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Patient in a hospital environment, References Mc Cormack D. Nutrition -…
Patient in a hospital environment
Is he in a malnutrishioned state or at risk?
State of disease caused by an excess or deficit of one or more nutrients
Is the patient having difficulties achieving its nutritional goal?
Yes
Monitor
No
Is the gut functional?
Yes
Total
Parental nutrition
Intestinal failure Clasificaction
Type 1
Acute condition, reversible and it lasts <21 days
Type 2
Prolonged acute condition, metabolic Inestability and can last weeks or months
Type 3
Chronic condition, reversible or irreversible and it can last months or years
Indications:
Short bowel syndrome
Bowel obstruction
GI fistula
When oral nutrition cannot be indicated
Severe malnutrition
Enteral + Parenteral
Used as a strategy for the optimization of nutrition intake in those patients who are critically ill.
Partial
Minimal enteral nutrition: 10-20ml/hour/day (240-480 ml/day)
No
Check por posible problems with the gut
Enteral nutrition
Indications
Prolonged anorexia
Severe protein undernutrition
Coma
Liver failure
Burns
Head trauma
Gastroparesia
Complications associated to diabetes
Crohn
Pancreatitis
Contraindications
Obstruction, perforation, peritonitis.
Vomit
Diarrea
Active bleeding
Necrotic pancreatitis
NEC
Terminal patient
Shock
Early enteral nutrition
Feeding in the first 48 hours after hospital admission
Will the patient require nutritional support for more than 4 weeks?
No
Temporal
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Yes
Permanent
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Complications
Infectious
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GI
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Metabolic
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Refeeding Syndrome
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Mechanic
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Long term
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Indirect calorimetry
Calculates heat production from oxygen and CO2 consuption.
Weir equation
Used to calculate the expenditure of energy
EE= (29VO2-1.1VCO2)-2.17 (Nitrogen in urin)
Additional supplements
Micronutrients as pharmaconutrition
Kidney disease
Calcium, Iron, B6,C, Folate and D
Cancer patients
Omega 3 (1-2gr/day)
Used to stabilize cell membranes and inhibit inflammatory cytokines
Vitamine C (1g)
Quimiotoxicity
Arginine
Angiogenic Effect
Pancreatic disease
Glutamine (0.3gr/kg)
Energy (25-30kcal/kg)
Protein demand (1.2-1.5 gr/kg)
Selenium 600mg
Vitamin C 0.54g
Liver disease
Fiber
Carnitine (40mg/kg/day)
Calculations
Lipids 30%
1-2g/kg/day
Proteins 20%
1-2.2g/kg/day
water: 30ml/kg/day
Carbohydrates 50%
To avoid hyperglicemia use the glucose metabolic rate
Carbs/weight in kg/1440 * 1000
4-7 mg/kg/day
Is he in a undernoirushied state or at risk?
Lack of nutrients
Yes
Screening tools
MNA
Used to identify patients 65 years old and over who are malnourshed or at risk of malnutrition
NRS
Used to identify the presence of undernutrition and risk of undernutrition of patients in a hospital setting
MUST
Used to identify patients who are at risk of undernutrition or obese.
Ferguson
SGA
Used to identify benefit for nutrition in hospital patients
Lab tests in ICU
Albumin: 3.5-5.4 g/dl (Used in ICU for presence of SEPSIS and septic Shock)
Prealbumin: 15-53 mg/dL (Used to detect presence of Liver damage, tissue damage)
Transferrin: 200-360 mg/dl (used to detect Inflamation and Iron levels)
RBP: 40-60 (Used to monitor nutritional status and the efficacy of parenteral nutrition)
Monitorization of the patient
With the use of Albumin, Transferrin
Transferrin
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Prealbumin
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If these proteins levels rise--> good indicator
Body composition
Double Energy X-Ray: Measures bone mass, muscle mass and fat mass--> Gold Standard
Bioelectrical impedance: Measures fat mass through its resistance to electricity
Body Circumference Measurements
Limitations: There has to be an observer and you cannot observe the patients progress.
Consequences
Altered GI physiology, altered inmunity, lower cardiac output, longer hospital stay, greater cost, postsurgical complications, lower glomeruralr filtration, lower growth rate and lower therapeutic response.
