Inland Power Exception Dr. Zulema B.

Stolarz Nutritional Support

Consists of the implementation of special measures to address malnutrition in pa tients with various diseases or to prevent malnutrition in patients at nutrition al risk. It covers a range of techniques graded according to the needs of each p atient, beginning with an oral adaptation or implementation of alternative tube (enteral nutrition) or through intravenous catheters (parenteral nutrition). Endocrinol Nutr 2004, 51 (4) :149-57 By way of emergency food A) Enteral (tube) 1) Nonsurgical nasogastric intubation or nasogastric or orogas tric orogastroyeyunal 2) intubation surgical gastrostomy jejunostomy 3) percutan eous endoscopic intubation B) parenteral nutrition (intravenous) for direct veni puncture through a catheter. Dr. Zulema Stolarz Enteral feeding It consists of the arrival of food to some sector of the digestive tract through a tube. For this reason only be used liquid diets Enteral feeding Reduce patient morbidity and mortality. Decreases the hospital stay. With the co mplete digestive system function. Prevents complications. Da sustained nutrition , more convenient and less expensive than parenteral. You can continue at home . Directions From infancy to geriatrics. include injury at birth and psychomotor retardat ion in children and cerebrovascular accident (CVA), senile dementia, trauma and neurosurgical sequelae in adults. The important prerequisites include a functi onal gastrointestinal tract and longevity significantly. Indications for enteral feeding A) They can not eat 1) Coma 2) swallowing mechanics impairment 3) mechanical impairment (stenosis of the esophagus, pyloric syndrome) B) You must not eat 1) high output GI fistula 2) Acute Pancreatitis 3) extensive small bowel resection 4) Severe malabsorption 5) chronic inflammatory bowel dis eases in acute period (Crohn's and ulcerative colitis) Dr. Zulema Stolarz Indications for enteral feeding C) Do not want to eat 1) Reasons for psychiatric disorders (anorexia nervosa) 2) socio-political groun ds (hunger strike) D) They eat but do not meet their requirements 1) hypercatabolic (burned, septic , trauma) 2) Anorexia (cancer, sepsis, sensory disturbances and sensory) 3) Fear (eating is painful or causes diarrhea, or increase an existing, etc. ) Dr. Zulema Stolarz

Management Methods The liquid diet can be supplied b) gravity can be in the form: • Continuous • Discontinuation: 4-6 servings of 500 ml and last approximately 2 hours. c / u • Continuous • Cyclic: the food is supplied during the night and st opped for the day. c) the method is infuser pump Highways

In jejunum feeds should use the method with continuous infusion pumps. In reachi ng the stomach by gastric emptying: • Normal: discontinuous • Alternate method: A method with continuous infusion pumps gastrointestinal tolerance: in case of d ifficulty digestoabsortiva continuous method is used with infusion pumps, starti ng with low volumes. Short Term Visits: Routes of administration Placement of the probe: • bloodless: using natural orifices (nose, mouth) • Surgical: surgical procedure s performed by at the stomach (gastrostomy), small intestine (jejunostomy) or le ss frequent at the level of the pharynx (faringostomía) or esophagus (esophagost omy) . Enteral feeding Enteral feeding pumps Gastrostomy Gastrostomy tubes Enteral feeding Type of nutrients A full enteral feeding should supply the amount of water, calories and protein n eeded by each patient.

Water boiled or mineral, or as cooking fruit juice and / or vegetables or in inf usions. Carbohydrates: soluble mono or disaccharides (used at concentrations <10 -15% to avoid hyperosmolarity). Oligosaccharides: maltodextrin. Protein: calcium caseinate, hydrolyzed protein, soy or milk powder or skim milk (in lactose into lerance: lactose-free milk) Fat: cream or milk, which are already emulsified. Vi tamins and minerals such as pharmaceutical preparations (syrup or pediatric drop s). Percutaneous endoscopic gastrostomy for a period of time (two months).

The PEG is a minimally invasive technique. It is performed with local anesth esia and sedation. Requires a gastroenterologist and / or surgeon. In expert s is safe, quick with very low morbidity and mortality.€ The original tube can stay for 8-12 months. Do not bother the patient, easy to use and cleaning. Y ou can hide under clothing and replace it with a button. May be withdrawn at a ny time. Endoscopic enteral access methods Access nasal / oral Probe nasal / oral gastric feeding gastric decompression gastric decompression g astric gastric Food Food Food jejunal jejunal Less than 1 month Probe nasal / oral gastrojejunal 1 month Probe nasal / oral small bowel 1 month Dr. Zulema Stolarz Endoscopic enteral access methods Percutaneous or surgical Gastrostomy Used for Gastric decompression gastric feeding Time Required 1 month and more Gastrojejunostomy Jejunal Feeding Gastric Decompression 6 months and more Jejunostomy Jejunal feeding 1 month and more Dr. Zulema Stolarz Complications Aspiration. Peritonitis. Displacement of the probe. Leakage around the site. Obstruction of the probe. Complications of enteral feeding Complication Brocoaspiración tube blockage Cause • Lack of maintenance. • Passage bad diluted medication. • Gastric emptying inad equate. • Gastroesophageal reflux. • Probes inappropriate. • Long retention of t he probe. Control

