Nutrition Flashcards
Indications for parenteral nutrition
- Prolonged obstruction or ileus (>7d)
- High output fistula
- Short bowel syndrome
- Severe Crohn’s
- Severe malnutrition
- Severe pancreatitis
- Unable to swallow: e.g. oesophageal Ca
Nutrition screening
MUST - malnutrition universal screening tool
MUST
Low risk - 0 - monitor weekly
Medium risk - 1 - monitor 3 days
High risk - 2 + - refer to dietician
Takes into account:
- BMI
- Unplanned weight loss
- Current intake
When to refer to a dietician
NBM for 3+ days Pressure ulcer grade 2+ Pt request Haemodialysis TPN
Refeeding syndrome
Decreased carb intake → catabolic state with less insulin, fat and protein
catabolism and depletion of intracellular phosphate
- Refeeding → increased insulin in response to carbs and increases cellular PO4 uptake.
- Hypophosphataemia
- Rhabdomyolysis
- Respiratory insufficiency
- Arrhythmias
- Shock
- Seizures
• Enzymes are down regulated so ammonia not sufficiently metabolised causing toxicity
Physiological stress effect
Hyper-metabolic state and catabolic response
Assessment
All patients admitted to hospital should be screened for malnutrition and have their nutritional state assessed - MUST
Nasogastric tube feeding (NGT)
If unable to take sufficient calories orally or dysfunctional swallow
Gastrostomy feeding
If oesophagus blocked/dysfunctional
Jejunal feeding (jejunostomy)
If stomach inaccessible or outflow obstruction
Parenteral nutrition
If jejunum inaccessible or intestinal failure (IF)
Should surgery be delayed to optimise nutrition first
No
SNAP
Sepsis – Overwhelming infection present must be corrected otherwise feeding will be largely useless
Nutrition – Once the infection is corrected, suitable nutritional support should be provided
Anatomy – Define the anatomy of the GI tract so that surgery can be planned
Procedure – Definitive surgery SN&A
Correcting albumin
Treat underlying cause not simply feeding patient more protein
Enhanced Recovery After Surgery
- Reduction in ‘Nil By Mouth’ times (clear fluids up to 2 hours pre-surgery)
- Pre-operative carbohydrate loading
- Minimally invasive surgery
- Minimising the use of drains and nasogastric tubes
- Rapid reintroduction of feeding post-operatively
- Early mobilisation
Entero-Cutaneous Fistulae
High fistula (jejunal) - may need support with enteral or parenteral nutrition
Low fistulae (ileum/colon) - low fibre diet
High Output Stoma treatment factors
Distance From DJ Flexure to Jejunostomy
Distance From DJ Flexure to Colostomy
How to reduce stoma output if infection and active disease is excluded (5)
- Reduction in hypotonic fluids to 500ml/day
- Reduction in gut motility with high dose loperamide and codeine phosphate
- Reduction in secretions with high dose PPI bd
- Use of WHO solution to reduce sodium losses
- Low fibre diet to reduce intraluminal retention of water
Where possible, which of the following feeding routes should be used to optimise a patient’s nutritional status pre-operatively?
Oral feeding
