Nutrition Supportive

Dr Sri Rahardjo. Span

Anestesi Reanimation
RS DR Sardjito
Normal nutrition
 Normal daily diet
 200g carbohydrate (880 kcal)
 90g fat (810 kcal)
 80g protein (320 kcal)
 Recommended requirements
 1800 – 2800 kcal/day
 44-56 g protein
Normal feeding
 Alternate feeding and fasting
 After food
 Plasma glucose and amino acid levels
increase
 Insulin secretion
 Decreased glucagon secretion
 Glycogen reserves, protein synthesis
 Excess stored as lipid
Normal fasting
 Plasma glucose and amino acids fall
 Reduced insulin, increased glucagon
 Gluconeogenesis and glycogenolysis
 Release of amino acids from muscle
 24 hour glycogen reserves
Starvation
 Fast longer than 48 – 72 hr
 Further reduction in insulin and increase in
glucagon
 Hormone sensitive lipoprotein lipase triggers
release of FFAs from fat
 Excess FFAs converted to ketone bodies
 Energy substrate for brain and heart

 Ketosis decreases skeletal muscle

breakdown by reducing glucose requirements
 Decreased BMR – decr peripheral T4 to T3
Nutrition during stress.
Stress response
 Increased sympathetic tone and
catecholamine secretion
 Glycogenolysis
 HS-LPL increases serum FFA, glucose,
insulin
 Protein breakdown
 Peaks 4 – 8 days after injury
Neoplasia :
 Hormonal stress response
 Cachectin and IL-1
 Liver function abnormalities
 Glucose intolerance
 Increased skeletal muscle breakdown
Goals in nutrition
1. Detection and correction of preexisting
malnutrition
2. Prevention of progressive protein-energy
malnutrition
3. Optimisation of patient’s metabolic state
4. Reduction of morbidity and time to
convalescence
American Society for Parenteral and
Enteral Nutrition, 1993
Goals in nutrition
 Decrease catecholamine secretion
 Correct hypotension, hypoxia and pain
 Decrease mediator levels (treat sepsis)
 Nutrition to enhance protein synthesis and
retard protein breakdown
Enteral nutrition
Indications
 Any patient with a functioning gut who
cannot swallow
 Unconscious
 Bulbar palsy or oesophageal pathology
 Respiratory failure
 Sepsis
 Burns
 TPN only if no functioning gut
Feeding tubes
 Nasogastric
 Transpyloric
 nasoduodenal or nasojejunal
 Gastrostomy or jejunostomy

Problems:
 tube placement (must always Xray)
 gastroparesis
Benefits
 Cheap, safe, physiological
 Gut protection
 Bowel is nourished via lumen
 Bacterial translocation
 Stress ulcer prophylaxis
Risks
 Tube malposition
 Nasopharyngeal or gastric erosion
 Regurgitation and aspiration
 Diarrhoea
Feed formulas

 Isoosmolar low residue feeds (1 kcal/ml)

 Isocal, Ensure, Nutrison
 Standard feed: 30 – 40 kcal/kg/day
 Elemental feeds
 ‘predigested’
 Oligosaccharides, oligopeptides, amino acids,
medium chain triglycerides
 Short gut syndrome or pancreatic
insufficiency
Special feeds
 High energy (1.5 kcal/ml)
 Catabolic patients eg burns

 Glutamine enriched
 Enhanced -3 fatty acids
 Branched chain amino acids
 ‘Immunonutrition’ eg Impact

No convincing evidence of benefit over good

‘standard’ feeding
Benefits of early feeding
 Canadian Critical Care Trials Group
 10 major ICUs block randomised
 Strict attention to feeding protocol vs
 Control

Sick patients (APACHE II >18)

Mortality fell from 39% to 31%

Doig G. et al, presented at American Thoracic Society, May 2001

To be repeated in 20 Australian and New Zealand ICUs
Total Parenteral Nutrition
History
 Hyperalimentation
 Increased mortality

 TPN
 Very popular in 1970s and 1980s
 Now used less frequently as benefits of good
enteral nutrition recognised
 ‘Bowel rest’ – flawed concept
Indications
 Lack of small bowel
 Long term and home TPN

 Inability to use bowel

 Complex GI pathology unlikely to resolve in a
few days
 Severe intraabdominal sepsis
Complications
 Catheter related
 Insertion, sepsis
 Solution complications
 Hepatic dysfunction
 Polymyopathy
 Osteomalacia
 Acalculous cholecystitis
 Metabolic: increased BSL, low Na+, K+, Ca++,
HPO42- , Mg2+, metabolic acidosis, vitamin and
trace element deficiencies
TPN Administratoin
 Premixed eg Baxter or prepared by
pharmacy under a flow hood
 Begin with 650 – 1300 nonnitrogen kcal/day
 (20 – 40 ml/hr of amino acid / dextrose mixture)
 Increase daily to between 30 and 80 ml/hr
depending on age and sex and degree of
malnutrition
 20% Intralipid 500ml, 1 – 4 x / week for
essential fatty acids
TPN Administration
 If severely malnourished
 Start feeds on low rate, increase slowly over
two weeks
 Risk of “refeeding syndrome”

 Change to enteral feeds as soon as

patient tolerates it
Enteral vs parenteral
 Better nitrogen retention and weight gain
 Gut mucosal barrier integrity, mucosal
structure and trophic hormones
 Better survival despite same ISS
Chang et al, Crit Care Med, 1987, 15:909-914

 Fewer septic complications

Moore F.A. et al, Ann Surg, 1992, 216:172-183