innovative nutrition management in wound healingaado.org/file/nurse_wound-mgt-ws_sep13/nutrition...
TRANSCRIPT
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Terry TING, Dietitian, MSc, MBA,President‐elect of HK Nutrition Association,
INNOVATIVE NUTRITION MANAGEMENT IN WOUND HEALING
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Topics
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• Older people are at high risk of developing pressure ulcers, as reflected in the fact that 70‐73% of those develop pressure ulcer are over 65 years old. (Whitington et al 2000, Thomas 2006)
• Incidence of the pressure ulcer in hospitalized patient 6.2% and 8.8 %. ( Baumgarten et al .2003,2006)
• 1.61 % for older patient in an outpatient setting. ( Margous et al.2003)
• The pressure sore incidence is 25.16% in Hong Kong Nursing Home.( Wai‐yung Kwong et al 2009)
For your information!
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Function of Some Key Nutrients Involved in Wound Healing
• Proteins (Amino acids)• Needed for platelet function, neovascularization, lymphocyte formation, fibroblast proliferation, collagen synthesis, and wound remodelling
• Required for certain cell‐mediated responses, including phagocytosis and intracellular killing of bacteria
• Gluconeogenic precursors• CHO (Glucose)
• Energy substrate of leukocytes and fibroblast• Fats (fatty acids and cholesterol)
• Serve as building blocks for protaglandins, isoprostanes• Energy source of some cell types• Are constituents of triglycerides and fatty acids contained in cellular and subcellular membranes
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Impact of Malnutrition on Clinical Outcomes
Protein & Kcal DepletionProtein & Kcal Depletion
Loss of Lean Body MassLoss of Lean Body Mass
Suppress immuneSuppress immune
Impaired organ function
Impaired organ function
Impaired Ventilator capacity
Impaired Ventilator capacity
Poor wound healing
Poor wound healing
Increase infection or sepsisIncrease infection or sepsis
SIRD‐MOD‐MOFSIRD‐MOD‐MOF
Increase mortalityIncrease mortality
Nutrition Care
Process
Prof J Asprer, Nutritional Immunomodulationin Critical Illness, 2009
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營養不良的併發症
•抑壓免疫系統•影響傷口癒合•增加住院日數•增加感染的風險
•影響精神狀態•增加再入院率•增加醫療費用•增加發病率•增加死亡率
References:•Lisa A. Barker, et al, 2011•BAPEN (British Association for Parenteral and EnteralNutrition) Quality Group, 2010•Christian Löser. 2010
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Nutrient Requirement for wound healing
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Which Nutrient is the most important for wound healing??
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Function of Some Key Nutrients Involved in Wound Healing
• Proteins (Amino acids)• Needed for platelet function, neovascularization, lymphocyte formation, fibroblast proliferation, collagen synthesis, and wound remodelling
• Required for certain cell‐mediated responses, including phagocytosis and intracellular killing of bacteria
• Gluconeogenic precursors• CHO (Glucose)
• Energy substrate of leukocytes and fibroblast• Protein sparing effect
• Fats (fatty acids and cholesterol)• Serve as building blocks for protaglandins, isoprostanes• Energy source of some cell types• Are constituents of triglycerides and fatty acids contained in cellular and subcellular membranes
• Protein sparing effect
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Function of Some Key Nutrients Involved in Wound Healing
Vitamin CHydroxylates proline and lysine in collagen synthesisFree radical scavengerNecessary component of complement that functions in immune reactions and increases defenses to infection
B VitaminsServes as cofactor of enzyme systemsRequired for antibody formation and white blood cell function, essential for nucleic acid metabolism
Vitamin AEnhance epithelialization of cell membraneEnhance rate of collagen synthesis and cross‐linkng of newly formed collagenAntagonizes the inhibitory effects of glucocorticoids on cell membranes
