Transcript Document

Inflammatory bowel disease(IBD)-ulcerative colitis
and Crohn’s
alterations in microbiome play a role in IBD
1)different oxidative pathways in the altered
2)more aggressive nutrient uptake by altered
microbiome-this favours the altered microbiome
3) altered microbiome is more virulent
180 minutes
120 multiple choice questions-120 points
-4 short answer question-60 points
multiple choice-lecture 7a-12c inclusive
short answer-whole Nutr2105 course
Nutrition 2106-Fall 2014- Principles of
Nutrition in Metabolism
Nutrition 2101-Nutritional AssessmentTheory-Fall 2014
Nutrition 2107- Introduction to Sports
Nutrition-Winter 2015
Nova Scotia now spends 47 cents of every budget
dollar on healthcare(10 years ago it was 40 cents)
-is the publically funded healthcare system in its
present form sustainable?
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Lecture 10a
17 March 2014
Enteral and Parenteral Feeding
Enteral Feeding
-refers to use of intestine (uses oral or tube feeding
to direct nutrients to intestine)
-called complete enteral feeding if formula is
primary source of nutrients
-complete formulas can be used in smaller
quantities to supplement table foods
-complete formulas required if patient is on tube
feeding or oral liquid diet for more than a few days
Types of enteral formulations
-characterised by type of protein in the formulation
Types of enteral formulations
Appropriate for people who are able to digest and
Contain complete proteins (complete refers to
whole proteins or combination of protein
isolates(purified proteins))
Blenderised formulas contain protein from pureed
foods (e.g. blenderised meats)
Types of enteral formulations
Pre-digested protein- so only get small
peptides or just free amino acids
Some have medium chain triglycerides or are
very low in fat
Types of enteral formulation
Provide a single nutrient
Modules can be combined with other modules or
with minerals and/or vitamins to address the
specific needs of a patient
Candidates for tube feeding
Anybody who:
•can not get food down orally or
•has mental incapacitation
•are malnourished or
•has high nutrient requirements or extensive
intestinal resections or is on a ventilator
•gastrointestinal obstructions or fistulas
•in short anyone who cannot access or utilise GI
tract on their own
Distinguishing characteristics of enteral
1) Nutrient density
1.0 kcal/ml- standard
1.2 – 2.0 kcal/ml for nutrient dense formulas
-nutrient dense formulations are given in
smaller volumes to persons with fluid
balance issue- e.g. congestive heart
Distinguishing characteristics of enteral
2) Fibre
if administered over short time - low to moderate
fibre - otherwise gas and distension can be an issue
if long term administration -then higher amounts
of fibre
Distinguishing characteristics of enteral
3) Osmolality- measure of concentration of
molecular and ionic particles in solution
-serum is 300 milliosmoles/kg of solution
-isotonic solution is 300 milliosmoles/kg
-hypertonic is greater than 300
milliosmoles/kg of solution
-hypertonic can induce diarrhea in
intestine so a slow introduction of
hypertonic solution for intestinal
route is essential
Tube placement-1) transnasal or 2) direct catheter
Nasogastric-children and adults-larger nose
than infants so nasogastric is used in children
and adults
Orogastric-infants- smaller nose than adults
and children so orogastric is used
Nasoduodenal-nose to duodenum
Nasojejunal placement-nose to jejunum
Tube placement
2) Catheter direct to stomach or jejunum
Enterostomies- surgical placement of catheter
-Gastrostomy- direct to stomach
-Jejunostomy-direct to jejunum
Safehandling of formulations
Open and closed systems
Open- exposed to air
Closed-not exposed to air
Keep your fingers out of the soup for open
Initiating and progressing a tube feeding
Formula delivery techniques-Intermittent
•Best to stomach
•No more than 250-400 ml over 30 minutes
•Use- depends on tolerance
Bolus feeding included here (300-400 ml) in
10 minutes
Initiating and progressing a tube feeding
Formula delivery techniques
Continuous feeding
Delivered slowly over 8-24 hours
Good for people who have received
nothing though GI tract for a long time,
hypermetabolising persons and those
receiving intestinal feedings
Formula volume and strength
institutionally based- standard
operating procedures (sops)
Initiating and progressing a tube feeding
Additional matters
Supplemental water
-standard formulas contain about
850 ml of water/per formula
-most people need about 2 L of
water per day
Gastric residual volume
-amount left over from previous
feedings-significance of this?
