1. به نام خدا

2. Immunonutrition: modulate the immune system facilitate wound healing
reduce oxidative stress

3. l-glutamine l-arginine omega-3 fatty antioxidants
contain certain compounds:
l-glutamine
l-arginine
omega-3 fatty
antioxidants

4. ASPEN/ESPEN: Immune-modulating enteral formulations (supplemented with agents such as arginine, glutamine, nucleic acid,
ω-3 fatty acids, and antioxidants) should be used for the appropriate
patient population (major elective surgery, trauma, burns, head and
neck cancer, and critically ill patients on mechanical ventilation),
with caution in patients with severe sepsis.

5. To receive optimal therapeutic benefit from the immune-modulating
formulations, at least 50%–65% of goal energy requirements should
be delivered daily.

6. L-ARGININE plays fundamental roles in protein metabolism
polyamine synthesis
critical substrate for nitricoxide (NO) production

7. stimulates the release ; growth hormone
insulin growth factor and insulin
all of which may stimulate protein synthesis and promote wound healing.
The enzyme, l-arginase, metabolizes l-arginine to l-ornithine,
an amino acid implicated in wound healing.

8. . Normal l-arginine intake is 3 to 5 g/d.
Guidelines for arginine supplementation can be summarized as follows:
. Normal l-arginine intake is 3 to 5 g/d.
Higher than normal (supraphysiologic) l-arginine
supplementation is necessary

9. Dietary supplementation with l-arginine alone should not be used, as only diets
Immunonutrition incorporating supraphysiologic quantities Of l-arginine ideally should be started preoperatively as an oral dietary supplement and continued in the postoperative

10. A clear benefit of l-arginine-containing immunonutrition has
not been observed in medical patients, particularly those with
sepsis.
All elective surgical patient populations, including patients
undergoing operations for head and neck cancer and patients
undergoing cardiac or GI surgery, appear to benefit from the useof immunonutrition formulas containing l-arginine.

11. Risk vs Benefit Arginine

12. OMEGA-3 FATTY ACIDS
incorporated into phospholipids and thereby influence
the structure and function of cellular membranes.
as substrates for the enzymes cyclooxygenase,
lipoxygenase, and cytochrome P450 oxidase
increasing the quantity of omega-3 fatty acids
(found in fish oils) in the diet reduces platelet aggregation, slows blood clotting, and limits the production of proinflammatory cytokines. .

13. administration of dietary lipids rich in omega-3 fatty acids can modify the lipid profile and favorably affect clinical outcome a mong critically ill patients with ARDS

14. L-GLUTAMINE:
The amino acid, l-glutamine, plays a central role in nitrogen transport within the body.
used as a fuel by rapidly dividing cells, particularly
lymphocytes and gut epithelial cells.
substrate for synthesis of the important endogenous antioxidant
translocation of enteric bacteria and endotoxins is reduced and infective complications less frequent.

15. l-Glutamine unfortunately is unstable in aqueous solutions.
To overcome this problem, l-glutamine is added to TPN solutions as adipeptide (l-alanyl-l-glutamine).
In patients receiving EN, l-glutamine powder can be dissolved into the nutrition formulation.

16. Glutamine (enteral):
All: The addition of enteral glutamine to an EN regimen (not already
containing supplemental glutamine) should be considered in
thermally injured, trauma, and mixed ICU patients.

17. is an essential component of the most important
Selenium;
is an essential component of the most important
extra- and intra-cellular antioxidant enzyme family, the glutathione peroxidases (GPX).
doses of 750–1000 mcg/day should probably not be
exceeded in the critically ill, and aministration of supraphysiological
ddoses should perhaps be administratlimited to 2 weeks.
20-60 mcg

18. Recommended Daily Intake
Ascorbic acid (C) 200 mg
Vitamin A IU
Vitamin D mg
Vitamin E IU

19. Which Nutrient for Which Population?
Elective
Surgery
Critically Ill
General
Septic
Trauma
Burns
Acute Lung Injury
Arginine
Benefit
No benefit
Harm(?)
(Possible benefit)
Glutamine
Possible Benefit
PN Beneficial
Recom-mend …
EN Possibly Beneficial:
Consider
Omega 3 FFA
Anti-oxidants
Canadian Clinical Practice Guidelines

