1 / 39

Nutrition

Nutrition. . . . and the surgical patient. Nutrition. ENERGY SOURCES Carbohydrates Fats Proteins. Nutrition. Carbohydrates Limited strorage capacity, needed for CNS (glucose) function Yields 3.4 kcal/gm Pitfall: too much = lipogenesis and increased CO2 production. Nutrition. Fats

glenda
Download Presentation

Nutrition

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Nutrition . . . and the surgical patient

  2. Nutrition ENERGY SOURCES • Carbohydrates • Fats • Proteins

  3. Nutrition • Carbohydrates • Limited strorage capacity, needed for CNS (glucose) function • Yields 3.4 kcal/gm • Pitfall: too much = lipogenesis and increased CO2 production

  4. Nutrition • Fats • Major endogenous fuel source in healthy adults • Yields 9 kcal/gm • Pitfall: too little=essential fatty acid (linoleic acid) deficiency—dermatitis and increased risk of infections

  5. Nutrition • Proteins • Needed to maintain anabolic state (match catabolism) • Yields 4 kcal/gm • Pitfall: must adjust in patients with renal and hepatic failure

  6. Nutrition Fats Non-protein  Calories Carbohydrates Protein  Calories Proteins

  7. Nutrition • Requirements • HEALTHLY 70 kg MALE • Caloric intake=35 kcal/kg/day (max=2500/day) • Protein intake=0.8-1gm/kg/day (max=150gm/day) • Fluid intake=30 ml/kg/day

  8. Nutrition • Requirements ? SURGICAL PATIENT ?

  9. Nutrition • Special considerations • Stress • Injury or disease • Surgery • Prehospital/presurgical nutrition

  10. Nutrition • The surgical patient . . . . • Extraordinary stressors (hypovolemia, bacteremia, medications) • Wound healing • Anabolic state, appropriate vitamins (A, C, Zinc) • Poor nutrition=poor outcomes • For every gm deficit of untreated hypoalbuminemia there is ~ 30% increase in mortality

  11. Nutrition HEALTHLY 70 kg MALE Caloric intake 35 kcal/kg/day (max=2500/day) Protein intake 0.8-1gm/kg/day (max=150gm/day) Fluid intake 30 ml/kg/day SURGERY PATIENT Caloric intake *Mild stres, inpatient 20-25 kcal/kg/day *Moderate stress, ICU patient 25-30kcal/kg/day *Severe stress, burn patient 30-40 kcal/kg/day Protein intake 1-1.8gm/kg/day Fluid intake INDIVIDUALIZE

  12. Nutrition Non-protein  Calories 30% 70% Protein  Calories Proteins

  13. Nutrition • Measures of success • Serum markers • Retinol binding protein, prealbumin, transferrin, albumin

  14. Nutrition • Measures of success • Nitrogen balance • Protein ~ 16% nitrogen • Protein intake (gm)/6.25 - (UUN +4)= balance in grams • Metabolic cart (indirect calorimetry) • ICU patient, measure of exchange of O2 and CO2 • Respiratory quotient =1

  15. Nutrition • What route to feed? • GUT, GUT, GUT • When to feed? • EARLY, EARLY, EARLY TPN

  16. Diet Advancement • Traditional Method • Start clear liquids when signs of bowel function returns • Rationale • Clear liquid diets supply fluid and electrolytes that require minimal digestion and little stimulation of the GI tract • Clear liquids are intended for short-term use due to inadequacy

  17. Diet Advancement • Recent Evidence • Liquid diets and slow diet progression may not be warranted!! • Clinical study • Early post-operative feeding with regular diets vs. traditional methods demonstrated no difference in post-operative complications • Emesis, distention, NGT reinsertion, and Length of stay

  18. Pitfalls… • For liquid diets, patients must have adequate swallowing functions • Even patients with mild dysphagia often require thickened liquids. • Must be specific in writing liquid diet orders for patients with dysphagia

  19. Patients who cannot eat . . . ? • Two types of nutritional support • Enteral • Parenteral

  20. Indications for Enteral Nutrition • Malnourished patient expected to be unable to eat adequately for > 5-7 days • Adequately nourished patient expected to be unable to eat > 7-9 days • Following severe trauma or burns

  21. Enteral Access Devices • Nasogastric/nasoenteric (temporary) • Gastrostomy (long-term) • Percutaneous endoscopic gastrostomy (PEG) • Open gastrostomy • Jejunostomy • Percutaneous endoscopic jejunostomy (PEJ) • Open jejunostomy • Transgastric Jejunostomy • Percutaneous endoscopic gastro-jejunostomy (G-J) • Open gastro-jejunostomy

  22. Feeding Tube Selection • Can the patient be fed into the stomach, or is small bowel access required? • How long will the patient need tube feedings?

