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What you should know in clinical nutrition Nutritional assessment Nutrients deficiency : Protein, energy, vitamins, minerals (Macro/trace elements) Over Nutrition : Obesity, Dyslipidemia, Vitamin & minerals excess Nutrition support : EN, PN, Nutrition support in specific diseases Nutrition and disease prevention/modification Functional food
Glucose and Insulin after Preop. and Postop. Glucose Infusion Tests
25 20 15
GLUCOSE p (mmol/L)
Glucose IRI
10 5 0
MINUTES GITest
IRI
80 mU/L 40 0
30
60
90
30
60
90
PREOPERATIVE
CONVENTIONAL
INTENSIVE
Morning BS mg/dl
173
103
33
71
Cumulative Survival of Patients under Conventional vs. Intensive Insulin Therapy In ICU
Intensive insulin
Conventional insulin
50 100 150 200 250
VARIABLE >14 days of IC (%) >14 days ventilatory support (%) Septicemia (%) Antibiotics >10 days (%) Polineuropathy at any time (%)
CONVENTIONA L TREATMENT
INTENSIVE TREATMENT
P VALUE
<0.001
p = 0.0009
40 35 30 25 20 15 10 5
0 0 50 100 150 200 250
Van den Berghe G et al. Crit Care Med 2003; 31: 359-366
addition of dietary fiber may improve glycemic control High monounsaturated fatty acids may also improve glycemic control Feeding frequency depends on type of insulin used
Parenteral nutrition
Addition of insulin in glucose bottle or dripping parallel to glucose Follow up TG as well as glucose
Blood Glucose Response to Standard and Disease Specific Enteral Formulas in Type 1 Diabetes
Blood glucose (mg/dL)
300 250 200 150 100 50 Standard 0 -30 0 30 60 90 120 150 180 210 240
Peters A et al, Am J Med 1989 Time (Minutes)
Disease specific
Blood Glucose Responses to Diabetes-specific and Standard Enteral Formula in Stress-induced Hyperglycemia
Blood glucose (mg/dL) 300
250 200 150 100 50 Standard 0 0 1 2 3 4 5 6 7 Diabetes-specific
Diabetic Formula
Commercial formula
Glucerna Glucerna SR Choice DM
Blenderized diet
Change composition of glucose to fructose or starch Reduce fat composition
Since this patient has high stress, is there any rational to use Glutamine and other immuno-nutritions?
Fat
Omega-3 fatty acids
Others
Nucleotides (RNA)
Arginine
NH3+
H3+N-C-NH-CH2-CH2-CH2-C-COONH H
Conditionally essential amino acids Stimulate the secretion of GH, insulin, insulin-like growth factor-1, prolactin Precursor of Nitric oxide (NO)
Arginine Supplementation
protein breakdown nitrogen retention Promote wound healing tumor growth lymphocyte proliferation activity of NK, lymphokine activated killer cells phagocytic activity of neutrophil
Glutamine
NH3+
NH3+
H2N-C-CH2-CH2-C-COO Most abundant amino acids Conditionally essential amino acids Substrate for hepatic gluconeogenesis Precursor of nucleotides, glutathione Energy source of enterocytes, rapidly mitotic cells eg. immune cells H
Glutamine Supplementation
protein synthesis hepatic gluconeogenesis nitrogen retention Maintain small bowel mucosal thickness and prevent villi atrophy
Group 2 Group 1
PGE1 PGF1 TXA1 LTA3 LTC3 LTD3 PGD2 PGE2 PGF2 PGI2 TXA2 LTA4 LTB4 LTC4 LTD4 LTE4
Number of infections
60 50 40 30 20 10 0-
p = 0.03
p = 0.007
Immunonutrition Standard enteral formula
Ventilation
Hospital stay
Early Enteral Administration of a Formula Supplemented with Arginine, Nucleotides and Fish Oil in Intensive Care Unit Patients
Length of hospital stay (day)
120 100 80 60 40 20 0 Regular formula Supplemented formula
0 0
0 1
1 1
0 3
1 3
0 5
Early Enteral Administration of a Formula Supplemented with Arginine, Nucleotides and Fish Oil in ICU Patients (Multicenter, Perspective, RCT)
Number of days in hospital stay/ Number of patients with acquired infection
p < 0.05
25 20 15 10 5 0 Hospital stay UTI Bacteremia Immunonutrition Standard enteral formula
Early Post-operative Enteral Immunonutrition: Clinical Outcome and Cost-comparison Analysis in Surgical Nutrition
German Marks (000s)
140 120 100 80 60 40 20 0 Early complication Total cost 52.6 47.8 31 74.6 83.6 Immunonutrition Standard enteral formua 122.4
Outcome and Cost-effectiveness of Perioperative Enteral Immunonutrition in Patients Undergoing Elective Upper GI Surgery
German Marks (000s)
250 200 150 100 50 0
Early Late complication complication Total
Since this patient has respiratory failure, does he need fat modification diet?
EN in Respiratory Failure The major concern is about CO2 overproduction which can precipitate respiratory failure or compromise weaning CO2 induced respiratory failure were reported in COPD cases who received more than 2,000 kcal from CHO per day Usually patients with respiratory failure are in hypercatabolic state and require higher energy and protein
EN in Respiratory Failure Not all patients with respiratory failure need high fat formula AGA may be necessary to monitor the over-production of CO2 if high energy is provided In cases who high fat formula is indicated the available formula is Pulmocare, Respalor, or modified BD
If the patient develops acute renal failure after a week of treatment, how would you provide the nutrition support for him?
Nutrients provided and restricted? Route? Formula?
Metabolic abnormalities in patients with ARF differ from one case to another. In the same patient, the abnormalities can change from day to day or even hour to hour.