20. Current nutritional status Current metabolic and disease states
ADULT : NUTRITIONAL REQUIREMENTS
The nutritional requirements of each patient will depend upon a number of factors including:
Age
Activity level
Current nutritional status
Current metabolic and disease states

21. 1)Calorie Requirements:
Metabolic cart
predictive equations

22. If available, indirect calorimetry can be used to measure energy expenditure using gas exchange
When indirect calorimetry is not possible, there are many possible predictive equations
whichever method (indirect calorimetry or predictive equation) is used, the optimal energy provision for hospitalized patients has yet to be determined

23. Metabolic cart (28, 29):
Indirect calorimetry using a “metabolic cart” measures actual energy expenditure by collecting, measuring and analyzing the oxygen consumed (VO2) and the carbon dioxide (VCO2) expired. From these measurements the respiratory quotient (RQ) is calculated

24. RQ = VOz/VCOz
b. REE = (3.94 [VOz] [VCOz]) (2.17 [UUN])

25. Note:
Patient has to be intubated for the test to be performed
FIO2<60%,
no air leak
chest tube leak.

26. PREDICTIVE EQUATIONS
Harris-Benedict
Miflin St. Jeor (MSJ)

27. Use of Indirect Calorimetry vs. Predictive Equations
PCG:
2013 Recommendation: There are insufficient data to make a recommendation on the use of indirect calorimetry vs. predictive equations for determining energy needs for nutrition or to guide when nutrition is to be supplemented in critically ill patients.

28. Conclusions:
The use of indirect calorimetry compared to predictive equations to meet enteral nutrition needs has no effect on mortality.

29. (A.S.P.E.N) Predictive equations should be used with
caution, as they provide a less accurate measure of energy requirements than indirect calorimetry in the individual patient.

30. Calorie Requirements:
CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS

31. Resting energy expenditure (REE)—the energy expenditure while resting in the supine position with eyes open
About 10% greater than BEE

32. Sleeping energy expenditure (SEE)
It is usually 10% to 15% lower than REE
Activity energy expenditure (AEE)
During maximum exercise it can be 6- to 10-fold greater than the BEE.

33. Total energy expenditure (TEE)
the sum of energy expended during periods of sleep, resting, and activity.

34. eREE = eBEE • stress factor eTEE = eREE • activity factor
estimated resting energy
expenditure;
eREE = eBEE • stress factor
eTEE = eREE • activity factor
estimated total energy
expenditure

35. Stress Factors COPD: 10%-15% Major surgery: 15%-25% Infection: 20%
Long bone fracture: 20%-35%
Malnutrition: Subtract 10%-15%
Burns: Up to 120% depending on extent
Sepsis: 30%-55%
Major trauma: 20%-35%
COPD: 10%-15%
Sedated mechanically ventilated patients: Subtract 10%-15%.

36. Activity Factors Sedated mechanically ventilated patients: 0-5%
Bedridden, spontaneously breathing nonsedated patients: 10%-15%
Sitting in chair: 15%-20%
Ambulating patients: 20%-25%

37. Daily Caloric Requirements
Using Measured or Estimated REE
Using Body Weight
Sedated mechanically
ventilated patients
• REE
20-24 kcal/kg
Unsedated mechanically ventilated patients
1.2 • REE
22-24 kcal/kg
Spontaneously breathing critically ill patients
• REE
24-26 kcal/kg
Spontaneously breathing ward patients (maintenance)
1.3 • REE
Spontaneously breathing ward patients (repletion)
• REE
25-30 kcal/kg

38. HBE or MSJ x Injury factor
University of Kentucky Medical Center
KCAL/Kg
HBE or MSJ x Injury factor

39. University of Kentucky Medical Center
KCAL/Kg
Wound Healing: kcal/kg, increase to kcal/kg if the pt is underweight or losing weight.
Sepsis and Infection: kcal/kg
Trauma: kcal/kg
Acute Spinal Cord Injury (SCI) 23kcal/kg or HBE w/o stress factor
Chronic SCI: 20-23kcal/kg depending on activity
Stroke: 19-20kcal/kg or (HBE x )
COPD: kcal/kg

40. ARF: kcal/kg
Hepatitis: kcal/kg if well-nourished 30kcal/kg), kcal/kg if malnourished
Cirrhosis without encephalopathy: kcal/kg
Cirrhosis with encephalopathy: 35 kcal/kg
Severe Acute Pancreatitis: 35 kcal/kg

