Inpatient nutrition_Creamer

Inpatient nutrition_Creamer - The Science of Effective...

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The Science of Effective Pediatric Inpatient Nutrition 2005 Kevin M. Creamer M.D., FAAP Medical Director, PICU WRAMC Chief, Pediatric Nutrition Support Team
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A hypothetical case Starvin Marvin is a 2 y.o. who presents with a 2-3 week Hx of fevers, weight loss, pallor, decreased energy, appetite and activity PE reveals Wt 13kg , down 1.5 kg, pallor, petechia,+ HSM Labs reveal WBC 26 K with 50% blasts, anemia and thrombocytopenia
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Hospital Course Day 1 - NPO, IVFs, labs, Xrays Day 2 – NPO for BM and LP, as well as Hickman Day 3- Chemo, picky PO Day 4-6 - continued poor PO, with emesis occasionally Day 7-10 – emesis resolves, PO inadequate Day 12 – pancytopenia, sepsis with GNR
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Teaching points Nutritionally-at-risk from the word GO Debilitated Ortho spine patient Recurrent bowel obstruction patient No nutrition plan, No monitoring, No intervention Hope is not a method Could sepsis event been avoided??
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Inpatient Nutrition Goals Think about nutritional status on every patient Outline the dynamic between illness, nutritional state and secondary morbidity Recognize need to estimate/calculate goals calories in order to reach the goal Individualized goals for time course, and disease process Institute effective nutrition support with the help of Pediatric nutritionist
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Acute Stress
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The 5 W’s of Inpatient Nutrition Why, Who, When, Where, What ?
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Acute Stress Major Surgery, Sepsis, Burns, Trauma Result in massive outpouring of catechols, ACTH, GH, ADH, glucagon, somatomedins Insulin inhibition, elevation of glucose and free fatty acids ↑ Inflammatory Cytokines: TNF, IL 1 , IL-6 PMN release and degranulation Mucosal permeability Stress hormones and mediators ↑ release of cAMP which down-regulate lymphoid immune activity
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Acute Stress NPO state starves gut mucosa Gut mass  50% in 7 days of fasting Gut contains 80% of body’s immune tissue “GALT and MALT” Intestinal sIgA ↓ in 5 days ↑ Th1 pro-inflammatory lymphocytes Major stress doubles protein turnover Skeletal muscle cannibalized for fuel for enterocytes (glutamine) Stechmiller JK, Am J Crit Care, 1997
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Bacterial Translocation Disruption of mucosal barrier Ischemia-reperfusion during shock risk of ulceration and permeability Bacterial translocation Culture(-), found bacterial DNA in blood stream Cytokine amplification in lymphatics and liver
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Bacterial Translocation Enteral nutrition can prevent translocation Trophic feeds stimulate gut hormones and nourish mucosa, increase blood flow, re-energize tight junctions, improve brush border Enteral vs. Parenteral feeds - postop septic related complications Enteral feeds stimulate Th2 lymphocytes which PMN adhesion in lung Deitch EA, Ann Surg, 1987, 1990;Border JR, AnnSurg, 1987; Carrico CJ, Arch Surg, 1986; Alverdy JC, Surgery, 1988; Moore J, JPEN, 1991,Kudsk,Am J Surg, 2002
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Is nutrition such a big deal?
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Inpatient nutrition_Creamer - The Science of Effective...

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