Sef Lucrari Dr. Claudiu COBUZMedic specialist diabet zaharat, nutritie si boli metaboliceDoctor in stiinte medicale

CURS 9 - Anorexia canceroas i caexia

IntroducereNu exista la ora actuala recomandari nutritionale unanim acceptate si bazate pe dovezi pentru terapia nutritionala in cancere; Cancerele au localizari si tablouri clinice foarte variabile;Caracteristica nutritionala comuna este slabirea in greutate (pana la casexie) si malnutritia

Evaluarea nutritionalaIndicele de prognostic nutritionalGreutate, pliul cutanat, albumina si transferina serica, testul cuntanat de hipersensibilitate intarziata.Evaluarea globala subiectiva Istoricul greutatii, al aportului alimentar,Examenul obiectiv nutritionalEvaluarea necesitatii alimentatiei orale, enteralesau parenteraleEvaluarea riscurilor terapiei nutritionale agresiveProteine in exces, grasimi in exces, aport hiprcaloric

Malnutritia/denutritia

O stare in care deficitul energetic si de nutrienti (proteine, vitamine si minerale) produce efecte masurabile clinic asupra compozitiei si functiei tesuturilor.

Caexia n cancerSindrom clinic caracterizat prin pierdere n greutate, anorexie, slbiciune muscular.Caracteristici: alterri metabolice multiple dezechilibru hidric dezechilibre electrolitice alterarea progresiv a funciilor vitaleClinic: pacient palid, tegumente atrofie, diminuarea rezervelor adipoase, edeme, pierderea masei musculare

Evaluarea malnutritiei/denutritieiUna sau mai multe dintre urmatoarele: IMC < 18.5 kg/m Scadere in greutate neintentionata mai mare de 10% in ultimele 3-6 luni IMC < 20 kg/m si scadere in greutate mai mare de 5% in ultimele 3-6 luni.

Plan de interventie in malnutitie/denutritieSCREENINGDIAGNOSICINTERVENTIA (REALIMENTAREA)ORALENTERALPARENTERALMONITORIZAREREEVALUARENational Institute of Health and Clinical Excellence, 2006*

Persoane cu risc pentru malnutritie/denutritieUna sau mai multe dintre urmatoarele: Au manacat putin sau deloc tim de mai mult de 5 zile si/sau vor manca putin sau deloc in urmatoarele 5 zile sau mai mult; Capacitate de absorbtie redusa, catabolism intens si/sau pierderi nutritionale crescute si/sau nevoi nutritionale crescute.

Evaluarea suportului nutritionalSuportul nutritional se va calcula in functie de: Necesarul energetic/caloric, proteic, hidro-electrolitic, in micronutrienti si fibre; Nivelul de activitate fizica si patologia asociata; Toleranta digestiva, instabilitatea metabolica potentiala si de riscul realimentarii; Durata estimata a suportului nutritional.

Principii de realimentare

Realimentarea se incepe cu maxt 10 kcal/kg/zi Cresterea aportului se face progresiv Restaurarea echilibrului volemic si monitorizarea balantei hidroelectrlitice sunt prioritare; Asigurarea aportului de multivitamine/tiamina si minerale; Aport suplimentar de potasiu, fosfati si magneziu.

Suportul nutritional oralsiPana la reluarea aportului nutritional normalPacient cu malnutritie/denutritie sau cu riscDeglutitie si tranzit digestiv normale

Alimentatia enteralasiSe individualizeaza calea de acces si suportul nutritionaPana la reluarea alimentatiei oraleTractul gastrointestinal este functional si accesibilDaca suportul nutritional oral nu este posibil sau este ineficient

Alimentatia parenteralaSe va utiliza calea de acces cea mai accesibilaSe opreste atunci cand pacientul poate fi alimentat oral sau enteralsauIntroducere progresiva si monitorizare atentaPacient malnutrit/denutritTract gastrointestinal nefunctional sau perforatAport oral sau enteral insuficient sau nesigur

Pacienti cu risc crescut la realimentareUna sau mai multe dintre urmatoarele: IMC < 16 kg/m2 Scaderi in greutate mai mari de15% in ultimelet 3-6 luni Aport nutritional redus sau de loc in ultimele 10 zile Nivele scazute de K, fosfat sau Mg la initierea realimentariiDoua sau mai multe dintre urmatoarele: IMC < 18.5 kg/m2 Scadere in greutate mai mare de 10% in ultimele 3-6 luni Aport nutritional redus sau de loc in ultimele 5 zile Istoric de abuz de alcool sau tratamente cu insulina, chimioterapie, antiacide sau diuretice

Regim nutriional adecvat la bolnavul cancerosAport energetic: 30-35kcal/kgc/ziAport proteic: 1-2 g aminoacizi/kgc/ziLipide: 30-50% din aportul energeticSuplimentarea cu acid eicosapentaenoic -3 (blocheaz activitatea citokinelor)Suplimentarea n funcie de caz cu vitamine, oligoelemente, eventual glutamin, acizi biliari i enzime pancreatice.

