Nutrition

Question 1

Stem1: A critically burnt ill patient is in ITU and requires nutrition. In this
station you will be asked the physiology of nutrition and its clinical
application.

• Given these 2 X-rays:
  Q1: Compare the findings in both X-rays.

Answer 1

“This is an AP chest radiograph of an adult male/female. The
chest x-ray view is adequate and the NG tube cannot be seen
bisecting the carina and is above the midline to the level of the
diaphragm. The tip of the nasogastric tube is also not visible
below the diaphragm. I can confirm that this tube is not in a safe
position to commence feeding”

……………………

“This is an AP chest radiograph of an adult male/female. The
chest x-ray view is adequate and the NG tube can be seen
bisecting the carina and remaining in the midline to the level of
the diaphragm. The tip of the nasogastric tube is visible below the
diaphragm and is at least 10cm beyond the gastro-oesophageal
junction. I can confirm that this tube is in a safe position to
commence feeding”

Question 2

Q2: How to confirm that NGT is in place?

Answer 2

By radiological confirmation Xray
and By detection of Ph from aspirate

Question 3

Q3. If you check the PH of the aspirate & it’s 5.5, what to do ?

Answer 3

I will not use NGT for feeding as it’s not in the stomach

Question 4

Stem 2. A 55-ycar-old man with long standing Crohn’s discase admitted with abdominal pain and vomiting for 5 days, his weight was 52kg before his recent illness , abdomen was mildly tender, distended and tympanic on percussion. Ileocecal resection with 1ry anastomosis done , but he was taken to OR 4 days later with anastomotic leak for with laparotomy & ileostomy done.

Given this X-ray.
Q4. What’re the findings? Diagnosis?

Answer 4

Xray of Abd and Pelvis it’s spine in position
Dilatation of intestine with stack of coins most propably
Small bowel obstruction

Question 5

Q5. What could be the cause for IO in this patient?

Answer 5

Most propably Crohns’s causing strictures

Question 6

Q6. What arc the feeding options to used for this patient?

Answer 6

TPN due to anastomotic leak

Question 7

Q8. What are the disadvantages of using only glucose as energy source in post-op patient?

Answer 7

Pt is already has high glucose from stress, more glucose will convert to fat and cause fatty liver and affect liver function.
other is glucose oxidation will release a lot of CO2 leading to Resp. Failure and increase vent. Requirement

Question 8

Q9. Other than glucose, what are the constituents of TPN providing significant energy source?

Answer 8

Fat particles

Question 8

Q7. What are components of TPN?

Answer 8

CHO – Lipid – PTN – water – essential FA – Minerals

Question 9

Q10. Indication of’TPN?

Answer 9

Head trauma , Fracture mandible and loss of function of bowel, high output fistula and acute pancreatitis. And burn pts

Question 10

Q11. Indication of enteral feeding?

Answer 10

Pt is malnourished, mild pancreatitis, sepsis pt and fistula.

Question 10

Q12: Why enteral feeding is preferred over TPN?

Answer 10

Give access directly to GI which keep mucosa integrity, Cheaper, rapid, less complicated

Question 10

Q13. What is the cause of mucosal atrophy?

Answer 10

Due to deficiency in glutamine
Inflammation , Infection , autoimmune dis, Chronic alcohol and medications

Question 10

Q14. Whal is the results of mucosal atrophy?

Answer 10

Bacterial translocation

Question 11

Q15. Complications of TPN ?

Answer 11

Line-related:
- Infection, sepsis
- Thrombophlebitis
- Thrombosis
- Pneumothorax
- Hemothorax

Feed-related:
- Fluid overload
- Electrolyte imbalance
- Hyperchloremic metabolic acidosis
- Hyperlipidemia
- Hyperammonemia
- Essential fatty acid deficiency
- Hypo/hyperglycemia
- Excess CO2 production (ventilatory problems)
- Re-feeding syndrome
- Gut atrophy and bacterial translocation

Question 11

Q16. What is refeeding syndrome? Why it’s fatal?

Answer 11

It is a metabolic disturbance which occur on feeding a person following a period of starvation. The metabolic consequences include:
· Hypophosphataemia
· Hypokalaemia
· Hypomagnesaemia
. Abnormal fluid balance

Question 12

Q19. Why Nasojeujenal feeding is better than nasogastric feeding ?

Answer 12

Bypass the Stomach
less liability to pneumonia
Avoids gastric phase of stimulation
Doesn’t stimulate pancreatic secretions
Feed delivered directly to the intestine thus maintaining mucosal integrity

Question 12

Stem 3. A middle aged man brought to ED with fracture mandible.
Q21. What are the indications of mandibular fracture fixation?

Answer 12

Neurovascular compression
cosmetic reason
Malalignment
to regain early oral feeding

Question 12

Q17. Complication of enteral feeding ?

Answer 12

Tube related:
 Kinking
 Misplacement
 Injury
 Migration
 Blockage,
 Infection (sinusitis)
 Aspiration pneumonia
Feed related:
 Diarrhea
 Nausea
 Vomiting
 Aspiration
 Refeeding syndrome
 Fluid & electrolyte imbalance
 Deranged liver functions

Question 13

Q18. Whal should be monitored regularly during TPN?

Answer 13

Monitoring During TPN:
* Weight: Daily if fluid concerns, otherwise weekly, then monthly.
* BMI: At start, then monthly.
* If weight can’t be obtained: Monthly mid-arm circumference or triceps skin fold thickness.
* Daily: Electrolytes until stable, then once or twice a week.
* Weekly: Glucose, phosphate, magnesium, LFTs, calcium, albumin, FBC, MCV if stable.
* 2-4 weekly: Zinc, folate, B12, and copper if stable.
* 3-6 monthly: Iron, ferritin, and manganese (for home parenteral nutrition).
* 6 monthly: Vitamin D.
* Bone densitometry: Initially, then every 2 years for home parenteral nutrition.

Question 13

Q20. What is TPN ratio of Carbohydrates, protein & fat?

Answer 13

Adjusted according to every pt, no fixed formula present