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8/2/2019 Case Approach in Nutrition Support
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Case approach in nutrition
support October 2005
Preyanuj YamwongResearch Center for Nutrition Support,
Siriraj Hospital
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What you should know in clinical nutrition
Nutritional assessment
Nutrients deficiency : Protein, energy,vitamins, minerals (Macro/trace elements)
Over Nutrition : Obesity, Dyslipidemia,
Vitamin & minerals excess Nutrition support : EN, PN, Nutrition
support in specific diseases
Nutrition and diseaseprevention/modification
Functional food
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Case 1
67
BS 180 mg/dL
Route of nutritional support Energy requirement
Protein requirement
Type of protein
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Glucose and Insulin after Preop. and Postop. Glucose
Infusion Tests
0
40
80
120
160
200
240
0
5
10
15
20
25
GLUCOSE p
(mmol/L)
Glucose
IRI
5 30 60 90 5 30 60 90
PREOPERATIVE POSTOPERATIVE
Giddings et al. Ann Surg 1977;186:681-686
MINUTES
GITest
IRI
mU/L
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Intensive Insulin Therapy
7133Insulin dose U/day
103173Morning BS mg/dl
INTENSIVECONVENTIONAL
Van den Berghe et al. 2001
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Cumulative Survival of Patients under Conventional vs. IntensiveInsulin Therapy In ICU
80
84
88
92
96
100
80
84
88
92
96
100
DAYS AFTER ADMISSION20 40 60 80 100 120 140 160 50 100 150 200 250
Van den Berghe et al, 2001
Intensive insulin
Conventionalinsulin
Intensive insulin
Conventional
insulin
HOSPITAL SURVIVAL (%)SURVIVAL IN ICU (%)
DAYS AFTER ADMISSION
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Effects on Morbidity of Intensive Insulin Treatment on
Critically Ill Patients
VARIABLECONVENTI ONA
L TREATMENT
I NTENSI VE
TREATMENT
P VALUE
>14 days of IC (%) 15.7 11.4 0.01
>14 days ventilatorysupport (%)
11.9 7.5 0.003
Septicemia (%) 7.8 4.2 0.003
Antibiotics >10 days(%)
17.1 11.2
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Is Strict Normoglycemia Necessary ?
> 150 mg / dl
< 110 mg / dl
110-150 mg / dl
0
5
10
15
20
25
30
35
40
45
0 50 100 150 200 250
p= 0.026
p= 0.0009
Days after inclusionCumulativeHazard(%)(inhospitaldeath)Patients in ICU for > 5 days (N = 451)
Van den Berghe G et al. Crit Care Med 2003; 31: 359-366
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Diabetes mellitus and stress induced hyperglycemia
Most common pathogenesis : insulin resistance
Enteral formula
addition of dietary fiber may improve glycemic control
High monounsaturated fatty acids may also improve
glycemic control
Feeding frequency depends on type of insulin used
Parenteral nutrition
Addition of insulin in glucose bottle or dripping parallelto glucose
Follow up TG as well as glucose
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Blood Glucose Response to Standard and Disease Specific EnteralFormulas in Type 1 Diabetes
0
50
100
150
200
250
300
-30 0 30 60 90 120 150 180 210 240
Standard Disease specific
Time (Minutes)
Blood glucose (mg/dL)
Peters A et al, Am J Med 1989
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Blood Glucose Responses to Diabetes-specific and Standard Enteral
Formula in Stress-induced Hyperglycemia
0
50
100
150
200
250
300
0 1 2 3 4 5 6 7
Standard Diabetes-specific
Blood glucose (mg/dL)
Day
Coulston AM, Clin Nutr 1998
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Diabetic Formula
Commercial formula
Glucerna
Glucerna SR
Choice DM Blenderized diet
Change composition of glucose tofructose or starch
Reduce fat composition
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Since this patient has high stress, is there
any rational to use Glutamine and otherimmuno-nutritions?