  23. Gastric vs. Small Bowel Access • “If the stomach empties, use it.” • Indications to consider small bowel access • Gastroparesis/gastric ileus • Abdominal surgery • Significant gastroesophageal reflux • Pancreatitis • Aspiration • Proximal enteric fistula or obstruction

  24. Enteral Nutrition Case Study • 78-year-old woman admitted with new CVA • Significant aspiration detected on bedside swallow evaluation, confirmed on modified barium swallow study • Speech language pathologist recommended strict NPO with alternate means of nutrition

  25. What is parenteral nutrition? • Parenteral Nutrition • AKA • total parenteral nutrition • TPN • hyperalimentation • Liquid mixture of nutrients given via the blood through a catheter in a vein • Mixture contains all the protein, carbohydrates, fats, vitamins, minerals, and other nutrients needed to maintain nutrition balance

  26. Indications for Parenteral Nutrition • Malnourished patient expected to be unable to eat > 5-7 days AND enteral nutrition is contraindicated • Patient failed enteral nutrition trial with appropriate tube placement (post-pyloric) • Severe GI dysfunction is present • Paralytic ileus, mesenteric ischemia, small bowel obstruction, enteric fistula distal to enteral access sites

  27. TPN vs. PPN • TPN • High glucose concentration (15%-25% final dextrose concentration) • Provides a hyperosmolar formulation (1300-1800 mOsm/L) • Must be delivered into a large-diameter vein through central line • Peripheral parenteral nutrition (PPN) • Similar nutrient components as TPN, but lower concentration (5%-10% final dextrose concentration) • Osmolarity < 900 mOsm/L (maximum tolerated by a peripheral vein) • Because of lower concentration, large fluid volumes are needed to provide a comparable calorie and protein dose as TPN

  28. Parenteral Access Devices • Peripheral venous access • Catheter placed percutaneously into a peripheral vessel • Central venous access (catheter tip in SVC) • Percutaneous jugular, femoral, or subclavian catheter • Implanted ports (surgically placed) • PICC (peripherally inserted central catheter)

  29. Complications of Parenteral Feeds • Hepatic steatosis • May occur within 1-2 weeks after starting TPN • May be associated with fatty liver infiltration • Usually is benign, transient, and reversible in patients on short-term TPN—typically resolves in 10-15 days • Limiting fat content and cycle feeds over 12 hours to control steatosis in patients on long-term TPN

  30. Parenteral Nutrition Case Study • 55-year-old male admitted with small bowel obstruction • History of complicated cholecystecomy 1 month ago. Since then patient has had poor appetite and 20-pound weight loss • Patient has been NPO for 3 days since admit • Right subclavian central line was placed and plan noted to start TPN since patient is expected to be NPO for at least 1-2 weeks

  31. Nutrition • What route to feed? VS TPN

  32. Nutrition • What route to feed? TPN TPN

  33. Benefits of Enteral Nutrition(Over Parenteral Nutrition) • Cost • Tube feeding cost ~ $10-20 per day • TPN costs up to $1000 or more per day! • Maintains integrity of the gut • Tube feeding preserves intestinal function; it is more physiologic • TPN may be associated with gut atrophy • Less infection • Enteral feeding—very small risk of infection and may prevent bacterial translocation across the gut wall • TPN—high risk/incidence of infection and sepsis

  34. Refeeding Syndrome • “The metabolic and physiologic consequences of depletion, repletion, compartmental shifts, and interrelationships of phosphorus, potassium, and magnesium…” • Severe drop in serum electrolyte levels resulting from intracellular electrolyte movement when energy is provided after a period of starvation (usually > 7-10 days) • Sequelae may include • EKG changes, hypotension, arrhythmia, cardiac arrest • Weakness, paralysis • Respiratory depression • Ketoacidosis / metabolic acidosis

  35. Refeeding Syndrome • Prevention and Therapy • Correct electrolyte abnormalities before starting nutrition support • Continue to monitor serum electrolytes after nutrition support begins and replete aggressively • Initiate nutrition support at low rate/concentration (~ 50% of estimated needs) and advance to goal slowly in patients who are at high risk

  36. Over and Under Feeding • Risks associated with over-feeding • Hyperglycemia • Hepatic dysfunction from fatty infiltration • Respiratory acidosis from increased CO2 production • Difficulty weaning from the ventilator • Risks associated with under-feeding • Depressed ventilatory drive • Decreased respiratory muscle function • Impaired immune function • Increased infection

  37. Food for Thought (that is . . . nutrition for your brain) Life is not measured by the number of breaths we take, but by the moments that take our breath away.   TPN

  38. References • American Society for Parenteral and Enteral Nutrition. The Science and Practice of Nutrition Support. 2001. • Han-Geurts, I.J, Jeekel,J.,Tilanus H.W, Brouwer,K.J., Randomized clinical trial of patient-controlled versus fixed regimen feeding after elective abdominal surgery. British Journal of Surgery. 2001, Dec;88(12):1578-82 • Jeffery K.M., Harkins B., Cresci, G.A., Marindale, R.G., The clear liquid diet is no longer a necessity in the routine postoperative management of surgical patients. American Journal of Surgery.1996 Mar; 62(3):167-70 • Reissman.P., Teoh, T.A., Cohen S.M., Weiss, E.G., Nogueras, J.J., Wexner, S.D. Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial. Annals of Surgery.1995 July;222(1):73-7. • Ross, R. Micronutrient recommendations for wound healing. Support Line. 2004(4): 4.

More Related