case approach in nutrition support

8/2/2019 Case Approach in Nutrition Support

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Case approach in nutrition

support October 2005

Preyanuj YamwongResearch Center for Nutrition Support,

Siriraj Hospital


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What you should know in clinical nutrition

Nutritional assessment

Nutrients deficiency : Protein, energy,vitamins, minerals (Macro/trace elements)

Over Nutrition : Obesity, Dyslipidemia,

Vitamin & minerals excess Nutrition support : EN, PN, Nutrition

support in specific diseases

Nutrition and diseaseprevention/modification

Functional food


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Case 1

67

BS 180 mg/dL

Route of nutritional support Energy requirement

Protein requirement

Type of protein


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Glucose and Insulin after Preop. and Postop. Glucose

Infusion Tests

0

40

80

120

160

200

240

0

5

10

15

20

25

GLUCOSE p

(mmol/L)

Glucose

IRI

5 30 60 90 5 30 60 90

PREOPERATIVE POSTOPERATIVE

Giddings et al. Ann Surg 1977;186:681-686

MINUTES

GITest

IRI

mU/L


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Intensive Insulin Therapy

7133Insulin dose U/day

103173Morning BS mg/dl

INTENSIVECONVENTIONAL

Van den Berghe et al. 2001


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Cumulative Survival of Patients under Conventional vs. IntensiveInsulin Therapy In ICU

80

84

88

92

96

100

80

84

88

92

96

100

DAYS AFTER ADMISSION20 40 60 80 100 120 140 160 50 100 150 200 250

Van den Berghe et al, 2001

Intensive insulin

Conventionalinsulin

Intensive insulin

Conventional

insulin

HOSPITAL SURVIVAL (%)SURVIVAL IN ICU (%)

DAYS AFTER ADMISSION


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Effects on Morbidity of Intensive Insulin Treatment on

Critically Ill Patients

VARIABLECONVENTI ONA

L TREATMENT

I NTENSI VE

TREATMENT

P VALUE

>14 days of IC (%) 15.7 11.4 0.01

>14 days ventilatorysupport (%)

11.9 7.5 0.003

Septicemia (%) 7.8 4.2 0.003

Antibiotics >10 days(%)

17.1 11.2


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Is Strict Normoglycemia Necessary ?

> 150 mg / dl

< 110 mg / dl

110-150 mg / dl

0

5

10

15

20

25

30

35

40

45

0 50 100 150 200 250

p= 0.026

p= 0.0009

Days after inclusionCumulativeHazard(%)(inhospitaldeath)Patients in ICU for > 5 days (N = 451)

Van den Berghe G et al. Crit Care Med 2003; 31: 359-366


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Diabetes mellitus and stress induced hyperglycemia

Most common pathogenesis : insulin resistance

Enteral formula

addition of dietary fiber may improve glycemic control

High monounsaturated fatty acids may also improve

glycemic control

Feeding frequency depends on type of insulin used

Parenteral nutrition

Addition of insulin in glucose bottle or dripping parallelto glucose

Follow up TG as well as glucose


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Blood Glucose Response to Standard and Disease Specific EnteralFormulas in Type 1 Diabetes

0

50

100

150

200

250

300

-30 0 30 60 90 120 150 180 210 240

Standard Disease specific

Time (Minutes)

Blood glucose (mg/dL)

Peters A et al, Am J Med 1989


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Blood Glucose Responses to Diabetes-specific and Standard Enteral

Formula in Stress-induced Hyperglycemia

0

50

100

150

200

250

300

0 1 2 3 4 5 6 7

Standard Diabetes-specific

Blood glucose (mg/dL)

Day

Coulston AM, Clin Nutr 1998


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Diabetic Formula

Commercial formula

Glucerna

Glucerna SR

Choice DM Blenderized diet

Change composition of glucose tofructose or starch

Reduce fat composition


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Since this patient has high stress, is there

any rational to use Glutamine and otherimmuno-nutritions?


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Nutrients with Immuno-modulatingProperties

Amino acids Glutamine

Arginine

Fat

Omega-3 fatty acids

Others Nucleotides (RNA)


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Arginine

Conditionally essential amino acids

Stimulate the secretion of GH, insulin,insulin-like growth factor-1, prolactin

Precursor of Nitric oxide (NO)