2 Youtubes- enteral feeding
Class activity
Design an enteral feeding for the
pathology/problem of your choice that meets
the dietary principles of adequacy, variety,
moderation, nutrient density, energy control,
and balance
Lecture 10b
17 March 2014
Parenteral Feeding
Parenteral Feeding (going around ie circumventing
the intestine)
Nutrients go directly into blood stream bypassing
gastrointestinal tract-this is done by intravenous
needle or catheter
Used when a patient cannot, due to physical or
psychological impairment, consume sufficient
nutrients enterally
Used when patients gi system will not adequately
process food for body
Actual infusion depends on site of infusion and
patient’s fluid and nutrient requirements
Types of Parenteral Nutrition
Peripheral parenteral nutrition (PPN)peripheral vein used
Total parenteral nutrition (TPN)-superior
vena cava used
Basic difference between the two is the
concentration of nutrients infused (higher
concentration is used for TPN due to more
rapid dilution in superior vena cava)
Parenteral Feeding
Usual fluid volume is 1.5-2.5 L over a 24 hour
period for most people
Parenteral Feeding
Composition of ingredients in bag for intravenous
Amino acids
Lipid emulsion
Sterile water
Dextrose- provides 3.4 kcal/g and not 4 kcal/g
-difference is due to what?
Concentration is 12.5 % (max for peripheral
introduction) to 25 % (total parenteral
Restricted in ventilator patients because
oxidation of glucose produces more carbon
dioxide than does oxidation of fat
Mixture of essential and non-essential amino
Concentration 3.5-15 %
Quantity of amino acids depends on patients
estimated requirements and hepatic and renal
Lipid emulsions
Safflower and soybean oil with egg lecithin
used as an emulsifier (why the emulsifier and
how does it work?)
Significant source of calories
Lipid emulsions
Available in 10, 20, 30 % concentrations
supplying 0.9 and 1.8 and 2.7 kcal/ml
respectively-Do the math
Usual dose is 0.5 to 1 g/kg/day to supply 20-30
% of total kcal requirement
IV fat contradicted for severe hepatic
pathology, hyperlipidemia or severe egg
Used cautiously with atherosclerosis, blood
coagulation disorders
Dictated by patients blood chemistry values
and physical assessment findings
Standard multivitamin and trace mineral
preparations added to parenteral solutions to meet
micronutrient needs
-must be isotonic and therefore low in
dextrose and amino acids to prevent phlebitis
and increased risk of thrombus formation
-need to maintain isotonic solutions of
dextrose and amino acids while avoiding fluid
overload limits the caloric and nutritional
value of PPN
delivers complete but limited nutrition
the final concentration cannot exceed 12.5 %
dextrose-also uses lower concentrations of amino
vitamins and minerals are added
lipid emulsion may be added to supplement calories
depending on the patients tolerance
-provides temporary nutritional support
-short term- 7-10 days and do not require more
than 2000 to 2500 kcal per day
-may be used for a post surgical ileus or
anastomotic leak or for patients who require
nutritional support but are unable to use TPN
because of limited accessibility to a central vein
-sometimes used to supplement an oral diet or tube
feeding or transition from TPN to enteral intake
Hypertonic solutions provide more dextrose and/or
protein but they must be delivered centrally in a
large diameter vein so that they can be quickly
TPN is used when nutritional requirements are
high and anticipated need is relatively long
3 litres of 10 % dextrose provides only 1020 kcal
-traditionally-catheter to superior vena cava
figure 21-2
severe malnutrition
GI abnormalities : due to obstruction,
peritonitis, severe acute pancreatitis
after surgery or trauma especially that
involving extensive burns, sepsis
need for supplementation of inadequate oral
uptake in patients who are being treated
aggressively for cancer
bone marrow transplantation
-constant infusion for 8-12 hours
-used for home patients
-used to support inadequate oral
-allows insulin and glucose to drop
when infusion is not taking place
-switch from continuous TPN to cyclic
TPN should be gradually decreased by
several hours per day and signs of
glucose overload and fluid imbalance
should be monitored
Lecture 10c
17 March 2014
Surgery and Burns
-patient should be well nourished prior to
surgery-this gives better recovery
-however, surgical patients are often
malnourished due to anorexia,
nausea, vomiting, burns, fever,
malabsorption, and blood loss
-surgical prep- range of actions include:
-high calorie protein diet
-enteral feeding
-parenteral feeding
-nothing by mouth (NPO) for a least 8 hours
prior to general anesthesia due to risk of
-oral intake is resumed after bowel sounds
return- usually 24-48 hours after surgery
-start with clear liquids to full liquids to soft
or regular diet as tolerated post-op
-usually a high protein high calorie diet is
appropriate-this helps with healing
-hypermetabolism involved- why?
