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Nutritional Support of the Cacectic Patient Recap Risk of Malnutrition Nutritional assessment History and examination Anthropological Biochemical Calculation of nutritional needs TE = NPE + PE NPE = CHO and lipids Study Aims Substrate changes Acute starvation Chronic Starvation Strategy for nutritional support Enteral access routes Complications of enteral feeding Pathophysiology Acute Starvation Depletion of liver glycogen (rapid) Insulin fall, glucagon rise Hepatic GNG Amino-acids from muscle protein Alanine and glutamin prefered (75%) Build up by insulin Breakdown in absence of insulin Lipolysis Energy for GNG from FFA oxidation Insulin fall stimulates lipolysis Liberates glyserol Pathophysiology – A. Starvation Conservation of substrate Glucose to lactate in haemopoetis Sx Glyserol (from lipolysis) Recycled via glucogenic Cori cycle Hepatic GNG Branched chain Amino Acids From proteolysis Direct oxidation in cardiac tissue and skeletal muscle In Crebs from alanine and glutamine Stimulates protein synthesis and inhibit breakdown Resulting increase in u - N output Pathophysiology – C. Starvation Starvation by above methods 8 – 12g/day N excretion (340g prot) 35% LBM in 1 month = Fatal Survival for 2 – 3 months due to Decreased energy expenditure Altered brain substrate Decreased SV and HR (CO) Voluntary mobilisation decreases due to fatigue Ketone oxidation Fall in glucose utilisation Rise in ketones Inhibits hepatic GNG Pathophysiology - Starvation Decrease in EE Conserving protein Catabolism = protein breakdown or auto-canabalism Strategy for nutritional support Nutritional Assessment GIT assessment Non-functional Functional •Diarrhoea •Obstruction Access Long term Short term •Peritonitis •Oral •Oral •Vomiting •Gastrostomy •Naso-gastric •Ileus •PEG •Naso-duodenal •Short bowel syndrome •Jejunostomy •Naso-jejunal •Jejunostomy TPN TEN Remains absent Returns Normal GIT Fx Compromised GIT Fx Polymeric feeds Semi-elemental feeds GIT function Enteral feeding Enteral = in the gut Needs intact GIT Patent Functional Needs access Oral Gastric All about gastric emptying Duodenal Jejunal About absorption and volume accomodation Enteral Access Routes (other than oral) Gastric Naso-gastric Oro-gastric Via pharingostomy GAstrostomy PEG Surgical Duodenal Naso and oro-duodenal Placement Blind techniques Accidental Endoscopic or PEG extensions Enteral Access Routes (other than oral) Jejunal Naso or oro-jejunal At time of open abdomen Jejunostomy Enteral formulars Semi-elemental Nutritionally not balanced Polymeric Nutrtionally balanced Low in fat Proteins in form of AAS, Peptides and polypeptied Easy to digest Low residue Digestion normal Residue normal Indications for enteral support Basal need not met by intake Large deficit not net by intake Increased need (BMR) hypermetabolism Burns Head injury Partial functioning GIT Limitation on volume Complications Tube related / mechanical Pulmonary Aspiration Sinusitis Misplacement and dislodgement Erosions and necrosis Reflux Blockage Underfeeding Complications Metabolic Diarrhoea Hypertonic solutions Inadequate absorption Lactose deficiency Starvation hypoalbunemia Excess fat Overfeeding (see previous lecture) Refeeding Severe hypo-phosphatemia and hypo-kalemia secondary to chronic starvation To little ATP for absorption