P year‎ > ‎Systematic teaching‎ > ‎

13.01.30 Nutritional support

Complications
  • Gastrostomy
    • Perforation
      • Bit of colon trapped between stomach and abdominal wall (blind procedure)
    • Peritonitis
    • Pain
      • Remember they may be unable to express
  • Parenteral
    • Infection from line
    • Thrombosis
    • Electrolyte/LFT derangement


Parenteral nutrition

  • Placement
    • Lower third of SVC
    • Careful you don't go into the RA
  • Feeds
    • Off-the-shelf
      • Often don't contain any micronutrients
      • Can be modified in lab
    • Customised
  • Indications
    • Obstruction
    • Perforation
    • Short bowel
      • Anatomical
      • Functional
    • High output small bowel fistula
    • Prolonged ileus (in extreme cases)
  • NOT for PN
    • Post-GI surgery
      • Passage of food normally helps anasatmoses
    • Acute pancreatitis
    • Absent bowel sounds
      • These come mostly from the colon - so small bowel may still be working


Nutritional requirements

  • Energy 25-35 kcal/kg
  • Protein 0.8-1.5 g
  • Fluids 30-35 ml/kg
  • Electrolytes
  • Micronutrients


Refeeding syndrome

  • Key change is hypophosphataemia
    • NB affects oxygen dissociation curve
  • Also:
    • Changes in Na/K as ATPase starts working again
    • Co-factors taken up by cells (thimine, Mg)
    • Salt and water retention
      • Can cause oedema
      • Beware giving fluids if urine o/p falls!
  • Avoidance:
    • Start at 50% of requirements
    • Increase slowly
    • Give:
      • Thiamine 200 mg OD
      • Vitamin B co-strong TT QDS


Medico-legal

  • Withdrawing nutrition support is equivalent to withholding
  • Artificial support is deemed medical treatment, not basic care


Notes

  • Nursing homes will typically take PEGs but not NGs
    • => Questionable indication

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