Professional Documents
Culture Documents
Energy Sources
Nutrition Requirements
Diet Advancement
Micronutrients for wound healing
Enteral versus Parenteral Nutrition
Case studies
Energy Sources
Carbohydrates
Limited storage capacity, needed for CNS function
Yields 3.4 kcal/gram
Pitfall: too much=lipogenesis and increased CO2 production
Fats
Major endogenous fuel source in healthy adults
Yields 9 kcal/gm
Pitfall: too little=essential fatty acid (linoleic acid deficiency-dermatitis
and increased risk of infections
Protein
Needed to maintain anabolic state (match catabolism)
Yields: 4 kcal/gm
Pitfall: must adjust in patient with renal and hepatic failure
Elevated creatinine, BUN, and/or ammonia
Nutrition Requirements
Healthy Adults
Calories: 25-35 kcals/kg
Protein: 0.8-1 gm/kg
Fluids: 30 mls/kg
Requirement Change for the Surgical Patient
Special Considerations
Stress
Injury or disease
Surgery
Pre-hospital/pre-surgical nutrition
Nutrition
Calories:
Increase to 30-40 kcals/kg
Patient on ventilator usually require less
calories ~20-25 kcal/kg
Protein:
Increase to 1-1.8 grams/kg
Fluids:
Individualized
Diet Advancement
Traditional Method:
Start clear liquids when signs of bowel function
returns.
Rationale: Clear liquid diets supply fluid and
electrolytes in a form that require minimal digestion
and little stimulation of the GI tract.
Clear liquids are intended for short-term use due to
inadequacy
Diet Advancement
Recent Evidence:
Suggests that liquid diets and slow diet progression
may not be warranted!!
Clinical study:
Looked at early post-operative feeding using
regular diets or very fast progression vs. traditional
methods of NPO until bowel function with slow diet
progression and found no difference in post-
operative complications. (emesis, distention, NGT
reinsertion, LOS,)
Keep in Mind…
Per SLP
When using liquid diets, patients must have
adequate swallowing functions.
Even patients with mild dysphagia often require
thickened liquids.
Therefore, be specific in writing liquid diet orders
for patients with dysphagia
Micronutrients in Wound Healing
Vitamin A:
Cellular differentiation, proliferation, epithelialization,
collagen synthesis, counteract catabolic effect of steroids.
RDA=3333 International Units
Appropriate dose=25,000 IU per day x 10 days in setting of high dose
steroids or deficiency.
Avoid long term supplementation due to high risk of toxicity with fat-
soluble vitamins.
Vitamin C:
Collagen synthesis
RDA=50-90 mg/day
Low levels are common in high risk population (elderly,
smokers, cancer, liver disease).
Appropriate dose: 500 mg x 10 days
When is it needed?
Illness resulting in inability to take in adequate nutrients by
mouth
Illness or surgery that results in malfunctioning gastrointestinal
tract
Two types:
Enteral nutrition
Parenteral nutrition
Indications for Enteral Nutrition
Parenteral Nutrition
also called "total parenteral nutrition," "TPN," or
"hyperalimentation."
It is a special liquid mixture given into the blood via
a catheter in a vein.
The mixture contains all the protein, carbohydrates,
fat, vitamins, minerals, and other nutrients needed.
Indications for Parenteral Nutrition Support
Acid/base balance
Adjust TPN/PPN anion concentration to maintain
proper acid/base balance
Increase/decrease chloride content as needed
Since bicarbonate is unstable in TPN/PPN
preparations, the precursor—acetate—is used; adjust
acetate content as needed
Complications of Parenteral Nutrition
Hepatic steatosis
May occur within 1-2 weeks after starting PN
May be associated with fatty liver infiltration
Usually is benign, transient, and reversible in
patients on short-term PN and typically resolves in
10-15 days
Limiting fat content of PN and cycling PN over 12
hours is needed to control steatosis in long-term PN
patients
Complications of Parenteral Nutrition Support
(continued)
Cholestasis
May occur 2-6 weeks after starting PN
Indicated by progressive increase in TBili and an elevated serum
alkaline phosphatase
Occurs because there are no intestinal nutrients to stimulate
hepatic bile flow
Trophic enteral feeding to stimulate the gallbladder can be
helpful in reducing/preventing cholestasis
Gastrointestinal atrophy
Lack of enteral stimulation is associated with villus hypoplasia,
colonic mucosal atrophy, decreased gastric function, impaired GI
immunity, bacterial overgrowth, and bacterial translocation
Trophic enteral feeding to minimize/prevent GI atrophy
Parenteral Nutrition Case Study
Cost
Tube feeding cost ~ $10-20 per day
TPN costs up to $1000 or more per day!
Maintains integrity of the gut
Tube feeding preserves intestinal function; it is more physiologic
TPN may be associated with gut atrophy
Less infection
Enteral feeding—very small risk of infection and may
prevent bacterial translocation across the gut wall
TPN—high risk/incidence of infection and sepsis
Refeeding Syndrome
“the metabolic and physiologic consequences of
depletion, repletion, compartmental shifts, and
interrelationships of phosphorus, potassium, and
magnesium…”
Severe drop in serum electrolyte levels resulting from
intracellular electrolyte movement when energy is
provided after a period of starvation (usually > 7-10
days)
Physiologic and metabolic sequelae may include:
EKG changes, hypotension, arrhythmia, cardiac arrest
Weakness, paralysis
Respiratory depression
Ketoacidosis / metabolic acidosis
Refeeding Syndrome (continued)
Reference:
American Society for Parenteral and Enteral Nutrition. The Science and Practice of Nutrition
Support. 2001.
Han-Geurts, I.J, Jeekel,J.,Tilanus H.W, Brouwer,K.J., Randomized clinical trial of patient-
controlled versus fixed regimen feeding after elective abdominal surgery. British Journal of
Surgery. 2001, Dec;88(12):1578-82
Jeffery K.M., Harkins B., Cresci, G.A., Marindale, R.G., The clear liquid diet is no longer a
necessity in the routine postoperative management of surgical patients. American Journal of
Surgery.1996 Mar; 62(3):167-70
Reissman.P., Teoh, T.A., Cohen S.M., Weiss, E.G., Nogueras, J.J., Wexner, S.D. Is early oral
feeding safe after elective colorectal surgery? A prospective randomized trial. Annals of
Surgery. 1995 July;222(1):73-7.
Ross, R. Micronutrient recommendations for wound healing. Support Line. 2004(4): 4.