Download Nutrition in Specific Diseases

Why feed?
All critical illness lead to catabolic state, with
muscle wasting.
Prolonged weaning, increased infection rate
Malnutrition maybe present in as many as
40% of ICU patients.
Why feed?
Improved wound healing
Decreased catabolic response to injury
Improved GI structure and function
Improved outcome
Organisation of Nutrition
Support
Screen
Recognise
Treat
Oral
Enteral
Monitor & Review
Parenteral
“What is food to one man may be fierce
poison to others.”
Lucretius
Nutrition In Diabetes
Mellitus
Nutrition in diabetes
Critical illness causes insulin resistance
and hyperglycemia even in patients without
known DM.
The direct results are periods of
hyperglycemia and altered blood lipid values
that cause high morbidity and mortality
exhibited by these patients.
Nutrition in diabetes (cont.)
Nutritional Requirements
Low CHO
High MUFs
Protein requirements(15% to 20% of energy
intake) 0.8g/kg ideal body weight in diabetic
nephropathy.
Fiber intake: daily intake of 25g to 40g of a
mixture of soluble and insoluble fiber.
Minerals especially antioxidants
Nutrition in diabetes (cont.)
Nutritional support with enteral or
parenteral feeding, usually requires insulin
therapy in patients with diabetes.
Nutrition in Respiratory
Diseases
Nutrition in Respiratory Diseases
Effects of Malnutrition:
Diminishing respiratory muscle strength,
Altering ventilatory capacity, and
Impairing immune function.
Nutrition in respiratory diseases (cont.(
Nutritional Requirements
Determination of daily energy requirements
(total calories)
Substrate mix
Protein
20% of total calories
1–2 gm/kg daily
Carbohydrates
60–70%
Fats
20–30%
Nutritional Support in
Hepatic Failure
Nutritional Support in Hepatic
Failure
Prevalence of malnutrition
20% in compensated liver disease to more than
80% in those patients with decompensated
disease.
Nutrition in hepatic failure (cont.)
Etiologies of malnutrition in chronic
liver disease:
Decreased Intake
Altered absorption
Metabolic alterations
Iatrogenic Factors
Nutrition in hepatic failure (cont.)
Suggested Caloric Requirements
Per
Kilogram
of
Estimated
Euvolemic Weight
Refeeding risk: 15–20 calories/kg euvolemic
weight
Maintenance: 25–30 calories/kg euvolemic
weight
Anabolism: 30–35 calories/kg euvolemic
weight
Nutrition in hepatic failure (cont.)
Estimated Fluid Excess in Patients
with Ascites:
• Mild Ascites 3–5 kg
• Moderate Ascites 7–9 kg
• Severe Ascites 14–15 kg
Nutrition in hepatic failure(cont.)
Suggested protein provision:
Current recommendations are to provide adequate
medication (lactulose, Neomycin, Metronidazole)
to control encephalopathy, and optimize protein to
as much as the patient is able to tolerate.
• 1.0 to 1.5 g/kg euvolemic weight as tolerated;
• 0.8 g/kg if refractory encephalopathy is present.
Nutrition in hepatic failure(cont.)
Branched Chain Amino Acids (BCAA)
The use of these products should be limited
to
those
patients
with
intractable
encephalopathy, as most patients tolerate
normal protein formulas with conventional
medications.
Nutrition in hepatic failure (cont.)
Micronutrients:
Thiamine, magnesium and folate deficiency
Multi-vitamin with minerals that contain iron
should be avoided until iron status is
established.
Zinc deficiency is common in patients with
cirrhosis
Nutrition in hepatic failure (cont.)
Guidelines for Improving Oral Intake
Avoid prolonged periods of NPO.
Provide small meals and snacks during the
day.
Encourage an evening snack to reduce
duration of overnight fasting.
Encourage oral liquid supplements.
Avoid any unnecessary diet restriction.
Provide
foods
appropriate
for
chewing/swallowing abilities.
Optimize gastric emptying.
Nutrition in hepatic failure (cont.)
Enteral feeding
Nutrient-dense formulas (1.5 to 2.0
calorie/ml)
Portion of the lipid content as medium chain
triglyceride (MCT) in case of steatorrhea.
Nutrition in hepatic failure (cont.)
Parenteral feeding
Peripheral parenteral nutrition
Parenteral protein
Limiting IV lipid provision to less than one
gram of long chain fat per kg .
Nutritional Support in
Renal Failure
Nutritional Support in Renal Failure
Prevalence of malnutrition
Malnutrition occurs in up to 40% of patients
with renal failure..
Nutrition in renal failure (cont.)
Etiologies of malnutrition in chronic
renal disease:
Decreased Intake
Diet Restrictions
Loss of nutrients in dialysate
Concurrent illness and hospitalizations
Increased inflammatory and catabolic
cytokines
Chronic blood loss
Acidosis
Accumulation of toxins such as aluminum
Endocrine disorders
Nutrition in renal failure (cont.)
Calculating Calorie Needs
Adjusted weight =
ideal weight + [(actual edema-free weight – ideal
weight) × 0.25]
Nutrition in renal failure (cont.)
Nutrition Therapy
Oral therapy
Occult gastroparesis and bacterial
overgrowth
Dietary potassium
Dietary sodium
Dietary phosphorus
Nutrition in renal failure (cont.)
Enteral feeding
Calorie-dense formula and slower feeding
rate during periods of delayed gastric
emptying.
Use of prokinetic drugs increased.
Nutrition in renal failure (cont.)
Parenteral Nutrition
Volume overload
Intradialytic parenteral nutrition (IDPN).
Nutrition in Acute
Pancreatitis
Nutrition in Acute Pancreatitis
Malnutrition
pancreatitis
in
patients
with
In the 25% of patients who develop severe
acute pancreatitis.
