

In late starvation protein(1gm leads to In late starvation protein(1gm leads to 4KCL) becomes the only source after 4KCL) becomes the only source after depletion of fat and carbohydrate depletion of fat and carbohydrate stores .stores .

2.Build-up requirements2.Build-up requirements

Provided by proteinProvided by protein The minimum for dynamic keep a healthy The minimum for dynamic keep a healthy

adult in a positive nitrogen balance is adult in a positive nitrogen balance is estimated at 35-40 g protein/day. estimated at 35-40 g protein/day.

The hypercatabolic patient [severe sepsis, The hypercatabolic patient [severe sepsis, severe trauma and burns and in severe severe trauma and burns and in severe disease conditions as pancreatitis.] may disease conditions as pancreatitis.] may need 3 or 4 times this amount. need 3 or 4 times this amount.

3.Vitality requirements3.Vitality requirements

1-Water : resting individual need 30 1-Water : resting individual need 30 mL/Kg/daymL/Kg/day

2-VitaminsA : balanced diet usually 2-VitaminsA : balanced diet usually provides sufficient vitaminsprovides sufficient vitamins

-Vitamin C -Vitamin B12 -Folinic acid-Vitamin C -Vitamin B12 -Folinic acid

-Vitamin A -Vitamin K-Vitamin A -Vitamin K

3-Minerals and trace elements:3-Minerals and trace elements:

Na, K, Fe, Ca and MgNa, K, Fe, Ca and Mg

B. Assessment of B. Assessment of nutritional statusnutritional status

1.Body weight. 1.Body weight.

2.Body mass index [BMI]. BMI = WEIGHT 2.Body mass index [BMI]. BMI = WEIGHT [Kg]/ HEIGHT2 [M2]. Normally, it ranges [Kg]/ HEIGHT2 [M2]. Normally, it ranges between 20 and 25.between 20 and 25.

3.Upper arm circumference. Feeding is 3.Upper arm circumference. Feeding is indicated if < 25 cm in the male or < 23 cm indicated if < 25 cm in the male or < 23 cm in the female.in the female.

4.Triceps skin fold thickness. The minimum is 4.Triceps skin fold thickness. The minimum is 10 mm in the male and 13 mm in the female.10 mm in the male and 13 mm in the female.

5.Serum albumin shouldn't be < 3.5 g/dL.5.Serum albumin shouldn't be < 3.5 g/dL.

C. MalnutritionC. Malnutrition 1.Etiology:1.Etiology:

a. Preoperative malnutrition may result from:a. Preoperative malnutrition may result from:

(1)Starvation, which may be secondary to:(1)Starvation, which may be secondary to:

(a)Poverty and inability to obtain food.(a)Poverty and inability to obtain food.

(b)Dysphagia. (c)Vomiting(b)Dysphagia. (c)Vomiting

(d)Self neglect, eg alcoholics and the elderly.(d)Self neglect, eg alcoholics and the elderly.

(2)Failure of digestion, eg(2)Failure of digestion, eg

(a)Pancreatic or biliary disease, eg (a)Pancreatic or biliary disease, eg carcinoma, stone.carcinoma, stone.

(b)Duodenal or jejunal disease, eg fistula, (b)Duodenal or jejunal disease, eg fistula, blind loop syndrome.blind loop syndrome.

b.Postoperative malnutrition is usually b.Postoperative malnutrition is usually the result of the stress of surgery and the result of the stress of surgery and is of a transient nature. However, it is of a transient nature. However, it may be as severe with such major may be as severe with such major operations as esophagectomy and with operations as esophagectomy and with paralytic ileus.paralytic ileus.