41. Organ Transplant: 30-35 kcal/kg
Cancer: Sedentary/normal wt = kcal. Hypermetabolic, need to gain weight, or anabolic = kcal/kg.
Hypermetabolic, malabsorption, severe stress: > 35 kcal/kg
. Obese = kcal/kg

42. Major Non-elective HBE x 1.3 - 1.5 Minor Elective HBE x 1.2
Estimated Calorie Needs: HBE or MSJ x Injury factor
Major Elective HBE x
Major Non-elective HBE x
Minor Elective HBE x
Minor Non-elective HBE x
Infection w/temp HBE x

43. Traumatic Brain Injury (CHI) HBE x 1.4
Multiple trauma & CHI HBE x 1.4 – 1.6
Pentobarbital coma HBE x 1.0 – 1.2
Stroke and SAH HBE x
Pneumonia (or ARDS) HBE x
Neuromuscular Blockade HBE x 1

44. Energy:
ASPEN
Use 25-30kcal/kg, or predictive equations, or indirect calorimetry.
Consider hypocaloric feeding in critically ill obese (BMI >30kg/m2), e.g % of target energy requirements, or 11-14kcal/kg actual body weight, or 22-25kcal/kg ideal body weight.

45. ESPEN : 20-25kcal/kg in acute phase of critical illness.
25-30kcal/kg in recovery phase.

46. Carbohydrates
provide 4 kcal/g (IV dextrose = 3.4 kcal/g) with an RQ of 1.0.
Between 40% and 60% of total caloric needs (or 70% of nonprotein calories)

47. Minimum 2g/kg ESPEN 2009
Maximal glucose oxidation rate is 4-7 mg/kg/minute/24hours.
Ideally keep to ≤5mg/kg/minute/24hours

48. Protein Normal patient = 0.8 to 1.0 g/kg
2. Postsurgical, mild trauma = 1.25 to 1.5 g/kg
3. Severe trauma, sepsis, organ failure = 1.5 to 2.0 g/kg
4. Burn (>20%) or severe head injury ~2.0 g/kg

49. g protein/kg ESPEN
g protein/kg if BMI<30kg/m ASPEN
2g/kg ideal weight if BMI 30-40kg/m2.
2.5g/kg ideal weight if BMI >40kg/m2.

50. caloric requirements (or 30% of nonprotein calories)
Fat
provides 9 kcal/g with an RQ of 0.7.
Between 20% and 30% of total
caloric requirements (or 30% of nonprotein calories)
g/kg ESPEN

51. ENTERAL NUTRITION

52. 1)Oral intake is contraindicated
INDICATIONS FOR INITIATION OF ENTERAL NUTRITION
1)Oral intake is contraindicated
Examples
Dysphagia, mechanical ventilation, mandibular fractures, head & neck surgery, neurological impairment, demyelinating diseases such as amyotrophic lateral sclerosis, muscular dystrophy, etc.

53. 2)Inability to meet markedly increased nutritional needs with oral intake
Examples
Burns, trauma, radiation therapy, chemotherapy, sepsis/infection, closed head injury

54. 3)Inability to meet basic nutritional needs with oral intake alone
Examples
Anorexia, cancer, head and neck tumors

55. 4)Need to bypass part of the GI tract to allow enteral nutrition
Examples
Pancreatitis, gastric outlet obstruction, esophageal cancer, gastroparesis

56. 5)The need for supplemental nutrition due to decreased absorption
Examples
Short bowel syndrome, inflammatory bowel disease, fat malabsorption or other malabsorptive syndromes such as cystic fibrosis

57. Benefits of Enteral Nutrition (compared with Parenteral Nutrition)
Stimulates immune barrier function
Physiologic presentation of nutrients
Maintains gut mucosa
Attenuates hypermetabolic response
Simplifies fluid/electrolyte management
More “complete” nutrition than parenteral nutrition
o iron, fiber, glutamine, etc. are not provided.
Less infectious complications (and costs associated with these complications)
Stimulates return of bowel function
Less expensive

58. Delivery Method: Bolus feeding Continuous or cyclic:
Intermittent feeding
Bolus feeding

59. Continuous or cyclic
18-24 h
25cc/h
8-24h double
cc/h

60. Intermittent feeding usually 240-480ml, over a 45-60 minute
period 5-8 times per day. Preferred by ambulatory patients.
Disadvantage includes:
poor tolerance since a larger feeding volume is administered over a short time.

