Parenteral Nutrition in Obstructive Colon Cancer

Gardian Lukman Hakim

What :

“Provide adjunctive therapy to support thestress response, provide exogenous nutrientsto reduce drain on endogenous stores and thedepletion of lean body mass, and prevent theconsequences of protein malnutrition”

• “provision of early enteral feeding”

• Attaining access and initiating enteral feeding is considered part of basic resuscitation

Cancer Patient (CxPt) : Metabolic Point of View

• CxPt are frequently malnourished

• Cause :

1. Nutritional Status Before Cx

2. Tumor itself

3. Cancer therapy

CxPt :

• Tend to be immunosupressed

• The benefits of nutrition support may outweigh concern about nutrition effect on tumor growth

• The value of nutrition support in CxPt : provide exogenous substrates to meet protein and energy requirements.

Metabolic Changes in CxPt :

• Glucose intolerance, increased fat depletion, and protein turnover.

• Unable to conserve energy because of inefficient metabolisms.

• A lot of mediators such as hormones, cytokines, and growth factors nutritional derangements.

• Negative energy balance.

Protein Carbohydrate Lipid

TNF-α Muscle Proteolysis Glycogenolysis DecreasedLipogenesis

Protein Oxidation DecreasedGlycogenesis

Decreased LPL in fat tissue

Hepatic Protein synthesis

Gluconeogenesis

Glucose Clearence

Lactate Production

IL-1 4 Hepatic Protein Synthesis

Gluconeogenesis Lypolysis

GlucoseClearence Decreased LPL Synthesis

Fatty Acid Synthesis

IL-6 Hepatic Protein Synthesis

Lypolysis

Fatty Acid Synthesis

IFN-α IncrreaseLypolysis

Decreased LPL Activity

Starvation vs Stress Metabolisms

Characteristi Starvation Hypermetabolism

Energy Expenditure Decreased Increased

Respiratory Quotient Low (0,7) High (0,85)

Response to Feeding +++ +

Mediator Activation + +++

Primary Fuels Fat Mixed

Gluconeogenesis + +++

Proteolysis + +++

Protein Synthesis + +++

Ureagenesis + +++

Ketone Formation ++++ +

When :

• Nutrition support should be considered once hemorrhage has been controlled, devitalized tissue debrided, fractures stabilized, and the patient rescuscitated from shock.

• Nutrition intervention is appropriate in the catabolic phase when hemodynamic stability is attained.

Why :

• It seems logical that nutrition related morbidity and mortality can be prevented or ameliorated by appropriate and timely nutrition intervention.

Where :

Nutritional Assessment and Monitoring :

• History and Physical Exam remain mainstaymore useful in ambulatory setting or in chronic patient.

• Skin Fold Thickness (SFT) & Mid Arm Circumference (MAC) Not Practical in Recumbent Position

Nutritional Assessment and Monitoring :

• Albumin :

Half-life 20 days

Insensitive in acute changes

Useful in predicting surgical mortality and monitoring status over long term

• Transferin : half-life 8-10 days. Inverse by serum iron.

• Retinol-binding protein : 12 hours half-life

• Thyroxin-binding prealbumin :

Half-life 2-3 days

Fall early in catabolic illness, rise early in subsequen decrease in acute phase reactant.

Nitrogen Balance :

• Most consistently associated with improve outcome.

• Ideally positive balance is the goal.

• Nitrogen Balance : Intake-Output

• Intake : Protein or AA /6,25

• Output : Urinary nitrogen losses + 2 g

• Urinary Nitrogen Losses : UUN+ 20% UUN

Nitrogen Balance :

• Classically involve 24-hour measuring, but 12 or 6 hour urine collection can be obtained.

• Usually calculated weekly

Another Laboratoy Data :

• CBC

• Serum Electrolyte (Na/K/Cl/HCO3/Ca/Mg/PO4)

• Blood Glucose

• Liver Function , Renal Function.

How :

• Target of Calories : 25-30 kcal/kg/day

• Obesity is adjusted :

IBW+0,25(ABW-IBW)

Obesity adjusted X 25-30.

Carbohydrate Requirements :

• 60-70% of non protein calories

• Excess of glucose administration :

1. Hyperglicemia

2. Excess of carbon dioxide production

Fat Requirements :

• 15-40% total calorie requirements

• Not exceed 1-1,5 g/day

• Complication due to excess of fat

1. hyperlipidemia

2. immunosuppression

3. hypoxemia impaired oxygen diffusion and v/q mismatch.

Protein Requirement :

• Protein demands are markedly increaseed.

• Protein synthesis is responsive to amino acid infusions.

• Protein requirement is between 1,2-2 g/kg/day

Electrolyte, vitamin, and so on

• Must be maintain between normal limit.

Enteral vs Parenteral Nutrition

• General consideration is the works of gut

• Enteral route is prefered

• Advantage of enteral route :

1. Easy administration

2. Good tolerance

3. Promotion of mucosal growth and development.

4. Maintaning the barrier function of the GI tract.

• Mechanical obstruction is contraindicated to enteral nutrition.

• In this case total parenteral nutrition is prefered.

Terima Kasih