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