1. Nutritional Support of the Cacectic Patient

2. Recap Risk of Malnutrition Risk of Malnutrition Nutritional assessment Nutritional assessment History and examination History and examination Anthropological Anthropological Biochemical Biochemical Calculation of nutritional needs Calculation of nutritional needs TE = NPE + PE TE = NPE + PE NPE = CHO and lipids NPE = CHO and lipids

3. Study Aims Substrate changes Substrate changes Acute starvation Acute starvation Chronic Starvation Chronic Starvation Strategy for nutritional support Strategy for nutritional support Enteral access routes Enteral access routes Complications of enteral feeding Complications of enteral feeding

4. Pathophysiology Acute Starvation Acute Starvation Depletion of liver glycogen (rapid) Depletion of liver glycogen (rapid) Insulin fall, glucagon rise Insulin fall, glucagon rise Hepatic GNG Hepatic GNG Amino-acids from muscle protein Amino-acids from muscle protein Alanine and glutamin prefered (75%) Alanine and glutamin prefered (75%) Build up by insulin Build up by insulin Breakdown in absence of insulin Breakdown in absence of insulin Lipolysis Lipolysis Energy for GNG from FFA oxidation Energy for GNG from FFA oxidation Insulin fall stimulates lipolysis Insulin fall stimulates lipolysis Liberates glyserol Liberates glyserol

5. Pathophysiology – A. Starvation Conservation of substrate Conservation of substrate Glucose to lactate in haemopoetis Sx Glucose to lactate in haemopoetis Sx Recycled via glucogenic Cori cycle Recycled via glucogenic Cori cycle Glyserol (from lipolysis) Glyserol (from lipolysis) Hepatic GNG Hepatic GNG Branched chain Amino Acids Branched chain Amino Acids From proteolysis From proteolysis In Crebs from alanine and glutamine In Crebs from alanine and glutamine Direct oxidation in cardiac tissue and skeletal muscle Direct oxidation in cardiac tissue and skeletal muscle Stimulates protein synthesis and inhibit breakdown Stimulates protein synthesis and inhibit breakdown Resulting increase in u - N output Resulting increase in u - N output

6. Pathophysiology – C. Starvation Starvation by above methods Starvation by above methods 8 – 12g/day N excretion (340g prot) 8 – 12g/day N excretion (340g prot) 35% LBM in 1 month = Fatal 35% LBM in 1 month = Fatal Survival for 2 – 3 months due to Survival for 2 – 3 months due to Decreased energy expenditure Decreased energy expenditure Decreased SV and HR (CO) Decreased SV and HR (CO) Voluntary mobilisation decreases due to fatigue Voluntary mobilisation decreases due to fatigue Altered brain substrate Altered brain substrate Ketone oxidation Ketone oxidation Fall in glucose utilisation Fall in glucose utilisation Rise in ketones Rise in ketones Inhibits hepatic GNG Inhibits hepatic GNG

7. Pathophysiology - Starvation Decrease in EE Decrease in EE Conserving protein Conserving protein Catabolism = protein breakdown or auto-canabalism Catabolism = protein breakdown or auto-canabalism

8. Strategy for nutritional support Nutritional Assessment GIT assessment Functional Non-functional Diarrhoea Obstruction Peritonitis Vomiting Ileus Short bowel syndrome TPN GIT function Remains absent Access Long term Oral Gastrostomy PEG Jejunostomy Short term Oral Naso-gastric Naso-duodenal Naso-jejunal Jejunostomy TEN Normal GIT Fx Compromised GIT Fx Returns Polymeric feeds Semi-elemental feeds

9. Enteral feeding Enteral = in the gut Enteral = in the gut Needs intact GIT Needs intact GIT Patent Patent Functional Functional Needs access Needs access Oral Oral Gastric Gastric All about gastric emptying All about gastric emptying Duodenal Duodenal Jejunal Jejunal About absorption and volume accomodation About absorption and volume accomodation

10. Enteral Access Routes (other than oral) Gastric Gastric Naso-gastric Naso-gastric Oro-gastric Oro-gastric Via pharingostomy Via pharingostomy GAstrostomy GAstrostomy PEG PEG Surgical Surgical Duodenal Duodenal Naso and oro-duodenal Naso and oro-duodenal Placement Placement Blind techniques Blind techniques Accidental Accidental Endoscopic or PEG extensions Endoscopic or PEG extensions

11. Enteral Access Routes (other than oral) Jejunal Jejunal Naso or oro-jejunal Naso or oro-jejunal At time of open abdomen At time of open abdomen Jejunostomy Jejunostomy

12. Enteral formulars Semi-elemental Nutritionally not balanced Nutritionally not balanced Low in fat Low in fat Proteins in form of AAS, Peptides and polypeptied Proteins in form of AAS, Peptides and polypeptied Easy to digest Easy to digest Low residue Low residuePolymeric Nutrtionally balanced Nutrtionally balanced Digestion normal Digestion normal Residue normal Residue normal

13. Indications for enteral support Basal need not met by intake Basal need not met by intake Large deficit not net by intake Large deficit not net by intake Increased need (BMR) - hypermetabolism Increased need (BMR) - hypermetabolism Burns Burns Head injury Head injury Partial functioning GIT Partial functioning GIT Limitation on volume Limitation on volume

14. Complications Tube related / mechanical Tube related / mechanical Pulmonary Aspiration Pulmonary Aspiration Sinusitis Sinusitis Misplacement and dislodgement Misplacement and dislodgement Erosions and necrosis Erosions and necrosis Reflux Reflux Blockage Blockage Underfeeding Underfeeding

15. Complications Metabolic Metabolic Diarrhoea Diarrhoea Hypertonic solutions Hypertonic solutions Inadequate absorption Inadequate absorption Lactose deficiency Lactose deficiency Starvation hypoalbunemia Starvation hypoalbunemia Excess fat Excess fat Overfeeding (see previous lecture) Overfeeding (see previous lecture) Refeeding Refeeding Severe hypo-phosphatemia and hypo-kalemia secondary to chronic starvation Severe hypo-phosphatemia and hypo-kalemia secondary to chronic starvation To little ATP for absorption To little ATP for absorption