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Function of Some Key Nutrients Involved in Wound Healing
Vitamin DNecessary for absorption, transport, and metabolism of calcium
Indirectly affects phosphorus metabolism
Vitamin EFree radical scavenger
Vitamin KNeeded for synthesis of prothrombin and clotting factors VII, IX, and X
Required for Ca‐binding protein
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Function of Some Key Nutrients Involved in Wound Healing
ZincStablizes cell membranes; enzyme cofactors
Needed for cell mitosis and cell proliferation in wound repair
IronNeeded for hydroxylation of proline and lysine in collagen synthesis
Enhances bactericidal activity of leukocytes
Haemoglobin oxygen transport to wound
CopperIntegral part of the enzyme lysyloxidase, which catalyzes formation of stable collagen cross‐links
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Nutrition Support for wound healing
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Energy and Nutrient Requirements of Patients with Sore• Energy
• Use indirect calorimeter to measure the energy need• 30 – 40kcal/kg body weight per day • Harris‐Benedict times stress factor (1.2 for stage II ulcer, 1.5 for stage III and IV ulcers) ~ usually over estimated
• Protein• The recommended range of protein 1.25 to 1.5g/kg BW (AHCPR 1994,EPUAP 2009)
• 1.5g/kg BW to improved nitrogen balance (ESPEN 2009)• 2.0 grams per kilogram body weight may not increase protein synthesis and may contribute to dehydration in the elderly
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Conventional Options of Nutrition Support• Modification of Hospital Diet
• Suit therapeutic needs• Energy‐ and/or protein‐dense foods• Modify food choices to suit personal preferences/needs
• Oral supplement• Complete nutrition liquid formulaes• Regular and disease‐specific• Modular supplements
• e.g. Energy, protein, fat or fibre supplements• Tube feeding
• Indicative for patients with dysphagia or persistent poor oral intake
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營養不良的併發症
•抑壓免疫系統•影響傷口癒合•增加住院日數•增加感染的風險
•影響精神狀態•增加再入院率•增加醫療費用•增加發病率•增加死亡率
References:•Lisa A. Barker, et al, 2011•BAPEN (British Association for Parenteral and EnteralNutrition) Quality Group, 2010•Christian Löser. 2010
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Challenges in Meeting Nutrient Requirements
• ? SKY HIGH energy and nutrient requirements• Poor/fluctuating oral intake
• Food preferences• Physical and environmental factors• Pain• Inflammation• Polypharmacy• Digestion and absorption problems due to aging
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種類 熱量 蛋白質 脂肪 膽固醇 鐵質
碎肉粥480毫升
165卡路里
6克 2克 23毫克 1.7毫克
魚湯240毫升
76卡路里
4.6克 4.6克 27.3毫克 微量
葡萄糖飲品
300毫升
300卡路里
微量 0 0 0
全脂奶240毫升
150卡路里
8克 8.2克 33.2毫克 0.122毫克
營養奶240毫升
250卡路里
10克 4.6克 0 3.4毫克
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Modified Diet (High Nutrition Puree)
•A high energy & high protein pureed mixed was designed by PWH Dietetics and Catering dept.
•To maintain oral intake capacity as long as possible
•Support from the ward staff is essential
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• Red Tray System• Protected Meal Time
Seven Steps Approach to stop Malnutrition
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Choosing the Enteral Feeding Site
Can the GI tract be used?
No Yes
Tube feeding for more than 6 weeks?
No Yes
Nasoenteric Tube
Risk for pulmonary aspiration?
YesNo YesNo
Nasogastric Tube Jejunostomy
Parenteral Nutrition
Enterostomy Tube
Nasoduodenalor nasojejunal tube
Gastrostomy
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Complications of Enteral Feeding
• Electrolyte imbalance (46%)• Hypo or Hyper K, Na, PO4, Ca
• Hyperglycemia (35%)• Diarrhea (33%)
• >500ml every 8 hr or >3 stools/s for at least 2 consecutive days• Only 20% of diarrhea related to formula
• Constipation (30%)• Nausea & Vomiting (20%) Critical Care Med 2002• Tube Clogging (13%)
Prof. Timothy Kwok, 2002, Medical Complication of Enteral Feeding In Frail Older People, CUHK
• Under & Overfeeding are common!
