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Copy of nutrition

Copy of nutrition

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Published by Danielle

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Published by: Danielle on Feb 20, 2011
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01/31/2013

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Albumin
1.plasma
 oncotic pressure
2.maintenance o
vascular volume
3.regulation o
endothelial permeability
4.drug binding- phenytoin- warfarin- phenylbutazone5.toxin binding- free Hb, Fe
++
, bilirubin- arachidonic acid6.free radical scavenger- O
2
radicals7.transport- FFA- hormones, trace elements- enzymes, lysosomes8.heparin-like activity- enhances inhibition of Xa by AT-III9.inhibition of platelet aggregation10.gastrointestinal absorptive function11.longer t
½
β
than synthetic colloidsproblems associated with
 hypoalbuminaemia
in critically ill patients,a.decreased oncotic pressure & increased oedema formationb.increased endothelial permeabilityc.increased incidence of diarrhoea, decreased tolerance of enteral feedingd.? increased coagulopathye.? increased damage from ischaemia, reperfusion injury etc.f.toxicity- drugs- bilirubin, free Hb, etc.
 problems
with giving albumin (NSA-5%/20%)1.increased blood volume, fluid overload2.anaphylactoid responses- less with NSA than with SPPS3.expensive as a colloid4.salt loading with NSA5.may be rapidly metabolized by the liver in severe catabolic states6.not effective as TPNi.no essential AA's- valineii.low calorie concentration~ 250 kcal/l
ICU - Nutrition
 
Assessment & Requirements
a.history and observation- poor sensitivityb.body weight
> 10%
loss chronically> 6% loss acutelyaffected by fluid changes acutelynot indicative of cell mass in ICU patientsc.skeletal musclei.arm circumferencefalse assumptions that arm and arm muscle are circumferential and that bonearea is fixedhigh observer variationii.creatinine:height indexhigh variation in creatinine clearance with agedifficulties of 24 hour urine collectioniii.weight:height ratiohigh variability, eg. excess waterd.triceps skin-fold thicknesse.visceral proteini.albuminpoor indicator of early malnutritionlong plasma half-life (20 days) and large plasma pool (4-5g/kg)rapid fall in serum levels for multiple reasons(loss, redistribution, catabolism, dilution)ii.transferrin, prealbumin, retinol binding proteinmore accurate reflection of acute changesiii.haemoglobinpoor indicator (haemorrhage, transfusion, haemolysis)? reticulocyte percentagef.immune statusi.lymphocyte count< 1000/µl (N > 1500/µl)ii.delayed hypersensitivity response (TB, Candida)significant reduction in malnourished patientsg.vitamin deficiencyi.WCC- vit. Cii.RBC- B
12
, folate, Fe
++
, transketolaseless useful in assessment of acute nutritional states
ICU - Nutrition
2
 
 KoretzAJRCCM 1995
assumed
 nutritional support
would improve outcome as,1.observed association between poor nutritional status and clinical outcome2.NS improves the markers of malnutrition3.obvious fact that death will follow an indefinite period of no nutrition4.retrospective / prospective reports of efficacy5.perspective that doing something is better than nothinghowever, appealing as these are,1.
 association
does not prove causationmalnutrition may be a marker of more severe disease, not a cause2.improvement of markers of nutrition does not necessarily correlate with improvedclinical outcome3.death 2° to malnutrition only occurs in extreme circumstances4.uncontrolled trials do not support interventional efficacy5.these abnormalities are a
 natural response
to injury, preserved by evolutionmost of the clinical trials of NS/PNS
 have not
been able to demonstrate improved outcomeconversely, several have shown increased risk of 
infection
, especially in the settings of cancerchemotherapy and surgerymeta-analysis of perioperative PNS trials have suggested a reduction in perioperative morbidityby 5%
 NB:
reviewing PRCT's of NS versus no support, concluded "although it is likely NS willnot provide dramatic benefit, these trials are inadequate to prove that NS has nobenefit at all"ie, possiblity of type II errorcomparative studies of PNS versus ENS have shown with PNS,1.higher death rate2.more infective complicationsone study only showed an advantage with PNS, however they used bolus feeds through largebore NG tubes
?
 aspiration
this data could not be reproduced when repeated with continuous, higher density feeds, giventhrough fine bore tubes
ICU - Nutrition
3

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