Nutritional Support in Emergency Patients

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NUTRITIONAL SUPPORT

IN EMERGENCY

PATIENTSJOYDEEPGHOSE


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Objectives of nutritional Support1)To prevent nutritional complications of surgery-infections and wound dehiscence.

2)To reduce the convalescence phase of surgicaltherapy.

The following can occur in patients who are malnourished- 1. muscle wasting and impairment of skeletal muscle function

2. impairment of respiratory muscle function


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3. impairment of cardiac muscle function

4. atrophy of smooth muscle in GI tract

5. impaired immune function

6. impaired healing eg. Wounds and anastomosis

=> increased risk of post- operative morbidity and mortality.


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METABOLIC RESPONSE TO TRAUMA

AND SEPSIS

TRAUMA Increased breakdown of protein, loss o nitrogen (in excess of

synthesis ) and in proportionate to the degree of operative trauma.

Factors responsible TNF, IL-1,

CNANGES IN CARBOHYADRATE METABOLISM- Increased glycogenolysis

glyconeogenesis

Decreased peripheral utilization of glucose

Resistanse to insulin

=> hyperglycemia diabetes of injury Brought about by GLUCAGON, ADRENALINE.

Development of HYPOGLYCEMIA in critically ill pts. = extremelypoor prognosis and invetible mortality.


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Increased lipolysis with increased fatty acid formation (used as fuel source)

brought about by - GLUCAGON , NORADRENALINE.

SEPSIS There is substantial loss of body nitrogen 15-20 g / day

With increased glycogenolysis , glyconeogenesis , hyperglycemic state,increased peripheral utilization of glucose , lipolysis, free fatty acidproduction.

A significant abnormality in septic patients is

Disruption of inner mitochondrial membrane leading to block in theenergy transduction pathways with consequent reduction in aerobicmetabolism of both glucose and fatty acids.

the body therefore depends on anaerobic metabolism of glucoseresulting in increase in LACTATE production.


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OVERALL

There is increased substrate turnover, accompanied byincrease in RESTING METABOLIC EXPENDITURE (RME ).

The TOTAL ENERGY EXPENDITURE(TEE )

RME

Activity energy expenditure ( depends on physical work )

Diet induced energy expenditure.

Under normal circumstances approximate calorierequirement is 25-30 kcal/kg/day.

Non-protein calorie requirement (carbohydrate + fat =2000kcal/day) should have a definite relationship with nitrogenintake = 150:1 .


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Additional energy requirements in disease

states-

Elective surgery 0.1 x RME

Trauma 0.3 x RME

sepsis 0.5 x RME

Massive burns 1 x RME


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ASSESEMENT OF NUTRITIONAL STATUS OF

PATIENTS

1. Body height and weight-

BMI = wt in kg/ height ( m )2

Man- 20-25

Woman- 20-23 2. Subcutaneous skinfold thickness- using skinfold calliper.

Triceps skinfold thickness

Male- min 10 mm

Female- min 13 mm

Multiple site skinfold thickness better, good correlation

with total body fat content.


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3. BIOCHEMICAL MEASURES-

s. albumin- not a reliable indicator, as-

relatively long half life -21 days

huge extravascular store altered in trauma,sepsis, malignancy, despite adequate

intake,

Alternatives =

s. transferrin 7 days s. pre-albumin 2 days

s. retinol binding protein - 1-2 hrs


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4. NITROGEN BALANCE- the total nitrogen intake iscompared with the loss from all sources such as urine( urea),

stool, skin etc.

Nitrogen balance = dietary protein x 0.16 ( urine urea

nitrogen + 2g stool + 2g skin )

Urine urea N = URINE UREA(MMOL) X 28

Although it is not a prognostic indicator, it is still an imp,. Way

of assessing a pts, nutritional requirements and response to

nutritional support.