2.Manifestations:2.Manifestations:

a. General:a. General:

(1)Physical and mental exhaustion(1)Physical and mental exhaustion

(2)Infection, due to immunosuppression(2)Infection, due to immunosuppression

(3)Intolerance to radio- and chemo-therapy(3)Intolerance to radio- and chemo-therapy

b.Metabolic:b.Metabolic:

(1)Lowered rates of enzyme synthesis(1)Lowered rates of enzyme synthesis

(2)Impaired oxidative metabolism of drugs by (2)Impaired oxidative metabolism of drugs by the liverthe liver

c.Healing problems:c.Healing problems:

(1)Wound dehiscence(1)Wound dehiscence

(2)Leakage from bowel anastomoses(2)Leakage from bowel anastomoses

(3)Delayed callus formation(3)Delayed callus formation

(4)Disordered coagulation(4)Disordered coagulation

D.Indications of D.Indications of nutritional supportnutritional support

1.Diminished food intake in:1.Diminished food intake in:

a. Preoperative malnutrition b.Comaa. Preoperative malnutrition b.Coma

c.Postoperative ileus lasting for > 4 daysc.Postoperative ileus lasting for > 4 days

2.Diminished digestion and absorption, eg:2.Diminished digestion and absorption, eg:

A-Pyloric stenosis b.Pancreatic disease A-Pyloric stenosis b.Pancreatic disease

c.Biliary disease d.Malabsorption c.Biliary disease d.Malabsorption syndromesyndrome

e.Short bowel syndrome f.Radiation enteritise.Short bowel syndrome f.Radiation enteritis

g.Ulcerative colitis h.Duodenal fistulag.Ulcerative colitis h.Duodenal fistula

3.Chronic disease, eg:3.Chronic disease, eg:

a. Chronic cardiac, hepatic or renal a. Chronic cardiac, hepatic or renal diseasedisease

b.Malignant diseaseb.Malignant disease

4.Hypercatabolic states:4.Hypercatabolic states:

a.Polytraumaa.Polytrauma

b.Burnb.Burn

c.Sepsisc.Sepsis

ENTERAL NUTRITIONENTERAL NUTRITION A. By mouth: Other routes should be attempted A. By mouth: Other routes should be attempted

only when it is not possible to use this route.only when it is not possible to use this route. B. By nasogastric tube:B. By nasogastric tube:

1.Types1.Types

a.Ordinary Ryle's tube b. Fine-bore NG tubea.Ordinary Ryle's tube b. Fine-bore NG tube

2.Indications:2.Indications:

a.To overcome a severe esophageal stricture.a.To overcome a severe esophageal stricture.

b.To feed the comatosed, enabling the tube to b.To feed the comatosed, enabling the tube to reach the duodenum, thus decreasing the risk of reach the duodenum, thus decreasing the risk of pulmonary aspiration in this high-risk group.pulmonary aspiration in this high-risk group.

3.Precautions:3.Precautions:

a. Making sure that gastric emptying is a. Making sure that gastric emptying is normalnormal

b.Fine tube blockage can be overcome b.Fine tube blockage can be overcome by 2 mL water. c. All feeds should be by 2 mL water. c. All feeds should be stored at 4o C until use, not exposed to stored at 4o C until use, not exposed to room temperature for 8 h and discarded room temperature for 8 h and discarded if not used after 12 h.if not used after 12 h.

d.Bacteriological monitoring is d.Bacteriological monitoring is essential, as kitchens may be a source of essential, as kitchens may be a source of Klebsiella infectionKlebsiella infection

4.Complications:4.Complications:

a. Nausea ± vomiting ± diarrhea, usually a. Nausea ± vomiting ± diarrhea, usually due to anaerobic contamination. This can due to anaerobic contamination. This can simply be treated by metronidazole 500 simply be treated by metronidazole 500 mg bid.mg bid.

b. Gastro esophageal reflux and pulmonary b. Gastro esophageal reflux and pulmonary aspiration, particularly with the aspiration, particularly with the nasogastric tube in the absence ofnasogastric tube in the absence of

the gag reflex and especially in the the gag reflex and especially in the comatose.comatose.

c.Diabetes and hyperosmolar states, mainly c.Diabetes and hyperosmolar states, mainly related to a high carbohydrate intake, with related to a high carbohydrate intake, with particular hazard to the established particular hazard to the established diabetic.diabetic.

C. By tube enterostomyC. By tube enterostomy1.Definition. Tube enterostomy is the operative 1.Definition. Tube enterostomy is the operative

placement of a tube or catheter into the GIT.placement of a tube or catheter into the GIT.