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Complications of Enteral Feeding
• Pulmonary Aspiration• Risk factors: sedation, supine position, mal‐position of the feeding tube,
mechanical ventilation, vomiting, bolus feeding delivery method, poor oral health, advanced age, and lack of nursing staff A.S.P.E.N 2009
• No adequate powered studies demonstrated a relationship between aspiration pneumonia & GRV A.S.P.E.N 2009
• Feeding protocol suggest not to stop feeding if GRV remain
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Misconceptions on Enteral Feeding
•Rice Water• Studies proven effective in alleviating diarrhea (reduce stools/d)• Contains less than 40g CHO in 1L (
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Consequences of Overfeeding
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• Glutamine (EPUAP 2009)• healing may be its function as a fuel & source for fibroblasts and epithelial cells needed for healing.
• Safe maximum dose for glutamine 0.57g/Kg/BW• Supplemental glutamine has not been shown to improve wound healing and more studies are needed
• Arginine (EPUAP 2009)• stimulates insulin secretion promotes the transport of amino acids into tissue cells and supports the formation of protein in the cells
• Maximum safe dosages of arginine have not been established• Avoid using Arginine suppl. in sepsis patient due to the stimulation of nitric oxide (NO) production ‐ hypotension
• Not available in PN due to stability• HMB (Beta‐Hydroxy beta‐methylbutyric acid )
• has been shown to inhibit breakdown of protein, such as muscle protein• usually used in muscle building• Further study to prove wound healing effect and safety dose
Special Nutrients
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Special Nutrition SupportFor Wound Healing
Formula Route Features Limitation
Abound Oral & Enteral Contain arginine, HMB, gultamine
Not nutritionally complete,
Perative Oral & Enteral Contain Arginine, Fair acceptance for oral route, and high Osmolarity
AlitraQ Enteral Elemental, contains arginineand glutamine
Expensive, not for oral route, low fat and low eletrolytes,
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Some Common FormulasFormula Route Features Limitation
Ensure/NutrenOptium & Fiber1 Cal/ml
Oral Economic, available every where, acceptable taste
High Osmolarity,no fiber
Fresubin 2 Kcal Oral Energy Dense, acceptable taste High Osmolarity,no fiber
Ultracal1 Cal/ml
Enteral Good tolerance, adequate electrolytes, high soluble fiber, cheap, high protein, isotonic
Monitor electrolytes level, use w/ caution in CRF, DM. may need high vol. to meet requirement.
Osmolite HN Enteral Similar to Ultracal but no fiber Similar to Ultracal
Osmolite, Isocal1 Cal/ml
Enteral Good tolerance, cheap, isotonic Low electrolytes, low protein,
Glucerna or Resource DM1Cal/ml
Both Lower CHO level, High in fat
Compleat1 Cal/ml
Both Real food, high protein, moderate CHO Expensive, chicken taste
Resource Boosts Breeze 1Cal.ml, Fresubin jucy
Oral Fruit base formula, High osmolarity, not a complete formula
Isosource 1.5 Cal
Both Energy dense, high protein, better fluid control
Less tasty, expensive, dehydration risk
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Nutrition Support (Oral Formulas)
Formula Oral supplements Comments
Normal Ensure, Nutren , Enercal Plus etc…
Low cost, better taste
Energy Dense Fresubin 2kcal, Fresubin Jucy, Fibersource HN, Resource Plus, Isosource 1.5Cal, Enercal plus 1.5 kcal, …etc
Small gastric volume, Fluid restriction, energy boosting, lactose free,
Disease Specific Supportan, Renlion, Gulcerna, Nepro, Suplena, Pulmocare, Oral Impact, Perative, Prosure…etc
Expensive, lactose free, designed for diseases
Elemental Peptamen, Peptamen Prebio, Vital HN, AlitraQ
Expensive, best absorption,
Non-complete Formula
Abound, Beneprotein, Benefiber, Polycal…ect
Not a complete formula
Acceptance
**Most of the Enteral Formula are Lactose free
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Nutrition Support (Tube Feeding)
Formula Enteral supplements Comments
Normal Isocal, Ultracal, Osmolite, Osmolite HN, Jevity…etc
Isotonic, cheap, may or may not contain fiber
Energy Dense Isosource 1.5Cal, Fibersource. Small gastric volume, Fluid restriction, energy boosting, lactose free,
Disease Specific Supportan, Renlion, Gulcerna, Nepro, Suplena, Pulmocare, Impact, Perative, Prosure…etc
expensive, lactose free, designed for diseases, hypertonic
Elemental Peptamen, Peptamen Prebio, Vital HN, AlitraQ…etc
Expensive, best absorption,
Non-complete Formula Abound, Beneprotein, Benefiber, Polycal…ect
Nutrient augmentation
