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Clinical Nutrition
part I
Jacek Szopinski MD. PhD
Department of General Surgery and Transplantology
Collegium Medicum in Bydgoszczy,
Nicolaus Copernicus University in Torun, Poland
Supply of energy, proteins, electrolytes, trace
elements and vitamins in the form of intravenous
fluids or intra-GI tract formulae to the patients
who are not able to eat normally due to the main
disease or/and its complications
+ the new discipline of medicine
CLINICAL NUTRITION
Nutritional requirement
• Nutrients are substances that are not synthesized in
the body in sufficient amounts and therefore must
be supplied by the diet
Nutritional requirements:
Macronutrients: carbohydrates, proteins, fat
Micronutrients: vitamins, minerals, trace elements
Water
The completeness rule
• Providing clinical nutrition we should
always supply ALL nutrients (macro-,
micro- and water)
so, glucose infusion
IS NOT NUTRITION !
basic rule of clinical nutrition
Malnutrition
Malnutrition
Simple
starvation
Stress starvation
Lack of nutrients
= undernutrition
Malnutrition
Simple starvation
hunger strikers
anorexia nervosa
neurological diseases
(Parkinson, SLA, dementia, stroke)
most of cancer patients in the
begining of the disease
Simple starvation
Simple starvation
Stress starvation
Stress starvation
Stress starvation
Stress starvation
Stress starvation
Physiological results of
malutrition • loss of body weight (loss of the mass of organs,
tissues)
• loss of muscle mass – musle weakness,
immobility (sitting, laying) – progress of muscle
loss – poor lung ventilation – peumonia
• worsening of the function of different organs –
organ insufficiency
Physiological results of
malutrition • low albumin concentration (transport !)
• low Fe, low vitamin B12, low proteins – anemia
• no energy / structure nutrients for syntheis
especially immunological system
- less immune cells (leukocyte CD4, CD 8)
- less antibodies (Ig G,M,A)
Physiological results of
malutrition
FROM CLINICAL POINT OF VIEW
severe undernutrition = severe immune deficiency
Physiological results of
malutrition
• less lympoid tissue – GALT (gut associated
lymphoid tissue)
– 70 % of the mass of limphoid tissue of the body;
- sensitive to food antigenes
– if no food i the GI tract – apoptosis
GALT (Gut Associated Lymphoid Tissue)
Physiological results of
malutrition
• dysfunction of the mucosa of the GI tract –
(enterocytes are fed from circulating blood in 50 % and
directly from the lumen of GI tract in 50% -
if no food = edema of enterocytes = loss of intercellular
connections = loss of adhesion proteins = loss of
mucosal villi )
72 hrs fasting
Physiological results of
malutrition • loss of GI tract integrity
+ low acid output in the stomach
+ GALT apoptosis
+ increase of bacterial toxicity
= bacterial
translocation
„Trophic nutrition”
• Enteral nutition with small amounts of enteral
formula used with intention to „feed” musosa
of GI tract
• The amount used is not enough to provide
daily energy / nutrients demand of the whole
body
Diagnosis of malutrtion….
or better:
estimation of nutritional status
Malnutrition
Screening tools
• NRS 2002 (Nutritional Risk Screening)
• MUST (Malnutrition Universal Screening
Tool)
Diagnostic tools
• SGA (Subjective Global Assessment of
Nutritional Status )
Estimation of nutritional status
• Anthropometry (BMI, midarm circumference)
• Biochemistry (plasma albumin, prealbumin
whole protein, transferrin, number of limphocytes)
• Anamesis (diet analysis, weight loss)
• Dynamic measures (handgrip dynamometry)
Malnutrition BMI
Anthropometry
MAC MidArm Circumference
at the not domiating extremitty
half of the length of arm
betten than BMI in older people !
Anthropometry
TSF Triceps Skinfold Thickness
3 measurements – average
not precise: mistakes 20 %
MAC(cm) – (3,14 x TSF mm)
Anthropometry
DEXA Dual-energy X-ray absorptiometry
Anthropometry
BIA bioelectrical impedance analysis
Biochemistry
• ALBUMIN
in the onset of the disease
not in renal/liver insufficiency
better indicator of the general status of the
patient and pronosis than nutrition !
