Palliative care; Nutritional Support

Human digestive system

Effect of disease states on nutrition

Nutritional screening and assessment

1. Nutritional screening

   • Usually done on admission to the wards

   • Can be done by ppl with no background in nutrition

   • To quickly identify individuals at nutrition risk

2. Refer to dietitian / nutritional specialist

3. Nutritional assessment

   • An in-depth, systematic process that integrates and interpret patient data to identify nutrition-related problems  (ABCD)

   • e.g. Anthropometric measurements, Biochemical assessment (vit + min levels), Clinical assessment (clinical hist), Dietary assessment (has intake dropped in the past 3-6m)

4. Formulation of nutritional regime

Energy requirements

Energy requirements - Modes of REE/BMR measurement

Protein requirements

what is enteral nutrition

enteral nutrition - types of feeding tubes

enteral nutrition - Modes of administration

enteral nutrition - types of formula

enteral nutrition - Drug administration via feeding tube

enteral nutrition - Common complications

enteral nutrition - Monitoring parameters

Signs of intolerance (e.g. abdominal cramping, bloating, N/V/D)

Gastric residual volume -> intestinal aspiration of gastric contents 30-60min after feeding. To see how much feed is flowing into the intestine

Electrolytes

Fluid balance

Weight

enteral nutrition - Strategies to maximize tolerance to EN

Continuous instead of bolus

Use of prokinetic agents (e.g. metoclopramide, domperidone, IV erythromycin)

Post-pyloric feeding if intolerant to gastric feeding

Use of isotonic formula -> the higher the calorie the higher the osmolarity

Semi-elemental/elemental feeds for patients with malabsorptive issue (e.g. short bowel syndrome)

enteral nutrition - Make use of the physiological function of the GIT

Maintain functional integrity of the gut

Undergo first-pass metabolism -> helps to neutralize toxins in feed, promote efficient nutrient utilization (converts nutrient to active form)

Maintains normal gallbladder function -> production of cholecystokinin

Maintain gut-associated and mucosal-associated lymphoid tissues

Less complications than parenteral nutrition

Less expensive

what is parenteral nutrition

parenteral nutrition - types of access devices

parenteral nutrition - types of catheters

parenteral nutrition - composition

parenteral nutrition - macronutrients

parenteral nutrition - micronutrients

parenteral nutrition - Drug-nutrient interaction

parenteral nutrition - Device related complications

Occlusion in IV catheter -> body recognizes it as a foreign body

• Thrombosis / clotting

• Inappropriate flushing techniques -> push pull technique to create turbulence to flush out clots

• Precipitates as a result of drug incompatibilities, crystallization

• Lipid residues

Mal-positioning -> pt may accidentally touch and cause the line to move

Catheter-related bloodstream infection (CRBSI) -> cause may be contaminated + its nutrients for bacteria

parenteral nutrition - Metabolic complications

refeeding syndrome - pathophysiology

Starvation → low insulin, body uses fat/protein → total body depletion of electrolytes

Refeeding (↑ carbs during feed time) → ↑ insulin → shift of electrolytes into cells

Result: rapid ↓ in serum:

• Phosphate (most important)

• Potassium

• Magnesium

Also: sodium/water retention → fluid overload

refeeding syndrome - Management strategies

refeeding syndrome - Monitoring parameters

Electrolytes

Blood glucose level

Fluid balance

Weight

Renal function tests - creatinine, blood urea nitrogen, Chloride/CO2

Liver function tests

Triglycerides

Signs of infection e.g. differential blood count, fever, redness/pus around site of line access

Ethical considerations to artificial nutrition

Key dilemma in provision of artificial nutrition and hydration in patients nearing end-of-life, advanced dementia

Artificial nutrition = oral nutritional supplements, EN, PN

• Deemed as medical interventions/clinical therapy, not just “foods”

Aims of palliative/EOL care: to provide relief and support, manage physical symptoms, address psychological needs

Guiding principles: autonomy, beneficence, non-maleficence, justice

Summary