Nutrition seminar edited final (1).pptx

Nutrition Resident's Seminar

1. Nutritional Management In Medical patients Dr Eleni (IMR2) Moderator Dr Hiwot (Consultant internist, Gastroenterologist) JULY 25, 2023

2. Outlines Introduction to Nutritional therapy Enteral Nutrition Parenteral therapy Nutrition in liver Cirrhosis References

3. Nutritional therapy specialized nutritional support (SNS) EN - delivery of a liquid nutrient formula through a tube placed in the stomach or SI PN - infused of nutritionally complete mixture of crystalline amino acids, dextrose, triglyceride emulsions,minerals,electrolytes and micronutrients directly into the bloodstream optimized voluntary nutritional support - is used when a patient’s barriers to adequate nutrition Every critically ill patient staying for more than 48 hr in the ICU should be considered at risk for malnutrition.

4. Indication SNS is not required for hospitalized patients: At low nutritional risk Appear well nourished and Are expected to resume volitional intake within 5 to 7 days following admission SNS should be initiated promptly in the hospitalized patient : at high nutritional risk and unable to maintain volitional oral intake NRS-2002 or the NUTRIC Score on all patients admitted to the hospital for whom volitional intake is anticipated to be insufficient

5. Three steps of management of in-hospital nutritional disorders 1.screening and diagnosis; 2.determination of the severity and urgency of treating a diagnosed nutritional disorder 3.selection of the modality of SNS, its composition, and the details of providing it 5

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7. Supply nutrients to meet metabolic needs and alter disease course Acute critical illness  Meet catabolic demand ,Preserve muscle breakdown Recovery  Meet anabolic demand ,Provide substrates for repair Full targeted medical nutrition therapy is considered to achieve more than 70% of the resting energy expenditure (REE), but not more than 100 % avoid under nutrition and over-nutrition. Goal

8. Nutritional therapy How? Route When? Early Vs late What? Composition

9. Recommendation Use NUTRIC score to screen nutrition risk within 48 hours of admission Enteral feeding is preferred over parenteral feeding Initiate early enteral feeding within 24-48 hours Do not initiate early (<7 days) parenteral feeding if well nourished Initiate early parenteral feeding if malnourished or high nutrition risk

10. Enteral Nutrition Provision of nutrients via Intestinal route Supports the functional integrity of the gut as well Effective stress ulcer prophylaxis Maintains tight junctions and Stimulate GI blood flow Promote GI hormone release (CCK, gastrin, bile acids) Maintain GI immune function ;GALT maintained Secretory IgA reduce bacterial translocation and alteration of normal flora, reduce villous and mucosal atrophy 13

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12. EN should be attempted before PN Sepsis after hemodynamic stabilization Stable hypoxemia and compensated or chronic/sub acute /permissive hypercapnia and acidosis 24-48h after the GI-bleeding has stopped and no signs of re-bleeding are observed Absent bowel sound (unless bowel ischemia or obstruction suspected ) Intra-abdominal hypertension without abdominal compartment syndrome Consider temporary reduction or discontinuation of EN if intra-abdominal pressure values further increase on EN TBI , stroke ( ischemic and hemorrhagic) Spinal cord injury, ECMO Extensive burn, major thoracic and abdominal surgery

13. Contraindications for EN Cardiac –hemodynamic instability ,circulatory shock GI -Severe Diarrhea ,intractable vomiting , Paralytic ileus, Mechanical Obstruction, Severe GI bleeding, Acute pancreatitis, GRV >500ml/6hr , Enterocutaneous fistula, abdominal compartment syndrome, bowel ischemia Complication of enteral feeding –aspiration ,sever diarrhea ,intestinal ischemia or infract Absolute contraindications to EN mechanical GI obstruction uncontrolled peritonitis ischemic bowel

14. Accessto EN Gastric - OG or NG , standard to initiate EN ,access required for <4wk post-pyloric or deep jejunal - only in those patients who are intolerant of gastric feeds GERD, gastric fistula, GOO or at high risk for aspiration . Percutaneous - access should be used for patients anticipated to require EN for >4 weeks , PEG, PEJ, PEGJ

15. Gastric feeding More physiologic (gastric buffer natural hormonal response) Gastric acid sterilize content and decrease bacterial contamination Tolerate larger volume and high osmolarity feeding Cheaper, easier Post pyloric feeding Prevents gastric residual volume Prevent gastric distention  improve respiration Lower osmolarity feeding Decrease risk of aspiration

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17. . When to start EN? High nutritional risk and malnourished, EN should be initiated within 24–48 hr of admission. ESPEN (Singer at al., 2019) recommends slow increase in the dose for the first 48hr or early acute phase of critical illness, with increase to full feeding progressively from day three. In contrast to this, ASPEN (Mc Clave et al., 2016) suggests that high nutrition risk patients should reach >80% of calculated goal energy and protein targets within 48-72hours, while monitoring for refeeding syndrome.

