ASSESSMENT AND MONITORING OF NUTRITIONAL STATUS. PRINCIPLES OF NUTRITIONAL SUPPORT, ENTERAL AND PARENTERAL NUTRITION. DIETARY CONSTITUENTS PROVIDING A SUFFICIENT ENERGY INTAKE. Michaela Králíková Department of Biochemistry Faculty of Medicine MU 1 EVALUATION OF NUTRITIONAL STATUS ¢Long-term state of nutrition ¢Actual (contemporary) state of nutrition ¢ ØData to assess: antropometric laboratory: biochemical hematological imunological 2 ANTROPOMETRIC DATA 3 ¢weight w, height h ¢BMI ¢Broca index ¢Arm muscles circumference (arm circumference – π . triceps skinfold /cm/) ¢triceps skinfold ¢body composition ¢ ¢ ¢18.5 – 24.9 kg/m2 ¢h (cm) – 100 = w (kg) ¢♂ ≥ 25 cm, ♀ ≥ 20 cm ¢ ¢ ¢♂ 12.5 mm, ♀ 16.5 mm ¢Normal values What are your values? LABORATORY DATA ¢Total protein/S ¢Albumin /S (t1/2 = 21 days) ¢Prealbumin /S (t1/2 = 2 - 3 days) ¢Transferrin /S (t1/2 = 7 days) ¢RBP (t1/2 = 0.5 day) ¢CRP /S ¢Zn /S (binds to alb) ¢Chol (long-term indicator) ¢Blood count ¢Total lymphocytes number, number of CD4, CD8 ¢Ig /S ¢Delayed skin reaction ¢ 4 DISORDERS OF NUTRITION - MALNUTRITION ¢State of nutrition linked to deficiency, dysbalance or rebundance of energy, proteins and other nutrients 5 Simple undernutrition, simple cachexy, marasmus Energy malnutrition Stress undernutrition, kwashiorkor, kwashiorkor-like undernutrition Protein malnutrition Undernutrition Obesity BMI > 30 kg/m2 Waist circumference ≥ 94 cm ♂, ≥ 80 cm ♀ SIMPLE UNDERNUTRITION ¢= energy malnutrition ¢Insufficient intake of carbohydrates, lipids and proteins ¢Progressive symmetric weight loss leading to cachexy in otherwise healthy individuals with limited food intake ¢atrophy of GIT ® restoration of nutrition p.o. is not possible!! ¢Sources of energy: lipolysis in adipose tissue → acetyl-CoA → ¢ ¢ proteolysis in striated muscles → AA for synthesis of plasma proteins 6 Krebs cycle → reduced cofactors → RC → ATP gluconeogenesis → glc synthesis of keton bodies – en. substrate for CNS, myocardium, muscles Výsledek obrázku pro kachexie Výsledek obrázku pro kachexie STRESS UNDERNUTRITION ¢= protein malnutrition ¢Insufficient protein intake + fast proteolysis ¢Causes: ↓ intake, ↑ loss, ↑ needs, ↑ breakdown (catabolism), ↓ synthesis (liver) ¢Water retention, ascites and edemas at the same or increasing weight ¢Presence of systemic inflammation with ↓ insulin and ↑ stress hormones, STH and proinflammatory cytokines ¢Sources of energy: proteolysis in muscles and albumin → AA for gluconeogenesis, proteosynthesis (AFP, wound healing…) ¢ ¢ lipolysis in adipose tissue → to little acetyl-CoA 7 Výsledek obrázku pro stresova podvyziva COMPARISON OF SIMPLE AND STRESS UNDERNUTRITION Simple undernutrition Stress undernutrition Origination weeks - months days Inflammation no present Weight ↓ normal - ↑ Muscle mass slightly ↓ extremely ↓ Fat mass ↓ ↓, normal or ↑ Content of water and Na+ ↓ ↑ Serum proteins, albumin normal extremely ↓ Acute phase proteins (AFP) normal ↑ Example geriatric cachexy, mental anorexia, m. Crohn, chronic pancreatitis sepsis, trauma, surgery, burns, acute pancreatitis 8 METABOLISM IN OBESITY ¢Insulin resistance + release of adipokines produced by adipose tissue (leptin, resistin, angiotensinogen, adipsin, ACE, CETP, TNFa, IL-6 et al.) ¢ ¢↑ lipolysis in adipose tissue → ↑ FA in blood ¢↓ activity of LPL → ↑ TAG in blood + stopped liponeogenesis ¢Excess FA to liver → formation of VLDL → ↑ TAG and chol in blood ¢ → ectopic accumulation of lipids ¢↓ utilization of glc in muscles and adipose (GLUT-4) ¢↑ accumulation of liver glycogen 9 THE DAILY REQUIREMENTS OF BASIC NUTRIENTS 10 ¢Energy ¢ ¢Carbohydrates ¢Proteins ¢Lipids ¢ ¢Reccomended daily intake ¢ ¢40 (55) – 60 % (2 (4) - 6 g glc /kg/day) ¢0.8 g/kg/day (0.8 – 1.6 g/kg/day) ¢25 - 35 % (1 – 1.5 g/kg/day), min. 15 - 20 % ¢ ¢ Carbohydrates Proteins (AA) Lipids Anabolic ration of nutrients 6 g/kg 1 g/kg 1 – 1.5 g/kg Stress ratio of nutrients 2 - 3 g/kg 1.5 - 2 g/kg 0.7 g/kg Why? Need for essential FA (LA, ALA) and lipophilic vitamins intake. ENERGY BALANCE ¢Energy ingested = energy expended ¢ ¢Resting metabolic rate RMR (kJ/day) = 100 . w (kg) = 4.2 . S (m2) ¢reserves formation ¢heat production ¢activity ¢ ¢stress 11 · rise in body temperature by 1°C ® + 15 % RMR · · activity factor: bedridden ® 1.2 RMR not - bedridden ® 1.3 (heavy physical activity ® 2) · trauma factor: small surgery ® 1.2 severe surgery ® 1.35 sepsis ® 1.6 severe burns ® 2.1 1 kcal = 4.19 kJ What is your RMR (in kJ, kcal)? CARBOHYDRATES ¢RDA = 2 – 6 g glc /kg / day ≈ 40 – 60% of energy supply ¢ ¢ ¢ Enteral nutrition: Starch, oligosaccharides (maltodextrin), sugars Parenteral nutrition: Glc: isoosmolar – 5% (50 g/l = 278 mmol/l), low energy content 10% (100 g/l = 556 mmol/l), 15% (150 g/l = 833 mmol/l) – peripheral or central vein 20% (200 g/l = 1111 mmol/l) and more – only central vein 12 OSMOLALITY OF GLC SOLUTIONS 13 qG5 = 5 % Glc = 5 g Glc / 100 g of solution 50 g Glc / 1000 g » 50 g Glc / 1 L Mr(Glc) = 180 osmolarity = 50 : 180 = 0.278 mol / 1 L = 278 mmol / 1 L osmolality » 280 mmol / kg qnormal osmolality of blood plasma = 275 - 300 mmol / kg H2O qThe infusion of 5 % glc is isotonic with blood plasma. OSMOLALITY OF GLC SOLUTIONS 14 qG15 = 15 % Glc = 15 g Glc / 100 g of solution 150 g Glc / 1000 g » 150 g Glc / 1 L Mr(Glc) = 180 osmolarity = 150 : 180 = 0.833 mol / 1 L = 833 mmol / 1 L qThe highest osmolality for infusion into a peripheral vein is 850 mmol/kg = 15% glc solution - without any additives !!! REM. – DIETARY FIBER ¢Biological definition: Carbohydrates which are not lysed enzymatically in the small intestine and thus are passed into the large intestine. ¢Chemical definition: Non-starch polysacharides and lignin. ¢ ¢ ¢ ¢ ¢ ¢ ¢RDI = 3 g /MJ adults ¢Children, teens 3 - 20 ys.: age + 5 g ¢Estimated intake Europe, USA 150 kJ/day; developing countries 700 kJ/day 15 Water-soluble: pectin, inulin, gums, mucilage and storage polysaccharides (guar gum) Water-insoluble: celulose, hemicelulose, lignin; psyllium Seed coat of blond plantain (plantago ovata), blond psyllium FUNCTION OF INSOLUBLE FIBER ¢Acceleration of intestinal passage, ↑ stool weight and volume ¢↓ resorption of bile acids, ↓ chol /S ¢↓ resorption of sugars ¢↓ resorption of lipids ¢↓ resorption of minerals and microelements 16 Výsledek obrázku pro nerozpustná vláknina WHAT IS HAPPENING WITH SOLUBLE FIBER IN THE COLON? ¢Fermented by bacteria ¢Products: acetic, propionic, butyric acids ¢These acids are utilised by enterocytes – 70% of energy ¢Significance : to maintain the intestinal barrier ¢↑ resorption of Na+ and water 17 Výsledek obrázku pro vláknina Na^+ is transported with originating FA. NEED OF PROTEINS Reccomended daily intake of proteins* in g / kg / day Infants (0 - 1 year) 2.0 Children (1 - 10 years) 1.2 Adolescents 1.0 Adults 0.8 Pregnant and breastfeeding women 1.1 Sportmens 1.3 – 2.0 Parenteral nutrition (AA) or other nutritional support 1.0 – 1.5 Minimal intake 0.4 – 0.5 18 *valid in case of sufficient intake of non-protein energy 250 – 800 kJ / g nitrogen Why? AMINOACIDS (AA) 19 ¢Val ¢Leu ¢Ile ¢Met ¢Phe ¢Thr ¢Trp ¢Lys ¢His ¢Arg ¢Gln ¢(Glu) ¢Cys ¢Tyr ¢ ¢Essencial ¢Semiessencial SPECIFIC PHARMACOLOGIC EFFECTS AND INDICATIONS OF SELECTED ESSENCIAL AA 20 ¢Val, Leu, Ile ¢- favour muscle proteosynthesis (especially in DM) ¢- inhibit sarcopenia ¢His ¢- ↑ need in renal insufficiency Why? INCREASED NEEDS OF SEMIESSENCIAL AA 21 Tyr + Cys -infants -lack of Phe and Met -liver insufficiency Arg -growth -sepsis, injuries, post-operative period (resource of optimal immunological defence mechanisms, synthesis of collagen) -immunity stimulation -NO synthesis -antineoplastic effect INCREASED NEEDS OF SEMIESSENCIAL AA 22 Gln -stress situations – energy substrate for immune system cells (lymphocytes, macrofages, fibroblasts), enterocytes, kidneys -metabolic substrate for NA bases synthesis (cell division - mucosis, bone marrow) -important source of nitrogen, the main AA of plasma -maintaining the intestinal barrier (toxins, starvation, radiation, inflammation) Unstable in parenteral nutrition solutions! LIPIDS ¢RDA = 0.5 – 1.5 g /kg/ day ≈ 25 – 40% of energy supply ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢source of essencial FA, fat-soluble vitamins 23 Enteral nutrition: vegetable oils (rapeseed, sunflower, soya, coconut) Parenteral nutrition: 10-20% lipid