The development of local complications or
secondary infections can produce a “second
wave” of nutritional insult .
Nutrition in Acute Pancreatitis (cont.)
Enteral or parenteral?
1970’s ,coincided with other improvements in
supportive care for pancreatitis , PN
improved nutrition status.
1980’s,PN was described as “a standard
component of therapy”.
In 1997, the first randomized study of jejunal
EN compared to PN in acute pancreatitis
demonstrated that not only was jejunal EN
safe and effective, but in fact, resulted in
decreased infectious complications and
reduced cost compared to PN.
Nutritional Support In
Burned Patients
Nutritional support in burned
patients
Burns are a tissue injury resulting in
 protein denaturation
 edema
 loss of intravascular fluid volume
 caused by chemical, thermal, radiation, or
electrical contact.
Nutrition in burned patients (cont.)
There are three important reactions of the
body to a burn injury, which include
 Metabolic
 Hormonal
 Immune Response
Nutrition in burned patients (cont.)
Feeding the burned patient
The first 24-48 hours of nutritional
intervention
replaces
lost
fluid
and
electrolytes.
Initiation of feeding is recommended within 412 hours of hospitalization.
Nutrition in burned patients (cont.)
Calculation of energy needs
is usually based on the Curreri method:
24 kcal × kg usual body weight + 40 kcal ×
% TBSA (with a maximum of 50% TBSA)
Adults are often calculated to need 35-40
kcal/kg/day.
Nutrition in burned patients (cont.)
Nutritional Requirements
CHO: Glucose administration at a rate of 5
mg/kg/min is optimum for adults. The child
glucose requirement is 5-7 mg/kg/min.
Lipid: 15% of energy requirements is
sufficient.
Nutrition in burned patients (cont.)
Protein: approximately 25% of total
energy should come from protein.
• Adults : 1g protein /kg + 3g x % burn.
• Children : 3g protein/kg + 1g x % burn.
Then 24 hours UUN (urinary urea nitrogen)
is done twice weekly and proteins are given
according UUN/24h g x 1.2 +4 = g protein
/24 h.
Arginine
Is one amino acid important in the
healing of burn wounds associated with:
Reduced hospital stay & infection rate.
It is also a precursor to nitric oxide, which
increases blood flow to the wound and
causes vasodilatation.
Glutamine
Another important amino acid has been
shown to
 Preserve integrity of the intestinal mucosa,
 Reduce infection and maintain immune
function in burn patients
 Decrease the translocation of bacteria and
bacterial survival in animals.
Ornithine α-ketoglutarate, a precursor of
glutamate and glutamine, has been shown to
be beneficial when administered to burn
patients.
Nutrition in burned patients (cont.)
Vitamin requirements :
Vitamin A, which is important in proper
immune function and epithelialization, in the
amount of 10,000 IU/day and 5,000 IU/day in
children under three years old.
Vitamin C supplementation are 250 mg twice
daily for children under 10 years old and 500
mg twice daily for adult.
Nutrition in burned patients (cont.)
Minerals
Are also important to monitor in the
nutritional
care
of
burn
patients.
Supplementation of zinc, copper, and
selenium during the first week.
Calcium,
phosphorus,
magnesium,
sodium, and potassium levels monitored
cautiously.
Nutrition In Short Bowel
Syndrome
Nutrition in short bowel syndrome
Short bowel syndrome (SBS) is a complex
condition resulting from either loss of
intestine and/or an impairment of absorptive
capacity of the remaining small bowel.
Malabsorption is an integral part
of the definition of SBS.
Nutrition in short bowel syndrome(cont.)
Pathophysiology:
Consequences depend on the extent and site
of bowel resection.
Chologenic diarrhea occurs if more than 1m
of ileum is resected.
Electrolyte disturbance
Bacterial colonization
Nutrition in short bowel syndrome (cont.)
Increasing oral energy intake up to 200–
419% of the basal metabolic rate can avoid
the need for PN in more than half of all
patients with SBS.
Protein :1.5–2 g/kg BW/day.
Nutrition in short bowel syndrome(cont.)
Fat : After resection of more than 1m of the
ileum but with an intact jejunum and colon,
restriction of fat can reduce fatty acid-induced
diarrhea.
20–60 g medium chain triglycerides per day.
Nutrition in short bowel syndrome(cont.)
In the maintenance phase, Resting energy
expenditure is about 24 kcal/kg BW/day.
Avoidance of PN and restriction to EN as the
only nutritional therapy is contraindicated if
the absorptive capacity of the bowel is so
low.
Nutrition In Neurological
Patients
Nutrition in neurological patients
Malnutrition is common after severe traumatic
brain injury (TBI).
The resting metabolic expenditure typically
increases by 140% in a non paralyzed patient
with severe TBI.
Nutrition in neurological patient(cont.)
Branched chain amino acids from muscle
protein are used for energy metabolism.
Nitrogen wasting is increased with excretion
of as much as 9-12 g/day.
Nutrition in neurological patient (cont.)
Early enteral or parenteral feeding is
advisable with the aim of providing at least
140% of the daily basal metabolic caloric
requirements by the third or fourth day after
injury.
Nutrition in neurological patient (cont.)
Enteral administration is preferable.
A surgical jejunostomy provides
convenient enteral route.
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Nutritional Requirements
in Sepsis
Nutritional requirements in sepsis
Malnutrition can prolong the course of sepsis
and increase the risk of complications.
In general enteral route is preferable to the
parenteral route but it should not be started
during the initial phase of rescussitation.
Nutrition in septic patient (cont.)
As soon as the patient achieves a degree of
haemodynamic stability (within 24-48 hours)
enteral nutrition should be started.
Careful control of blood glucose between 80110 mg/dL.