Suportul nutriional perioperatorPoate s reduc incidena complicaiilor perioperatorii, mai ales infecioase, prin reducerea imunosupresiei postoperatorii. - efect dovedit cert la pacientul cu malnutriie preexistent (

Nutriia enteral versus nutriia parenteral Nutriia enteral se asociaz cu o rat mai sczut a complicaiilor postoperatorii i cu o spitalizare mai scurt.Nutriia parenteral are ca efecte secundare excesul hidric, electrolitic, hiperglicemie, dezechilibre metabolice, toate cu o inciden crescut a complicaiilor.

Nutriia artificial la domiciliu este acceptat la pacienii cu: afagie sau stenoze cronice intestinaleSperan de via peste 2 luni, cu malnutriie prin nfometare, nu prin progresie tumoralAbsena simptomelor majore care nu sunt legate de alimentaieFr metastaze tumorale n organele vitalePoate s creasc supravieuirea cu 3-6 luni.

ConcluziiNeoplazia cauzeaz depleie nutriional.Depleia nutriional agraveaz prognosticul oncologic pentru c terapia antineoplazic este mai greu suportat. Apare un cerc vicios n care terapia este mai prost tolerat i care se asociaz cu mortalitate mai mare.Imbuntirea statusului metabolic i nutriional la un bolnav cu cancer cresc ansele supravieuirii i calitatea vieii.

Formule nutriionale pentru pacienii neoplaziciEnterale: valoare energetic 1500kcal/l proteine: 27% lipide 40% carbohidrai 33% fibre 12g/l ap 760ml/l antioxidani vitamina A, C, E, seleniu acizi grai -3Dozaj: pacieni moderat hipermetabolici 32.5 kcal/kgc/zi pacieni hipermetabolici 45 kcal/kgc/zi

Formule nutriionale pentru pacienii neoplaziciParenteral: compoziie optim de aminoacizi, glucide i lipide, acizi grai -3 antioxidani: vit. A, C, E, seleniu oligoelemente

Prezentare de cazM.V., 52 ani, sex masculinNeoplasm esofagian, cu disfagie severa, etilism si tabagism cronic Inlime: 1.72m, Greutate 53kg. IMC= 17.30.Se suplimenteaz aportul enteral gastrostoma de alimentatie produs valoare energetic 1500kcal/l proteine: 27% lipide 40% carbohidrai 33% fibre 12g/l ap 760ml/l antioxidani vitamina A, C, E, seleniu acizi grai -3Se administreaza 2000 ml produs enteral (40kcal/kgc/zi)

Sindromul de realimentatie

Caracteristici Incidenta de 5-25% la pacientul neoplazicCategorii de risc: anorexia nervoasa malnutritia cronica alcoolism cronic post prelungit copii subalimentati

Fiziopatologie Sindromul se asociaza cu: hipofosfatemie, hipomagnezemie, hipopotasemie, deficit vitaminic, retentie hidrica.Hipofosfatemia: parestezii, convlusii, alterarea starii de constienta, coma, insuficienta respiratorie cu hipoventilatie alveolara, rabdomioliza, trombocitopenie, coagulare alterata, alterarea functiei leucocitare.

Hipomagnezemia si hipopotasemia: aritmii cardiace, stop cardiac, paralizii, parestezii, confuzei, rabdomioliza, insuficienta respiratorie.Deficitul de vitamine: deficitul de tiamina apare datorita consumarii ei in timpul glicolizei. Consecinta depletiei este acidoza lactica, afectarea memoriei pe termen scurt si sindrom Korsakov.Retentia hidro-salina: formarea edemelor, decompensare cardiaca.

ClinicPoate sa apara insuficienta cardiaca congestiva, aritmii cardiace, delir, neuropatie, convulsii, insuficienta respiratorie, rabdomioliza, mialgii, insuficienta renala acuta prin mioglobinurie, trombocitopenie, alterarea coagularii.

Prevenire si tratamentMonitorizare: functiile vitale, echilibrul hidric, electroliti plasmatici si urinari, analiza gazelor sangvine.Prevenire: administrarea tiaminei 50-250mg, impreuna cu glucoza.Aportul in prima zi 50% din necesarul calculat (20kcal/kgc/zi- maxim 500-1000kcal/zi), apoi se creste treptat in timp de 1 saptamana pana la necesarul calculat.In caz ca apar deficitele se adauga: fosfat 40-80mmol/zi, magneziu 8-16mmol/zi, potasiu 80-120mmol/zi.Aportul de sodiu trebuie sa fie initial mic, apoi daca apare retentia hidro-salina, aportul de lichide si sodiu trebuie redus.

Prezentare de caz - continuareSe administreaza 2000 ml produs enteral (40kcal/kgc/zi).La 4 ore de la inceperea nutritiei pacientul prezinta fibrilatie ventriculara, se incep manevrele de resuscitare, fara rezultat.Parametri Astrup: pH 7.01, BE=-23, bicarbonat 14, Na=150, K= 1.8.Diagnostic de deces??????????Tulburare maligna de ritm. Hipopotasemie severa.

