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