emulsions (of olive, soybean oil + event. fish, coconut) Give names of essential FA. LA 18:2 (9,12), ALA 18:3 (9,12,15) SIGNIFICANCE OF FATTY ACIDS ACCORDING TO THEIR CHAIN LENGHT ¢2 - 4 C: resorption to portal vein, probably inhibit chol synthesis in the liver energy for enterocytes (70% of en., intestinal barrier) ¢ ¢6 - 10 C: fast energy: resorption to portal vein, b-oxidation without carnitine; component of MCT ¢ ¢≥ 12 C: resorption to thoracic duct (as CM), carnitine needed for their transoprt to mtch matrix; component of LCT ¢12 – 16 C: energy, atherogenic ¢≥ 18 C: energy, structure of PL, TAG ¢20 C (DHGLA, AA, EPA): synthesis of eicosanoids 24 SATURATED FATTY ACIDS WITH 12C – 16C CHAIN ¢Highly atherogenic, increase total cholesterol ¢ ¢ ¢ ¢lauric 12:0 – increases total and HDL cholesterol ¢myristic 14:0 (Myristica fragrans) – 4x more efective than 16:0 ¢palmitic 16:0 25 ↑ synthesis of chol de novo ↓ affinity of LDL-receptors to LDL (only C14:0 and C16:0?) SATURATED FATTY ACIDS WITH 12C – 16C CHAIN SOURCES Fatty acid (% of total FA) Coconut fat Palm fat Palm kernel fat Milk fat Lard Olive oil Rapeseed oil Sunflower oil Butyric 4:0 x x x 3,6 x x x x Capronic 6:0 0,5 x 0,3 2,2 x x x x Caprylic 8:0 7,8 x 4,4 1,2 x x x x Caprinic 10:0 6,7 x 3,7 2,5 x x x x Lauric 12:0 47,5 0,2 48,3 4,5 x x x x Myristic 14:0 18,1 1,1 15,6 14,6 1,7 x x x Palmitic 16:0 8,8 44,0 7,8 30,2 25,0 8,4 3,6 6,3 Stearic 18:0 2,6 2,0 10,5 15,0 2,5 1,5 4,6 Palmitooleic 16:1 (9) x x x 5,7 3,0 0,7 x x Oleic 18:1 (9) 6,2 39,2 15,1 16,7 45,0 78,0 61,6 26,7 Linoleic 18:2 (9, 12) 1,6 10,1 2,7 2,4 8,0 8,3 21,7 61,2 α-linolenic 18:3 (9, 12, 15) x 0,4 x x x 0,8 9,6 x 26 Pánek J.: Odborné výživové hodnocení palmového a palmojádrového tuku 2015 LIPIDS – PREFERABLE RQ ¢RQ = ¢ ¢ ¢glc: C6H12O6 + 6 O2 → 6 CO2 + 6 H2O ¢ ¢ RQ = 6 / 6 = 1.0 ¢ ¢palmitic a.: C16H32O2 + 23 O2 → 16 CO2 + 16 H2O ¢ ¢ RQ = 16 / 23 = 0.7 ¢ ¢Lower CO2 production during oxidation of FA – important source of energy in ventilatory problems. 27 CO2 O2 DAILY REQUIREMENT FOR BASIC NUTRIENTS Water 30 – 40 ml /kg Energy 25 – 30 kcal = 105 – 126 kJ /kg Glc 2 – 6 g /kg Lipids 1 – 1.5 g /kg AA 0.8 – 1.6 g /kg Sodium 1 – 2.5 mmol /kg Potassium 1 – 2.5 mmol /kg Calcium 0.05 – 0.1 mmol /kg Magnesium 0.1 – 0.2 mmol /kg Phosphorus 0.4 mmol /kg 28 1 kcal = 4.19 kJ Vitamins Trace elements BASIC CONCEPT OF CLINICAL NUTRITION 29 http://img99.rajce.idnes.cz/d9902/9/9367/9367066_9950040714e4e56efe1577f55cb2d95a/images/005_Pobyt_ v_Krajske_nemocnici_v_Usti_n._L..jpg http://nd03.jxs.cz/328/683/a9dc93c627_88767035_o2.gif DIET SYSTEM IN CR – BASIC DIETS No. Name Energy value kJ Specification 0 fluid 6 000 – 12 000 1 pappy 9 500 2 GIT- saving 9 500 Fried food – free. Proteins 80 g, lipids 70 g, sacchar. 320 g 3 basic (rational) 9 500 Proteins 80 g, lipids 70 g, sacchar. 320 g 4 with fat restriction 9 500 Limited lipid content 55 g. 5 residue-free 9 500 Without dietary fibres. 6 with protein restriction 9 500 Limited protein content 50 g. 8 reducing 5 300 Limited energy value. 9 diabetic 7 400 Limited saccharides content 225 g. 10 saltless 9 500 Limited salt content. 11 nutritive 12 000 Increased energy value. 12 infant 5 500 1.5 – 3 years. 13 pediatric 7 000, 8 800 4 - 6, 6 - 12 years. 30 1 kcal = 4.19 kJ DIET SYSTEM IN CR – SPECIAL DIETS No. Name Energy value Specification 0S tea Nutritionally deficient!!! 0-ND nutritionally defined 8 000 - 12 000 kJ Individual. 4S with strict fat restriction 7 000 kJ Limited energy and lipid content. 9S diabetic chary 7 400 kJ Limited carbohydrates content 225 g + fried food – free. 31 DIET SYSTEM IN CR – STANDARDIZED DIETS ¢Gluten-free diet ¢Lactose-free diet ¢Pancreatic diet – in accute pancreatitis ¢Renal diet – in chronic renal failure 32 ALGORITHM OF NUTRITIONAL SUPPORT 33 http://www.propagacenainternetu.cz/wp-content/uploads/myslete-kreativne.jpg ¢Why? ¢Normal food? ¢Feeding of patient, insreased supervision, individual diet ¢ ¢Oral nutrition support ¢ ¢Enteral tube feeding ¢ ¢Parenteral nutrition ¢ ¢ Is GIT functional? Is p.o. intake possible? no yes no yes, partly yes KINDS OF NUTRITIONAL SUPPORT ¢Fortified diet ¢Enteral nutrition ¢Parenteral nutrition 34 Normal