H3+N-C-NH-CH2-CH2-CH2-C-COO

-

NH H

NH3+


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protein breakdown

nitrogen retention

Promote wound healing

tumor growth lymphocyte proliferation

activity of NK, lymphokine activated

killer cells phagocytic activity of neutrophil

Arginine Supplementation


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Glutamine

Most abundant amino acids

Conditionally essential amino acids Substrate for hepatic gluconeogenesis

Precursor of nucleotides, glutathione

Energy source of enterocytes, rapidlymitotic cells eg. immune cells

H2N-C-CH2-CH2-C-COO-

NH3+

H

NH3+


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Glutamine Supplementation

protein synthesis

hepatic gluconeogenesis

nitrogen retention Maintain small bowel mucosal

thickness and prevent villiatrophy


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Linolenate

Diet

-LinolenateEicosatrienoate

Group 1PGE1

PGF1

TXA1

LTA3

LTC3

LTD3

Eicosatrienoate

Arachidonate

Group 2

PGD2PGE2

PGF2

PGI2

TXA2

LTA4

LTB4

LTC4

LTD4LTE4

Group 3

PGD3PGE3

PGF3

PGI3

TXA3

LTA5

LTB5

LTC5Diet

-LinolenateEicosatetraenoate

Octadecatetraenoate

Eicosapentaenoate

Diet

(dihomo---Linolenate)


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Reduced Postoperative Infections with an Immune-

enhancing Nutritional Supplement70

60

50

40

30

20

10

0 -

Wound

Pulmonary

Intestinal

Urinary

Other

None

Immunonutrition(n = 82)

Standard enteralformula (n = 47)

Numberofinfectio

ns

Synderman CH, et al 1999


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Prospective DBRCT of Enteral Immunonutritionin the Critically Ill

02

4

6

810

12

14

1618

20

Ventilation Hospital stay

Immunonutrition

Standard enteralformula

p = 0.007

p = 0.03

Atkinson S, et al Crit Care Med 1998

Days


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0

20

40

60

80

100

120 Regularformula

Supplementedformula

Early Enteral Administration of a Formula Supplemented

with Arginine, Nucleotides and Fish Oil in Intensive CareUnit Patients

Length of hospital stay (day)

0 0 1 0 1 0 1 Inc. of post-feeding inf.0 1 1 3 3 5 5 No. of acquired inf.


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Early Enteral Administration of a Formula Supplemented with

Arginine, Nucleotides and Fish Oil in ICU Patients (Multicenter,Perspective, RCT)

0

5

10

15

20

25

30

Hospital stay UTI Bacteremia

Immunonutrition


Clinical outcome in successful feeders

Numberofdaysinh

ospitalstay

/

Numberofpatientswithacquiredinfection

p < 0.05

Bower RH, et al Crit Care Med 1995


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Early Post-operative Enteral Immunonutrition: ClinicalOutcome and Cost-comparison Analysis in Surgical Nutrition

52.647.8

31

74.683.6

122.4

0

20

40

60

80

100

120140

Early

complication

Total cost

Immunonutrition

Standard enteralformua

Senkel M, et al Crit Care Med 1997

German Marks (000s)


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Outcome and Cost-effectiveness of Perioperative Enteral

Immunonutrition in Patients Undergoing Elective Upper GISurgery

0

50

100

150

200

250

Early

complication

Late

complication

Total

Immunonutrition


Senkel M, et al Arch Surg 1999

German Marks (000s)


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Six-month outcome of critically ill patients given Glutamine-

supplemented parenteral nutrition

Griffiths RD, et al . Nutr 1997;13:295-302


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Available Immunonutrition Formula

Neomune : high protein (64 g/1000 kcal),

with Glutamine and fish oil

Dipeptiven : dipeptide contains glutamine


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Since this patient has respiratory

failure, does he need fat modificationdiet?


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Respiratory quotient (RQ)

O2 consumption while metabolizing

CO2 productioncertain amount of nutrient

C6H12O6 + 6O2 6CO2 + 6H2O


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EN in Respiratory Failure

The major concern is about CO2 over-

production which can precipitaterespiratory failure or compromise weaning

CO2 induced respiratory failure were

reported in COPD cases who receivedmore than 2,000 kcal from CHO per day

Usually patients with respiratory failure

are in hypercatabolic state and requirehigher energy and protein


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EN in Respiratory Failure

Not all patients with respiratory failure

need high fat formula AGA may be necessary to monitor the

over-production of CO2 if high energy is

provided

In cases who high fat formula is indicatedthe available formula is Pulmocare,

Respalor, or modified BD


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Available high fat formula

Pulmocare

Respalor

Addition of oils in standard feeding

formula


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If the patient develops acute renal

failure after a week of treatment,how would you provide thenutrition support for him?

Nutrients provided and restricted?

Route?

Formula?


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Metabolic Derangement in ARFHypermetabolism and hypercatabolism

Accumulation of metabolic productsAcidemia

Underlying hypercatabolic conditionIncrease certain catabolic hormone(glucagon & PTH) due to ARF itself

Poor dietary intake

Influenced more by the nature of the illnesscausing ARF


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Metabolic Derangement in ARFHypermetabolism and hypercatabolism

Glucose intolerance : insulin resistanceProtein and amino acids abnormalities :protein catabolism, azotemia

Influenced more by the nature of the illnesscausing ARF


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Protein Catabolism in ARF Average UNA

12+7.9 g/D in patients with rhabdomyolysisvs.

