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Toronto Notes 2019 Clinical Nutrition Clinical Nutrition
Determination of Nutritional Status
• correctedweightloss(expressedasbodymassindex[kg/m2])ismostimportantparameterinassessing need for nutritional support
• SubjectiveGlobalAssessment:simplebedsidetooltoassessnutritionalstatus,tohelpidentifythose who will benefit from nutritional support
Gastroenterology G47
Investigations
• plasmaproteins:albumin,pre-albumin(shorterhalflifethanalbumin),transferrin • decreasemayindicatedecreasednutritionalstatusordiseasestate
• thyroid-bindingglobulin,retinol-bindingprotein(maybetoosensitive)
• anthropometry(e.g.tricepsskinfoldthickness),gripstrengthlessoftenused
Table 22. Small Bowel Nutrient Absorption
Fe CHO
Duodenum +++ +++ Jejunum + + Ileum + +
Enteral Nutrition
Definition
Proteins, Lipids Na+, H2O
Bile Acids
Vit B12
• enteralnutrition(tubefeeding)isawayofprovidingfoodthroughatubeplacedinthestomachorthe small intestine
• choiceoftubes:nasogastric(NG),nasojejunal(NJ),percutaneousendoscopicgastrostomy(“G-tube”or “PEG tube”), percutaneous endoscopic jejunostomy (J-tube)
• tubescanalsobeplacedendoscopically,radiologicallyorsurgically
Indications
• oralfeedinginadequateorcontraindicated
Feeds
• polymericfeedscontainwholeprotein,carbohydrate,fatasaliquid,withorwithoutfibre
• elementalfeedscontainproteinasaminoacids,carbohydrateassimplesugars,fatcontentlow(therefore
high osmolarity)
• specificdiets:lowcarbohydrate/highfatsolutionforventilatedpatients(carbohydratehasahigh
respiratory quotient so minimizes carbon dioxide production), high energy, low electrolyte solutions for dialysis patients
Relative Contraindications
• non-functioninggut(e.g.intestinalobstruction,enteroenteralorenterocutaneousfistulae) • uncontrolleddiarrhea
• GIbleeding
Complications
• aspiration
• diarrhea
• refeedingsyndrome(rare):carbohydratecanstimulateexcessiveinsulinrelease,leadingtocellular
uptake and low serum levels of phosphate, magnesium, potassium
• overfeedingsyndrome(rare):hypertonicdehydration,hyperglycemia,hypercapnea,azotemia(from
excess protein)
Most Common Indications for Artificial Nutrition Support
• Preexisting nutritional deprivation
• Anticipated or actual inadequate energy intake by mouth
• Significant multiorgan system disease
Whenever possible, enteral nutrition is ALWAYS preferable over parenteral nutrition
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