61. Bolus feeding Bolus feeding is discouraged in the ICU.
rapid infusion via syringe through a gastrostomy tube
may result in nausea, diarrhea, distention, cramps, or aspiration cc
3-5h
5-10min

62. (glucose and fructose).
Carbohydrate (CHO):
Concentration & form of CHO constitute major differences between formulas
Forms of CHO include:
Simple sugars and monosaccharides
(glucose and fructose).
Disaccharides
(sucrose, lactose, and maltose)
require enzymatic conversion to monosaccharides in the intestinalbrush border prior to absorption.

63. Polysaccharides and oligosaccharides
, produced from hydrolysis of starch, result in glucose polymers of intermediate chain lengths.
Starch hydrolysis
increases the solubility and osmolality of the product

64. Intact protein, found in whole foods, requires complete digestion.
Three major categories are classified by degree of digestion required:
Intact protein, found in whole foods, requires complete digestion.
Crystalline amino acids –
theoretically require minimal digestion. The small particle size increases the osmolality

65. short bowel and Crohn's disease and pancreatic insufficiency.
Hydrolyzed protein –enzymatically hydrolyzed to smaller peptide fragments and free amino acids, partially hydrolyzed protein requires digestion while di and tri-peptides are absorbed directly.
Useful in conditions such as:
short bowel and Crohn's disease and pancreatic insufficiency.

66. Fat:
Increases the caloric density but does not contribute to the osmolality.
Most formulas contain long chain triglycerides (LCT) with variable amounts of medium-chain triglycerides (MCT) and mono and diglycerides.

67. MCT are transported via the portal system directly
into the blood stream
they are oxidized to ketones and carbon dioxide.
MCT does not require emulsification for absorption
their use is indicated with CF, liver disease, pancreatitis,
and other disorders where fat absorption may be impaired.

68. All: EN should be started within the first 24–48 hours following
Timing of enteral nutrition
All: EN should be started within the first 24–48 hours following
admission

69. PCG
2013 Recommendation:
Based on 16 studies, we recommend early enteral nutrition (within hours following admission to ICU) in critically ill patients.

70. Conclusions:
1) Early enteral nutrition, when compared to delayed nutrient intake is associated with a trend towards a reduction in mortality in critically ill patients.
2) Early enteral nutrition, when compared to delayed nutrient intake is associated with a significant reduction in infectious complications

71. 3) Early enteral nutrition, when compared to delayed nutrient intake has no effect on ICU or hospital length of stay.
4) Early enteral nutrition, when compared to delayed nutrient intake improves nutritional intake

72. PCG Achieving Target Dose of Enteral Nutrition
There were no new randomized controlled trials since the 2009 update and hence there are no changes to the following summary of evidence.

73. ASPEN: The feedings should be advanced toward the patient’s goal
Dosage of enteral feeding
ASPEN: The feedings should be advanced toward the patient’s goal
over the next 48–72 hours
Efforts to provide > 50%–65% of goal energy should be made in
order to achieve the clinical benefit of EN over the first week of hospitalisation.

74. No general amount can be recommended as EN therapy has
ESPEN:
No general amount can be recommended as EN therapy has
to be adjusted according to the progression/course of the disease
and to gut tolerance

75. ASPEN/CCPG: If unable to meet energy requirements (100%
of target goal energy) after 7–10 days by the enteral route
alone, consider initiating supplemental parenteral nutrition
ESPEN: All patients who do not meet their nutritional needs after 2 days should receive supplemental PN.

76. Haemodynamically unstable patients
ASPEN: In the setting of haemodynamic compromise :
patients requiring significant haemodynamic support
including high dose catecholamine agents, alone
in combination with large volume
fluid or blood product resuscitation to maintain cellular perfusion),
EN should be withheld until the patient is fully resuscitated and/or stable.

77. Immune-modulating enteral formulations
ASPEN/ESPEN: Immune-modulating enteral formulations supplementaed with agents such s arginine, glutamine, nucleic acid, ω-3 fatty acids,
and antioxidants) should be used for the appropriate
patient population (major elective surgery, trauma, burns, head and neck cancer, and critically ill
patients on mechanical ventilation),
with caution in patients with severe sepsis

78. Complications of overfeeding include (but not limited to):
. Hyperglycemia
. Lipogenesis
Fluid and fat gain rather than lean body mass gain
Fatty liver
Immunosuppression (with excessive lipid and linoleic acid intake)
Increased minute ventilation (VE)
Excessive CO2 production impairing pulmonary status/vent wean

79. DRUG NUTRIENT INTERACTIONS WITH ENTERAL PRODUCTS
Only administer sucralfate (CarafateR), omeprazole, antacids, iron salts, and ketoconazole (NizoralR) into the stomach

80. Stop continuous tube feedings for 1 hour before and 1 hour after each phenytoin (DilantinR) dose to maximize the drug
absorption.