3.8+2.4 g/D in ARF from other causes

Feinstein EI, et al, 1981

Net protein degradation 200-250 g/D

Feinstein EI, et al, 1983Leonard CD, et al, 1975


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Metabolic Derangement in ARF

Hypermetabolism and hypercatabolism

Glucose intolerance : insulin resistance

Protein and amino acids abnormalities : proteincatabolism, azotemia

Lipid metabolism : hypertriglyceridemia

Acid-base disturbance : metabolic acidosis

Fluid imbalance : hyper- / hypovolumia

Electrolytes imbalance :hyper- / hyponatremia,hyper- / hypokalemia, hyperphosphatemia,hypocalcemia


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Metabolic abnormalities in patients withARF differ from one case to another.

In the same patient, the abnormalitiescan change from day to day or evenhour to hour.


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Nutrients Requirement and Limitation

Goals :

Energy 30-35 Kcal/Kg/D

Protein 1.5-2 g/Kg/d

Potential nutrients restriction in early

phase

- Water

- Potassium- Sodium

- Phosphate


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Renal Replacement Therapy

Intermittent

hemodialysis

Continuous AV /

VV hemodialysis(CAVHD,CVVHD)

Peritonealdialysis


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Renal Repalcement Therapy and Its Impact on

Nutritional Support Acute peritoneal dialysis

Continuous peritoneal dialysis

loss of protein 5-9 gm/D in dialysate, glucose absorbed from dialysate

Hemodialysis

Loss of amino acids 6-9 gm/dialysis Increase energy expenditure during dialysis

Continuous hemodiafiltration (VV, AV)

Glucose absorbed from dialysate (5.8 gm./Hrfor 1.5% glucose 1 L/Hr.)

loss of amino acids ~13-24 gm. /D


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ARF (GFR ARF CVVH / CVVHD5-10) non HD 3/wk CAVH

stress high stress ARF

Protein/AA 0.55-0.6 of 1.2 of 1.5-2.5 of(g/kg/d) mixed AA mixed AA mixed AA

Energy 30-45 30-45 30-45

(kcal/kg/d)

Fat (% of 20-30 20-30 20-30

total energy) (-- --- --- --- -- if not sepsis -- --- --- --- --- --)

Water --- --- --- --- --- as tolerate --- --- --- --- --- --

ASPEN Guidelines 2001

Daily Recommendation of Patients with ARF


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Feeding Formula

Preferred concentrated, low Na & low

K formula

Protein content depends on the

status : pre-, post dialysis High protein for post dialysis : Nepro

Low protein for pre-dialysis : Prosobee,

Pregestimil


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Intravenous formula

Renal formula : ~ 60% of EAA is

necessary when less than 40 g/day ofAA are provided

Formula : Kidmin, Nephrosteril,Amiyu


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Assessment of Adequacy of NutritionSupport

Energy : Dry weight

Protein : Serum albumin: Urea Nitrogen Appearance (UNA)

UNA (gm/D) = UUN + 0.6BWi

(BUNf

-BUNi

)

+ BUNf (BWf-BWi)

: Total Nitrogen Appearance (TNA)

TNA (gm/D) = 1.27 + 1.19UNA


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In conclusion, how you are going tofeed this patient?

Priority Setting is the key!Priority Setting is the key!


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18

96 .159.

BMI = 96/(1.59)2

= 37.97kg/m2

Case 2


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Body mass index for Asian people

Grading BMI (Kg/m2)

Underweight < 18.5Normal 18.5 - 22.99

pre-obese 23.0 - 24.99Obese gr. 1 25.0 - 29.99Obese gr. 2 > 30.0


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Obesity : Definition

Ideal body weight :

overweight > 110% of ideal body weight

Obese > 120% of ideal body weight(Female : height [cm]110,

Male : height [cm]100)

Percent of body fat :

> 30 in female, > 20% in male


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Obesity : Definition

Waist circumference :

BMI (Kg/m2) Waist circumference

> 25 male 94 cm./ 37 female 80 cm. / 31

> 30 male 102 cm./ 40 female 88 cm. / 35

90 cm 80 cm

94 cm 80 cm


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Morbid Obesity

BMI > 35 kg/m2

or obesity associated withsevere/cardiovascular

complications


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Pear shape/Gynoid type Apple shape/Android

Waist / hip ratio that reflects higher risk of CAD

Women > 0.8 Men > 1,


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1896 .159.75.

?

?