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19. Dosing for EN One of the three strategies should be used to determine caloric requirements: ( i ) Indirect calorimetry (ii) predictive equations (iii) Simple weight-based equations Protein requirements should be determined independently of caloric needs.

20. Indirect calorimetry REE(kcal/min)=3.94(Vo2) +1.1(Vco2) REE(kcal/day)=REE *1440 RQ= VCO2/VO2 0.6-0.7 starvation /underfeeding/ lipolysis 0.84-0.86 desired/mixed fuel utilization 0.9-1 CHO metabolism >1 overfeeding/ lipogenesis Limitation –expensive ,time consuming -underestimate calorie requirement by 10-15% in resting patient -unreliable Fio2>60%

21. Harris bendict equation for resting energy expenditure Male=66.5+13.7W(kg) +5H(cm) -6.8A(yr) Female=66.5 +9.6W (kg)+1.8H -4.7A( yr ) TEE=REE*AF*DF*TF

22. Dosing weight underweight ( BMI <18.5 kg/m 2 ), use the current weight as the initial dosing weight. normal BMI 18.5 to 24.9 kg/m 2 or overweight BMI 25 to 29.9 kg/m 2 , use the current weight. obese ( BMI ≥30 kg/m 2 ), it should be adjusted. dosing weight = IBW + 0.4 (ABW - IBW). IBW - male=50+0.91(H-152.4) -female=45.5+0.91(H-152.4) or weight corresponding to ideal BMI of 22kg/m2

23. Cont… Protein Mild to moderate illness require only 0.8 to 1.2 g/kg/d . Critically ill generally require 1.2 to 1.5 g/kg/d. Patients with severe burns , CRRT may need as much as 2 g/kg per day. Calories starting point for most is 18 kcal/kg per day a goal of 25 to 30 kcal/kg /d within one week is reasonable for most stable patients. A goal of 35 kcal/kg/d is an acceptable goal if weight gain is desired in a relatively stable patient

24. Other indications for a high protein diet are Polymorbid medical inpatients (>/= 1.0 g/kg/day) Patients with CLD (normal weight: 1.2 g/kg BW/ day, malnourished 1.5 g/kg BW/day, Patients with cancer (> 1 g/kg/day and, if possible up to 1.5 g/kg/day). – Geriatric patients (at least 1 g protein/kg BW/day) Patients with decubitus ulcer: protein intake should be above 1 g/kg/ day and, if possible up to 1.5 g/kg/day, and 1.25-1.5 g/kg BW/day in adults at decubitus ulcer risk. Patients with chronic pancreatitis (amount not specifically defined ). 28

25. Cont…. Permissive underfeeding (i.e., hypo caloric feeding) is an acceptable alternative to full feeding and may be considered in: Acute Lung Injury/Acute Respiratory Distress Syndrome (ALI/ARDS) (ii) Obesity with BMI>30 (iii) Placement on PN over the first week of nutrition therapy for all classes of obesity , the goal of the EN regimen should not exceed 65%–70% of target EE as measured by IC or weight based dosing .

26. Daily nutrition requirement Calories Use 25-30kcal/kg, or predictive equations, or indirect calorimetry ASPEN 2016 Hypo caloric feeding in early acute phase: - ≤20kcal/kg or ≤70% ESPEN2019 20-25kcal/kg Carbohydrate provision should not exceed 5mg/kg/minute ESPEN 2019 Fat provision should not exceed 1.5g /kg /day ESPEN 2019 Consider hypo caloric feeding in critically ill obese (BMI >30kg/m2), not greater than 65-70% of target energy requirements, or 11-14kcal/kg actual body weight, or 22-25kcal/kg ideal weight if BMI >50kg/m2 ASPEN 2013/2016 Use indirect calorimetry in critically ill obese or consider adjusted body weight or ideal body weight at BMI of 25kg/m2 ESPEN 2019 Protein 1.3g/kg delivered progressively ESPEN 2019 1.5-2g/kg in trauma 1.2-2g/kg ASPEN 2016 in critically ill obese 1.2g/kg or 2-2.5g/kg ideal weight ASPEN 2013 2.5g/kg ideal weight if BMI >40kg/m2 In critically ill obese ASPEN 2016 use urinary nitrogen loss as a guide or lean body mass ESPEN 2019 Protein in AKI 1.2-2g/kg ASPEN 2016 Up to 2.5g/kg if on CRRT ASPEN 2016 Protein should not be restricted ASPEN 2016