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Nutrients with Immuno-modulatingProperties
Amino acids Glutamine
Arginine
Fat
Omega-3 fatty acids
Others Nucleotides (RNA)
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Arginine
Conditionally essential amino acids
Stimulate the secretion of GH, insulin,insulin-like growth factor-1, prolactin
Precursor of Nitric oxide (NO)
H3+N-C-NH-CH2-CH2-CH2-C-COO
-
NH H
NH3+
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protein breakdown
nitrogen retention
Promote wound healing
tumor growth lymphocyte proliferation
activity of NK, lymphokine activated
killer cells phagocytic activity of neutrophil
Arginine Supplementation
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Glutamine
Most abundant amino acids
Conditionally essential amino acids Substrate for hepatic gluconeogenesis
Precursor of nucleotides, glutathione
Energy source of enterocytes, rapidlymitotic cells eg. immune cells
H2N-C-CH2-CH2-C-COO-
NH3+
H
NH3+
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Glutamine Supplementation
protein synthesis
hepatic gluconeogenesis
nitrogen retention Maintain small bowel mucosal
thickness and prevent villiatrophy
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Linolenate
Diet
-LinolenateEicosatrienoate
Group 1PGE1
PGF1
TXA1
LTA3
LTC3
LTD3
Eicosatrienoate
Arachidonate
Group 2
PGD2PGE2
PGF2
PGI2
TXA2
LTA4
LTB4
LTC4
LTD4LTE4
Group 3
PGD3PGE3
PGF3
PGI3
TXA3
LTA5
LTB5
LTC5Diet
-LinolenateEicosatetraenoate
Octadecatetraenoate
Eicosapentaenoate
Diet
(dihomo---Linolenate)
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Reduced Postoperative Infections with an Immune-
enhancing Nutritional Supplement70
60
50
40
30
20
10
0 -
Wound
Pulmonary
Intestinal
Urinary
Other
None
Immunonutrition(n = 82)
Standard enteralformula (n = 47)
Numberofinfectio
ns
Synderman CH, et al 1999
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Prospective DBRCT of Enteral Immunonutritionin the Critically Ill
02
4
6
810
12
14
1618
20
Ventilation Hospital stay
Immunonutrition
Standard enteralformula
p = 0.007
p = 0.03
Atkinson S, et al Crit Care Med 1998
Days
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0
20
40
60
80
100
120 Regularformula
Supplementedformula
Early Enteral Administration of a Formula Supplemented
with Arginine, Nucleotides and Fish Oil in Intensive CareUnit Patients
Length of hospital stay (day)
0 0 1 0 1 0 1 Inc. of post-feeding inf.0 1 1 3 3 5 5 No. of acquired inf.
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Early Enteral Administration of a Formula Supplemented with
Arginine, Nucleotides and Fish Oil in ICU Patients (Multicenter,Perspective, RCT)
0
5
10
15
20
25
30
Hospital stay UTI Bacteremia
Immunonutrition
Standard enteralformula
Clinical outcome in successful feeders
Numberofdaysinh
ospitalstay
/
Numberofpatientswithacquiredinfection
p < 0.05
Bower RH, et al Crit Care Med 1995
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Early Post-operative Enteral Immunonutrition: ClinicalOutcome and Cost-comparison Analysis in Surgical Nutrition
52.647.8
31
74.683.6
122.4
0
20
40
60
80
100
120140
Early
complication
Total cost
Immunonutrition
Standard enteralformua
Senkel M, et al Crit Care Med 1997
German Marks (000s)
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Outcome and Cost-effectiveness of Perioperative Enteral
Immunonutrition in Patients Undergoing Elective Upper GISurgery
0
50
100
150
200
250
Early
complication
Late
complication
Total
Immunonutrition
Standard enteralformula
Senkel M, et al Arch Surg 1999
German Marks (000s)
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Six-month outcome of critically ill patients given Glutamine-
supplemented parenteral nutrition
Griffiths RD, et al . Nutr 1997;13:295-302
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Available Immunonutrition Formula
Neomune : high protein (64 g/1000 kcal),
with Glutamine and fish oil
Dipeptiven : dipeptide contains glutamine
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Since this patient has respiratory
failure, does he need fat modificationdiet?
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Respiratory quotient (RQ)
O2 consumption while metabolizing
CO2 productioncertain amount of nutrient
C6H12O6 + 6O2 6CO2 + 6H2O
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EN in Respiratory Failure
The major concern is about CO2 over-
production which can precipitaterespiratory failure or compromise weaning
CO2 induced respiratory failure were
reported in COPD cases who receivedmore than 2,000 kcal from CHO per day
Usually patients with respiratory failure
are in hypercatabolic state and requirehigher energy and protein
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EN in Respiratory Failure
Not all patients with respiratory failure
need high fat formula AGA may be necessary to monitor the
over-production of CO2 if high energy is
provided
In cases who high fat formula is indicatedthe available formula is Pulmocare,
Respalor, or modified BD
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Available high fat formula
Pulmocare
Respalor
Addition of oils in standard feeding
formula
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If the patient develops acute renal
failure after a week of treatment,how would you provide thenutrition support for him?
Nutrients provided and restricted?
Route?
Formula?
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Metabolic Derangement in ARFHypermetabolism and hypercatabolism
Accumulation of metabolic productsAcidemia
Underlying hypercatabolic conditionIncrease certain catabolic hormone(glucagon & PTH) due to ARF itself
Poor dietary intake
Influenced more by the nature of the illnesscausing ARF
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Metabolic Derangement in ARFHypermetabolism and hypercatabolism
Glucose intolerance : insulin resistanceProtein and amino acids abnormalities :protein catabolism, azotemia
Influenced more by the nature of the illnesscausing ARF
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Protein Catabolism in ARF Average UNA
12+7.9 g/D in patients with rhabdomyolysisvs.
