Dr.

Anil Gurnani Group Director Critical Care Kailash Group of Hospitals

Artificial feeding is the treatment of gastrointestinal failure in the same sense that dialysis is the treatment of renal failure!

Majority of hospitals lack an expert team to provide nutritional support!

Why should we feed people who are ill?

remember how much he has had, and how much he ought to have today
Florence Nightingale, 1859

 Prechristian Egypt -

Herodot administered first nutrient enema (History of artificial Nutrition)

16th Century -> New Millenium

 Growing threat of nosocomial infections 30 - 50% malnaurished (Martindale RG, 1999)

 Surgical Patients (Swe, Fran):

4-31%

Orthopaedic Patients (USA)

Oncological Patient (Ger)

:
:

18-51%
61%

India. ? ? ?

 Increases length of stay in ICU

Increases number of days on ventilator

Poor outcome : Trauma, Sepsis, Major Surgery

A. High dose corticosteroids B. Antiendotoxin antibody C. Anti-TNF monoclonal antibodies D. Platlet-activating factor antagonists E. NSAIDs - Ibuprufen
Cleveland - Clinic Journal of Medicine, Vol. 69, No. 1, Jan 2002

 Activated Protein - C Cost of 4 days therapy - Rs. 4 lacs/- !!

 12 Centre Study 395 Malnonrished Patients Study Group : Preoperative 7 days and Post-operative 3 days TPN
: No nutritional Support

Control Group

 Results :

Infectious complications more In malnourished (Mild, Moderate) In severely malnourished, the difference was 5% Vs 43%, TPN Vs Control

Malnutrition closely
related to outcome

Who makes the decision ?

Infections: 1st

2nd

3rd

Antibiotics

The start of the patients journey

Infections: 1st

2nd

3rd

Antibiotics

The start of the patients journey

To feed or Not to feed is

Not the Question

 Whom to feed ?

When to feed ?? How to feed ???

 Critically ill patients

 Short term Long term

Contd.

Major Gut disorder Short bowel syndrome

Malabsorption syndromes

Woodcock etal, Nutrition 2001

Clinically certain 498 patients

267 TPN

231 EN

 Inadequate nutritional intake: -78% EN Vs 25% PN, p < 0.001 EN associated with higher overall mortality No significant difference in septic morbidity Conclusion: When in doubt go PN

 15-39% intolerant.

Respiratory Compromise
Access Complication: - Oesophagitis - Gastritis - Jejunal Necrosis

 Peripheral Venous access Central Venous access

 Easy More Thrombophlebitis

Short length, Cyclical rotation

Optimal length (35-42 Cm)

 Needs experience Juglar

Subclavian
Long term

 Macronutrients

Micronutrients
Immunonutrients

 Nutritionally complete
Safe

No risk of precipitation
Ready to use

Freedom from contamination associated with mixing

 Energy

: 25-30 kcal/kg/day

Glucose
Fat Nitrogen

: 2-4 gm/kg/day
: 1-2 gm/kg/day : 0.10.3 gm N/kg/day

Aminoacids: 0.6-2 g AA/kg/day

Contd.

Non Protein Calories

60 70% as Glucose
30 35% as Fat

 Starters
Add-on

Top-up
Supplement

Fortify

 Glucose plus Lipids

Better utilisation : Nitrogen balance

Glucose oxidation & metabolism: better Glucose intolerance & Hyperglycemia: Less

 Lipids reduce osmolarity : used for diluting high conc. of glucose Lipids protect against thrombophlebitis

 10% & 20%, soyabean oil

EFA : Linoleic,Linolenic & Arachidonic

0.5-1gm/kg body wt./day,30-40% calories Osmolarity ~ 300 mosm/l

Contd.

* Precautions:
Severely impaired hepatic/renal function
Hyperlipidemic states Monitor trigyclerides, platelet count

Contd.

Interference with lab. Measurements 5-6 hrs fat free interval. Interfere with pulmonary circulation

 5% & 10% solution, ph 5.5-6.5

1-1.5 gm/kg/day
AA: 50-100 g/l, N2 content : 8-16 g/l

Osmolarity : 990 mosm/kg

* Precautions:
Disturbance of aminoacid metabolism Metabolic acidosis Advanced liver/kidney insufficiency Acute folate deficiency

 Blood sugar
S.Electrolytes

: 6 8 hrly
: daily

LFT, Triglycerides : weekly

KFT

: twice a week

Lymphocyte count : weekly

 Tailor - made Customised (pre-prepared)

60Kg. Adult
Proteins :
10% :

75gm
750ml

 Glucose
25% Dextrose

: : : :

200gm. 800ml. 50gm. 250ml

Fat
20%

 Administration of all the nutrients

Together and Continuously

Ability to mix fat emulsions, aminoacids and glucose in single container.

Advantages
Optimal utilisation of calories

Effective and Natural

Minimises metabolic complications - Reduced volume load - Reduced CO2 production - Avoids hyperglycemia - Less Fat Synthesis

 Copper
Zinc

:
:

0.3 mg
3.0 mg

Manganese Selenium Chromium Iodine Molybdenum

: : : : :

0.7 mg 120 mcg 20 mcg 120 mcg 20 mcg

Specialised area of
Intensive Care Medicine

Immune Modulating Nutrition

(IMN)

Modulation of the immune response with naturally occuring nutrients in order to limit tissue injury, reduce infection rates and morbidity.

 Aminoacids
- Glutamine, Arginine Essential Fatty Acids - Linoleic & linolenic - Omega 3 Fatty acids

 Liver
Kidney * Maintain Protein & Caloric requirements

Prevent Catabolism

 Protein turnover increased to

greater than three times.

Branched chain Amino Acids :

Useful energy source (8%BCAA)

 Aminoacid uptake is impaired

Essential Aminoacids (7%)

Low Nitrogen content

It takes a strong fish to swim against the current, even a dead one can float with it !!!

 As an individual or a society, we cannot change the evils that exist, but we can try to change the philosophies

 Occasions do not make a man either strong or weak, but they show what he is !