*NOTES FOR PRESENTERSRefer to introduction NICE guideline, page 4

Malnutrition is common. Many people who are unwell in hospital or the community, are likely to eat and drink less than they need. This impairment of food and fluid intake may be short-lived as part of an acute illness, or prolonged if there are chronic medical or social problems. *NOTES FOR PRESENTERSOnce a person has been screened, the decision of whether to give nutrition support can be made. Nutrition support should be considered for people who are malnourished or at risk of malnourishment.

All healthcare professionals involved in starting or stopping nutrition support should be aware of the ethical and legal considerations surrounding patient consent and withdrawing or withholding support, bearing in mind that the provision of nutrition support is not always appropriate. Guidance issued by the General Medical Council and the Department of Health should be followed. You can see their websites for details (www.gmc-uk.org and www.dh.gov.uk).

*NOTES FOR PRESENTERSWhen screening - dont forget risk assessment*NOTES FOR PRESENTERSPeople who are at risk of malnutrition, and who should also be considered for nutrition support, will have one or more of the following:have eaten little or nothing for more than 5 days and/or likely to eat little or nothing for the next 5 days or longerhave poor absorptive capacity, are catabolic and/or have high nutrient losses and/or have increased nutritional needs.

Once people have been identified as needing treatment, they should be treated according to the type of treatment that would best suit their needs.

*NOTES FOR PRESENTERSIndividual patients nutritional needs vary with their current and past nutritional history and the nature of their condition. It is therefore essential to estimate nutritional requirements before instigating nutrition support. Since either inadequate or excessive macronutrient or micronutrient provision can be harmful, recommendations on appropriate levels would ideally be based on large studies comparing the effects of different levels of feeding on clinical outcomes e.g. complications, length of stay, and mortality.

The overall aim when devising a prescription, whether for oral, enteral or parenteral nutrition, is to provide the patient with their complete requirements via single or combined routes. The prescription of any supplementary nutrition support by enteral or parenteral routes should therefore account for any current oral intake from food and/or oral nutritional supplements.

The prescription should contain the right levels of energy, protein, fluid, electrolytes, minerals and fibre, and be reviewed according to the persons progress.

*NOTES FOR PRESENTERSPlease refer to the NICE Quick Reference Guide page 19*NOTES FOR PRESENTERSOptions for oral nutrition support should be considered for any patients taking inadequate food and fluid to meet their requirements, unless they cannot swallow safely or have inadequate gastrointestinal function. Oral nutrition should be considered as the first step in nutrition support and includes, for example, fortified food, additional snacks and/or sip feeds.

You should refer to the NICE guideline or the quick reference guide for feeding surgical patients.

Oral support will not be the best option for everyone, and some of the reasons for this are covered in the next slide.*NOTES FOR PRESENTERSFor the purposes of this guideline, enteral tube feeding refers to the delivery of a nutritionally complete feed (containing protein or amino acids, carbohydrate with or without fibre, fat, water, minerals and vitamins) directly into the gut via a tube. The tube is usually placed into the stomach, duodenum or jejunum via either the nose, mouth or the direct percutaneous route. Enteral tube feeding is not exclusive and can be used in combination with oral and/or parenteral nutrition. Patients receiving enteral tube feeding should be reviewed regularly to enable re-instigation of oral nutrition when appropriate. Most enteral feeding tubes are introduced at the bedside but some are placed surgically, at endoscopy or using radiological techniques, and some are inserted in the community. Enteral tube feeding should be considered for patients who are malnourished or at risk of malnourishment, who cant be fed orally and who have a working and accessible gut.

Whenever possible the patient should be aware of why this form of nutrition support is necessary, how it will be given, for how long, and the potential risks involved. There may be considerable ethical difficulties in deciding if it is in a patients best interests to start a tube feed.*NOTES FOR PRESENTERSParenteral nutrition refers to the administration of nutrients by the intravenous route. It is usually administered via a dedicated central or peripheral placed line. Parenteral feeding should be considered in patients for whom oral or enteral feeding isnt appropriate or they have an inaccessible or perforated gut.

Parenteral nutrition is an invasive and relatively expensive form of nutrition support (equivalent to most new generation IV antibiotics daily) and in inexperienced hands, can be associated with risks from line placement, line infections, thrombosis and metabolic disturbance. Careful consideration is therefore needed when deciding to who, when and how this form of nutrition support should be given. Whenever possible, patients should be aware of why this form of nutrition support is needed and its potential risks and benefits.

The feed should be given progressively, and monitored closely. Parenteral feeding should be stopped when the patient is established on feeding from the oral or enteral route.

Whichever method of feeding is chosen, the patient should be monitored, and any adjustments needed made accordingly.*NOTES FOR PRESENTERSSome patients will be considered to be at very high risk of developing refeeding problems. Refeeding problems encompass life-threatening acute micronutrient deficiencies, fluid and electrolyte imbalance, and disturbances of organ function and metabolic regulation that may result from over-rapid or unbalanced nutrition support. They can occur in any severely malnourished individuals but are particularly common in those who have had very little or no food intake, even including overweight patients who have eaten nothing for protracted periods.

These patients should be cared for by healthcare professionals who are appropriately skilled and trained and have expert knowledge of nutritional requirements and nutrition support.