2.Indications:2.Indications:

a. Inability to insert a fine-bore NG tubea. Inability to insert a fine-bore NG tube

b.When more than 4 weeks of enteral feeding is b.When more than 4 weeks of enteral feeding is anticipated.anticipated.

3.Contraindications:3.Contraindications:

a.To tube enterostomy in general: partial or complete a.To tube enterostomy in general: partial or complete gastric or intestinal obstruction.gastric or intestinal obstruction.

b.To gastrostomy:b.To gastrostomy:

(1)Gastric disease(1)Gastric disease

(2)Impaired gastric emptying(2)Impaired gastric emptying

(3)Significant GER(3)Significant GER

(4)Loss of the gag reflex(4)Loss of the gag reflex

4.Types:4.Types:a.Gastrostomiesa.Gastrostomies

b.Jejunostomies:b.Jejunostomies:

PARENTERAL PARENTERAL NUTRITIONNUTRITION

A. Indications:A. Indications:

1.When enteral feeding is not feasible [ie 1.When enteral feeding is not feasible [ie intestinal failure, which may be temporary or intestinal failure, which may be temporary or permanent].permanent].

a. Temporary intestinal failure occurs as a a. Temporary intestinal failure occurs as a consequence of the temporary ileus consequence of the temporary ileus following any abdominal surgery.following any abdominal surgery.

b.Permanent intestinal failure occurs with b.Permanent intestinal failure occurs with small bowel resection. It is an indication for small bowel resection. It is an indication for home parenteral nutrition.home parenteral nutrition.

2.To supplement the deficient items in enteral 2.To supplement the deficient items in enteral feeding.feeding.

B.Contraindications:B.Contraindications:

The following are not absolute The following are not absolute contraindications. They are relative contraindications. They are relative contraindications, i.e. they need to be contraindications, i.e. they need to be corrected first before the corrected first before the commencement of parenteral nutrition.commencement of parenteral nutrition.

1.Heart disease 1.Heart disease

2.Shock2.Shock

3.Blood dyscrasias3.Blood dyscrasias

4.Chronic liver disease4.Chronic liver disease

5.Disorders of fat metabolism5.Disorders of fat metabolism

6.Uncontrolled DM6.Uncontrolled DM

C.Solutions:C.Solutions:

1.Composition:1.Composition:

a. Carbohydrates. The most commonly used a. Carbohydrates. The most commonly used are glucose, fructose and sorbitol.are glucose, fructose and sorbitol.

b.Fats.b.Fats.

c.Amino acids. Essential and branched c.Amino acids. Essential and branched chain amino acids are the most important. chain amino acids are the most important. They are available in a crystalline form.They are available in a crystalline form.

d.Na, K, Ca, PO4 and Mg are present in all d.Na, K, Ca, PO4 and Mg are present in all the commercially available preparations.the commercially available preparations.

e.Other minerals, vitamins and trace e.Other minerals, vitamins and trace elements are added to the infusions elements are added to the infusions whenever indicated.whenever indicated.

2.Preparations. 2.Preparations.

a.Vamin a.Vamin

b.Intralipid 20%b.Intralipid 20%

D. Route of administration:D. Route of administration: 1.This should be a central great vein, in order to 1.This should be a central great vein, in order to

avoid peripheral vein thrombosis by the irritant avoid peripheral vein thrombosis by the irritant hypertonic solutions. This has traditionally been hypertonic solutions. This has traditionally been achieved by subclavian vein cannulation, with achieved by subclavian vein cannulation, with skin tunnel formation. The tip of the catheter skin tunnel formation. The tip of the catheter should lie within the SVC in order to avoid the should lie within the SVC in order to avoid the risk of subclavian venous thrombosis.risk of subclavian venous thrombosis.

2.Recently, silicone-rubber catheters have 2.Recently, silicone-rubber catheters have become available. They can be introduced via become available. They can be introduced via the cephalic vein and advanced to reach the the cephalic vein and advanced to reach the SVC. Their advantage is that they can be left for SVC. Their advantage is that they can be left for as long as possible, even for years, unless they as long as possible, even for years, unless they cause problems. This is particularly of benefit cause problems. This is particularly of benefit for the patient with permanent intestinal for the patient with permanent intestinal failurefailure..