27. Nitrogen Balance Every 6.25 g of administered protein (or AAs) contains approximately 1 g of N. The adequacy of protein intake can be evaluated with the nitrogen balance Balance positive -anabolic state negative – catabolic state Limitation – NOT accurate in renal failure increasing protein intake will not achieve a positive nitrogen balance unless the intake of non protein calories is adequate

28. Formulations With difference in osmolarity, caloric density, and amount of protein per calorie, electrolyte, vitamin, and mineral content Standard Concentrated Predigested The vast majority of hospitalized patients will tolerate a standard polymeric formula with or without fiber.

29. Standard Provides sufficient nutrition for most patients. Contains simple and complex carbohydrates, long chain FFA, essential vitamins, minerals, micronutrients and lactose free Isotonic to serum. Calorie 1kCal/ml (50% CHO, 30% fat, 20% protein) Protein 40g/L ( 40g/1000kcal) Most patients require additional water. Concentrated For water restricted patients Hyperosmolar to serum Calorie 1.2, 1.5, 2 Kcal/ml Less likely to be tolerated if given rapidly in a tube placed beyond the pylorus Can rarely result in diarrhea, dumping syndrome ,intolerance , hyperglycemia Predigested Protein hydrolyzed to short peptides, less complex carbohydrates, medium chain fatty acids Calorie 1-1.5 Kcal/ml For patients with Thoracic duct leaks, chylothorax, chylous ascites Malabsorption syndromes Intolerance to standard diet 33

30. Cont…. Indications for use of specialized formulae are limited. Routine use of formulas designed to be immune- modulatory , elemental/ semi-elemental, disease-specific (diabetes), and organ-specific(hepatic, renal, pulmonary) are discouraged.

31. Disease/organ specific formulations Pulmonary formula - specialized formula for COPD and ARDS High fat to carbohydrate ration Low CHO/high fat (40% CHO, 50% fat) Less CO2 production  lower MV suffices Reduce respiratory quotient Reduce work of breathing Facilitate weaning BCAA, ω-3 fatty acids derived from fish oil to increase delivery of anti-inflammatory properties Hepatic formula i.e-nutri-hep,hepatic Aid 2 high BCAA and lower AAA lower aromatic amino acids to prevent hepatic encephalopathy Do not restrict protein Fluid and sodium restricted to attenuate effects of ascites Renal formula i.e - nepro,suplena,nutri -renal… Volume restricted preparations ,relatively lower k, mg, p essential amino acids Do not restrict protein. Diabetic formula i.e-glytrol,resource diabetic…. Low sugar ( oligosaccharides) ,higher fat ,fiber

32. Ensure -lactose and gluten free 1kcal/ml ,250ml serving provide 9gm protien,34gm CHO,9gm fat,200gm water, vitamins and minerals with osmolarity of 379mosm/L Ensure plus -1.5kcal/ml ,237ml serving provide 14.8gm protein ,11.8gm fat ,47.3gmCHO ,vitamins and minerals with osmolarity of 500mosm/L ,complete and balanced nutrition ideal for tube feeding Drawback Expensive 3400birr/container One container enough for 7-8 servings based on 1500 – 2000kcal/diet. Approx. 2days/container (max)

33. Blenderized tube feeding(BTF ) is defined as the use of blended foods and liquids given directly via the feeding tube. This is used in many developing countries primarily because it is cheaper than commercially prepared feeds Advantages Exposure to real foods and tastes Possible improvement in gastro-intestinal (GI) symptoms like reflux or constipation A possible cost savings Disadvantages The consistency is thicker than a traditional commercial formula. has difficulty moving through a feeding pump or tubing. 37

34. Alternative recipe blenderized tube feeding 38

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36. Administration Initial Trophic feeding (10-20Kcal/hr or 10-20ml/hr) and then slowly increasing to target maintenance dose is the general recommendation Patients may receive their tube feedings by bolus intermittent , or continuous methods . Bolus Vs continuous has no difference in Mortality, Nosocomial Infections, Length of stay, and MV duration An intermittent or continuous feeding regimen, rather than the rapid bolus method, may be used to limit the risk of tube-feeding aspiration 40

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38. Monitoring EN ESPEN Recommendation –in ICU setting ,bowel motility (indicator of bowl contractility, not related to mucosal integrity/barrier function/absorptive functions) not required to initiate EN GI intolerance - absence of bowl sounds, vomiting, diarrhea, distension /discomfort, GIB, high gastric residual volume Checking routinely for GRV is no longer recommended.