Acute peritoneal dialysis Continuous peritoneal dialysis loss of protein 5-9 gm/D in dialysate, glucose absorbed from dialysate Hemodialysis Loss of amino acids 6-9 gm/dialysis Increase energy expenditure during dialysis Continuous hemodiafiltration (VV, AV) Glucose absorbed from dialysate (5.8 gm./Hr for 1.5% glucose 1 L/Hr.) loss of amino acids ~13-24 gm. /D
20-30 20-30 20-30 (-- --- --- --- -- if not sepsis -- --- --- --- --- --) --- --- --- --- --- as tolerate --- --- --- --- --- -ASPEN Guidelines 2001
Feeding Formula
Preferred concentrated, low Na & low K formula Protein content depends on the status : pre-, post dialysis
High protein for post dialysis : Nepro Low protein for pre-dialysis : Prosobee, Pregestimil
Intravenous formula
Renal formula : ~ 60% of EAA is necessary when less than 40 g/day of AA are provided Formula : Kidmin, Nephrosteril, Amiyu
Energy : Dry weight Protein : Serum albumin : Urea Nitrogen Appearance (UNA)
UNA (gm/D) = UUN + 0.6BWi (BUNf-BUNi) + BUNf (BWf-BWi)
Case 2
18 96 . 159 .
BMI = 96/(1.59)2 = 37.97 kg/m2
Body mass index for Asian people Grading Underweight Normal pre-obese Obese gr. 1 Obese gr. 2 BMI (Kg/m2) < 18.5 18.5 - 22.99 23.0 - 24.99 25.0 - 29.99 > 30.0
Obesity : Definition
Ideal body weight :
overweight > 110% of ideal body weight Obese > 120% of ideal body weight (Female : height [cm] 110, Male : height [cm] 100) Percent of body fat : > 30 in female, > 20% in male
Obesity : Definition
Waist circumference : BMI (Kg/m2)
> 25 > 30
Waist circumference
male 94 cm./ 37 female 80 cm. / 31 male 102 cm./ 40 female 88 cm. / 35
90 cm 94 cm
80 cm 80 cm
Morbid Obesity
BMI > 35 kg/m2 or obesity associated with severe/cardiovascular complications
Apple shape/Android
Waist / hip ratio that reflects higher risk of CAD Women > 0.8 Men > 1,
18 96 . 159 . 75 . ? ?
Obesity : complications
Metabolic complications (Waist > 100 cm in
male, > 90 cm in female) insulin resistance & diabetes Dyslipidemia Acanthosis nigricans Hypertension
Cardiovascular disease
coronary artery disease
Obesity : complications
Mechanical effects :
Joint : ankle joint, knee joint, back pain Respiration : sleep apnea syndrome fungal infection, varicose vein breast, endometrium, prostate, esophagus
Skin :
Cancer :
/ /
//
DM HT Allergy Depressive illness Schizophrenia Seizure OSA Polycystic ovarian syndrome Hypothyroidism Stress & anxiety Sulfonylurea Beta-blocker Antihistamine Antidepressant, Li Antipsychotic drugs
Obesity : Management
Diet control Exercise & increase physical activity Behavioral modification Drug therapy Surgery
Year
DPP. N Engl J Med. 2002; 346: 393-403
30
Metformin
20
Lifestyle
10
/?
Diet Activity BMI 23-25 no risk Increase WC DM/CAD/HT/HL BMI 25-30 no risk Increase WC DM/CAD/HT/HL BMI > 30 no risk Increase WC DM/CAD/HT/HL Drug VLCD X X (consider) (consider) (consider) Surgery
Orlistat (Xenical) Action : inhibitor of pancreatic lipase : reduces fat absorption about 30% Effect : Weight reduction -9.2% vs. 5.8% after 2 yr. : Weight reduction > 10% : 42.1% vs. 22.7% after 2 yr. : Reducing LDL-C, TG : Improvement of glycemic control
XENDOS results
: Effect of Xenical on body weight
Placebo + lifestyle
Xenical + lifestyle
Week
Sjostrom et al. 9th ICO, Sao Paulo 2002. Poster Presentation
Sibutramine (Reductil) Action : inhibition of re-uptake of serotonin and nor-epinephrine : resulting in prolonged satiety rather than anorectic effect Effect : Reduce BW, waist circumference, serum lipid levels Side-effect : may increase BP and HR in some cases : constipation : dry mouth : insomnia : no fenfluramine-like adverse effect
Case 3 35 1 tenderness & guarding epigastric area U/S diffuse enlargement of pancrease Serum amylase 1234 IU/L severity APACHE score moderate to severe pancreatitis
Enteral feeding
Stimulation of pancreatic enzyme secretion with various type of nutrient & site of feeding Stimulation of pancreatic exocrine secretion were similar by both intragastric and intraduodenal feeding Jejunal feeding did not associate with increase pancreatic enzyme and bicarbonate secretion Feeding of fat cause more secretion of pancreatic enzyme than feeding of CHO Amount of protein feeding (10% to 40% of total calories) was not associate with different enzyme secretion
Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis Serum lipase Serum amylase
600 500 400 300 200 100 06000 5000 4000 3000 2000 1000 01 2 3 4 5 6 7 8 9 10
TEN TPN
Time
Time
1 2 3 4 5 6 7 8 9 10
Acute pancreatitis : oral/gastric stimulation of pancreas should be avoid Acute pancreatitis Total Parenteral Nutrition
- Hyperglycemia - Catheter related sepsis - IV fat ?
Enteral feeding
- Use elemental diet, drip continuously - Jejunal tube beyond ligament of Treitz Nasojejunostomy under endoscopy Intraoperative tube placement