What is the role of nutrition support in multi-morbid patients
prevent malnutrition which prevents
1. increased complications
2. poor wound healing
3. compromised immune status
4. impairment of organ functions
5. increased mortality
6. increased use of healthcare resources
nutrition screening
using 3min-NS, to all patients,
weight loss, daily intake, muscle wastage
routes of nutrition administration
- enteral nutrition
- pre-pyloric(nasal/stomy)
- post-pyloric(nasal/stomy)
- bolus/ continuous - parenteral access
- peripheral
- central
a) non-tunnelled central venous catheter
b) tunnelled central venous catheter
c) peripherally inserted central catheter
d) port-a-cath
nutrition assessment
using the -point subjective global assessment(SGA)
- A(height and weight)
- B(biochem- electrolytes, albumin)
- C(clinical - PMH/Med/PE)
- D(Diet history)
1 is the worst
monitoring parameters
potential complications of nutrition therapy
common causes of malnutrition
- cancer - chemo, taste alteration, n/v
- ascitis - pressure on GI, stomach cannot expand
- conditions that affects nutrients absorption
- body under stress from surgey/burn
- increased nutrients loss from renal dialysis
energy requirements
in kcal
depends on resting, physical activity, stress factor
measurement: indirect calorimetety, weight based(25-35 for general hospitalized), predictive(only basal)
protein requirements
in g
healthy adult: 0.8g/kg/day
trauma/surgery/burn: 1.5 - 2g/kg/day
sepsis/critical illness: 1.5 - 2, up to 2.5g/kg/day
CKD (not on dialysis): 0.6-0.8
CKD(on HD/PD): 1.2
CKD(CRRT): up to 2
pre-pyloric pros and cons
- more physiologic
- high tolerance to bolus feeding
- wide range of enteral products
- used for venting to remove gastric
cons: not used for feeding in those with delayed gastric emptying
post pyloric pros and cons
- smaller bore, less discomfort
2.. used when there is dysfunction of GI - minimize aspiration risk
cons: higher risk of tube clogging
pros and cons of bolus administration
- more physiologic
- no pump required
- greater freedom for ambulation
pros and cons of continuous administration
- pump assisted at a constant rate
- better tolerated(less bloating/discomfort)
- lower risk of aspiration
examples of disease specific formulas
DM - glucerna 1kcal/ml
conditions with increased energy and protein needs - Fresubin protein energy 1.5kcal/ml
Renal, on dialysis - Nepro HP 1.8kcal/ml
Renal, not on dialysis - Nepro LP1.8kcal/ml
Inflammatory diseases, cancer - NutriFriend 1kcal/ml
Types of EN formula
- modular - to enhance a specific nutrient component
- (Semi) elemental - for impaired GI
- Polymeric - with sufficient GI function
- disease-specific
administration of incompatible drugs in EH feed may cause
- precipitation
- curdling, clumping of protein in acidic
- alteration of dosage form
- DDI with fluroquinolone(cipro)
common complications of EN feeding
- occlusion of feeding tube
- tube migration
- infections esp if dilute feed with h20
- aspiration
- nausea and vomiting
- diarrhea and constipation
- Refeeding syndrome
how to prevent and mitigate DNI
flush access before and after administration, use alternatives
strategies to maximise tolerance to EN
- continuous instead of bolus
- use of prokinetic agents(metoclopramide, domperidone, IV erythromycin)
- Post-pyloric
- use of isotonic formula
- semi-elemental/ elemental feeds for those with malabsorption issue
why is EN preferred over PN
- maintain functional integrity of the gut
- undergo first pass metabolism, promote efficient nutrient utilization
- maintains normal gallbladder function
- maintain gut-associated lymphoid tissues
- less complications than PN - IFLAD
- Less expensive
peripheral parental access VS central access
P:
- tip is outside of central vessels
- requires freq resite
- nutrient delivery limited by osmolarity and concentration
C:
- position in large bore blood vessels
- can be use in long term care
which electrolytes are known to cause precipitation
calcium and phosphate
what make lipid solution not stable
acidic ph, esp in dextrose solution which is pH2
administration of incompatible drugs in PN feed may cause
- precipitation
- loss of drug activity
- phase separation of lipid emulsions
- toxicity