meal enriched with energy, macronutrients, or micronutrients. PROTIFAR 225 gm prášek pro roztok FANTOMALT 1X400GM Prášek pro roztok maltodextrin (enzymatically digested cornstarch) concentrated milk protein, emulsifier (soya lecithin) ENTERAL NUTRITION 35 Sipping Tube feeding Nutritionally incomplete Nutritionally complete ENERGY (CALORIFIC) VALUE OF NUTRITION SUPPORT Øhypocaloric < 1 kcal/1 ml = < 4.19 kJ/1 ml Ø Øisocaloric 1 kcal/1 ml = 4.19 kJ/1 ml Ø Øhypercaloric > 1 kcal/1 ml = > 4.19 kJ/1 ml ¢ 36 SIPPING ¢= oral nutrition support ¢the most used nutrition support ¢advantages: Øready to use, easy to consume Ødefined content of energy and nutrients Ødefined content of vitamins and trace elements Øeasily absorbed Øgood bioavailability 37 SIPPING 38 FRESUBIN ORIGINAL S ČOKOLÁDOVOU PŘÍCHUTÍ 4X200ML Roztok ENSURE PLUS PŘÍCHUŤ JAHODA 1X220ML Roztok Nutridrink základní řada Proteins – milk, soya Carbohydrates – maltodextrin, sucrose Vegetable oils Vitamins Trace elements Minerals Nutridrink Compact SIPPING ¢Generally 1 – 1.5 kcal/ml (4.19 – 6.28 kJ/ml) ¢16-20 % proteins, 25-30 % lipids and 50-54 % carbohydrates ¢ ¢Products with higher energy content: 1.2 – 1.6 – 2.0 kcal/ml 5 – 6.7 – 8.4 kJ/ml Ørequirement for highly energy-rich diet (Tu), limited oral intake (organic reasons, dysorexia) ¢ ¢Products with higher protein content: ØBetter wound healing; surgery, Tu, seniors. ¢ ¢Products with diet. fiber: ↑ bowel motility, ↓ constipation, soften stools, ↓ absorption of diet. fat and chol, source of short FA (C2-4) after fermentation ¢ 39 Nutridrink Protein Nutridrink Multi Fibre Diasip Cubitan SIPPING – SPECIAL PRODUCTS ¢DM – maltodextrin is replaced with starch, other dextrins or fructose, lower content of proteins and energy ¢ ¢↑ Gln – better immune response, regeneration precesses ¢ ¢Patients with s decubiti (↑ proteins, Arg, vit. C, A, E, trace elements) ¢ 40 Through the nose Percutaneous (through the abdomen) Nasogastric tube Faryngostomy Esophagostomy Gastrostomy (PEG) Nasoduodenal tube Extended gastrostomy Nasojejunal tube Jejunostomy (PEJ) (ENTERAL) TUBE FEEDING ¢= complete nutrition via a tube to patients who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation 41 STERILE! MODE OF DELIVERY ¢Bolus method - only into the stomach boluses 50 − 300 ml 2 - 3 hour intervals ¢ ¢Continuously - enteral pump steady over 16–24 hours daily intermittently during the day with night break intermittently during the night with day break 42 WHAT IS ADMINISTERED ¢Mixed hospital diet ¢Polymer nutrition (defined nutritionally) ¢ ¢ ¢ ¢ ¢ ¢Oligomer nutrition (defined chemically) 43 Intact proteins (kasein) Polysaccharides Lipids (TG with long-chain FA = LCT) Dietary fiber Osmolarity ≤ 400 mmol/l Stomach, duodenum AA, di-, tripeptides Disaccharides, maltodextrin Lipids (MCT + LCT) Osmolarity > 450 mmol/l Jejunum Vitamins Minerals Trace elements Which is the most common side effect during administration of oligomer nutrition? MCT - source of en., LCT - anti-inflammatory, antithrombogenic effect (eicosanoids). Answer: Osmotic diarrhea. POLYMER NUTRITION ¢undigested nutrients ≈ similarity to natural food in terms of absorption ¢In patients with functional GIT with digestion enzymes production. ¢ ¢Hypocaloric, isocaloric, hypercaloric We start with hypocaloric nutrition and raise the energy content according to patient´s tolerance. ¢Special products with increased protein content ¢ with dietary fiber ¢ DM etc. 44 Název Energy (kcal/ 100 ml) Proteins (g/100 m) Carbohydrates (g/100 ml) Lipids (g/100 ml) Fiber (g/100 ml) Nutrison Advanced Peptisorb Pack 100 4-0 17.6 1.7 0 Survimed OPD 100 4.5 15.0 2.4 0 Novasource Peptide 100 3.8 12.5 3.9 < 0.3 OLIGOMER NUTRITION ¢Sterile, isocaloric (1 kcal/1 ml) 45 ¢ Indications ¢ ¢people who are malnourished or at risk of malnutrition, respectively, and meet either of the following criteria: ¢inadequate or unsafe oral and/or enteral nutritional intake ¢a non-functional, inaccessible or perforated (leaking) gastrointestinal tract ¢ 46 PARENTERAL NUTRITION = THE DELIVERY OF NUTRITION INTRAVENOUSLY PARENTERAL NUTRITION 47 ¢Exactly defined intake of nutrients ¢Possibility of nutrition modulation