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Metabolic complications (Waist > 100 cm in

male, > 90 cm in female) insulin resistance & diabetes

Dyslipidemia

Hypertension Cardiovascular disease

coronary artery disease

Other endocrinological complication : Amenorrhea (Polycystic ovarian syndrome)

Obesity : complications

Aca n t h o s is n i g r i ca n s


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Obesity : complications Mechanical effects :

Joint : ankle joint, knee joint, back pain

Respiration : sleep apnea syndrome

Skin : fungal infection, varicose vein

Cancer : breast, endometrium, prostate, esophagus

Gall stone

Social & psychological problems


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/

/


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// DM HT Allergy Depressive illness Schizophrenia

Seizure OSA Polycystic ovarian

syndrome

Hypothyroidism Stress & anxiety

Sulfonylurea Beta-blocker Antihistamine Antidepressant, Li Antipsychotic drugs

Transquilizer Contraceptive pills


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Diet control

Exercise & increase physical activity Behavioral modification

Drug therapy

Surgery

Obesity : Management


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Weight loss in the Diabetes Prevention Program

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0-8

-6

-4

-2

0

2

4

Year

Weight loss (kg)

DPP. N Engl J Med. 2002; 346: 393-403

Placebo

MetforminLifestyle

Di b t P ti P


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Cumula

tiveinciden

ce

ofdi

abetes(%)

Year

Diabetes Prevention Program

DPP.N Engl J Med. 2002; 346: 393-403

RR*58%

*Reduction in risk of progressing to type 2 diabetes versus placebo

Placebo

Metformin

Lifestyle

40

30

20

10

00 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

RR*31%

/?


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Diet Activity Drug VLCD Surgery

BMI 23-25

no risk X

Increase WC X

DM/CAD/HT/HL

BMI 25-30

no risk

(consider)Increase WC (consider)

DM/CAD/HT/HL

BMI > 30

no risk (consider)Increase WC

DM/CAD/HT/HL

/?

Orlistat (Xenical)


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Orlistat (Xenical )

Action : inhibitor of pancreatic lipase: reduces fat absorption about

30%

Effect : Weight reduction -9.2% vs. -5.8% after 2 yr.

: Weight reduction > 10% :

42.1% vs. 22.7% after 2yr.

: Reducing LDL-C, TG

: Improvement of glycemiccontrol

XENDOS results


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: Effect of Xenical on body weight

-4.1 kg

-6.9 kg

p


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Sibutramine (Reductil)


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Sibutramine (Reductil)

Action : inhibition of re-uptake of serotonin andnor-epinephrine

: resulting in prolonged satiety

rather than anorectic effect Effect : Reduce BW, waist circumference,serum lipid levels

Side-effect : may increase BP and HR in

some cases: constipation

: dry mouth

: insomnia: no fenfluramine-like adverseeffect


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Effect of Sibutramine on weight maintenance afterweight loss : a RT

The STORM St ud y Gr ou p, Lancet 20 00 , 2 1 1 9 - 2 5


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Case 3 35 1 tenderness &guarding epigastric area

U/S diffuse enlargement of pancrease Serum amylase 1234 IU/L

severity APACHE score

moderate to severe pancreatitis


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Acute pancreatitis : oral/gastric stimulationof pancrease should be avoid

Acute pancreatitis

Total Parenteral Nutrition Enteral feeding

Sti l ti f ti ti ith


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Stimulation of pancreatic enzyme secretion withvarious type of nutrient & site of feeding

Stimulation of pancreatic exocrine secretion weresimilar by both intragastric and intraduodenal feeding

Jejunal feeding did not associate with increasepancreatic enzyme and bicarbonate secretion

Feeding of fat cause more secretion of pancreatic

enzyme than feeding of CHO

Amount of protein feeding (10% to 40% of totalcalories) was not associate with different enzyme

secretion

Volume of pancreatic


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Volume of pancreatic

juice during enteraland total parenteralfeeding

Bodogy G, et al 1991,

Am J Surg

TEN

TPN

Comparison of the safety of early enteral vs


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Comparison of the safety of early enteral vsparenteral nutrition in mild acute pancreatitis

600 -

500 -

400 -

300 -

200 -

100 -

0 -

1 2 3 4 5 6 7 8 9 10

6000 -

5000 -

4000 -

3000 -

2000 -

1000 -

0 -

1 2 3 4 5 6 7 8 9 10

TEN

TPN

Serum amylase Serum lipase

Time

McClave SA, et al. 1997 JPEN

Time


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Acute pancreatitis : oral/gastric stimulation ofpancreas should be avoid

Acute pancreatitis

Total Parenteral Nutrition Enteral feeding

- Hyperglycemia - Use elemental diet, drip -- Catheter related sepsis continuously

- IV fat ? - Jejunal tube beyondligament of Treitz

Nasojejunostomy Intraoperative

under endoscopy tube placement

case approach in nutrition support

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