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