81. When diarrhea occurs, determine if any medication contains excessive quantities of sorbitol. Examples include:
acetaminophen elixir, codeine solution, diazepam solution, LomotilR, furosemide solution, guaifenesin syrup, lithium citrate
syrup, metoclopramide syrup, morphine sulfate solution potassium chloride elixirs, and some theophylline solutions.

82. 1)Stop the tube feeding prior to administration of meds.
GENERAL GUIDELINES FOR ADMINISTERING MEDICATIONS WITH ENTERAL FEEDINGS:
1)Stop the tube feeding prior to administration of meds.
2)Flush the feeding tube with ml of warm water or appropriate volume before and after giving medication through the tube.

83. 3)If more than one medication is being given at the same time, give each medication separately and flush the tube with 5-15 ml of warm water between medications.
4)Use liquid preparation if possible (if patient does not have diarrhea).

84. 7)tube feeding when done giving medications.
5)If a tablet form must be used, be sure it is finely crushed and dispersed in warm water.
6)Do not crush enteric-coated, sublingual, or sustained-release tablets, if in doubt check with
PharmD.
7)tube feeding when done giving medications.

85. 8)tube feeding when done giving medications.
7)Most liquid medications are hypertonic and should be diluted with 30-60ml of water prior to administration
8)tube feeding when done giving medications.

86. Categories of Enteral Formulas

87. Return up to 250 ml gastric residuals to the patient.
Notify physician if feedings held twice in 24 hours.

88. ASPEN -500ml Holding EN for gastric residual volumes
< 500 mL in the absence of other signs of intolerance should be
avoided.

89. For high-risk patients or those shown to be
intolerant to gastric feeding, delivery of EN
should be switched to continuous infusion.
Agents to promote motility such as prokinetic
drugs (metoclopramide and erythromycin)
or narcotic antagonists (naloxone and alvimopan)
should be initiated where clinically
feasible.

90. Diverting the level of feeding by post-pyloric
tube placement should be considered.
Use of chlorhexidine mouthwash twice a day should
be considered to reduce risk of ventilator-associated
pneumonia.

91. In the ICU setting, evidence of bowel motility
(resolution of clinical ileus) is not required in order toinitiate EN in the ICU.

92. Critically ill patients should be fed
via an enteral access tube placed in the small bowel if at high risk for aspiration
or after showing intoleranceto gastric feeding.

93. Parenteral nutrition is usually indicated in the following situations:
1)Documented inability to absorb adequate nutrients via the gastrointestinal tract
Massive small-bowel resection / Short bowel syndrome (at least initially)
Radiation enteritis
Severe diarrhea

94. 2)Complete bowel obstruction
3)Severe catabolism with or without malnutrition when gastrointestinal tract is not usable within 5-7 days

95. 4)Inability to obtain enteral access
5)Inability to provide sufficient nutrients/fluids enterally
6) Pancreatitis in the setting of intolerance to jejunal delivery of nutrients
7) Persistent GI hemorrhage
8) Acute abdomen/ileus

96. 9)High output enterocutaneous fistula and EN access cannot be obtained distal to the site.
10) Trauma requiring repeat surgical procedures / NPO status

97. Parenteral nutrition may be indicated in the following situations:
Enterocutaneous fistula as above
Inflammatory bowel disease unresponsive to medical therapy
Hyperemesis gravidarum when nausea and vomiting persist longer than 5 -7 days and enteral nutrition is not possible
Partial small bowel obstruction
Intensive chemotherapy /

98. Contraindications for Parenteral Nutrition:
1)Functioning gastrointestinal tract
2)Treatment anticipated for less than 5 days in patients without severe malnutrition
3)Inability to obtain venous access
4)A prognosis that does not warrant aggressive nutrition support
5)When the risks of PN are judged to exceed the potential benefits

99. A. MACRONUTRIENTS 2. PROTEIN 3)FAT COMPONENTS OF PARENTERAL NUTRITION:
1)CARBOHYDRATE
2. PROTEIN
3)FAT

100. CARBOHYDRATE
Dextrose contains 3.4 kcal/g (CHO is given as a dextrose monohydrate)
Requirements:
Minimum: 1 mg/kg/minute mg/kg/24hrs
Maximum: 5 mg/kg/minute 7200mg/kg/24hrs OR 7 g/kg/day OR 24 dextrose kcal/kg/day.