3.8+2.4 g/D in ARF from other causes
Feinstein EI, et al, 1981
Net protein degradation 200-250 g/D
Feinstein EI, et al, 1983Leonard CD, et al, 1975
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Metabolic Derangement in ARF
Hypermetabolism and hypercatabolism
Glucose intolerance : insulin resistance
Protein and amino acids abnormalities : proteincatabolism, azotemia
Lipid metabolism : hypertriglyceridemia
Acid-base disturbance : metabolic acidosis
Fluid imbalance : hyper- / hypovolumia
Electrolytes imbalance :hyper- / hyponatremia,hyper- / hypokalemia, hyperphosphatemia,hypocalcemia
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Metabolic abnormalities in patients withARF differ from one case to another.
In the same patient, the abnormalitiescan change from day to day or evenhour to hour.
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Nutrients Requirement and Limitation
Goals :
Energy 30-35 Kcal/Kg/D
Protein 1.5-2 g/Kg/d
Potential nutrients restriction in early
phase
- Water
- Potassium- Sodium
- Phosphate
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Renal Replacement Therapy
Intermittent
hemodialysis
Continuous AV /
VV hemodialysis(CAVHD,CVVHD)
Peritonealdialysis
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Renal Repalcement Therapy and Its Impact on
Nutritional Support Acute peritoneal dialysis
Continuous peritoneal dialysis
loss of protein 5-9 gm/D in dialysate, glucose absorbed from dialysate
Hemodialysis
Loss of amino acids 6-9 gm/dialysis Increase energy expenditure during dialysis
Continuous hemodiafiltration (VV, AV)
Glucose absorbed from dialysate (5.8 gm./Hrfor 1.5% glucose 1 L/Hr.)
loss of amino acids ~13-24 gm. /D
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ARF (GFR ARF CVVH / CVVHD5-10) non HD 3/wk CAVH
stress high stress ARF
Protein/AA 0.55-0.6 of 1.2 of 1.5-2.5 of(g/kg/d) mixed AA mixed AA mixed AA
Energy 30-45 30-45 30-45
(kcal/kg/d)
Fat (% of 20-30 20-30 20-30
total energy) (-- --- --- --- -- if not sepsis -- --- --- --- --- --)
Water --- --- --- --- --- as tolerate --- --- --- --- --- --
ASPEN Guidelines 2001
Daily Recommendation of Patients with ARF
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Feeding Formula
Preferred concentrated, low Na & low
K formula
Protein content depends on the
status : pre-, post dialysis High protein for post dialysis : Nepro
Low protein for pre-dialysis : Prosobee,
Pregestimil
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Intravenous formula
Renal formula : ~ 60% of EAA is
necessary when less than 40 g/day ofAA are provided
Formula : Kidmin, Nephrosteril,Amiyu
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Assessment of Adequacy of NutritionSupport
Energy : Dry weight
Protein : Serum albumin: Urea Nitrogen Appearance (UNA)
UNA (gm/D) = UUN + 0.6BWi
(BUNf
-BUNi
)
+ BUNf (BWf-BWi)
: Total Nitrogen Appearance (TNA)
TNA (gm/D) = 1.27 + 1.19UNA
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In conclusion, how you are going tofeed this patient?
Priority Setting is the key!Priority Setting is the key!
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18
96 .159.
BMI = 96/(1.59)2
= 37.97kg/m2
Case 2
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Body mass index for Asian people
Grading BMI (Kg/m2)
Underweight < 18.5Normal 18.5 - 22.99
pre-obese 23.0 - 24.99Obese gr. 1 25.0 - 29.99Obese gr. 2 > 30.0
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Obesity : Definition
Ideal body weight :
overweight > 110% of ideal body weight
Obese > 120% of ideal body weight(Female : height [cm]110,
Male : height [cm]100)
Percent of body fat :
> 30 in female, > 20% in male
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Obesity : Definition
Waist circumference :
BMI (Kg/m2) Waist circumference
> 25 male 94 cm./ 37 female 80 cm. / 31
> 30 male 102 cm./ 40 female 88 cm. / 35
90 cm 80 cm
94 cm 80 cm
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Morbid Obesity
BMI > 35 kg/m2
or obesity associated withsevere/cardiovascular
complications
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Pear shape/Gynoid type Apple shape/Android
Waist / hip ratio that reflects higher risk of CAD
Women > 0.8 Men > 1,
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1896 .159.75.
?
?
