Nutrition Support of the Surgical Patient

1. Nutrition Support of the Surgical Patient Randa Jaroudi, Pharm.D Clinical Coordinator TPN Coordinator KKUH

2. Nutrition • Nutrition allows the body to be provided with all basic nutrients substrates and energy required for maintaining or restoring all vital body functions from carbohydrate and fat and for building up body mass from amino acid.

3. Malnutrition • Malnutrition—come from extended inadequate intake of nutrient or severe illness burden on the body composition and function—affect all systems of the body

4. Type of Malnutrition Marasmus Protein – calorie malnutrition The patient's oral diet may include an acceptable protein:calorie ratio but is inadequate in quantity and calories. (depleted somatic proteins, normal visceral proteins) Normal Albumin and transferrin Patients look thin and malnourished. e.g. Patients with mild to moderate starvation, common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa

5. Clinical Manifestations • Weight loss • Reduced basal metabolism • Depletion skeletal muscle and adipose (fat) stores • Decrease tissue turgor • Bradycardia • Hypothermia

7. Type of Malnutrition • Kwashiorkor (Kwa-shior-kor) Protein malnutrition the diet contains various amounts of nonprotein calories (inadequate, adequate, or excessive) from carbohydrates and fats, but is deficient in total protein and essential amino acids. (normal somatic proteins depleted visceral proteins) ↓ Serum Albumin and transferrin Patients appear normal or overweight e.g. Hypercatabolic critical care patients, chronic diarrhea, chronic kidney disease, trauma , burns, hemorrhage, and liver cirrhosis

8. Clinical Manifestations • Marked hypoalbuminemia • Anemia • Edema and ascites • Muscle atrophy • Delayed wound healing • Impaired immune function

10. Diagnosis Mixed Marasmus-Kwashiorkor: (depleted somatic and visceral proteins) All above data are reduced Patients appear cachexic and severely malnourished. e.g. *Chronic hypercatabolic patients (250 to 500g loss of weight) *Prolonged starvation Marasmic-kwashiorkor is a mixed form of any PCM symptoms. It frequently occurs when the marasmic patient experiences the catabolic stress of illness or trauma.

11. Medical causes (Risk factors for malnutrition) • Recent surgery or trauma • Sepsis • Chronic illness • Gastrointestinal disorders • Anorexia, other eating disorders • Dysphagia • Recurrent nausea, vomiting, or diarrhea • Pancreatitis • Inflammatory bowel disease • Gastrointestinal fistulas • Cancer

12. Metabolic Rate Normal range Long CL, et al.JPEN 1979;3:452-6

13. Protein Catabolism Normal range Long CL.Contemp Surg 1980;16:29-42

14. The Goals of Preoperative Nutrition Support • ↓ surgical mortality • ↓surgical complications and infection • Reduce the catabolic state and restore anabolism • ↓the hospital length of stay • Speed the healing/recovery process

15. Indications Aggressive nutritional support (enteral or parenteral) should be considered in minimum 3 of: • Looks clinically malnourished. • Has a low serum albumin <3.5g/dL. • Has a recent loss of 10% or greater within • Has a history of recent poor intake. • Who as a consequence of his illness is going to be or has been NPO for 5-7 days. The term “If gut works, use it” remains the golden rule. However, recently this was changed to: If gut works use it; and if gut works partially, use it partially.

16. Preoperative Nutrition Assessment-1 1. Medical & Nutritional History Medical history includes acute or chronic disease, medication, surgeries, & other therapies (i.e., chemotherapeutics, immunosuppressive) Nutrition Historyincludes recent changes in appetite or weight, activity level, use of diet. Subject Global Assessment (SGA)

17. Preoperative Nutrition Assessment-2 2. Physical examination Logical assessment from head to toe 3. Anthropometric parameters • % of IBW = Actual weight x 100/Ideal body weight • Triceps Skinfold Thickness (TSF) for assessing fat reserve. It is decreased when fat stores are depleted. • Midarm muscle circumference (MAC) to assess the degree of somatic protein depletion. TSF and Mid Arm Circumference are no more recommended as an accurate measurement. • Creatinine Height Index (CHI) to assess somatic protein stores. Serum Protein Determination to assess the degree of visceral protein depletion, e.g. Albumin, Transferring, Prealbumin. • Measure Total Lymphocyte Count (TLC) to assess Immune function becomes impaired 4. Lab assessment

18. Fat,Anthropometric parameters Assessment of body fat Triceps Skinfold Thickness (TSF) for assessing fat reserve. It is decreased when fat stores are depleted.