**Most of the Enteral Formula are Lactose free
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Formula choice, volume and rate depends on…
• Disease condition (DM, Hepatic, Kidney, COAD, GI problems, CA, palliative case, post or pre OT)
• Fluid Requirement (1kcal/ml or energy‐dense formula)• Energy and Nutrients Requirements (Malnourished, Under or overweight, electrolytes)
• Tolerance (intermittent or pump)• Laboratory results (nutrition status, RFT, LFT, Blood glucose)
• Availability • Price (Glucerna ~$19/can, Abound >$20/pack at retail price)
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••““DualDual‐‐Route Feeding in Route Feeding in Pressure Sore PatientsPressure Sore Patients””
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Possible Alternatives for Nutrition Augmentation
• PN is indicated and may allow adequate nutrition in patients whocannot meet their nutritional requirements via the enteral route, and should be limited to situations when EN is contraindicated or poorly tolerated (C)
• PN support should be instituted in the older person facing a period of starvation of more than 3 DAYS when oral or enteral nutrition is impossible, and when oral or enteral nutrition has been or is likely to be insufficient for more than 7‐10 DAYS. (C)
(ESPEN 2009)
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•Gut immunity can be stimulated by partial EN•When tolerance to EN is limited by gut dysfunction,•PN can deliver the required protein and calories, as well as some therapeutic nutrients (e.g. Glu, Fish oil)
•Nutritional goal is easily achieved with patient• comfort and safety, cosmetic concerns•Consequences of inadequate nutrition are avoided
(Prof. J Asprer 2009)
Benefits of Dual Route Feeding
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Combination Feeding(Enteral + Parenteral)•Combination feeding for whose clinical status does not warrant full enteral nutrition
•Patients following a combination feeding regimen receive parenteral and enteral nutrition simultaneously
•Small amount of enteral nutrition will preserve the barrier function of the GI tract
•On going studies on this area
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Nutrition Diagnosis•• Inadequate intake of energy and protein related to poor Inadequate intake of energy and protein related to poor oral intake evidenced by:oral intake evidenced by:•• Mean energy intake 800kcalMean energy intake 800kcal•• Mean protein intake 35gMean protein intake 35g
•• High risk of Malnutrition related to inadequate oral intake High risk of Malnutrition related to inadequate oral intake and abnormal level of nutrition indicators evidenced by:and abnormal level of nutrition indicators evidenced by:•• Inadequate intake according to estimated nutrient requirementsInadequate intake according to estimated nutrient requirements•• Low serum alb & Low serum alb & HbHb, elevated CRP, elevated CRP
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Nutrition Intervention• PPN plus oral nutrition support were given to all according to estimated requirements
• PPN (Kabiven Peripheral or Nutrilflex Lipid Peri)• +/‐ additives (Vitalipid‐N, Soluvit‐N, Addamel‐N, Dipeptiven, Omegaven)
• Oral Nutrition Support• Diet texture and perference modification• Enteral formula (e.g. Abound, Perative, Glucerna, Ensure etc..)
• Fluid requirement • 30ml/kg BW or 1ml per 1kcal intake
Micronutrients• Adjust according serum level (Na, K, Zn, PO4)
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PN Complications
•Hyperglycemia• Adjust dextrose• Insulin therapy (added to PN)
• hypoglycemia• Abrupt stopping of PN• 1‐2 hr taper down
• Electrolyte imbalance (Na, K, PO4)•Azotemia (renal impairment)•Mechanical
– phlebitis (K & Hypertonic solution)• – catheter occlusion• Infection• Calcium‐phosphate precipitate (reported 2 deaths)
• Lower pH (add L‐cysteine & hydrochloride) and increase amino acids content to lower the risk
• Use Calcium gluconate and Organic Phosphate
Life threatening
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Nutrition Related Complications• PNALD (Parenteral Nutrition Associated Liver Diseases)
• Elevated direct bilirubin concentrations (>2mg/dl, ~>33μmol), and in some cases progressing to hepatic failure
• Studies show omega 3‐based formula prevent development of PNALD• Refeeding Syndrome
• Too aggressive nutrition therapy (full strength on the 1st day)• Hypo PO4, K, Mg,
• Overfeeding• Hyperglycemia• High TG• Increased CO2 production• Fluid overload (PPN vs. CPN)
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•RF malaise, edema, muscle, weakness, hyperglycemia, and cardiac arrhythmia.