according to actual needs ¢Rapid treatment of any metabolic collapse ¢Suitable for patients with a complete absence of small intestine ¢Non-physiological ¢Complications (catheter tunnelling, infection, blood clot, metabolic) ¢Costs ¢ ¢Advantages ¢Disadvantages PARENTERAL NUTRITION ¢Complete ¢Incomplete ¢ ¢Short-term (< 2 weeks) ¢Long-term (> 2 weeks) ¢ 48 Výsledek obrázku pro parenterální výživa ROUTE OF ACCESS 49 ¢V. cava sup. Øv. subclavia l. dx. Øv. jugularis Ø(v. brachiocephalica sin.) ¢V. cava inf. Øv. femoralis Ø ¢≥ 900 mmol/l ¢Peripheral vein in a limb ¢For short-term parenteral nutrition (< 14 days) ¢ ¢< 900 mmol/l ¢< 600 mmol/l children ¢Central venous catheter ¢Peripheral venous catheter glc ≤ 15% (= 833 mmol/l), AA ≤ 5% Different balanced regimens for peripheral and central venous application! MODE OF DELIVERY ¢Continuous administration Øpreferred method of infusion ¢ ¢Cyclical delivery Øwhen using peripheral venous cannulae with planned routine catheter change ¢ ¢A gradual change from continuous to cyclical delivery should be considered in patients requiring parenteral nutrition for more than 2 weeks. ¢ 50 WHAT IS ADMINISTERED ¢Water + electrolytes: 30 - 40 ml/kg/day (according to current patient´s needs) ¢ ¢Energy: ± 120 kJ/kg/day (according to current patient´s needs) ¢ min. 105 kJ (25 kcal )/kg/day ¢ ¢WHEN TO DELIVER ¢ ¢During 24 – 48 hours after patient´s administration 51 ESPEN (Europian society for parenteral nutrition and metabolism) recommendation WHAT IS ADMINISTERED 52 Why? Výsledek obrázku pro hereditary fructose intolerance Hereditary fru intolerance (1 : 20 000, absence of aldolase B) – accumulation of fru-1-P (liver, kidneys, enterocytes) Extremely high fructose intake via infusion can lead to the consumption of large amounts of phosphate, which is then not available for the synthesis of ATP. (fru → fru-1-P → glyceraldehyde + DHAP) WHAT IS ADMINISTERED ¢AA: 1.0 – 1.5 g/kg/day all (essent., semiessent., nonessent.) essential 45-50% of the total share No protein hydrolysates, blood plasma fractions! Rate of administration 0.1 g/kg/hour ¢ Gln in critically ill pat. 0.2-0.4 g/kg/day ¢ ¢AA = proteosynthesis substrates and skeletal muscle protection. ¢With insufficient energy supplies, part of AAs is used for energy yield => to provide sufficient protein synthesis, the total energy of infused nutrients must be covered with 20% AA and 80% carbohydrates + lipids. 53 Gln separately as Ala-Gln Výsledek obrázku pro dipeptiven WHAT IS ADMINISTERED ¢Lipids: 0.7 – 1.5 g/kg/day ratio of energy from lipids : saccharides = 1 : 1 ¢ Rate of administration 100-150 mg/kg/hour ¢ 10-20% lipid emulsions (isotonic; of soya, olive oil, emulsifier = lecithin), particle size max. 1 mm, utilisation as CM ¢ ¢ ¢ ¢ Mix of MCT and LCT 54 ESPEN compared parenteral olive oil and soybean based products and made recommendations for the use of olive oil based emulsions. LIPID PREPARATIONS WITH THE ADDITION OF FISH OIL ¢Source of ω-3 fatty acids, high content of EPA and DHA ¢Example: NuTRIflex® Omega: ω-6:ω-3 PUFA = 3:1 ¢ (Optimal benefit ratio ω-6: ω-3 PUFA = 2:1 to 4:1) 55 Emulsions made from pure soybean oil should not be fat of the first choice in critically ill patients! Reduction of organ complications Shortening the length of stay in the hospital Reduced costs Fish oil reduces the incidence of SIRS (Systemic Inflammatory Response Syndrome) and CARS (Compensatory Anti-Inflammatory Response Syndrome) and hence the incidence of infectious complications, internal organ damage and dysfunction observed with an excess of omega-6 FA. This positive effect in treatment is reflected in the reduction of hospitalization time and the reduction in the number of complications, ie. the reduction in total costs. WHAT IS ADMINISTERED ¢Vitamins and trace elements: from day one 56 Thoughts on the composition of trace element mixes have recently shifted towards a minimum of heavy metals (manganese, iron, copper) and a higher supply of selenium and zinc. APPLICATION SYSTEMS 57 ¢Original system ¢Risk of infection, imprecize dosage, rate of administration of distinct nutrients ¢Uneven nutrient intake ¢Unhandy ¢ ¢Suitable for