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Nutritional Care of the Bariatric Patient in Critical Care Christine Ward Bariatric Dietitian September 2011

Nutritional Care of the Bariatric Patient in Critical Care Christine Ward Bariatric Dietitian September 2011. Aim . To identify factors that may impact on the nutritional care of the bariatric patient group Why this group may require a Critical Care admission?

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Nutritional Care of the Bariatric Patient in Critical Care Christine Ward Bariatric Dietitian September 2011

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  1. Nutritional Care of the Bariatric Patient in Critical CareChristine WardBariatric DietitianSeptember 2011

  2. Aim • To identify factors that may impact on the nutritional care of the bariatric patient group • Why this group may require a Critical Care admission? • What are the potential issues regarding feeding? • Which BMR estimation equation is most appropriate for the bariatric patient?

  3. Factors that may impact on nutritional care of bariatric patients • Obese patients generally viewed as over nourished • Potentially deficient in a number of nutrients • Respond to injury differently; can not utilise/mobilise fat stores for energy as well as lean counterparts • Will draw on lean mass for energy • Considered that they may already metabolically stressed due to obesity • 2 weeks Pre-operative dietary restriction ~1000kcal/day

  4. The bariatric candidate over nourished or not? 6/6/2014 4

  5. Type of Surgery Laparoscopic Procedures • Restrictive • Adjustable Gastric Band • Sleeve Gastrectomy • Restrictive and Malabsorptive • Roux-en-Y-Gastric Bypass • Duodenal Switch /BPD

  6. Critical care admission? • Planned Critical Care • Clotting issues thrombolysis • CPAP: patient not independent

  7. Unplanned Bariatric patients in Critical Care • Undiagnosed sleep apnoea • Prolonged ventilation • Large bleeds - liver • Conversion to open procedure • Rhabdomyolysis, renal failure, sepsis, respiratory failure • Anastomotic leak or stricture ERI: 5% patients (6-20% cited in many papers)

  8. Feeding Route? • Usual Protocol post surgery • Oral Route • Immediately post bariatric surgery if gut intact • day 1; sips, • day 2; clear fluid, • day 3; free fluid • Use of nutritional supplements, high protein where appropriate

  9. Enteral or Parenteral Nutrition • ? NG, NJ , gastrostomy / jejunostomy • Altered gastrointestinal anatomy/function • Which feed? • TPN • How soon? • ?Within 48 hours or ? NICE 2006 • Re-feeding issues K, Mg, PO, thiamin • Biochemistry monitoring (daily or as local protocol) • Is it possible to meet nutritional requirements? • Overfeeding vs. under feeding

  10. Risks from nutritional support for the obese patient • Overfeeding • Increase C02 , breathing and prolonged mechanical ventilation • Promotes fat infiltration of liver (esp. CHO) • Cautious administration of CHO (dextrose) fat and fluid for obese with T2DM, Congestive heart failure, metabolic syndrome (exacerbation of conditions)

  11. Hypo energetic feeding and protein sparing • Improved glucose control • Improved serum iron binding and albumin • Appropriate energy deficit without increasing lean tissue catabolism can be achieved • Dickerson et al 2004, Choban et al 2005, 1997 50% of energy requirements and 2.1g protein /kg IBW resulted in N balance

  12. Aim of nutritional support in critically ill patients? • Meeting measured energy requirements vs. preservation of lean body mass vs. risks of under or overfeeding

  13. BMR Prediction Equations (Schofield) • Criticism of current PENG guidance • Estimations equations based on healthy population • Inappropriate use of stress factors; overestimates • Use of static variable such as weight, the body’s physiology ?temperature and respiration rate • Based on a linear relationship between weight and BMR

  14. However • Findings from Horgan and Stubs 2003 re-examination of Schofield equation: • Small numbers of obese patients • BMI>30 =4.5% • The linear relationship between BMR, weight, height and age only evident to a weight of ~ 70-75kg

  15. BMR Prediction Equations • Over estimates requirements for high BMI • Adipose tissue to lean tissue relationship 75:25 • Main determinant of BMR is lean tissue • Obese have a higher absolute BMR due to a greater total mass of metabolically active tissue • BMR /Kg is lower due to the higher proportion of adipose tissue • BMR/Kg of fat free mass for most subjects is the same

  16. Henry/Oxford Equations 2005 • Based on studies from 1914-2005 • 10,552 BMR values • Rigorous evaluation of methodology • Advantages • Contains a more representative sample of the world population

  17. SACN recommendations (draft)(www.sacn.gov.uk) • Use of Henry BMR equations • Weight only • Height and weight • Henry found no significant advantage in ht & wt equation • For predicting BMR using weight only • (height difficult to obtain in clinical setting) • Launch later this year

  18. Assessment prior to feeding • As you would for other obese or lean individual • Up to date weight crucial • Scales suitable for purpose, bed, hoist, stand on, • Immediately pre-surgical for bariatric patients available • Reported weight or estimated • Knowledge of patient background, • type of surgery, • nutritional intake prior to surgery, • amount of weight loss/time • Potential for nutritional deficiencies

  19. Calculating nutritional requirements? Energy requirements Non stressed • Feed to BMR using actual body weight with -400-1000kcal for decrease in energy stores Mild to moderate stress: • Calculate as normal • Omit stress and activity avoiding adverse effects of overfeeding Severe stress • Might be necessary to add a stress factor to BMR

  20. Obesity Double Check In order of decreasing accuracy / evidence • Ireton Jones energy equations (critically ill but not ventilated) • Adjusted average weight (PENG pocket guide4) • 19-21 kcal/kg actual body weight (critically ill only) Glynn 1999, Alberda 2002

  21. Protein Requirements4 • 0.2g N/kg Actual body weight x 6.25 • And where • BMI >30 use 75% of the value estimated from actual weight • BMI> 50 use 65% of the value estimated from actual weight

  22. Fluid Requirements4 • Very individual; ventilation, • The guidelines err on side of caution • Fluid requirements not a linear relationship with weight, • Avoid fluid overload • Consider, is volume sensible? 2000-3000mls • Have losses been taken into account

  23. Final thoughts • Estimated Energy requirements only starting point • Review and monitor patient regularly • Consider duration of nutritional support? • Are nutritional goals being met? • Requirements change: patients clinical condition, nutritional status, stress level, prognosis • Never blindly follow guidelines: clinical judgement required

  24. References • American Society for Metabolic and Bariatric Surgery Guidelines 2008 • Ernst B, Thurnheer M, Schmid S M, Schultes B. Evidence for the necessity to systematically assess micronutrient status prior to bariatric surgery. Obesity Surgery. 2009; 19:66-73 • Flancbaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg. 2006;10(7):1033-7 • A Pocket Guide to Clinical Nutrition. 3rd Edition. The Parenteral and Enteral Nutrition Group of the British Dietetic Association. 2007 • Cheatham ML, Safcsak K, Brezinski SJ, et al Nitrogen balance, protein loss and open abdomen. Crit Care Med. 2007;35:127-131

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