•Na retention and expansion of the extracellularspace, resulting in wt gain and cardiovascular demands, fluid shifts can result in cardiac failure, dehydration to fluid overload
•High Risk Group:• wt lost > 10%, NPO for 7 to 10 day, prolong fasting, significant wt lost obese with gastric bypass surgery
• increase morbidity and mortality
Refeeding syndrome
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Case # 1
(Oral Diet + Nutrition Supplement*) x 75%
Oral Diet + Nutrition Supplements + PPN
Energy (Cal) ~1500Cal/d ~2300Kcal/d
Protein (g) ~75g/d ~ 114g/d
% Nutrients Met (Energy 80%, Protein 83%) (Energy 110%, Protein 126%)
••Grade IV pressure soreGrade IV pressure sore••Male 59y, BW = 55kg (baseline Dec)Male 59y, BW = 55kg (baseline Dec)••Poor oral intake ~ 800 Cal/d (w/o oral supplements)Poor oral intake ~ 800 Cal/d (w/o oral supplements)••Poor nutrition status Poor nutrition status –– Ser alb 25, Ser alb 25, HbHb 9.9, CRP 46.69.9, CRP 46.6••Est. Energy and protein requirement: Est. Energy and protein requirement:
••2100Kcal & 90g protein/d (for grade IV pressure sore patient)2100Kcal & 90g protein/d (for grade IV pressure sore patient)
*Oral Nutrition Supplements: Perative (300 Cal, argirine containing formula)Resource Breeze (250 Cal, Orange flavor high protein supplement)
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Case # 2• Grade IV pressure sore• Female 85y, BW = 45.8kg (baseline Dec)• Poor oral intake ~ 500 Cal/d (w/o oral supplements)• Poor nutrition status – Ser alb 29, Hb 8.6, CRP 30.1• Est. Energy and protein requirement:
• 1600Cal & 70g protein/d (for grade IV pressure sore patient)
(Oral Diet + Nutrition Supplement*) x
50%
Oral Diet + Nutrition Supplements + PPN
Energy (Cal) ~800Cal/d ~1600Cal/d
Protein (g) ~50g/d ~89g/d (13g from glutamine)
% Nutrients Met (Energy 57%, Protein 70%)
(Energy 100%, Protein 128%)
*Oral Nutrition Supplements: Perative (300 Cal, argirine containing formula)Beneprotein 3 scoops/d (72Cal, 18g protein/d)
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Case reviewed before discharge• Case # 1 (4 weeks)
• BW 58.2kg (increased by 6%)• Ser alb 33, CRP 3• Oral intake improved ~ 1800Cal/d
• Case # 2 (2 weeks)• Ser alb 35, Hb 11.1, CRP 4.8• BW nil• Oral intake improved (home diet taken)
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• A retrospective review• 11 Elderly patients Severe pressure ulcer ;Stage 3 and Stage 4 (National Pressure Ulcer Advisory Panel, 1989)
• Referred to dietitian for nutrition support and further referred for Dual Route nutrition augmentation
• Objective: • To see any clinical improvement with PPN in additional to the conventional treatment.
• To see any relationship between albumin/CRP and PPN.• To see any relationship before and after PPN supplement.