emergency care ¢Possibility of fast composition change, addition of medications ¢↓ risk of infection ¢Comfortable ¢Better utilisation of nutrients ¢Allows the simultaneous administration of required nutrients out of one container ¢ ¢It is impossible to change the composition ¢Costs ¢ ¢Multi-bottle system ¢All-in-one system http://pfyziollfup.upol.cz/castwiki2/wp-content/uploads/2012/01/parenteralnivyziva.jpg ESPEN recommends ALL-IN-ONE SOLUTIONS 58 ¢Individually prepared in hospital pharmacy just before administration ¢Company-produced ¢Two-chamber (AA + sugars) examples: Aminomix , Clinimix, Nutriflex ¢Three-chamber (AA + sugars + lipid emulsion) examples: Nutriflex Lipid, Kabiven, Olimel ¢Chambers are separated by a seal, which is broken just before application ¢24-month shelf life at room temperature ¢ ¢One-chamber ¢Multi-chamber 2 KINDS OF MULTI-CHAMBER BAGS ¢2-chamber bags Provide different formulations with amino acids, carbohydrates and electrolytes. According to individual patient requirements, lipids can be added via the lipid additive port and trace elements and other micronutrients can be added via the additive port. ¢ ¢3-chamber bags Provide different formulations and bag volumes with amino acids, carbohydrates and fat and are available with or without electrolytes. For individual needs, trace elements and other micronutrients can be added via the additive port. ¢ 59 60 vak1 the chamber with amino acids and electrolytes the chamber with glucose and electrolytes peel seal TWO-IN-ONE SOLUTION OF GLC AND AAs WHY ARE THE BAGS PRODUCED IN PHARM. COMPANIES MULTI-CHAMBER? 61 N H2 O = C N = C (H) (H) AA + glc aldimin ¢The amino group –NH2 from amino acids reacts with the carbonyl group of saccharides giving aldimin, e.g. „Schiff´s base“ (Maillard´s reaction). ¢Therefore the solution of amino acids cannot be sterilized in the mixture with saccharides. vak2lipid 62 Additive port HOW TO ADD LIPIDS OR ELECTROLYTES TO A 2-CHAMBER BAG 63 vak3 Injection port HOW TO ADD MEDICATIONS TO AN ALL-IN-ONE BAG EXAMPLE AND POSSIBILITIES OF A 2-CHAMBER ALL-IN-ONE BAG 64 ALL-IN-ONE BAGS - EXAMPLES 65 HOME PARENTERAL NUTRITION 66 Static mode http://www.prolekare.cz/dbpic/jp_52331_p_1-334 Mobile mode http://www.prolekare.cz/dbpic/jp_52331_p_2-x1000_1600 •classic infusion pump stand •infusion connection at about 16:00, the next morning at 8:00 will disconnect •equipped with alarms triggered when moving •From 1 Jan 2015, a new reimbursement code has been approved in CR: a mobile pump + backpack is included, the necessary nutrients and solutions for use. •↑ mobility of patients (> 50% out of bed) •Pump weight 300-700 g, battery life 12-24 h + external battery REFEEDING SYNDROME ¢syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished ¢Etiology: 67 hypophosphatemia hypomagnesemia hypokalemia DEVELOPMENT OF REFEEDING SYNDROME ¢Starvation → exhaustion of energy phosphate reserves necessary for basic cell functions (membrane transport incl. Na+/K+ ATPase, metabolism) ¢Refilling of glc → resumption of the metabolic pathways that require the supply of phosphates → starting anabolic processes due to insulin → phosphates and glc move into cells. ¢Together with P and glc, also K and Mg move IC, resulting in a decrease of plasma levels and hence the development of symptoms. 68 SYMPTOMATOLOGY ¢paresthesias, weakness, muscle paralysis, inability to breathe ¢mental changes (confusion, delirium) ¢retention of water and Na+ ¢arrythmias ¢cardiac arrest, heart failure ¢coma and even death 69 CRITERIA FOR DETERMINING PEOPLE AT HIGH RISK OF DEVELOPING REFEEDING SYNDROME 70 Patient has one or more of the following: • BMI less than 16 kg/m2 • unintentional weight loss > 15% within the last 3–6 months • little or no nutritional intake for more than 10 days • low levels of potassium, phosphate or magnesium prior to feeding. Or patient has two or more of the following: • BMI less than 18.5 kg/m2 • unintentional weight loss > 10% within the last 3–6 months • little or no nutritional intake for more than 5 days • a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics. THE PRESCRIPTION FOR PATIENTS AT HIGH RISK OF DEVELOPING REFEEDING SYNDROME