39. Complications of EN Aspiration Diarrhea - 15-18% of EN, Altered intestinal transit, altered intestinal microflora , drugs (PPI, prokinetics, antibiotics, sorbitol), hypertonic feeding, c.difficle Metabolic – Hyperglycemia ,Micronutrients deficiency , Refeeding syndrome Mechanical -Constipation, Fiber bezoars , Impaction, bowl obstruction, perforation, Procedure related complications ,BBS ,fistula formation

40. Refeeding syndrome Defined as clinical complication occurs as a result of fluid and electrolyte shift during aggressive nutritional rehabilitation of malnourished patients ASPEN diagnostic criteria -any drop in k/mg/po4 with in 5days of introduction by; 10-20%-mild 20-30%-moderate >30%/organ dysfunction/thiamine deficiency –sever

41. PARENTERAL NUTRITION when early EN is not feasible or sufficient enough to provide energy and protein goals . At low nutritional risk , PN should be withheld for the 1 st week . At high nutritional risk or severely malnourished hypocaloric PN dosing (≤20 kcal/kg/d or 80% of EE needs) with adequate protein (≥1.2 g protein/kg/d) be considered. Supplemental PN on top of EN - must be after 7 to 10 days for those unable to meet >60% of energy and/or protein requirements by the enteral route alone. (ASPEN/SCCM )

42. Access Must be via a central venous catheter because its high osmotic load. Peripheral PN (PPN) should not be used, as it leads to: has a high risk of phlebitis , thrombosis and loss of venous access sites generally provides inadequate nutrition therapy Peripheral veins are intolerant to the osmolarity of >800–900 mosm /l (central venous access allows tolerance of solutions up to 2,000 mosm /l) 3 types of central venous catheters (CVC) available for PN infusion: percutaneous CVCs, chronic indwelling CVCs, and implantable ports  

43. Con’t… For carbohydrates the upper limit should be 5 mg/kg/min For intravenous lipids the upper recommendation is 1 g/kg body weight/day with a tolerance up to 1.5 g/kg/day. Caloric contribution of dextrose is 3.4 Kcal/g , unlike dietary CHO 4Kcal/g , due to water component of dextrose-hydrate preparation. Caloric contribution of Amino acids is 4Kcal/g , Branched chain AA (BCAA) has lower mortality

44. Micronutrient supplementation Canadian Clinical Practice Guidelines (CPG) 2015 - combined vitamins and trace elements selenium supplementation alone or in combination with other antioxidants in critically ill patients is not recommended ,insufficient data regarding vit C and D ESPEN Guidelines 2019 - In critically ill patients with (25 hydroxyVit D <12.5ng/ml, or 50nmol/l) vit D3 (500,000 IU) as a single dose can be supplemented within a week of admission. - Antioxidants as high dose monotherapy should not be administered without proven deficiency. (ASPEN) Guidelines 2016 - A combination of antioxidant vitamins and trace minerals in doses reported to be safe in critically ill patients requiring specialized nutritional therapy , -Cannot make a recommendation regarding selenium, zinc and antioxidant supplementation in sepsis due to conflicting results

45. In patients with burns > 20% body surface area and critically ill trauma patient , additional entral doses of glutamine (0.3-0.5 g/kg/d) should be administered for 10-15 days as soon as EN is commenced. In ICU patients except burn and trauma patients , additional enteral GLN should not be administered. Continuous RRT 2 Weeks… severe copper deficiency An immune-modulating formula containing arginine and omega-3 fish oil used major surgery and are in a surgical ICU setting 49

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49. contraindication Severe hyperglycemia Hyperosmolarity Severe electrolyte abnormality Volume overload Severe Sepsis Complications Gut mucosal atrophy bacterial translocation-sepsis Blood stream infections Mechanical complications of catheter insertion Hyperglycemia 2xEN Electrolyte abnormality Macro/micronutrient excess/deficiency Refeeding syndrome Rebound hypoglycemia with sudden discontinuation Liver disease(PNALD) – elevated liver enzymes, non alcoholic fatty liver,corrhosis ,irreversible hepatic failure Acalculous cholecystitis (bile stasis) Wernicke encephalopathy

