1. بسم الله الرحمن الرحيم

2. Nutritional Screening Can physically eat food? Can physically eat food? Can patient tolerate food? Can patient tolerate food? Previous diet Previous diet 2

3. Objectives in Nutritional Screening Weight, height, Weight, height, Ask ideal weight Ask ideal weight Lab (Alb, Hct, hgb, FBS) Lab (Alb, Hct, hgb, FBS) Appearance (edema, skin tregor, cachexia, ulcer,..) Appearance (edema, skin tregor, cachexia, ulcer,..) 3

4. Weight :bed-scale (Seca 984- Germany)

5. Malnourished people NICE guideline (2006) describes people who are malnourished, as defined by any of the following: a body mass index (BMI) of less than 18.5 kg/m2 unintentional weight loss greater than 10% within the last 3–6 months a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.

6. People at risk of malnutrition those who have: eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for 5 days or longer a poor absorptive capacity and / or high nutrient losses and/or increased nutritional needs from causes such as catabolism

7. Important tip It is of important to consider nutrition support for people who are either malnourished or at risk of malnutrition.

8. Who needs Nutrition Support? Those with poor nutritional status Those with poor nutritional status Weight loss (>2.5 kg/month- unintentionally) Weight loss (>2.5 kg/month- unintentionally) Albumin < 3.5 g/dl) Albumin < 3.5 g/dl) 8

9. What’s Nutrition Support? 9 Methods to improve or maintain nutritional intake are known as nutrition support.

10. What’s Nutrition Support? 1- Oral (for example, fortified food, additional snacks and / or sip feeds) 10

11. What’s Nutrition Support? 2- Enteral – the delivery of a nutritionally complete feed directly into the gut via a tube 11

12. What’s Nutrition Support? 3- Parenteral – the delivery of nutrition intravenously. 12

13. When select Enteral way? If got still works, If got still works, But for 5 to 7 days did not take enough food But for 5 to 7 days did not take enough food 13 تغذیه روده ای زمانی در بیماران استفاده می شود که عملکرد دستگاه گوارش درست بوده اما بیمار به مدت 5 تا 7 روز و حتی بیشتر دربافت غذائی کافی نداشته ولذا نیازمندیهای غذائی وی از طریق خوراکی تامین نشده است.

14. Short term Enteral feeding? موارد استفاده کوتاه مدت از تغذ یه روده ای (کمتر از 4 هفته): نازوگاستریک: برای بیمارانی بکار می رود که می توان از معده بطور کامل استفاده کرد و نگرانی از جهت تهوع، استفراغ و آسپیراسیون وجود ندارد. نازوژژونال: برای بیمارانی که نیاز است معده و دئودنوم بای پس شود، مثلا آسیب معده با اسید، بیمارانی که در معرض آسپیراسیون هستند، و یا بیمارانی که تهوع و استفراغ مداوم دارند. 14 < 4 weeks < 4 weeks Nasogastric Nasogastric Nasojejunal Nasojejunal

15. Short term Enteral feeding: 15

16. Long term Enteral feeding? موارد استفاده بلند مدت از تغذ یه روده ای (کمتر از 4 هفته): گاستروستومی: به طریق جراحی با بیهوشی عمومی و یا از طریق زیر پوستی (PEG)، با یک تسکین داروئی، تحت کنترل اندوسکپی و با کیت مخصوص این کار انجام می شود(2). ژژنوستومی: برای بیمارانی تعبیه می شود که لازم است بمدت بیش از چهار هفته معده و دئودنوم بای پس شود(2). 16 > 4 weeks > 4 weeks Gastrostomy Gastrostomy Jejunustomy Jejunustomy

17. Gastrostomy (PEG)Gastrostomy (PEG) 17

18. The role of GI tract Immune competence and prevention of acute phase reactions. Metabolic function in amino acid metabolism As a mechanical barrier for bacterial translocation. Its importance for infectious complications such as nosocomial pneumonia.