-large quantities of nutrients leech through
burn area
-therefore fluid and electrolyte imbalances are
a problem
-result in anorexia, pain, emotional trauma,
weight loss and immune incompetence,
-after fluid and electrolytes are addressed and by
hour 72 (if bowel sounds)- oral intake begins
-if no bowel sounds by hour 96 then PPN or TPN
- regardless of routes of administration
-Protein 1.5-3.0 g /kg body weight/day
20-25 % protein, 50 % carbohydrate, 25 %
-Kcal- additional 40-60 kcal/kg body
-high fluid intake –including more potassium,
zinc and vitamins A and C (zinc, vitamins A
and C for wound healing) and vitamins B1, B2
and B3 (in proportion to increased energy
Table 29-1, p. 870
Table 29-2, p. 903
Table 29-3, p. 904
Dietary factors - cancer initiators
- these dietary components start
-additives and pesticides are of particular but
not exclusive concern here
-stomach cancer particularly high in parts of
world where pickled or salt-cured foods that
produce carcinogenic nitrosamines are
Dietary factors
-alcohol associated with high incidence of some
cancers, especially of the mouth, esophagus and
liver in all persons and breast cancer(postmenopausal) in females
-beer and scotch may contain nitrosamines
-wine and brandy may contain urethane
-urethane and nitrosamines are carcinogens
-moderation is the key to prevention here
Dietary factors –cancer promoters and inhibitors
-cancer promoters accelerate the rate of
progression of cancer once it has
- eg excess dietary fats
-linoleic acid- has been suggested to
-omega 3s have been suggested to
prevent or delay cancer
Dietary factors-antipromoters
Fruits and veggies as per Canada’s food guide
-fibre speeds up gi transit time thus reducing
carcinogen exposure
-fruits and vegetables containing antioxidants
that scavenge free radicals –such free
radicals contribute to cancer
-various phytochemicals activate enzymes that
can destroy carcinogens
Once cancer starts
-do nutritional assessment and respond accordingly
-early dietary intervention prepares body for
stresses that lay ahead
Weight loss, diarrhea, seborrhea, eczema, fever,
sweating-nutritional implications?
Nutritional implications can further deteriorate
patient’s health e.g. further immune response
Kcal requirement is increased compared to
non-infected persons in good health
Protein requirements 1-2 g/kg bw/day due to lean
body mass loss and other protein losses
Drugs can exacerbate nutritional difficulties
– medium chain triglycerides(mct) (6-12 carbon
fatty acids) for additional calories
-lipase and bile not required for mct- therefore
easier absorption
Vitamins and Minerals
recommendation-close to DRI-otherwise adverse
interactions with antiretroviral drugs
-small, numerous meals
-liquid commercial preparations
-antidiarrheals shortly before meals
-high soluble fibre foods like oatmeal, cooked
carrots, bananas, peeled apples and apple
sauce may help slow transit time (diarrhea
reduced perhaps)