19. Protein (Somatic Protein) • Assessment of the fat-free muscle mass (Somatic Protein)depletion • Mid-upper-arm circumference(MAC) TSF and MAC are no more recommended as an accurate measurement

20. Creatinine-height index (CHI ) • [measured urinary creatinine (24hr)/ Ideal urinary creatinine for a given height] • Ideal Cr = IBW x 23 mg/kg male • = IBW x 18 mg/kg female • CHI > 80 mild depletion • CHI 60 – 80 moderate • CHI < 60 severe

21. Average Body Mass Index (BMI) for Adult

22. Nutrition Provides • Energy • Amino Acid • Fluid & Electrolyte • Trace minerals (elements) • Vitamin • Certain drugs

23. Fluid Requirement

24. Fluid Requirement Amount of fluid requirement needed depend on age • Pediatric: 1st 10kg = 100ml/kg 2nd 10kg = 50ml/kg 3rd 10kg & up 20ml/kg • Adult: 30-35ml/kg Additional fluid for vomiting, nasogastric tube output, diarrhea, large open wound, fever, hyperventilation, fistula drainage.

25. Fluid Requirements Special situation for fluid restriction: • Fluid overload, • Cardiac, Renal, or Liver failure • Elderly • Medication NRC* recommends 1 to 2 ml of water for each kcal of energy expenditure *NRC= National research council

26. Energy Requirements

27. Total Energy Expenditure • TEE (kcal/day) = BEE x stress/activity factor • BEE: • The Harris-Benedict equation is a mathematical formula used to calculate BEE

28. Harris-Benedict Equation • Women = 655 + (9.6 x wt) + (1.7 x ht) - (4.7 x age) • Men = 66 + (13.7 x wt) + (5 x ht) - (6.8 x age) • Calories Multiply by stress factor

29. A correlation factor that estimates the extent of hyper-metabolism • 1.15 for bedridden patients • 1.10 for patients on ventilator support • 1.25 for normal patients The stress factors are: • 1.3 for low stress • 1.5 for moderate stress • 2.0 for severe stress • 1.9-2.1 for burn

30. Calories Requirements • Obesity: 18-20kcal/kg/day of IBW • Normal need: 25-30kcal/kg/day • Elective surgery: 28-30kcal/kg/day • Severe injury: 30-40kcal/kg/day • Extensive trauma/burn: 40-45kcal/kg/day

31. Carbohydrate • Primary energy substrate • The amount of carbohydrate is determined by • patient’s calorie requirement • glucose oxidation rate • optimal balance of carbohydrate and fat • Maximum oxidized rate 4 - 7mg/kg/min (adult).

32. Carbohydrate • Provide from a non nitrogen source • Energy requirement depends on number of factors! • Stress factors, increase calories requirements • 60% - 80% of caloric requirement as glucose

33. CHO Oxidation Rate • 1gm = 3.4kcal • Kcl ÷ 3.4 x 1000 ÷ 1440 ÷ wt kg = not more than 5mg/kg/min e.g. 1700 ÷ 3.4 x 1000 ÷ 1440 ÷ 70 = 4.9mg/kg/min or • 5 mg x 3.4 ÷ 1000 x wt x 1440 • 5 x 3.4 ÷ 1000 x 70 x 1440 = ~ 1700 kcal

34. Carbohydrate Source Starting with: • 200 - 250 gm or 15% dextrose solution started or 2.5 mg/kg/min • 100 - 150 gm or 10% - 15% dextrose solution in stress & DM • Increase gradually up to 5 mg/kg/min, • Max 7 mg/kg/min

35. How to Calculate Percentage • Total volume of fluid x 3.4 x % • e.g. 2000ml x 3.4 x 0.20 = 1360 kcal. Or • 1400 ÷ 3.4 ÷ 2000ml = 20% as started then • 1700 ÷ 3.4 ÷ 2000ml = 25% full requirement

36. Protein (Amino Acid) AAs are the vital components of body protein. The primary aim of providing AAs to the body is to prevent: • Disease related catabolic state. • The development of manifest protein deficiency with subsequent impaired wound healing. • Disturbances of blood clotting. • The impairment of hepatic and renal function. • A reduced immuno-competence.