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5. MUSCLE FUNCTION A. skeletal muscle

hand grip strength/ electrical stimulation of ulnar nerve

B. respiratory muscle

vital capacity/ asking the patient to blow hard on a strip of paper

held approx 10 cm from pts lips.

6. NUTRITIONAL RISK INDEX

1.519x s.albumin (g/l) + 0.417xcurrent wt/usual wt x 100.

Score


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PROVIDING NUTRITIONAL SUPPORTThe following methods may be used to reverse catabolic illness:

1.Provide optimum nutrition early with:

adequate energy and nutrient profile.

adequate protein.

necessary micronutrients.

2.Use anabolic agents if needed to increase the rate of anabolicactivity.

3.Provide exercise stimulus to muscles (an added anabolicstimulus).


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routes of Nutritional Support

There are two basic routes of providing nutritional

support to the patient:

1. Enteral route-oral,

nasogastric & nasojejunal,

gastrostomy & jejunostomy

2. Parenteral route.- central and peripheral


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Enteral Feedingadvantages-

prevents GI atrophy and gut barrier is maintained.decreasedmicrobial translocation

The Gut associated lymphoid tissue (GALT) is essential for

hosting immune response. maintain the integrity of the peritoneal immune response

Less expensive

Improves hepatic function

Total mucosal immunity (via sIgA)


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BY MOUTH- feeding by mouth requires commonsense, cleanliness

and compassion on the part of medical attendant.

BY NASOGASTRIC TUBE FEEDING- via fine-bore nasogastric tubes.

May be used in pts who requires nutritional support for a short

period of time


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BY GASTROSTOMY- STAMM/ JANEWAY/ PERCUTANEOUSENDOSCOPIC.

CONTRAINDICATION-

Gastric disease

Impaired gastric emptying

Significant reflux disease

COMPLICATIONS-

Aspiration, damage to visceral organs, sepsis, leakage and

peritonitis, hemorrhage, dumping and diarrhoea, tubeblockage, etc.


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BY JEJUNOSTOMY- WITZEL/ NEEDLE JEJUNOSTOMY

ADVANTAGES-

Less stomal leakage/ more efficient nutrient delivery

Gastric and pancreatic secretions are reduced as stomach isbypassed

Less nausea vomiting or bloating

Less risk of aspiration


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NUTRIENT SOLUTION AVAILABLE FOR ENTERAL NUTRITION-

POLYMERIC DIETS- nutritionally complete diets

ELEMENTAL DIETS-

They are required if the patient is unable to produce anadequate amount of digestive enzymes or has reduced area of

absorption eg. Short bowel syndrome/ severe pancreatitis.

Nitrogen source as oligopeptides, energy source is provided as

glucose polymers and medium chain fatty acids.

SPECIAL FORMULATIONS

They have been developed for pts with particular diseases-


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i)increased concentrations of branched chain amino acids anddecreased concentrations of aromatic amino acids in patients with

hepatic encephalopathy

ii) those with higher fat but lower glucose energy content for use in

pts who are artificially ventilated

iii) diets containing key nutrients that modulate immune response

etc.

MODULAR DIETS-

they allow the provision of a diet rich in a particular nutrient for usein an individual patient eg, diet enriched in protein if the patient is

hypoproteinaemic or in sodium if hyponatraemic. These diet can be

used to supplement other enteral regimens or oral intake.


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CONTRAINDICATIONS OF ENTERAL FEEDING-

intestinal obstruction

Paralytic ileus with vomiting and diarrhoea

High output intestinal fistulas Major intra- abdominal sepsis


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PARENTERAL NUTRITION-

broad indications-

pts with non-functioning or inaccessible GI tract

high output enteric fistulas In those in whom it is not possible to provide sufficient

nutrients enterally eg, short bowel syndrome, severe burns,

major trauma.

PARENTERAL ROUTES OF ACCESS- a) central venous access- positioning a catheter into SVC via

subclavian vein /internal jugular vein.


