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01 An Evolving Paradigm in The MGMT of Malabsorption and Maldigestion (DR R. Reddy)
01 An Evolving Paradigm in The MGMT of Malabsorption and Maldigestion (DR R. Reddy)
01 An Evolving Paradigm in The MGMT of Malabsorption and Maldigestion (DR R. Reddy)
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Intact Protein
Peptide-Based
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Peptides & Wound Healing
Many studies have shown that intact proteins fail
to heal massive pressure ulcers
Critical care enteral formula improves outcomes for a patient with chronic pressure ulcer. Brasseur K et al. Nutrition in Clinical Practice. 2001
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Peptides & Wound Healing
Preventing skin breakdown in a high risk patient. Obtaining a prealbumin and utilising a critical care tube feeding formula.
Phillips E. Presented at the 15
th
Annual Symposium on Advanced Wound Care and Medical Research Forum. 2001
In many patients, on intact protein formulas,
low prealbumin and albumin = poor healing
a
Peptides & Wound Healing
Preventing skin breakdown in a high risk patient. Obtaining a prealbumin and utilising a critical care tube feeding formula.
Phillips E. Presented at the 15
th
Annual Symposium on Advanced Wound Care and Medical Research Forum. 2001
Critical care enteral formula improves outcomes for a patient with chronic pressure ulcer. Brasseur K et al. Nutrition in Clinical Practice. 2001
Chronic massive pressure ulcers healed after commencing
peptide-based formula
Prealbumin & albumin increased due to nitrogen absorption and
retention (by peptide-based diet)
a
Peptides & Liver Function
Liver dysfunction is common in critical illness
Altered
Liver Function
Compromised
Immune Function
Removal
Endogenous Waste
Production
Vital Proteins
Improved hepatic protein responses with hydrolysed protein versus intact protein after trauma. Zaloga GP et al.
Critical Care Medicine 1992
a
Peptides & Liver Function
Peptide - based enteral formulas
Maintain
Liver Function
Albumin
Transferrin
Prealbumin
Production
Vital Proteins
Improved hepatic protein responses with hydrolysed protein versus intact protein after trauma. Zaloga GP et al.
Critical Care Medicine 1992
a
Peptides & Liver Function
Improved hepatic protein responses with hydrolysed protein versus intact protein after trauma. Zaloga GP et al.
Critical Care Medicine 1992
+ 14%
- 17%
Transferrin
20%
10%
0%
- 10%
- 20%
Peptide
Intact
Protein
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Peptides & Liver Function
Retinol-Binding Protein
Improved hepatic protein responses with hydrolysed protein versus intact protein after trauma. Zaloga GP et al.
Critical Care Medicine 1992
- 10%
0%
- 40%
- 50%
Peptide
Intact
Protein
- 20%
- 30%
- 1%
- 28%
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New Paradigm in
Feeding ICU Pts
The Enhanced Protein-Energy Provision via the Enteral
Route in Critically Ill Patients
The PEP uP Protocol
Daren Heyland et al. Critical Care 2010
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New Paradigm in
Feeding ICU Pts
The Enhanced Protein-Energy Provision via the Enteral
Route in Critically Ill Patients
The PEP uP Protocol
Daren Heyland et al. Critical Care 2010
Prospective single center study
Volume-based 24-hour feeding protocol that has
shown to be safe and acceptable to critical care
nurses
Enteral formula used was a semi-elemental diet
(Peptamen 1.5
Nestle)
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New Paradigm in
Feeding ICU Pts
I. Volume based goal
II. Trophic feeds
III. Promotility agents were commenced at the
initiation of feeds
IV. Residual volume tolerated up to 250 mls
V. Supplemental proteins (discontinued if EN
was tolerated)
Daren Heyland et al. Critical Care 2010
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New Paradigm in
Feeding ICU Pts
Conclusion
Traditional enteral feeding practices do not
adequately provide proteins and calories to critically
ill patients
This new feeding protocol challenges the traditional