T1/2 21 days
Biochemistry
• TRANSFERRIN
T1/2 7 days
less in the whole body
Fe dependent
Biochemistry
• PREALBUMIN
T1/2 2 days
good indicator of changes in nutritional
status
BLOOD MORPHOLOGY
• LYPHOCYTE COUNT
Norm: > 1,5 tys. / 1 mm3
1,2 – 1,5 slight malnutrition
0,8 – 1,2 moderate malnutrition
<0,8 severe malnutrition
Estimation of nutritional status
• Weight loss in time (10-15% in 3-6 mths)
• BMI
• Plasma albumin
• Plasma prealbumin
• Whole protein
• Transferrin
• Number of lymphocytes
SEVERE NUTRITIONAL RISK
• Weight loss > 10% / 3 months
or > 15% / 6 months
OR
Albumin < 3.0
OR
BMI < 18.5 kg/m2
Essential nutrient requirement
Stable weight:
energy intake ≈ energy output
Essential nutrient requirement
Sources of energy expenditure
► Resting Energy Expenditure (REE)
► Activity Energy Expenditure (AEE) Major
► Others: - energy for mobilizing food
- shivering thermogenesis Minor
Energy
Fuel: carbohydrates, fat, proteins, O2
Waste products: CO2
C6H12O6 + O2 = 6H2O + 6CO2 – 2,8 MJ
Direct calorimetry: measures heat changes
Indirect calorietry: measures O2 and CO2
Resting Energy Expenditure (REE)
• This is energy needed to maintain the
heart, lung, work for synthesis of new
chemical bonds & for maintaining
electrochemical gradient in cells.
• This requires 22kcal/kg/day averagely.
• Can be measured by calorimetry or
using Harris- Benedict equation
Indirect calorimetry
Harris – Benedict equation
Men
BMR = 88.362 + (13.397 x weight in
kg) + (4.799 x height in cm) - (5.677
x age in years)
Women
BMR = 447.593 + (9.247 x weight in
kg) + (3.098 x height in cm) - (4.330
x age in years)
Average Energy Intake
• Men:2800 kcal/day Varies based on
• Women: 1800 kcal/day body size/activity
Increase of energy expenditure
• Fever (13% / 1o C)
• Chills 100 %
• Visit of relatives 40 %
• Respiration 25 %
• Food intake 9 %
• Katecholamines 30 %
Decrease of energy expenditure
• Hypothermia (13% / 1o C)
• Muscle relaxants 40 %
• Analgetics 50 %
• Respiratory vent. 20 %
• Fasting 10-20 %
• B- blockers 25 %
Resting Energy Expenditure (REE)
Multiply REE by the following factors when
patient is stressed:
• Post-operation (REE x 1)
• Metastatic cancer (REE x 1.2)
• Intra-abdominal sepsis (REE x 1.3)
• Severe sepsis (REE x 1.4)
• Acute disease, postoperative phase
20 – 25 kcal / kgBW
• Anabolic phase
25 – 30 kcal / kgBW
• Severe malnutrition
30 – 35 kcal / kgBW
Clinicaly useful energy reqiurement
How much energy?
25 kcal/kg IBW
30 kcal/kg IBW
35 kcal/kg IBW
Perioperatively Burns
Sepsis
Repeted surgery
GI fistula
Obesity
20 kcal/kg IBW
Severe
malnutrition
What is nutrition support?
• An alternate means of providing nutrients to people who cannot eat
any or enough food
• When is it needed?
– Illness resulting in inability to take in adequate nutrients by
mouth
– Illness or surgery that results in malfunctioning gastrointestinal
tract
• Two types:
– Enteral nutrition
– Parenteral nutrition
Nutrition route
ENTERAL route always preferable unless contraindications:
• mechanical ileus,
• severe shock (non-stabilized),
• bowel ischemia (even suspected only)
IF the enteral route NOT POSSIBLE or at least 60% of daily energy intake can not be acheived
-> MIXED ENTERAL AND PARENTERAL NUTRITION
PARENTERAL route alone
Methods of enteral feeding
• Sip feeding
• Tube feeding
• Nasoenteral tube
• Tube enterostomy
• Percuteneous endoscopic jejunostomy
(PEG)
• Fine catheter needle jejunostomy
Sip feeding / oral nutritional
supplements (ONS)
Oral nutritional supplements
• protein rich (ie. Nutridrink Protein 125 ml)
before major non – cancer surgery
(2x daily/ 5 x days)
• with immunonutrition (i.e. Cubitan, Impact
Enteral) contain: ARG, GLU,
nucleotides
(2x daily / 5-7 days)
Enteral feeding “If the gut works – use it”
• Nasogastric (NG)
• Nasojejunal (NJ)
• Percutaneous Endoscopic Gastrostomy (PEG)
• Percutaneous Endoscopic Jejunostomy (PEJ)
• Radiologically Inserted Gastrostomy (RIG)
• Surgical Gastrostomy
• Surgical Jejunostomy (JEJ)
Nasoenteric tube
PEG or G-tube
PEG
(Percutaneous Endoscopic
Gastrostomy)
G-tube (gastric tube)
Microjejunostomy
1. Whole protein formulae (polymeric)
- contain intact proteins, and usually include lipids in the form of
long chain triglycerides (LCTs), and carbohydrates predominantly
as maltodextrins;
- require relatively normal gastrointestinal function for digestion
and absorption, but can be used successfully in up to 95% of
patients on artificial enteral nutrition;
- nutrients are not hydrolysed - osmolality reasonably close to the
physiological level (about 200 to 350 mosmol/kg).