37. Protein (Amino Acid) • 1g of protein = 4 Kcal • 1g of nitrogen is equivalent to 6.3g of protein • Non-protein k.cal: nitrogen • 150-200: 1 (normal patient) Note: In renal and hepatic failure the ratio is 1:300-400. Adult dose: Normal patients requirement 0.8-1.0 g/kg max. 2.5g/kg depend on patient status Renal failure patient 0.6 g/kg

38. Protein (Amino Acid) 12% - 16% of calories as protein Note: • Products containing only essential Aas have been formulated for renal failure. • BCAA (Branched Chain Amino Acids) are used for Hepatic Encephalopathy or in severely stressed patients.

39. Fat Emulsion • Essential linoleic acid stabilized by egg yolk phospholipids • Delivered in the form of an emulsion • fat emulsion has no isotonicity by itself, glycerol is added to render emulsion isotonic (300 mosm/l). • Concentrated source of calories • Source of essential fatty acids (EFAs) • Substitute for carbohydrate in diabetic & fluid restricted patients

40. Fat Emulsion •  Fat should provide 20-40% of total calories. • Fat provides a concentrated caloric source. 1g provide 10 Kcal. • Also fat is an alternative source to dextrose to the patients with compromised respiration since it does produce little CO2 in its metabolism. While dextrose, when oxidized, it produces CO2 which must be eliminated via lungs. • Start with 0.5g/kg/d  gradually up to1.5g/kg/d. • Administer over 12hr or max rate 15ml/hr

41. Fat Emulsion • The caloric density • 10% FE is 1.1 kcal/ml • 20% FE is 2 kcal/ml • 30% FE is 3 kcal/ml • There is LCT, and MCT/LCT products • 1gm = 9kcal of fat • Each 1ml = 2kcal • Lipid emulsions contain glycerol, so lipid emulsion does not have 9 kcal per gram as it would if it were pure fat. Some use 10 kcal/gm for lipid emulsions. • Propofol: Soybean oil in water emulsion, 1ml - 1.112kcal randa911@yahoo.com

42. Fat Emulsion Contraindications • Hyperlipdemia • Acute pancreatitis • Previous history of fat embolism • Severe liver disease • Allergies to egg, soybean oil or safflower oil

43. Electrolytes • Na, K, CL, Ca, Mg, PO4, & acetate. • Electrolytes given to maintain normal serum concentration or to correct deficit. • Requirements for specific electrolytes will vary according to the patients disease state randa911@yahoo.com

45. Restrict electrolytes • Severe renal dysfunction. • Edema & congestive heart failure. • Patients on corticosteroids. • Metabolic acidosis, acute pancreatitis fistulas, or diarrhea. • Metabolic alkalosis, vomiting. randa911@yahoo.com

46. Multivitamins B – Complex: Co-enzyme in absorptive and metabolic processes, transfer of energy from protein, fat and carbohydrateto the cells and their storage as ATP. Ascorbic Acid: Required for collagen synthesis, wound healing. An additional amount may be required in major burns, traumas, and extensive surgeries. Vitamin A: Essential for vision, the production of mucus-secreting epithelial cells and bone growth. Vitamin D: For calcium and phosphate hemeostasis and boncalcification. Vitamin K: For prothrombin generation (Fibrin Fibrinogen).

47. Vitamin K • TPN solution does not contain vitamin K and it can predispose patient to deficiency • Vitamin K 10 mg should be given weekly IV or IM if patient is on long-term TPN

48. Multivitamin and Trace Minerals • Standard form of multivitamin & trace mineral use. • Zinc, copper, manganese & chromium. • Additional of trace mineral required depend on GI losses. • Renal failure patients reduce dose • Biliary stasis disease, avoid copper & manganese randa911@yahoo.com

50. Additives • INSULIN: For hyperglycemia when glucose is spilling in urine. • HEPARIN: To promote blood circulation (especially with peripheral TPN) and to prevent thrombophlebitis. • HYDROCORTISONE: To prevent thrombophlebitis in patients receiving peripheral TPN. • ACETATE: For acidosis. • ZINC: Extra amount is needed for patient with severe stress, diarrhea, and ileostomy.