getting a patient…… to…… and through...
TRANSCRIPT
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Getting a Patient…… to……
and through
Transplantation
CHANTAL MOSTERT RD (SA)
B. Sc Dietetics Stellenbosch
Netcare Milpark Hospital
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I have the following financial and industry disclosures:
None
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Nutrition Goals Pre Transplant
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Muscle Mass: 88.7kgFat Mass: 13.8kgBone Mass: 3.8kgBody Fat: 13%Total Weight: 106.3kgHeight: 1.83m
Muscle Mass: 69.5kgFat Mass: 25.8kgBone Mass: 2.8kgBody Fat: 26.3%Total Weight: 98.1kgHeight: 1.76m
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Risks of Obesity Pre Transplant
Increased Morbidity and Mortality• Increased Risk of Bleeding
• Increased Ventilator Days
• Increased Risk Pressure Ulcers
• Airway Access Issues
• Difficulty Mobilisation
• Increased Inflammatory Response
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Obese Patients
• Unintentional Weight Loss • Does not Equal loss of fat mass
• Mostly Loss of Muscle Mass
• Should NOT be ignored
• Can have low muscle mass / Sarcopenia
• Often suffer from micronutrient deficiencies
Normal 71 – 75 kg
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Body Composition of BMI 19.8
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Disease Related Malnutrition (DRM)
• NOT ONLY LOW BMI
• Prevelance• 33% Malnourished on Admission• 66% Of these patients will have further decline of nutritional
status in hospital • 33% Of Well nourished patients will develop malnutrition in
hospital• DRM goes unrecognized and unmanaged in 70% of cases
• Disease Related Malnutrition• Economic burden
• $167.5 billion in USA• € 170 billion in Europe
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Risks of Malnutrition Pre- Transplant
• Poor wound healing
• High risk of pressure ulcers (4 X Higher)
• Longer time in ICU
• Difficulty weaning off ventilator
• Difficulty mobilising
• Higher risk of infections• Surgical Site Infections 2 x Higher
• Intravascular device Infections 16 X Higher
• Cather associated UTI 5 X Higher
3 x Higher Hospital Costs &
3 x Longer LOS
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Acute Phase – Critically Ill
• Haemodynamically Stable Patients
• Early Enteral Feeding (24 – 48 hours)
• Protection of Gut Associated Lymphoid Tissue• Spleen, Lymph nodes, Bone Marrow
• 2.5 x 1010 Ig producing cells
• GALT (Gut Associated Lymphoid Tissue)• 8.5 x 1010 Ig producing cells
70% of immune system is in the gut
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Nutritional Requirements - Acute
• Influenced by• Weight, Height, Age
• CVVH / ECMO
• Metabolic Stress
• This is not the time catch up!
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Critical Illness
Inflammation Nutrition
Muscle Atrophy
&
Muscular Weakness
ICU/Hospital LOS Functional status
& QOL
Mobility
Early
RehabilitationNutrition
Therapy
Duration of
mechanical
ventilation
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Nutrition Related Complications
Diarrhoea
Rule out infectious causes
Change of feeds
VomitingAnti emetics
Prokinetics
Abdominal Distention
IleusConsider TPN if you
cannot feed enterally
Avoid Nutrition Deficits!
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If you underfeed….
• Poor wound healing
• High risk of pressure ulcers (4 X Higher)
• Longer time in ICU
• Difficulty weaning off ventilator
• Difficulty mobilising
• Higher risk of infections• Surgical Site Infections 2 x Higher
• Intravascular device Infections 16 X Higher
• Cather associated UTI 5 X Higher
3 X Higher Hospital Costs &
3 x Longer LOS
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In Conclusion: Getting to…..
• Long Before Transplant:• Keep all patients transplant- and/or surgically ready
• Exercise / Healthy Eating
• Refer to Dietitian• Overweight / Gaining Weight / Obese
• Underweight / Sarcopenic / Unintentional weight loss
• Transplant Workup:• Comprehensive Nutritional Assessment
• Nutrition Plan
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In Conclusion: Getting through….
• Post Transplant (Acute)• Early Feeding & Early Mobilisation
• Dietitian / Physiotherapist
• Adequate Protein / Manage Nutrition Complications
• Post Transplant (Post Discharge)• Avoid high bacterial risk foods
• Avoid herbal supplements – drug nutrient interactions
• Healthy diet & Exercise
• Risk of Hyperglycaemia / Insulin Resistance / Obesity
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