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Metabolic complications (Waist > 100 cm in
male, > 90 cm in female) insulin resistance & diabetes
Dyslipidemia
Hypertension Cardiovascular disease
coronary artery disease
Other endocrinological complication : Amenorrhea (Polycystic ovarian syndrome)
Obesity : complications
Aca n t h o s is n i g r i ca n s
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Obesity : complications Mechanical effects :
Joint : ankle joint, knee joint, back pain
Respiration : sleep apnea syndrome
Skin : fungal infection, varicose vein
Cancer : breast, endometrium, prostate, esophagus
Gall stone
Social & psychological problems
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/
/
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// DM HT Allergy Depressive illness Schizophrenia
Seizure OSA Polycystic ovarian
syndrome
Hypothyroidism Stress & anxiety
Sulfonylurea Beta-blocker Antihistamine Antidepressant, Li Antipsychotic drugs
Transquilizer Contraceptive pills
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Diet control
Exercise & increase physical activity Behavioral modification
Drug therapy
Surgery
Obesity : Management
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Weight loss in the Diabetes Prevention Program
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0-8
-6
-4
-2
0
2
4
Year
Weight loss (kg)
DPP. N Engl J Med. 2002; 346: 393-403
Placebo
MetforminLifestyle
Di b t P ti P
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Cumula
tiveinciden
ce
ofdi
abetes(%)
Year
Diabetes Prevention Program
DPP.N Engl J Med. 2002; 346: 393-403
RR*58%
*Reduction in risk of progressing to type 2 diabetes versus placebo
Placebo
Metformin
Lifestyle
40
30
20
10
00 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
RR*31%
/?
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Diet Activity Drug VLCD Surgery
BMI 23-25
no risk X
Increase WC X
DM/CAD/HT/HL
BMI 25-30
no risk
(consider)Increase WC (consider)
DM/CAD/HT/HL
BMI > 30
no risk (consider)Increase WC
DM/CAD/HT/HL
/?
Orlistat (Xenical)
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Orlistat (Xenical )
Action : inhibitor of pancreatic lipase: reduces fat absorption about
30%
Effect : Weight reduction -9.2% vs. -5.8% after 2 yr.
: Weight reduction > 10% :
42.1% vs. 22.7% after 2yr.
: Reducing LDL-C, TG
: Improvement of glycemiccontrol
XENDOS results
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: Effect of Xenical on body weight
-4.1 kg
-6.9 kg
p
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Sibutramine (Reductil)
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Sibutramine (Reductil)
Action : inhibition of re-uptake of serotonin andnor-epinephrine
: resulting in prolonged satiety
rather than anorectic effect Effect : Reduce BW, waist circumference,serum lipid levels
Side-effect : may increase BP and HR in
some cases: constipation
: dry mouth
: insomnia: no fenfluramine-like adverseeffect
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Effect of Sibutramine on weight maintenance afterweight loss : a RT
The STORM St ud y Gr ou p, Lancet 20 00 , 2 1 1 9 - 2 5
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Case 3 35 1 tenderness &guarding epigastric area
U/S diffuse enlargement of pancrease Serum amylase 1234 IU/L
severity APACHE score
moderate to severe pancreatitis
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Acute pancreatitis : oral/gastric stimulationof pancrease should be avoid
Acute pancreatitis
Total Parenteral Nutrition Enteral feeding
Sti l ti f ti ti ith
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Stimulation of pancreatic enzyme secretion withvarious type of nutrient & site of feeding
Stimulation of pancreatic exocrine secretion weresimilar by both intragastric and intraduodenal feeding
Jejunal feeding did not associate with increasepancreatic enzyme and bicarbonate secretion
Feeding of fat cause more secretion of pancreatic
enzyme than feeding of CHO
Amount of protein feeding (10% to 40% of totalcalories) was not associate with different enzyme
secretion
Volume of pancreatic
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Volume of pancreatic
juice during enteraland total parenteralfeeding
Bodogy G, et al 1991,
Am J Surg
TEN
TPN
Comparison of the safety of early enteral vs
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Comparison of the safety of early enteral vsparenteral nutrition in mild acute pancreatitis
600 -
500 -
400 -
300 -
200 -
100 -
0 -
1 2 3 4 5 6 7 8 9 10
6000 -
5000 -
4000 -
3000 -
2000 -
1000 -
0 -
1 2 3 4 5 6 7 8 9 10
TEN
TPN
Serum amylase Serum lipase
Time
McClave SA, et al. 1997 JPEN
Time
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Acute pancreatitis : oral/gastric stimulation ofpancreas should be avoid
Acute pancreatitis
Total Parenteral Nutrition Enteral feeding
- Hyperglycemia - Use elemental diet, drip -- Catheter related sepsis continuously
- IV fat ? - Jejunal tube beyondligament of Treitz
Nasojejunostomy Intraoperative
under endoscopy tube placement