2. Peptide – based formulae (oligomeric)
- partially "pre-digested" and are thus more easily absorbed than
whole protein formulae.
- contain nitrogen predominantly in peptide form (chains of 2-50
amino acids).
- lipids are provided at least in part as MCTs, since these also are
more readily digested and absorbed.
3. Free amino acid formulae (monomeric)
contain single amino acids as the nitrogen source; very few
indications for their use, since oligopeptides are generally better
absorbed than free amino acids and combine this with lower
osmolality.
EN Standard formula
standard energy 0.9 – 1.2 kcal / ml
low energy < 0. 9
high energy > 1. 2
Indications for monomeric formulae
Some forms of congenital metabolic disease,
Severe allergy to dietary protein,
Nutritional treatment of Crohn's disease
Protein sources for the whole protein formulae are mostly milk proteins such
as casein, often together with soy proteins.
In peptide-based formulae hydrolysates of soy, lactalbumin, gelatine and/or
whey are used.
Amino acid-based formulae contain free amino acids, and accordingly do not
contain glutamine, because this amino acid is not stable in its free state.
Fat sources in standard formulae are predominantly mixtures of oils that are
high in polyunsaturated ω-6 fatty acids, such as sunflower, soy, safflower
and corn oils.
Recently, with increasing awareness of the positive effects of the ω-3 fatty
acids, canola oil has been added to many formulae, and sometimes fish oils
are added.
Medium chain triglycerides (MCT) derived from coconut oil form part of
several formulae. Peptide-based and elemental preparations often contain
dominant amounts of MCTs, on the basis that they do not require bile salts or
pancreatic lipase prior to absorption, and that they bypass the lymphatic
system with direct uptake into the portal circulation. Self-evidently the MCTs
do not contain any essential fatty acids, and a minimum of 5%
polyunsaturated fatty acids is added to any such mixture in order to ensure
that the formula is nutritionally complete.
Enteral formulae
Carbohydrate sources are predominantly partial enzymatic hydrolysates
of corn starch (maltodextrins with at least 10 glucose molecules). Some
formulae, especially those intended for oral use, may contain small
amounts of sucrose as this increases palatability. Some whole protein
formulae may also contain starch.
Minerals, vitamins and trace elements are added, usually to meet 100%
of each RDA in the volume of the formula required to yield 1500 kcal.
EN formulae generally do not contain
lactose, cholesterol, purines, or gluten
This is achieved by careful choice of the base materials rather than through
technical elimination processes. Cholesterol, for example, is avoided by the
selection of plant oils as the predominant lipid sources. Purines are absent
from the principal macro-ingredients (such as milk and soy). Gluten content
is minimised by the choice of corn-derived carbohydrates. The protein
component of most enteral products is added in highly concentrated powder
form, usually with a protein fraction of about 85%; this helps to ensure that
only negligible amounts of lactose remain despite the use of milk. Enteral
formulae are therefore safe for patients with primary or secondary lactose
intolerance, coeliac disease, and appropriate for use in those with gout or
hypercholesterolaemia.
Despite their use of manipulated products, enteral formulae are still based
on natural components mainly using common high quality staples.
Emphasising their artificiality is no more logical than in respect of regular
supermarket foods (such as milk desserts), and may be counterproductive
when encouraging their use by patients.
Short-Term vs. Long-Term
Tube Feeding Access
• No standard of care for cut-off time between
short-term and long-term access
• However, if patient is expected to require
nutrition support longer than 6-8 weeks, long-
term access should be considered
• To be continued ….. see part 2