protocols and introduces an innovative method that
maximizes benefits
In this study, there was an enhanced delivery of EN
This needs a large multicenter, multinational RCT in
critically ill patients to further determine the safety
and efficacy
Daren Heyland et al. Critical Care 2010
a
Evolving Paradigm in the
Management of Malabsorption &
Maldigestion
I. Introduction
II. Normal Protein Absorption & Digestion
III. Protein Absorption & Digestion in Acute &
Chronic Illness
IV. Role of Peptides & Evolving Paradigm
V. Conclusions
a
Peptide-Based Diets
Clinical Applications
1. Patients with impaired digestion and
absorption have reduced protein
absorption
Brinson R, et al. Intestinal absorption of elemental and standard enteral formulas in hypoproteinemic rats. JPEN 1998
Bounous G, et al. Elemental diets in prophylaxis and therapy for intestinal lesions: an update. Surgery 1989
a
Peptide-Based Diets
Clinical Applications
2. Patients with hypoalbuminemia
and also associated diarrhea
e.g. Protein loosing enteropathy
Brinson R, et al. Intestinal absorption of elemental and standard enteral formulas in hypoproteinemic rats. JPEN 1998
Bounous G, et al. Elemental diets in prophylaxis and therapy for intestinal lesions: an update. Surgery 1989
a
Peptide-Based Diets
Clinical Applications
3. Patients with hypermetabolism
e.g. SIRS, sepsis, polytrauma and burns;
i.e., in whom nitrogen utilisation is very
important
Brinson R, et al. Intestinal absorption of elemental and standard enteral formulas in hypoproteinemic rats. JPEN 1998
Bounous G, et al. Elemental diets in prophylaxis and therapy for intestinal lesions: an update. Surgery 1989
a
Clinical Indications for
Peptide-Based Formulas
Nutritional
Cardiac cachexia
Short bowel syndrome
Chronic pancreatitis
Acute Kwashiorkar-like hypoalbuminemia
Cystic fibrosis
Postoperative gastrostomy / jejunostomy
Failure to thrive
Brinson BR, et al. A Reappraisal of the Peptide-Based Enteral Formulas: Clinical Applications. Nutr Clin Pract 1989, 4:211-217
a
Clinical Indications for
Peptide-Based Formulas
Protein-Losing Enteropathy
Intestinal ischemia & lymphiectasia
Inflammatory bowel disease
Radiation enteritis
Small bowel lymphoma
Infectious enteritis (AIDS)
Bacterial overgrowth
Eosinophilic gastroenteritis
Brinson BR, et al. A Reappraisal of the Peptide-Based Enteral Formulas: Clinical Applications. Nutr Clin Pract 1989, 4:211-217
a
Clinical Indications for
Peptide-Based Formulas
Hypercatabolic Syndromes
Burns
Enteric fistula
Septic shock
Transplant surgery
Trauma
Brinson BR, et al. A Reappraisal of the Peptide-Based Enteral Formulas: Clinical Applications. Nutr Clin Pract 1989, 4:211-217
a
Summary
Peptide-Based Diet
Malbsorption
Maldigestion
Malnutrition
SIRS + Sepsis Syndrome
Acute Intestinal Failure
a
Summary
Peptide-Based Diet
Improved nitrogen absorption & utilisation
Reduced diarrhea
Stimulation of gut mass
Maintenance of gut integrity
Reduction of bacterial translocation
Brinson BR, et al. A Reappraisal of the Peptide-Based Enteral Formulas: Clinical Applications. Nutr Clin Pract 1989, 4:211-217
a
Summary
Peptide-Based Diet
Enhanced immune support
Improved linear growth
Maintenance of hepatic function
Improved visceral protein synthesis
Improved wound healing
Brinson BR, et al. A Reappraisal of the Peptide-Based Enteral Formulas: Clinical Applications. Nutr Clin Pract 1989, 4:211-217
Improve Clinical Outcome
a
Cases
In all three cases, a semi-elemental, peptide-
based enteral formula was commenced with the
traditional EEN protocol and progressed to full
feeds with supplemental PN and antioxidants
Brinson BR, et al. A Reappraisal of the Peptide-Based Enteral Formulas: Clinical Applications. Nutr Clin Pract 1989, 4:211-217
a
Patients With
Maldigestion & Malabsorption
Normal
Digesti
on
Mal
Digestion
Mal
Digestion
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Peptide-Based
Semi-elemental Diet
Normal
Digestion
Normal
Absorption
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Thank You
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Dr B Ravinder Reddy
drbravinderreddy@yahoo.com