Parenteral Nutrition in

Obstructive Colon Cancer

Gardian Lukman Hakim
What :
“Provide adjunctive therapy to support the
stress response, provide exogenous nutrients
to reduce drain on endogenous stores and the
depletion of lean body mass, and prevent the
consequences 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 DecreasedGlycogenesi Decreased LPL in fat
s tissue
Hepatic Protein Gluconeogenesis
synthesis
Glucose Clearence
Lactate Production
IL-1 4 Hepatic Protein Gluconeogenesis Lypolysis
Synthesis
GlucoseClearence Decreased LPL
Synthesis
Fatty Acid Synthesis
IL-6 Hepatic Protein Lypolysis
Synthesis
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

mainstaymore 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