SHOULD CONSIDER: ¢starting nutrition support at a maximum of 10 kcal (42 kJ)/kg/day, increasing levels slowly to meet or exceed full needs by 4–7 days ¢using only 5 kcal/kg/day in extreme cases (for example, BMI less than 14 kg/m2 or negligible intake for more than 15 days) and monitoring cardiac rhythm continually in these people and any others who already have or develop any cardiac arrythmias ¢restoring circulatory volume and monitoring fluid balance and overall clinical status closely ¢providing immediately before and during the first 10 days of feeding: thiamin 200–300 mg daily, vitamin B complex full dose daily and a balanced multivitamin/trace element supplement ¢providing oral, enteral or intravenous supplements of K (2–4 mmol/kg/day), P (0.3–0.6 mmol/kg/day), Mg (0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) Pre-feeding correction of low plasma levels is unnecessary. ¢ 71 OVERFEEDING SYNDROME 72 ¢= metabolic complications from overfeeding patients ¢ ¢patients at high risk of developing overfeeding problems = malnutrition pacients with too high total daily dose of nutrients ¢Energy need 125–145 kJ/kg/day of actual weight, ¢ at the beginning of nutr. support RDA of energy and ¢ nutrients should be reduced by up to half OVERFEEDING SYNDROME 73 hyperglycemia hypertriglyceridemia hyperlipoproteinemia liver steatosis ↑ production of CO2 hypercapnia respiratory failure osmotic diuresis and dehydration insulin stimulation Excessive glc administration 74 https://s-media-cache-ak0.pinimg.com/236x/8c/e0/a2/8ce0a2e92b23c86aa7fd0e9bde48c4bb.jpg CORRECT ANSWERS 1.Woman, 55 years, height 165 cm, weight 55 kg, chronic pancreatitis with severe malabsorption, celiac disease ¢ 2.Woman, 21 years, height 170 cm, weight 45 kg, treated for mental anorexia, already receives nutrition by mouth ¢ ¢ 3.Man, 20 years, healthy, athlete, wants to increase muscle mass ¢ ¢ 4.Woman, 65 years, height 165 cm, weight 65 kg, DM II, receives nutrition by mouth 75 → ①Diasip → ④Nutrison Advanced Peptisorb → ②Nutridrink protein → ③Nutridrink compact 76 https://s-media-cache-ak0.pinimg.com/236x/8c/e0/a2/8ce0a2e92b23c86aa7fd0e9bde48c4bb.jpg SELECT CORRECT ANSWERS: PARENTERAL NUTRITION A.Is usually delivered via a central vein. B. B. B.Can be used to maintain nutrition at home in some patients who require constant nutritional support. C. C. C.Must provide adequate calories from carbohydrate, typically using 5% dextrose. D. D. D.May lead to low levels of potassium, magnesium and phosphate as part of the refeeding syndrome. E. 77 The hyperosmolar glc and AA solutions are irritant and can lead to thrombophlebitis if a peripheral vein is used. With careful supervision and patient education this is possible in those who require long-term nutritional support. In order to deliver adequate calories from carbohydrate, a hypertonic solution of 20% glc is required. Otherwise, the volume of 5% glc to deliver adequate calories is excessively high. All these ions are incorporated into the cells and can be rapidly depleted from the extra cellular compartment when nutrients are provided to allow cell growth and repair. The high glc levels stimulate insulin secretion which encourages movement of the these ions into the cell. SELECT CORRECT ANSWERS: WITH REGARD TO VITAMINS IN THE DIET: A.Body stores of water-soluble vitamins are typically higher than those of fat-soluble vitamins. ¢ B.Vitamin C is an antioxidant vitamin which helps maintain iron in the reduced (ferrous) form. C. C. C.Thiamine deficiency can be found in chronic alcoholism when it may contribute to neurological and cardiac problems. D. D. D.Folic acid in excess can lead to increased incidence of neural tube defects in pregnancy. E. E. E.Retinol (vitamin A) can be partially derived from dietary hydrolysis of β-carotene. F. B. 78 There are normally relatively large stores of fat-soluble vitamins (e.g. A and D) but little storage of water-soluble vitamins. Ferrous iron is the more reduced ionic form of iron whose formation is assisted by the anti-oxidant qualities of vitamin C. Poor nutrition and associated thiamine deficiency is a recognised serious problem in chronic alcoholism. There