19. Jejunustomy 19

20. Indication of Enteral Feeding: 20 Dysphasia, coma, demencia Dysphasia, coma, demencia Those with depression, not reluctant to eat food Those with depression, not reluctant to eat food Nasojejunal Nasojejunal

21. Main indication for EN is prevention and treatment of malnutrition in order to improve outcome ;

22. Enteral Nutrition “If the gut works, use it!”

23. Importance of early EN support Absolute benefitsRelative benefits Satisfying nutrient needsWound healing Cost effectiveHospital stay Bowel mucosal integrity and massDecrease infections, and bacterial translocation Improve EN tolerance Suppress hyper- metabolic response Avoid PN complications Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)

24. An important consideration NPO should be withhold as soon as possible.

25. (American Journal of Critical Care. 2004;13:221-227) Common Reasons for NPO

26. Contraindication of oral and Enteral Feeding: 26

27. Methods of Enteral Feeding: 27

28. Indication of Parenteral Feeding: 28 Not working gut Peripheral veins Central veins

30. 30

31. Parenteral Nutrition (PN)

32. Consider oral nutrition support and stop when the patient is established on adequate oral intake from normal food if patient malnourished/at risk of malnutrition can swallow safely and gastrointestinal tract is working

33. Consider Enteral Nutrition and use the most appropriate route of access and mode of delivery stop when the patient is established on adequate oral intake from normal food has a functional and accessible gastrointestinal tract if patient malnourished/at risk of malnutrition despite the use of oral interventions

34. Consider parenteral nutrition use the most appropriate route of access and mode of delivery stop when the patient is established on adequate oral intake from normal food or enteral tube feeding and has either introduce progressively and monitor closely if patient malnourished/at risk of malnutrition a non-functional, inaccessible or perforated gastrointestinal tract inadequate or unsafe oral or enteral nutritional intake

35. When to start feeding following placement? 1.After surgery: no need for flatus or BM 2. PEG tube may be utilized for feedings within 2 hours in adults and 6 hours in infants and children. (B) feeding can be initiated within 24-48 hours. (A)

36. Malnutrition is still exist in hospitalized patients. Key messages

37. Patients Patients Benefit from Nutrition Support. Key messages

38. Hospital discharge

39. با تشکر

40. 40 Thanks for your attention. NematyM@mums.ac.ir

41. مرخصي از بيمارستان

42. با تشکر

44. The editorial of the 2006 ESPEN guidelines on Enteral Nutrition it is worth mentioning “Although nutritional support is therapy in most cases it is exactly what it says – supportive rather than specific treatment of the underlying disease.” (Lochs H, 2006)

45. Acknowledgment ICU patients MUMS Colleauges: Drs: Ghayour, Safarian, Norouzy, Azarpajooh, Alamdari. Mrs Siadat, Firouzy, and Tavallae Ms Shahsavan, Ghavami, Momenzadeh Mr Mohajery SAR

46. 46 Nutritional risk screening (NRS 2002) In this study NRS 2002 method, a system for screening of nutritional risk was used to assess malnutrition [20]. It is based on the concept that nutritional support is indicated in patients who are severely ill with increased nutritional requirements, or who are severely undernourished, or who have certain degrees of severity of disease in combination with certain degrees of undernutrition. Patients were scored in each of the two components; undernutrition and disease severity, according to whether they were absent, mild, moderate or severe, giving a total score 0–6. If patient was more than 70 years, one point was added to the total score. Patients with a total score of ≥3 were classified as nutritionally at-risk. Undernutrition was estimated using three variables used in most screening tools: BMI, percent recent weight loss and change in food intake, since these have reasonable evidence base in the literature, correlating with changes in function and clinical outcome.

47. Hospital Malnutrition Effectiveness of nutritional supplements in hospitals varies, probably due to the influence of poor appetite (Miline et al. 2005)

48. Mechanism ? The mechanism of cachexia in hospitalised patients remains largely unclear.

49. Appetite Regulation

50. Mechanism? Findings from Imperial's college's metabolic medicine lab suggested that peptide hormones released from the gut, such as ghrelin and peptide YY (PYY), which stimulate and inhibit the appetite, respectively, might play a role in the altered eating behaviour of patients, particularly intensive care patients because the anorexia in hospitalised patients is often characterised by a premature feeling of fullness and loss of hunger. Nematy, M. 2005 Batterham R, 2004 Nematy, M. 2007 Nematy, M 2006

51. Methodology: Bio-Impedance analyzer (BIA) (Body stat 1500 MDD, England)