Disease Specific Nutritional Support in Critically ILL: Nestle

Speaker: Dr. J.D. Sunavala, Head - Department of Critical Care Medicine, Jaslok Hospital, Mumbai and Consultant Physician & Intensivist, Breach Candy Hospital, Mumbai. Presented at: CRITICARE 2011 New Delhi, Workshop on Nutrition in Critical Care

Summary

In critically ill chronic patients the causes of malnutrition remain the same resulting in reduced appetite, increased catabolism, and decreased protein synthesis. In addition, it also leads to the inability to take in food. The physiological impact is either caused by stress or starvation, while the clinical impact causes increased inflammatory response, the consequences of which could include Hypoalbuminaemia, Extravasation of fluids and electrolytes, generalised oedema, pulmonary oedema, and Hacmodynamic instability. In this webinar, Dr. Sunavala talks about Metabolic Disorder in patients with renal failure, nutritional aspects of liver failure, NS in pulmonary diseases, GI Malignancy, and Cancer Cachexic Syndrome (CCS) among other things.

Causes of malnutrition in critically ill chronic patients, inability to take food, reduced appetite, increased catabolism, decreased protein synthesis, increased protein loss (wounds, burns, etc.), and pre-existing malnourishment. Nutritional Support (NS) in renal failure relates that SGA is a subjective technique it does not measure visceral proteins and does not provide follow up for nutritional therapy. It also requires information from patients which is not always possible and it does not estimate the extent of protein catabolism. Solutions providing exclusively essential amino acids should no longer be used. Lipids in PN should not exceed 1 gm/Kg/day with regular monitoring of S.triglycerides. Parenteral carbohydrates like Normoglycaemia should be the goal. During potassium and phosphate restriction, a fast decline of K+ phosphate levels can occur in ARF patients on commencing PN (Refeeding hypophosphataemia or hypokalaemia). Use of probiotics reduces incidence of bacteremia in liver transplant patients. Thiamin, folate, zinc supplements are also used for nutritional support. Monitoring S.K+ and S.Mg levels and replacing them. Closely monitoring blood glucose while restricting sodium intake is advised.

Nutritional support in respiratory diseases is followed through by N Assessment which is mainly judgemental/ SGA. Total calorie requirement should not exceed 35Kcal /Kg/day. Proportion of fat to carbohydrate should be around 30:70 and max of 35:65. Surgical oncology and nutritional support factors associated with weight loss in Ca patients have tumour related complications, treatment induced complications, psychological causes and Cancer Caehexia Syndrome (CCS). Cancer Caehexia Syndrome (CCS) is characterized by progressive weight loss with host tissue wasting, skeletal muscle atrophy, fatigue, anemia and hypoalbuminaernia. It is potentially life threatening. Unlike starvation weight loss cannot be reversed. CCS is probably caused by pro-inflammatory cytokines. High post-op mortality is also related to CCS.

Nutritional issues in specific GI malignancies are small bowel and colon post resection, decreased transit time and malabsorption, serious water anti electrolyte losses through ileostomies and resorption abnormalities following colon resection. Iron deficiency anaemia an inappropriate secretion of digestive enzymes in jejunal resection. Bacterial over growth, translocation and pancreatic enzyme losses and diabetes mellitus after Whipple‘s procedure.

Immune Enhancing Formulae Studied in Surgical Ca patients are immune enhancing enteral formulae containing mixtures of arginine nucleic acid & essential fatty acids which may be beneficial in malnourished patients undergoing major Ca surgery.