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Technical aspects of feeding lines: polyuerthane vs silicone:

Advantages of polyurethane tubes

It is stiffer at room temp, but at body temp, it becomes very

pliable

It has higher tensile strength- less chance of fracture

It has smaller outside diameter-easier cannulation

Greater resistance to thrombus formation


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Complications of central venous catheter-

Catheter related sepsis- 40% , staph, aureus, klebseilla,

candida sp.

Thrombosis of central vein-20%.

Pneumothorax, hemothorax

Major arterial damage

Embolism.

CATHETER CARE


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PERIPHERAL VENOUS ACCESS- indications-

In patients who donot require nutritional support for long

enough to justify the risks and complications of central line

In whom central venous catheterisation is contraindicated-

Central line insertion sites are traumatised

Thrombosis of central veins

Significant clotting defects

Increased risk of infective complications


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PROBLEMS WITH PERIPHERAL ROUTE-

There is a limit to the amount of nutrients that can be delivered andperipheral feeding should not be provided if there is highrequirement of protein, energy

High incidence of complications like phlebitis LIFESPAN OF PERIPHERAL I.V CATHETER CAN BE PROLONGED BY-

Aseptic precautions

Using a narrow- gauge cannula- better mixing and flowcharacteristics

Adding heparin and small dose of hydrocortisone to the infusionsolution

Using a vasodialator patch


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NUTRIENTS USED IN PARENTERAL FEEDING SOLUTIONS-mostfeeding teams decide on the nitrogen and energy contents.

NITROGEN SOURCES-

Casein hydroxylates or solution of crystalline L- amino acids,

that contains all essential AA with a broad spectrum of nonessential AA.

no single AA should predominate since, if its is ineffecientthen it will interfere with the use of others.

Attention is focused on the provision of L- glutamine-------- stimulates immune system , reduces

nitrogen losses post-operatively, maintains gut barrierfunctions


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L- arginine------------------ stimulates immune functions,

improves nitrogen retention, enhances wound healing.

Branched chain amino acids-------- improve protein synthesis

in the body.


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ENERGY SOURCES

Energy is supplied as a balanced combination of dextroseand fat.

GLUCOSE is the primary carbohydrate source and mainform of energy supply to majority of tissues.

During critical illness the bodys preferred calorie source isfat.

Usually for most cirmcumstanses , approximately 35- 50 %of the total calories are given as fat and non-protein calorie: nitrogen = 150:1 to 200:1

Other nutrients like vitamins and trace elements.

Fructose, sorbitol or alcohol products should not be used asthey cause lactic acidosis and hepatocellular damage.


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DELIVARY AND ADMINISTRATION OF TPN-

The feeding regimen is made up in a 3 L bag and comprises all

nutrients.

ADVANTAGES-

Cost-effectiveness, reduced risk of infections

More uniform administration of a balanced solution over a

prolonged period of time

Decreased lipid toxicity as a result of greater dilution of the lipidemulsion.

Ease of delivery and storage.


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MONITORING A PATIENT ON NUTRITIONAL SUPPORT

DAILY------------------- body wt, I+O chart, serum electrolytes,

S/U/C.

TWICE WEEKLY-------- s,albumin, total protein, serum calcium,

Mg, phosphate, LFT, CH. CONTRAINDICATION TO PARENTERAL NUTRITION-

Cardiac failure, hepatic failure, uncontrolled diabetes, shock,

severe blood dyscrasias, disorders of fat metabolism.


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BIOCHEMICAL COMPLICATIONS OF PARENTERAL NUTRITION

Hyponatraemia

Hypokalemia

Hypomagnesemia

Hypophosphataemia

Hyperammonaemia

Hyperglycemia

Hypoglycemia

Hyperosmolar dehydration

Cholestatic jaundice

Immunosuppression asso, with i.v fat emulsion


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Thank you

Documents

Nutritional Support in Emergency Patients