Deficit of macronutrientes
Carbohydrates: Hypoglycemia, Diabetic ketoacidosis
Proteins: Marasmus, Dry hair, Sensible cuticles, Hypoalbuminemia
Fats: Heart disease, Kidney failure, Stroke, metabolic syndrome
Deficit of micronutrients
Vitamin A: Vision problems
Thiamine: Muscle weakness
Niacin: Memory loss
Folate & vitamin B12: Megaloblastic anemia
Vitamin D: Osteomalacia
Vitamin C: Poor wound healing and scurvy
Copper: Mental retardation
Zinc: Growth retardation
Iodine: Problems with thyroid.
GLIM Criteria
Phenotypic
Weight loss
Low BMI
5% past 6 monts
10% beyond 6 monts
BMI<20 if <70 years and <22 if older than 70
Etiologic
Low food intake
Inflammation
Acute disease
ESPEN
Is he ar risk?
Significant weight loss, Less than 50% intake in 7 days, Screening tools at risk
Yes
BMI <18.5 kg/m2 or Unintentional weight loss (10% at any time or 5% in 3 months) If the patient is younger than 70 years--> BMI <20. If the patient is older that 70 --> BMI <22
What Formula should the patient get?
Oligomeric
Semielemental
Semidigested food
Di/tri peptides, Di/tri saccharides, No fiber
Polimeric
Contains macronutrients: Lipids, protein and carbohidrates
Used in patients with severe malabsorption disorders
Lomg chain fatty acids
Elemental
100% digested food
Peptides, AA, dextrin
Energy requierments
Normocaloric
1kcal/ml
Hypercaloric
1.2-2kcal/ml
Module nutrients
AA: Glutamine
Dextrose: Maltodetrine
Proteins: Casein
Lipids: Olive Oil
Lipids: Omega 3
Proteins
Hipoproteic
6%
Hepatic encefalopaty
Hiperproteic
18-21%
Burned patients
Trauma
Normoproteic
15%
1g*kg
Ethics
CPR
CPR2
No prognosis known
CPR3
Fatal prognosis, No moral imperative to give treatment
CPR1
Patient expected to respond to treatment and then go home
CPR4
No inminent fatal prognosis, there is no clear benefit of the treatment
Principles
Autonomy
No maleficence
Justice
Beneficence
Hydronutritional support
The obligation to prolongue the patients life stops when:
There is no benefit of the tratment towards the patient
Patient loses autonomy
Dehydration of patients in terminal deisease has shown benefit
Hydration can create
Vomit
Respiratory distress
Hyponatremia
Increased Uresis
Candidates
Coma patients
Patients who have lost autnomy and are in bed rest
Terminal cancer patients
Patient managment by multudisciplinary team
ICU staff
They have the task of observing the patients progress, having a closer look than the nutrisionist. They are the first ones to act upon an emergency
Hospital
The hospital must provide the medical staff with the right intruments and medications to care for the patients.
Nutritionist
Task of creating a diet that can benefit the patient and give him a better pronostic. He will take charge and will have to check in frecuently to check the patients status
Physical Therapist
He has to keep the patient moving, preventing any other infections or diseases
References
Mc Cormack D. Nutrition - When TPN is indicated [Internet]. Inmo.ie. 2018 [cited 3 December 2021]. Available from:
https://www.inmo.ie/article/printarticle/4377
Sigmon D, An J. Nasogastric Tube [Internet]. Ncbi.nlm.nih.gov. 2021 [cited 3 December 2021]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK556063/
Brown B, Roehl K, Betz M. Enteral Nutrition Formula Selection [Internet]. edisciplinas.usp. 2017 [cited 4 December 2021]. Available from:
https://edisciplinas.usp.br/pluginfile.php/2051003/mod_resource/content/1/Grupo%203%20-%20Artigo%202.pdf
Olsen N. Everything You Should Know About Refeeding Syndrome [Internet]. Healthline. 2020 [cited 2 December 2021]. Available from:
https://www.healthline.com/health/refeeding-syndrome#causes
Thomas D. Enteral Tube Nutrition - Nutritional Disorders - MSD Manual Professional Edition [Internet]. MSD Manual Professional Edition. 2020 [cited 3 December 2021]. Available from:
https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/enteral-tube-nutrition
6.Nickson C. Indirect Calorimetry and Metabolic Cart [Internet]. Life in the Fast Lane • LITFL. 2020 [cited 4 December 2021]. Available from:
https://litfl.com/indirect-calorimetry-and-metabolic-cart/