• Wash every 6 hours. of the probe. • prokinetic Injuries decubitus • Use appropriate. • No more than six weeks. Dr. Zulema Stolarz Complications of enteral feeding Mechanical Cause • Lack of control of the probe Rx • Loss perisonda. Complication • Linked to the obstruction of the probe. • Linked to the ostomy. Control • Control Rx before infusion. • Displacement or accidental release. • For cough or vomiting. • Change thicker tube Dr. Zulema Stolarz Complications of enteral feeding Digestive Complication • • • • • Cause Mixed Lactose intolerance hyperosmolar Pollution prepared by antibiotics Hypoalb uminemia Control • Adequate preparation of the food mixture • Use pump • Continue feeding • Diarrhea • Constipation • Lack of fiber • Altered motility • Add fiber • prokinetic Dr. Zulema Stolarz Complications of enteral feeding Digestive Cause • Drip • Osmolarity speed mixing Complication • Nausea and vomiting Control • Adjust speed • Edit Formula

• abdominal distension • Air Ticket • Indigestion • Osmolarity • Avoid air tubulatura • Edit Formula Dr. Zulema Stolarz Complications of enteral feeding Infectious Cause • Poor drainage • Lack of gastric cardia Complication • aspiration pneumonia Control • prokinetic • Related • Surgical Site Infection • Optimising care for the ostomy surgery • P eritonitis Dr. Zulema Stolarz Complications of enteral feeding Metabolic Cause • Diabetes • Stress • Use of steroids • Excess or deficit of water or sodium • • • • Excess or deficit of potassium Diarrhea Diuretics Hypokalaemia Complication • Hyperglycemia • Hyper-or hypo-or hyperkalemia hyponatremia • Feedback • Syndro me Control • Insulin • Modify type and amount of C. • Edit • Add sodium formula • • • • Suspend Edit Formula Treating Diarrhea Diuretics Potassium Supplement • Excessive intake calóricoproteica • Adjust caloric and protein value Dr. Zulema Stolarz Commercial preparations Commercial preparations Parenteral nutrition Is to provide the nutrients directly into the bloodstream, bypassing the digesti ve system, through a catheter inserted into a rich vein flow. Parenteral nutrition Purpose: Maintain or restore the patient's nutritional status. Objectives: d) meet the requirements or dietary needs. e) maintaining balances as possible energy, protein, water, mineral and vitamin content. f) seek to recover the rese rves consumed because of the disease. Dr. Zulema Stolarz Parenteral feeding patterns a) Total or complete b) Complementary c) Prolonged d) calorie e) Cyclic.

Dr. Zulema Stolarz Control and monitoring of the patient receiving parenteral nutrition Clinical management: Appearance of the patient. Vital Signs. weight daily. Daily control of inflow and outflow of fluid, electrolytes, calories and prot ein. Control of glycemia and glucosuria. Monitor the catheter insertion site . Dr. Zulema Stolarz Frequent indications of parenteral nutrition hypermetabolism. intestinal obstruction. Short bowel. fistula or high output ileostomies. intestinal ischemia. th. severe gastrointestinal tract hemorrhage Dr. Zulema Stolarz Type of nutrients Nutrient H. Sun Type dextrose solution 5, 10, 25, 50% emulsion to 10, 20%. Amino acids 3.5, 5, 7, 10, 11.5% C.: Lipids: Protein: Severe diarrhea.€ bacterial overgrow

Water Requirements According According balance: revenues and expenditures. caloric intake: 1ml/cal adults, children: 1. 5 ml / cal body weight According Parenteral nutrition Causes of infectious complications 1) Pollution in the puncture site 2) during the pipe handling 3) Obtaining blood samples from the catheter 4) Administration of medications by catheter 5) Use o f contaminated solutions 6) Determination of central venous pressure 7) Links wi th outside guides Dr. Zulema Stolarz central Metabolic complications of parenteral nutrition A) In the carbohydrate metabolism 1) Hyperglycemia (most common) 2) Glycosuria. Osmotic diuresis 3) acidotic hyper osmolar dehydration. 4) in the diabetic ketoacidosis. 5) reactive hypoglycemia Dr. Zulema Stolarz Metabolic complications of parenteral nutrition B) The protein metabolism 1) Hypoalbuminemia 2) hyperchloremic metabolic acidosis 3) Imbalances in serum a mino acid 4) hyperammonemia. Azotemia C) in fat metabolism 1) Hyperlipidemia 2) essential fatty acid deficiency 3) Changes in liver functio n Dr. Zulema Stolarz D) In the metabolism of minerals and vitamins

sHipofosfatemia. Hyperphosphatemia. sHipocalcemia. Hypercalcemia. sHiponatremia. Hypernatremia. sHipokalemia. Hyperkalaemia. sHipomagnesemia. sCarencias of trac e elements (Zn, Cu, Mn, Se, Cr). sAnemias (folic acid, vitamin B12, iron). sMani festaciones bone. sHipovitaminosis (hydro-and fat-soluble vitamins). Dr. Zulema Stolarz Metabolic complications of parenteral nutrition 10) Hypervitaminosis (fat-soluble vitamins). Parenteral nutrition Lipids Parenteral nutrition The benefit is very little risk and the cost is justified