is a clear association between folic acid deficiency and an increase in neural tube defects in pregnancy. Folic acid supplementation in pregnancy is advised. Dietary β-carotene can be hydrolysed in the intestine to form retinol. SELECT CORRECT ANSWERS: WITH REGARD TO PROTEIN IN THE DIET: A.It may contribute to the supply of energy. B. B.Supplies only seven of the essential amino acids. B. C.Is a source of ammonia which is detoxified through urea production. D. D. D. D.Must include an animal source to provide all essential amino acids in the diet. 79 The carbon skeleton of amino acids can contribute to energy supply. All essential amino acids can be provided through dietary protein. Ammonia is a toxic end product of amino acid metabolism that is converted to urea in the liver and then excreted through the kidneys. Using a variety of vegetable sources it is quite possible to provide all essential amino acids. SELECT CORRECT ANSWERS: IN THE PROVISION OF DIETARY ENERGY: A.Carbohydrates are preferred as they do not contribute to increasing body fat stores. B. B. B.Fats are not required as all energy and essential nutrition requirements can be met from other sources. C. C. C.The calorific value of lipids exceeds that of carbohydrate. ¢ D.Stored carbohydrate in the liver (as glycogen) is depleted after 18–24 h starvation. 80 Excess carbohydrate in the diet can be converted to fat and stored as fat in adipose tissue A source of fat is required to provide the essential fatty acids, linoleic and a-linolenic acids, in the diet. The calorific value of lipids is 38 kJ/g compared to 17 kJ/g for carbohydrates. The reserves of glycogen in the liver are relatively small and comparatively quickly depleted. https://heifer12x12.files.wordpress.com/2013/07/kwashiorkor.jpg?w=462 WHICH OF THE FINDINGS IN THE CHILD SHOWN AT RIGHT WOULD SUPPORT A DIAGNOSIS OF KWASHIORKOR? A.Shows increased serum albumin. B.Shows a good appetite. C.Appears plump due to increased adipose tissue. D.Has markedly decreased weight for height. E.Displays abdominal and peripheral edema. F. B. 81 Kwashiorkor is caused by inadequate protein intake in the presence of fair to good energy intake. Typical findings include abdominal and peripheral edema caused largely by a decreased serum albumin concentration. Anorexia is almost always present. Weight is often normal due to edema. Treatment includes a diet adequate in energy and high-quality protein. WHAT IS THE FORMULATION OF INDIVIDUALLY PREPARED PARENTERAL NUTRITION BAG? 82 ¢Fluids: 30 - 40 ml/kg/day = 1800 - 2400 ml ¢ ¢Nutrients: anabolic ratio: ¢ ¢Glc 6 g/kg actual weight: ¢6 x 60 = 360 g glc: 900 ml 40% glc – central vein! ¢ ¢AA 1 g/kg ideal weight: ¢1 x 85 = 85 g AA: 850 ml 10% solution – central vein! ¢ ¢Lipids 1 g/kg actual weight: ¢1 x 60 = 60 g: 300 ml 20% solution ¢ ¢ WE HAVE SOLUTIONS: GLC 5%, 10%, 15%, 20%, 40% AA (AMINOPLASMAL, NEONUTRIN) 5%, 10%, 15% LIPIDS (LIPOFUNDIN, SMOFLIPID, LIPOPLUS) 20% 83 ¢Man, 35 years, height 185 cm, weight 60 kg, m. Crohn, hospitalization for subileus, stenosis of terminal ileum ¢ ¢Fluids: 30 - 40 ml/kg/day = 2550 - 3400 ml ¢ ¢Nutrients: Stress ratio: ¢ ¢Glc 2.5 g/kg actual weight: ¢2.5 x 85 = 212,5 g glc: 500 ml 40% glc – central vein! ¢ ¢AA 2 g/kg ideal weight: ¢2 x 80 = 160 g AA: 1000 ml 15% (1600 ml 10%) solution – central vein! ¢ ¢Lipids 0,7 g/kg actual weight: ¢0.7 x 85 = 60 g: 300 ml 20% solution ¢ WE HAVE SOLUTIONS: GLC 5%, 10%, 15%, 20%, 40% AA (AMINOPLASMAL, NEONUTRIN) 5%, 10%, 15% LIPIDS (LIPOFUNDIN, SMOFLIPID, LIPOPLUS) 20% 84 ¢Man, 40 years, height 180 cm, weight 85 kg, hospitalization for severe burns ¢ ¢Fluids: 30 - 40 ml/kg/day = 1800 - 2400 ml ¢ ¢Nutrients: stress ratio: ¢ ¢Glc 2.5 g/kg actual weight: ¢2.5 x 80 = 200 g glc: 500 ml 40% glc– central vein! ¢ ¢AA 2 g/kg ideal weight: ¢2 x 90 = 180 g AA: 1 200 ml 15% solution – central vein! ¢ ¢Lipids 0.7 g/kg actual weight: ¢0.7 x 80 = 56 g: 280 ml 20% solution ¢ WE HAVE SOLUTIONS: GLC 5%, 10%, 15%, 20%, 40% AA (AMINOPLASMAL, NEONUTRIN) 5%, 10%, 15% LIPIDS (LIPOFUNDIN, SMOFLIPID, LIPOPLUS) 20% 85 ¢Man, 25 years, height 190 cm, weight 80 kg, in ICU after surgery of comminuted fracture of tibia