FORCED FEEDING

6. METHODS AVAILABLE FOR LONG TERM NUTRITION SUPPORT
1. Nasoenteric tube feeding
2. Gastrostomy tube feeding
3. Jejunostomy tube feeding

6.1 NASOGASTRIC OR NASOENTERIC

Fine bore tubes made of polyurethane or siliconised rubber are
used.
The final position can be checked radiologically.
They are well tolerated with no risk of oesophagecol ulceration or
chest complications.
The patient can learn to insert the tube themself in ambulatory
home entral nutrition.

6.2 GASTROSTOMY

Can be performed by an open surgical procedure when a nasogastric
tube cannot be passed due to an esophageal carcinoma or when
patient is unconscious(fig 5.1)

This procedure can also be done per-coetaneous with the help of
an endoscope (PEG) (Fig 5.2)

6.3 PERCUTANEOUS JEJUNOSTOMY

It is possible to place the tube end in the jejunum through a
percutaneous stab insertion gastrostomy
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URGENT FEEDING

5 Alternative Methods of feeding
ENTERAL FEEDING (Nasogasric or Gastric tube)
Patients with obstruction of upper GIT
Radiation loss of appetite
Full thickness skin burns
Major trauma
These patients will require enteral nutrition.
First because their calorific requirements cannot be met by parenteral feeds
Second those that have nutritonal needs that require long term replacement
The main energy providing constituents of enteral feeds are:

* Glucose or Triglycerides (sunflower seed oils)
Other constituents are:

* Electrolytes
* Minerals
* Trace metals
* And Vitamins

Some enteral feeds can be prepared to meet the specific needs of
Patients by the hospital nutrition departments.

Companies in the enteral food market now provide products that can
Be used to provide all the energy requirements or to supplement
Inadequate oral intake.

Enteral Feeding (Evidence Base)
Animal studies in burn trauma in rats, indicate early external feeding results in improved survival, a delay in feed by 24 hours, result in poor weights, and negative nitrogen balance.
It is suggested that external feeding in trauma restores, the immune / lymphoid tissue function thus maintaining survival, and clearance role, of the gut this protects the portal circulation and liver from bacterial invasion.
There is a body of opinion, that believes that glutamine availablelity, and uptake by the enterocyte for energy in the guts, has a large role to play in insuring the integrity of gut mucosa and its function.
The role of short chain fatty acids produced by colonic bacteria (colonocytes) from fermentation of pectin is another theory that supports enteral feeding 70% of the energy requirements of the coloncytes is derived from these short chain fatty acids a deficiency of these fatty acids threatens the integrity of colonic musosa barrier effect
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SURGERY IN THE STARVED

The nutritional status of surgical patients is crucial, it
affects the post operative recovery,wound healing, convelecsence
and final outcome of the procedure.It is important to assess
the status and correctional action be taken.



4.1 Assessment of nutrition status
The nutritional status may be assessed during general physical
examination and the criteria include :

- Body weight ( compared to ideal for height and age)
- Mid-arm muscle circumference (MUMC)
- Skin fold thickness
- Muscle grip

Nutritional status may also be assessed by investigations:

- Lymphocyte count
- Serum Albumin
- Transferrin levels
- Thyroxine binding pre-albumin

The confirmation of this can be obtained if there has been recent
weight loss of more than 10%.

A body weight less than 80% of ideal for height

- Serum albumin less than 30 gm/l
- Total lymphocyte count below 1.2 x 109/l
- Mid upper arm circumference (MUAC) correlates with BMI cut of 23 cm male & 22 cm females


4.2 Clinical Conditions
The major causes of inadequate intake are the disorders
leading to less than 50% intake of calorie requirements 7-10days
Underlying causes
- Severe dysphagia in the unconscious i.e Head injury, stroke
- Major full thickness burns
- Major Trauma
- Radiation
- Chemotherapy
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NUTRITION IN STARVING SURGICAL PATIENTS

3.3 FATS

Our main problem is supply of calories to a starving surgical
Patient, we need to prevent muscle breakdown loss, and supply
Enough calories for metabololic body requirements

Lipid supplementation can supply high energy source in starving
Patients, without the risk of hyper-glycaemia despite continuing
gluconeogenesis.
In stress and surgery 25-45% of energy can be sourced from lipids.
The fat is limited to 2 gm per Kg/body wt/ 24 hours to avoid fat
overload syndrome (fever, back pain, chills, etc.)

Fat basic facts
In normal circumstances Fats provide the body’s calories requirement (15 – 20%).
In starvation, the majority of calories have to be provided by fat which is converted to ketene bodies produced in the liver.
Steroids, catechols, glucagons, and some cytokines promote lipolysis, while insulin is an inhibitor.
Fat as 20% of non-protein calories in normal or moderate stress conditions seems to be optimal for hepatic protein synthesis.
The fat overload syndrome in parental feeding of fever, back pain, chills, pulmonary Insufficiency, and impairment of the reticuloendothelial system can occur.


4. NUTRITIONAL PROBLEM
All surgical patients cannot be assumed to be in healthy status.
Many patients seeking surgical treatment have been ill, with a
complaint for a variable period ranging from days (acute conditions) to weeks in chronic patients.
During this period their nutritional intake has been affected.
Some may be in alarming state of malnutrition.
Although minor degrees of proteins, and calorie limitation does
not affect the surgical outcome, most severe forms of nutritional
disorders do jeopardize post-surgical recovery, for they effect
wound healing, resistance to infection and thus the recovery
period is prolonged.

The most severe disorder effecting nutrition, are those that
effect oral intake (starvation) and these are disorders of
gastrointestinal tract.

Disorders of an inflammatory nature also cause catabolism and
thus are responsible for the negative nutritional status.
Malignant disorders may also be responsible for disturbing the nutritional status.
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FASTING SURGICAL PATIENT

3.2 CARBOHYDRATES

The human body has an internal supply of stored carbohydrates in the
form of glycogen.
This is enough for a 24 hr. without food intake.
Therefore, glucose (I.V)is the principal means of sparing protiens in a fasting surgical patient.
A minimum of 400 cal in 24 hours can minimise protein breakdown in starvation, it can cut it down by 50%.
In stress state of surgery, and in the presence of sepsis, insulin inhibited lypolysis does not work, thus
gluconeogenesis continues, and hyper-glycaemia occurs.

Wound repair also requires glucose and some amino acid (arginine)
Calories and protiens

Carbohydrates
Glucose is the major energy fuel used by the body.
The maximum rate of oxidation is 4-5 mg/min (7.2 g/ kg/day) 60-70% of body calories requirements are met through carbohydrates.
Carbohydrate stores are virtually depleted after a greater than 24 hours fast, with liver glycogen depleted and only small amounts of muscle glycogen remaining.
In the Krebs tricarboxylic acid cycle, glucose in completle oxidation, produces a larger amount of high energy phosphate, than in the incomplete oxidation of anaerobic glycolysis that produces lactate.
Glucose is an efficient means for protein sparing with at least 400 calories required in 24 hours.
Glucose can reduce the degree of proteolysis up to 50%. Numerous cell types, including muscle, neural tissue, red blood cells can thus be saved.
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