Nutrition

Published on 03/03/2015 by admin

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3 Nutrition

Feeding the patient

Case history

A surgical colleague phones you to ask about parenteral nutrition for a 70-year-old man who had an oesophago-gastrectomy 5 days previously. Postoperative care had been straightforward and no prior provision for parenteral nutrition had been made. It now seems likely that he has an anastomotic leak.

What should you advise?

Parenteral nutrition is never an emergency therapy. It can always wait until expert advice is available next day. You say that you will bring your consultant along the following morning.

Remember

• It is better to predict (if possible) whether some form of supplementary nutrition is likely to be required before an event

• Over 10% of patients in hospital are said to be malnourished.

How do you assess the nutritional state?

This can be done simply by looking at the patient! Does he look malnourished? Other parameters that can help are:

• Weight loss > 10%

• Serum albumin < 35 g/L

• Serum transferrin < 1.5 g/L

• Body mass index (BMI) = (kg) ÷ height (m²); the normal range is 18.5 to 24.9.

An evaluation of the nutritional status can be done using the MUST criteria (Fig 3.1).

Figure 3.1 ‘Malnutrition Universal Screening Tool’ (‘MUST’).

Reproduced with permission from the British Association for Parenteral and Enteral Nutrition (BAPEN): www.bapen.org.uk.

Nutrition will be necessary for

• All severely malnourished patients on admission to hospital

• Moderately malnourished patients who are not expected to eat for 3–5 days because of their illness

• Normally nourished patients not expected to eat for 7–10 days.

Methods of enterally feeding

• By fine-bore nasogastric tube (check position with pH paper and if in doubt, X-ray. Feeding tubes are usually placed endoscopically)

• Percutaneous endoscopic gastrostomy (PEG; refer to gastroenterologist for insertion) for prolonged period, i.e. > 30 days.

Methods of parenteral nutrition

Peripheral nutrition is the initial preferred option. Peripheral cannulas are inserted into the mid arm vein. Each catheter will last 5 days and the procedure has fewer complications than a central venous catheter.

Central nutrition. A cannula is inserted via an intra-clavicular approach into the subclavian vein in theatre. Infusions include nitrogen for protein synthesis, calories, electrolytes, vitamins and trace elements. Complications include sepsis, thrombosis, pneumothorax and embolism.

Most hospitals have nutrition teams to advise on the nutritional regimens that are required.

Remember

Remember to monitor carefully with:

• daily plasma electrolytes

• daily glucose

• weekly assessments of nutritional status.

Progress.

This patient was not suitable for enteral nutrition because of his gastrointestinal surgery; thus parenteral nutrition is appropriate.

He was started with peripheral nutrition via a mid arm cannula. However, after 5 days it was felt he required longer-term nutrition and a central catheter was inserted. The leak settled on conservative management and he was able to return home on soft foods 4 weeks later.

Further reading

The Journal of Parenteral and Enteral Nutrition (JPEN). www.nutritioncare.org/wcontent.aspx?id=172

National Institute for Health and Clinical Excellence. Nutrition support in adults, Clinical Guideline. 2006;32. www.nice.org.uk

Singer P, Berger MM, Van den Berghe G, et al. ESPEN guidelines on parenteral nutrition: intensive care. Clin Nutr. 2009;28:387–400.

Related

Kumar & Clarks Cases in Clinical Medicine