50. Termination of parenteral nutrition Goal –restart oral/ enteral feeding as soon as GI function improve Gradual transition from PN to oral/ enteral nutrition Reduce infusion rate to 50% for 1-2 hr before stopping PN(to minimize rebound hypoglycemia) When 60% of total energy and protein are taken orally/ enterally

51. Nutrition In Liver Cirrhosis Cirrhosis -impairment of non-oxidative glucose metabolism ,depleted hepatic glycogen , Reduced essential and polyunsaturated FA ,protein depletion and trace element deficiency , insulin resistance should be anticipated. PEM ranges from 20% in patients with well compensated disease and more than 60% in patients with advanced cirrhosis. Malnutrition is associated with a higher prevalence of ascites ,HRS , prolonged hospitalization ,mortality , refeeding syndrome and thiamine deficiency

52. Cont… Etiology of liver disease per se does not seem to influence the prevalence and degree of malnutrition but higher prevalence and profound in alcoholics. Cirrhotic patients should take 3-5meals a day and a late evening snack irrespective of the composition or type of formulation Sarcopenia( loss muscle mass and strength) is strong predictor of morbidity and mortality in 50-70% of cirrhosis patient ,assed using DEXA ,CT ,MRI. .

53. Cont.. Energy requirements in compensated cirrhosis is not higher than healthy individual and are capable of formation of lean body mass from oral Refeeding . REE is higher in patient with ALF, advanced Cirrhosis and ASH but unaffected in NASH For patient with cirrhosis and sedentary life style TEE=1.3*REE patient with Histological confirmed NASH - Vit E , selected probiotic and synbiotics are recommended to improve histology and liver enzyme but omega 3 FA, Mediterranean diet and Antioxidant ( vit C , resvasitol ) are not recommended.

54. Cont.. Patients with liver disease with or with out encephalopathy should be fed orally / EN as long as cough and swallowing reflexes are intact. Long-term PN can be associated with worsening of cirrhosis and liver failure with the concomitant risks of sepsis, coagulopathy , and death. With target of energy intake of 30-35 kcal/kg/d and a protein intake of 1.2-1.5 g/kg/d Non-malnourished and compensated cirrhosis - 1.2 g·/kg/d protein Malnourished / sarcopenic cirrhosis 1.5 g/kg/d protein should be ingested. Obese Cirrhotic patients a target energy intake of 25 kcal/kg/d and protein intake of 2.0-2.5 g/kg/d

55. Cont… Protein intake should not be restricted in cirrhotic patients with hepatic encephalopathy as it result in increases protein catabolism if high serum ammonia (>150 micrmol /l) with risk of cerebral edema defer protein intake 24-48hr until serum ammonia level is controlled. In the very rare case of a “protein intolerant” cirrhosis patient developing encephalopathy when ingesting normal amounts of mixed protein, vegetable protein and BCAA may be beneficial. No study show that BCAA is better than standard whole protein formula Long-term oral BCAA supplements (0.25 g/kg/d ) in advanced cirrhosis to improve event-free survival or quality of life.

56. Cont.. Rationale for use of BCAAs - reduced concentrations in liver failure, competing for binding sites in the CNS with aromatic amino acids , and their stimulatory effect on ammonia detoxification to glutamine In patients with HE receiving first-line therapy (antibiotics and lactulose ), there is no evidence that adding BCAAs will further improve mental status or coma grade. low sodium ( unpalatable) diet may increased risk of even lower food consumption should be balanced against its moderate advantage in the treatment of ascites ,moderate dietary sodium intake (60 mmol /day) is usually recommended the administration of micronutrients has no proven therapeutic effect apart from correction of deficiency states

57. Cont… For preoperative nutrition , specialized regimens (BCAA-enriched, immune-enhancing diets) were not superior to standard regimens regarding morbidity or mortality. After LTx , EN should be initiated within 12-24 hr postoperatively to reduce infection rate, energy intake of 30-35 kcal/kg/d and a protein intake of 1.2-1.5g/kg/d . Esophageal varices are no absolute contraindication for positioning a NGT. PEG placement is associated with a higher risk of complications ,due to ascites or varices , and thus, can only be used in exceptional cases. Contradictions include serious coagulation disorders (INR > 1.5,PTT > 50 s, platelets < 50,000/mm3) and severe ascites

58. References

59. . QUESTIONS and COMMENTS

60. . Thank you