Our Review
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1. Lack of peripheral venous access
2. Diabetic patients with poor glycaemic Control
3. Terminal stage of illness
4. Severe demented patients;
5. Non‐cooperative patient
Exclusion Criteria
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Energy Intake Changes
0
200
400
600
800
1000
1200
1400
1600
1800
Pre Energy
Post Energy
Protein Intake Change
0
10
20
30
40
50
60
70
80
Pre Prot
Post Prot
Average increase in energy intake and protein intake among the each patient
735 kcal increase 38g increase
kcal gm
PPN+oral supplement PPN+oral supplement
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• 11 patients were retreived; 3 male and 8 female • Average age: 79.9+/‐7.8• Mean Alb significantly increased from 25 to 29.9 mmol/l (p=0.022).• Mean CRP were decreased significantly from 126.3‐39.5mg/l (p=0.017).
• Zero mortality during study period
Results
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• Patients increase desire to eat during and after Dual route feeding• Nutrients Recommended level for wound patients may not be adequate enough for some sever pressure ulcer patients
• A win‐win‐win situation (all patties are happy)• Decrease use of antibiotic and dressing time
What is interesting!
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The lady, before
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After debridement, before PPN
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During PPN
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80 year‐old GentlemanMultiple Wounds
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After 23 Days Dual Route feeding
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PN: Types of Infusion
•Continuous (24hr)• Total volume of formula is administered over a 24 hour period• Hyperinsulinemia – fat deposition in the liver increase liver
complications•Cyclic (8-12hr)
• Volume is administered in one period, with infusion adjustments and a period of rest
• Reduce liver enzyme and lower chance of PNALD•Selection of infusion type depends on patient’s condition•Use a parenteral infusion pump
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Common 3‐in‐1 PN and additives in HA
• Smof Kabiven (CPN)• Smof Kabiven Peripheral (PPN)
• Nutriflex Lipid Special (CPN)• Nutriflex Lipid Peri (PPN)•Oilclinomel (CPN & PPN)
• Dipeptiven – glutamine solution• Soluvit N – water soluble vitamins
• Vitalipid N – Fat vitamins• Addamel N – trace elements• Omegaven – Fish oil for PN• NaCl soluition (23.4% ort 5.85%)
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Limitations……• No control group of patients• Number of patients in the study is small• Many confounders such as wound infection, comorbidities, different treatments, etc.
• Need better wound size measurement• Need a local clinical protocol
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PN Complications
• PNALD (Parenteral Nutrition Associated Liver Diseases) • Elevated direct bilirubin concentrations (>2mg/dl, ~>33ummol), and
in some cases progressing to hepatic failure• Studies show omega 3 based formula prevent development of
PNALD Paed SBD• Refeeding Syndrome
• Too aggressive nutrition therapy (full strength on the 1st day)• Hypo PO4, K, Mg,
• Overfeeding• Hyperglycemia• High TG• Increase CO2 production• Fluid overload (PPN vs. CPN)
• GI bacteria translocation & GI Atrophy
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•RF malaise, edema, muscle, weakness, hyperglycemia, and cardiac arrhythmia.
•Na retention and expansion of the extracellularspace, resulting in wt gain and cardiovascular demands, fluid shifts can result in cardiac failure, dehydration to fluid overload
•High Risk Group:• wt lost > 10%, NPO for 7 to 10 day, prolong fasting, significant wt lost obese with gastric bypass surgery
• increase morbidity and mortality
Refeeding syndrome
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Estimated Costing• PPN ~ HK$200‐250/d (assume 1 bag/d)• Additives ~ HK$110/d (all three)• Dipeptiven HK$250/bottle• Hospital diet ~ HK$20‐25/d• Enteral nutrition ~ HK$5‐35/pack• Estimated total nutrition cost from HK$585 – 660/d• (R/T feeding ~ HK$20 – 150/d)
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Recommendation
• Protocol for nutrition in wound management• Multidiscipline approach (doctor, nurse, dietitian, Pharmacist)• Patient centered care• Individualized (tailor made) nutrition care plan• Closely monitor (safety, complication, ethical concerns)• Attachment • Local study!
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Special ThanksMr. Gordon CHEUNGPresident of HKNA
Prof. HUNG Leung KimHead of Dept. of O&T, CUHK
Dr. David DAIGeriatric Consultant, Prince of Wales Hospital
Dr. LIU Kin WahGeriatric Associate Consultant, Queen Mary Hospital
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Parenteral Nutrition for Adult (NTEC)
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Thank you
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