Nutrition & Intestinal Failure(IF) Flashcards
(23 cards)
What is Refeeding Syndrome?
Patho physiology of Refeeding syndrome
What are the Risks for developing Refeeding Syndrome?
Management of Refeeding Syndrome
overview management of refeeding syndrome
How to assess nutrition for patient?
1) Screening of patient : Detecting patient who at risk for malnutrition to reduce morbidity and mortality of surgical patient
- using Nutritional Risk Screening 2002 ( NRS 2002)
2) Assessment
Objective
- History: recent weight loss, diet, socioeconomic status
- Clinical :thin, sparse hair, spooned or ridged nails, dry or scaling skin, angular stomatitis, glossitis, generalised muscle wasting, oedema
- Anthropometric studies: BMI, triceps skinfold, mid upper arm circumference
- Labaratory studies: Serum albumin (half life 21 days and can decreased in inflammation status) , pre albumin ( half life 48 hours) , serum transferrin, Retinol-binding protein, thyroxine binding prealbumin, total lymphocyte count, delayed hypersensitivity skin tests)
- Subjective ( Subjective Global assessment. (A, B and C) or NRS 2002
3) Nutrition care plans ( NCP)
What is Subjective Global Assessment and other measure tools?
o BMI
BMI > 20 Grade A – Mild malnourish
BMI 18-20 Grade B – Moderate malnourish
BMI < 18 kg/m3 Grade C – Severe malnourish
o Weight loss
A > 5% in 3/12
B > 5% in 2/12
C > 5% in 1/12 or >15% in 3/12
o Dietary intake in last week
A – food intake 50-75% from normal
B – 25-50%
C - < 25%
o Functional/medical problem
Pt weak but out of bad regularly (A)
Confined to bed d/t illness (B)
In ICU with assisted ventilation (C)
o Age
=/>70
Development of the Nutrition care plan
What are the indication of TPN?
Indication
- Preop
o When enteral feeding not achieve >60% of energy requirement
o Prolong intestinal failure (Fistula, reduce absorption, can’t reach target site)
- Postop
o Anticipate prolong fasting more than 1/52
o When enteral are contraindication
E.g Colonic surgery without protecting stoma
Esophageal resection
Converting Carbohydrate, Protein and Fat into calories
GLIM criteria for Severity of Malnourished
Classification of Enteral Nutrition ( ONS)
Classification of enteral formula (5 groups)
1. Polymeric formulae
a. Composed of intact proteins, disaccharides & polysachharides and variable amounts of fat and residue , also contain fibre for normal gut ( better absroption)
Contain intact macronutrients and require digestion:
* Intact proteins
* Polysaccharides
* Disaccharides
* Polyunsaturated fatty acids (PUFA)
* low-chain triglycerides (LCT)
b. E.g. Ensure.
- Low osmolarity ( <300mmol)
- cheaper
- Consist of Cow’s milk / soy protein
2. Sub/Semi elemental formula
- also known as Oligomeric
- Partially Hydrolysed protein
- LCT + MCT ( >40%)
- medium osmolarity ( 300 - 500 mmol)
- less fibre for better absroption in short gut syndrome patient or absorption problem patient
- Example: Peptamen®, Vital®, Isosource® HN
3.Elemental formulae
a.completely hydrolysed macronutrients (peptides and free amino acid)
- also known as monomeric formulae
- oligosacharrides
- LCT + MCT ( 35%)
- High osmolarity ( >600mmol)
- more expensive
4. Modular formulae
a. Designed for supplemental use, may provide additional calories or protein, tailor tube feeding to individual nutritional need. Nitrogen, carbohydrate, fat, electrolytes, vitamins and trace element as individual powder / liquid mixes,
b. E.g. Polycose, Promod, MCT oil.
5. Disease specific (speciality) formulae
a. Designed for specific organ dysfunction or metabolic stress
b. E.g. renal (Nepro), COAD (Pulmocare), DM (Glucerna).
🧠 Key Concept:
🧩 Semi-elemental = “Partially broken down”
🧬 Elemental = “Fully broken down” (purest form)
What is objective assessment (ABID)?
ABID
- Antropometric measurement
o BMI, mid arm circumference, triceps skin fold thickness.
- Biochemical measurement
o Albumin level, pre-albumin, retinol binding protein, thyroid binding pre-albumin, transferrin, measurement of individual nutritional component eg, Na, K, Ca, Mg, Thiamine etc.
- Immnunology assessment
oTotal lymphocyte count (1500-1800: mild depletion; 900- 1500: moderate depletion; <900: severe depletion), delayed type hypersentivity reaction, C3 level.
- Dynamic
o Hand grip dynometry, muscle power.
Complication of lean muscles loss
Type of route of administration
- Enteral
a. NG tube
b. Radiology: NJ tube.
c. Endoscopy: PEG tube
d. Operative: Gastrostomy, jujenunostomy. - Parenteral
a. Peripheral line.
b. Peripheral long lines.
c. Short central lines.
d. Tunnelled central lines eg: Hickman, chemoport.
Enteral vs Parenteral Nutrition
Overview of ONS ( in depth)
Overview of Intestinal Failure
Definition: The intestine has inadequate absorptive capacity to meet the nutritional, fluid & electrolyte needs to sustain life and growth requirements such that intravenous supplementation is required to maintain health and/or growth
Can be divided into:
- Anatomical ( type 1 to 3 - end juenostomy, jejunocolic or jejunoileal )
- Functional ( duration)
- Pathophysiological ( as shown in picture below)
- Clinical ( usage of IV drips)
Types/ Classification of Intestinal Failure
Types of Short bowel Syndrome ( under anatomical subtype of IF)
- extensive surgical resection
- functional <200cm
Causes:
Inflammatory (Crohn’s disease, diverticular disease, radiation enteritis)
Neoplastic (colon cancer, ovarian cancer, small bowel malignancy)
Iatrogenic (operation, percutaneous drainage)
Infectious disease (tuberculosis)
Trauma
Management of intestinal failure
high output fistula:
1) End jejunostomy, residual proximal bowel < 100cm
- Highest output
- Start Lomotil, loperamide, PPI, early and titrate
- Start recombinant analogue GLP-2, teduglutide
- Stable <1000mls
2) End ileostomy bowel length 150-200cm
- Moderate to high output
- Start Lomotil, loperamide, PPI, early and titrate
- Start recombinant analogue GLP-2, teduglutide
- Stable <500mls
Lomotil: Diphenoxylate-opiod (2.5mg) /atropine (0.025mg) (4 tablets followed by 2 tables QID ), also known as co-phenotrope, is a combination of the medications diphenoxylate and atropine, used to treat diarrhea
- cautious in heart problem patient. ( can induce tacycardia !)
Effect of Lomotil / Atropine
- Dryness of mouth, difficult swallowing
- Fever
- Bluring of vision, pts glaucoma (elderly)
- Retention of urine
hot like hare, dry like bone, red as beet, mad like hatter
Loperamide is a medication of the opioid receptor agonist class used to decrease the frequency of diarrhea ( 4-8mg daily in divided doesage - max 16mg daily)
Management of ECF
NICE guideline for malnutrition risk