101. Consequences of excess CHO administration:
Hyperglycemia
Glucosuria
Synthesis and storage of fat
Hepatic steatosis
Increased carbon dioxide production impairing pulmonary status/vent wean

102. Requirements:
Approximately 16% of protein or amino acids are nitrogen.
The goal should be to provide adequate protein to maintain a positive (2 to 4 g)
Requirements range from 0.8 g/kg/day to 2.5 g/kg/day.
Generally 15 – 20% of the daily caloric intake should come from protein.

103. PROTEIN Amino acid = 4 kcal/g
Protein calories should be included when calculating total caloric requirements

104. FAT
Minimum: To prevent essential fatty acid deficiency (EFAD), 2% to 4% of the total caloric requirement should come from linoleic acid (25 to 100 mg/kg/day)
Maximum: Maximal fat dosage should not exceed 60% of calories OR g/kg/day

105. Use with caution in patients allergic to eggs.
Lipids should be used with caution in patients with serum triglycerides (TG) > 400mg/dl.
Use with caution in patients allergic to eggs.

106. Lipids are generally administered over a 24 hour period
Guidelines for rate of infusion are < 0.11 g / kg / hr

107. Consequences of excess lipid administration:
Fat overload syndrome with neurologic, cardiac, pulmonary, hepatic and renal dysfunction
Thrombocyte adhesiveness
Accumulation of lipid in the reticuloendothelial system (RES), leading to RES dysfunction
Impaired immune response

108. MICRONUTRIENTS:

112. PARENTERAL NUTRITION CALCULATIONS:
CUSTOM PN:
Step 1 – Determine protein and calorie needs
Step 2 – Subtract protein calories (grams protein x 4) from total calories
Step 3 – Subtract lipid calories* from remaining calories
Step 4 – remaining will be dextrose calories

113. Minimum flow rates:
Dex/50 + g Pro/ = minimum flow rate
Central:
[(Dextrose kcals X 0.42) + (grams of protein X 10)] ÷ 24 = minimum hourly flow rate. Add
5 ml/hour for MVI, trace elements, etc. Round up to nearest increment of 5.
Peripheral: [(Dextrose kcals x 0.15) + grams of protein] ÷ 2.1 = minimum hourly flow rate. Add 5 ml/hour for MVI, trace elements, etc. Round up to nearest increment of 5.

114. COMPLICATIONS ASSOCIATED WITH PARENTERAL NUTRITION :
Metabolic complications; hyperglycemia is the most common – tight blood glucose control is optimal.
Gastrointestinal complications: steatohepatitis, cholestasis
Pharmacological complications
Manganese toxicity is possible with prolonged use of PN

115. Infection / sepsis
Metabolic bone disease

117. Nutritional modifications in disease
A. Diabetes. Low simple sugar. high fiber. and high fat to minimize hyperglycemia.
B. Renal failure. High calorie. low protein. and low electrolytes (phosphorus.
potassium) to prevent volume overload. hyperammonemia. and electrolyte
imbalance. However, in patients on dialysis. protein requirements
may actually increase.
C. Liver failure. Low protein. high branch chain amino acids to prevent
encephalopathy.
D. Respiratory failure. High calorie, high fat (low carbohydrate) to prevent CO2
accumulation.
E. Pancreatitis. Enteral. postpyloric (nasojejunal) feeding is superior to TPN.
F. Other GI diseases. If nonfunctional GI tract, may require TPN.
G. Trauma. Consider immune-enhancing diet.

119. Grade 1 ascites Mild ascites only detectable by ultrasound No treatment
Grade 2 ascites Moderate ascites evident by moderate symmetrical
distension of abdomen Restriction of sodium intake and diuretics
Grade 3 ascites Large or gross ascites with marked abdominal
distension
Large-volume paracentesis followed by restriction of sodium intake and diuretics (unless
patients have refractory ascites)