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OUTLINES IntroductionFundamental goals of nutritional support ERAS CriteriaWho require nutritional support? Post operative complications Criteria of malnutritionDaily fluid maintenance requirement Routes of administration of nutrition ASPEN Guidelines Enteral v/s parenteralPrinciples of TPNStandard regime and energy requirement
Fundamental goals of Nutritional support:
To meet the energy requirement for metabolic processes
To maintain a normal core body temperature
For tissue repair
ERAS CriteriaAvoidance of long periods of pre-operative fasting;
Re-establishment of oral feeding as early as possible after surgery; Integration of nutrition into the overall management of the patient; Reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function; Metabolic control, e.g. of blood glucose; Early mobilisation
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A) Patients already with malnutrition
B) Patients at risk of malnutrition
WHO CANT EAT:
ESOPHAGEAL/GASTRIC OUTLET OBSTRUCTION, HEAD & NECK INJURY/SURGERY, SHOCK
WHO CANT EAT ENOUGH:
SEVERE BURNS, MAJOR TRAUMA , SEPSIS
WHO WONT EAT:
ANOREXIA, DEPRESSION & EATING DISORDERS
WHO SHOULD NOT EAT:
BOWEL OBSTRUCTION/LEAKAGE, GI FISTULAS, SEVERE PANCREATITIS, IBD, RADIATION ENTERITIS, PROLONGED ILEUS
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POST-OP COMPLICATIONS
• Impaired defenses– decreased immunity– decreased phagocytosis– decreased chemotaxis
• Increased post-op infections• Impaired wound healing• Longer recovery period• Prolonged hospital stay
Criteria of Malnutrition
• O/H: Wt loss >10-15% within 6months
• BMI: <18.5 kg/m2
• Subjective global assessment: Grade C
• S-Albumin: <30g/L (with no evidence of hepatic or renal
dysfunction)
1/3rd to 1/4th part of fluid to be provided by Normal saline while rest through 5%
Dextrose
Daily maintenance requirement:
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ASPEN NUTRITION SUPPORT ALGORITHM
Functional GITYes No
Enteral nutrition Parenteral nutrition
Short term Long term/fluid restriction
PPN Central PN
GI Function returns
No
GI Function
Standard Nutrients
Speciality Formulas
Normal Compromised
Adequate progress to oral feeding
Adequate progress to more complex diet
and oral feedings as tolerated
Inadequate PN supplementation
Nutrient tolerance
Progress to total enteral feedings Yes
Nutrition Assessment
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Principles of TPN• Used only when indicated • All devices must be managed by staff trained in
aseptic • Cyclical feeds better than continuous infusion
(Infusion over 10-18 hrs) • Adequate adjustments in standard solutions as &
when required• Stop TPN when not needed • Never discontinue at once ( Ramp down) (Rate of infusion reduce to one half for 2 hrs, then half
again for 2 hrs & then discontinue)• Careful monitoring & watch for complications
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Parenteral nutritionstandard regimens
• Energy 30 kcal/kg/day (as energy and fat)• Amino acids 1.5g/kg/day• Electrolytes basal amounts• Vitamins and trace elements basal amounts
Above are maintenance requirements. Additional fluid and electrolytes may be required
Basic Energy Requirements:
-Esimated total caloric need of the patient : 25-35kcal/kg/day
( so, 1800-2100 kcal/day for a 70-kg man)
-Generally 30% of calories should be via lipid (fat) and the rest by glucose (carbohydrates)
-1.5 L of 20% dextrose contains 300g of Glucose and will provide 1200kcal
0.5 L of 20% Lipid emulsion contains 100g of lipids and will provide 900kcal.
-Thus , a combination will provide 2100kcal in 2L of fluids
Protein Requirement:
-Estimated daily requirement : 1-2g/kg/day
( so, 70g/day for a 70kg man)
-0.5 L of amino acid solution can thus complete the usual nutritional requirement within daily fluid allowance.
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Enteral vs Parenteral
Parenteral ‘guaranteed’ intake ‘never’ rejectedcan be used with short gut or absent gut
function
Less nutritionally effective than ENHyperglycaemia Electrolyte imbalanceHyperlipidemiaConstant supervisionNeeds long term CVCSterility and infection considerationsCostly
Enteral Requires functional gut can cause solute overloadVomiting, DiarrheaCan cause perforation(rarely)
Can be used to continue oral medsMore effective – on-line to portal system Encourages gut motility Normalises gut flora Electrolyte imbalance unusualLess supervisionLess infectionCheap(er)