Nutritionincriticallyillnew 141027102200 Conversion Gate02
Nutritionincriticallyillnew 141027102200 Conversion Gate02
Nutritionincriticallyillnew 141027102200 Conversion Gate02
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Assessment of Nutritional Status
Nutritional Assessment in critically ill patient is very difficult. These are
summarized as- A,B,C,D
Severe StressBEEX1.6
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Total Energy and fluid requirements:
Energy requirements can be calculated in various ways
but for all practical purposes- calorie intake is -
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A careful balance of macro-nutrients (protein, lipids
and carbohydrates) provide the energy requirements
whilst micronutrients (Vitamins and minerals) are
required in very small amounts to maintain health .
N Balance(g)=(Protein intake(g)/6.25)-(UUN+4)
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Daily requirements for electrolytes
NUTRIENT Enteral route Parenteral Route
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Daily requirements for trace elements
Enteral route Parenteral Route
Chromium 30mcg 10-15mcg
Copper 0.9mg 0.3-0.5mg
Fluoride 4 mg Not well defined
Iodine 150mcg Not well defined
Iron 18mg Not well defined
Manganese 2.3mg 60-100mcg
Molybdenum 45mcg Not well defined
Selenium 55mcg 20-60mcg
Zinc 11mg 0.5-5mg
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Daily Requirement of Vitamins
Water Soluble Vitamins Enteral route Parenteral
Thiamine B1 1.2mg 3.0mg
Riboflavin B2 1.3mg 3-6mg
Pantothenic acid 5mg 15mg
Niacin 16mg 40mg
Pyridoxine B6 1.7mg 4mg
Biotin B7 30mcg 60mcg
Folic Acid B10 400mcg 400mcg
Cyanocobalamine B12 2.4mcg 5mcg
Ascorbic acid C 90mg 100mg
Fat Soluble Vitamin
Retinoic Acid A 900mcg 1000mcg
Ergocalciferol D 15mcg 5mcg
Alpha-tocopherol E 15mg 10mg
Phytomenadione K 120mcg 1mg/24hr
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TIME TO START NUTRITION
The timing of initiating nutritional support is a
complex issue involving various factors which includes
–
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In general
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Early Enteral Nutrition:
Indication: Severe trauma (abdominal, major burns)
ARDS( acute respiratory distress syndrome)
Major abdominal Cancer surgery
Acute Malnutrition
Oral
Enteral
Parenteral
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Enteral:
Indication: when oral intake has been inadequate for 1-
3 days. Patients who are at risk of bacterial
translocation across the bowel (Burn Victims).
Contraindications:
Circulatory Shock
Intestinal Ischemia
Complete mechanical bowel obstruction or Ileus .
Severe Diarhhoea
Pancreatitis.
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Methods of enteral feeding
Nasogastric Tube : most common method
Naso-duodenostomy tube
Naso-jejunal tube
Jejunostomy tube.
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Modes of administration :
Bolus Feeding :
administration of 200-400ml of feed over 20-30 minutes
several times a day.
Intermittent feeding-
Administartion of 200-400 ml of feed over 30-60
minutes several times a day.
Continuous Feeding:
Feed given at continuous rate over 16-24 hrs per day.It is
preferred for small-intestine feeding.
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Feeding Formulas for enteral Feeding
There are many commercially prepared feeds available:
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How to give enteral nutrition?
Confirm tube position: Clinically and radiographically if
possible.
Secure the tube well.
Sit patient up- At least 300 to minimize the risk of reflux and
aspiration of gastric contents
Diarrhoea
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Parenteral Nutrition:
The only absolute indication of parenteral nutrition is
gasto-intestinal failure.
Route of Infusion:
peripheral
central
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Peripheral Parenteral Nutrition PPN:
The maximum osmolarity that can be tolerated by peripheral vein
is 900 mosm/L.
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Central Parenteral Nutrition: CPN
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INTRAVENOUS NUTRIENT SOLUTIONS:
Carbohydrates:These are provided by dextrose
solutions. These are available as 5%,10%,20%,50%,70%
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COMPLICATION OF TPN:
Catheter related: Pneumothorax, Hemothorax,
Chylothorax, Air embolism, Cardiac Tamponade,
Catheter sepsis.
Refeeding Syndrome
Overfeeding
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MONITORING OF PATIENTS:
Vital Signs: Temperature, blood pressure, pulse, respiratory rate
During first week measure serum electrolytes, blood urea, sugar and serum triglycerides
daily.
Unstable patients may require blood sugar and serum electrolytes measurements twice
daily.
Serum Calcium, AST, bilirubin, alkaline phosphate, phosphorus magnesium and blood
Once the desired infusion rate of TPN has been achieved and blood chemistry is Normal
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CONCLUSION:
Malnutrition is associated with a poor outcome in
critical illness.
Enteral Nutrition is mainstay of nutritional support
and should be started early in all patients in whome it
is safe to do so.
Parenteral nutrition has definite role but only in
selected patients.
In all patients receiving nutritional support it is vital
to achieve glucose control with insulin therapy and
important not to overfeed.
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Reference:
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Marik PE, Zolugo GP. Early Enteral Nutrition in acutely ill
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