SURGICAL NUTRITION

1. SURGICAL NUTRITION By;Col Abrar Zaidi

2. Sequence • A-Introduction • B-Nutritional elements and • daily requirements • C-Nutrition in surgical patients

3. A-Introduction

4. A-Introduction [cont] Importance • Malnutrition is common among surgical patients e.g.---major abdominal surgery • Malnutrition –associated with: High infection rate Increased hosp. stay Increased morbidity and mortality

5. A-Introduction [cont] Basic clinical considerations What/how much/how: To Feed • What and How Much nutritional elements are required- normal vs. disease • How to make assessment of the needs • Who Needs Nutritional Support • What are the specific needs • What Route should be used • How should we monitor ?

6. A-Introduction Human body is LIKE AN ENGINE. It burns fuel to generate energy that, in turn, is used to perform work to maintains its; a-Functional integrity b-Structural integrity

7. A-Introduction [cont] • The human body does several kinds of work, including mechanical work (e.g., locomotion, breathing), transport work (e.g., carrier-mediated uptake of nutrients into cells), and synthetic work (biosynthesis of proteins and other complex molecules).

8. A-Introduction[cont] • Indeed, all of these kinds of work are essential for life. • Requires energy - to do this work that comes from the energy present in the chemical bonds of the nutrients we consume.

9. A-Introduction [cont] The goals of nutrition support: • To minimize protein breakdown • Preserve lean body mass • Promote protein synthesis • Optimize immune responses.

10. B-ELEMENTS OF NUTRITION CC_1What and How Much nutritional elements are required- normal vs. disease

11. B-ELEMENTS OF NUTRITION Basic elements of nutrition • WATER • PROTIENS • CARBOHYDRATES • FATS • VITAMINS • MINERAL & TRACE ELEMENTS

12. B-ELEMENTS OF NUTRITION [cont]Assessment of requirements - considerations Quantitative estimation- principles: How much is the need -? • Estimate Average daily Requirement (EAR): • Recommended Daily Allowance (RDA) to meet the requirements of persons in a particular life-stage and gender group.  • Adequate intake (AI): based on observed or experimentally derived estimates of nutrient intake by a group or groups of healthy people.  • Tolerable Upper Intake Level (UL): the highest level of daily nutrient intake likely to pose no risks of adverse health effects .

13. B-ELEMENTS OF NUTRITIONAssessment of requirements - considerations • Gender, age & stage of life cycle (fetus, pregnant, lactating, child, adult, elder), • Disease states (malabsorption, maldigestion), inborn errors of metabolism, • Lifestyle ( labourer,clerk), • Medications, bioavailability,

14. B-ELEMENTS OF NUTRITIONAssessment of requirements - considerations • Energy expenditure for caloric requirements. • Protein requirements • fluid,electrolyes,trace elements,vits.

15. B-ELEMENTS OF NUTRITION [cont]Caloric requirements - Energy expenditure • Harris Benedict Equation  W = IBW in kg, A = age in yrs, H = ht in cm. • BMR for Male: 66 + (13.7 X W) + (5XH) - (6.8 X A)= kcal/d. • BMR for Female: 655 + (9.6 X W) + (1.8XH) - (4.7 X A). • Multiply X activity level / stress level:   Well nourished and unstressed = 1.  Confined to bed or minor surgery = 1.2.   Out of bed =  1.3.   Mild starvation = 0.85-1.  Bone trauma = 1.35.  Major sepsis = 1.6.  Severe burn = 2.1.  

16. B-ELEMENTS OF NUTRITION [cont]Caloric requirements - Energy expenditure Basal • > 50 kg male = 1485 kcal/d, female = 1399.  • 60 kg male = ~1630 kcal/d, female = 1544.  • 70kg male = 1750 kcal/d, female = 1680.  

17. B-ELEMENTS OF NUTRITION [cont]Caloric requirements - Energy expenditure • Daily energy required for maintenance = BMR X stress factor X 1.25 (an additional 25% for hospital activity • Daily energy requirements for wt gain = maintenance + 750 kcal.

18. B-ELEMENTS OF NUTRITION [cont]Caloric requirements - Energy expenditure Source of calories Glucose : Fats Ratio= 60 : 40

19. B-ELEMENTS OF NUTRITION [cont]Protein requirements • Normal: 0.8-1 g/kg/d protein (up to 60-70g/d).   • Moderate depletion/ stress: 1-1.5 g/kg/d.  • Severe: 1.5-2.  • Non protein (Gl + Lipids):25-30 kcal/kg/d.  • Calculate grams of nitrogen = grams of protein/ d/ 6.25.  • Nitrogen-to-calorie ratio is usually 1gN to every 150 kcal (1:150). • Need less protein with renal failure before dialysis and hepatic encephalopathy. • Multiple trauma/ burn/ sepsis --> 30-50 non protein and 1.5-3 protein. Stress factor ~ 1 gm/kg/24hr

20. B-ELEMENTS OF NUTRITION [cont]Vitamins, minerals and trace elements Can get catabolism and loss of lean body mass if low in K, Mg, Zn, P, sulfur. 

21. C-Nutrition in surgical patients • Who Needs • What and how much is needed • How to administer • How to monitor progress

22. C-Nutrition in surgical patients Major aspects of surgical care • Treatment of primary cause – surgery • Fluid and electrolytes • Antibiotics • Nutrition • Critical care /monitoring / support

23. C-Nutrition in surgical patientsNutritional Assessment Malnutrition is common in surgical patients Pre operative Postoperative

24. C-Nutrition in surgical patientsNutritional Assessment Preoperative malnutrition starvation or to a failure of digestion. Starvation is caused by: • Difficulty in obtaining food –poverty/Famine -self neglect, elderly, alcoholics • Difficulty in swallowing food -dysphagia • Difficulty in retaining food – vomiting/diarr. Failure of Digestion/absorption caused by; Short gut/Pancreatic or biliary disease (carcinoma or jaundice due to stones), fistula blind-loop syndrome others

25. C-Nutrition in surgical patientsNutritional Assessment Postoperative (post-traumatic) malnutrition Usual happening Transient nature - short period of starvation stress reaction to trauma. Recovery -from any nitrogen deficit due to protein catabolism will follow on return to normal feeding. Any delay in return to a normal diet makes malnourishment likely to occur • Nature of disease and operation –oesophagectomy • Complication -paralytic ileus /peritonitis • Others

26. c-Nutrition in surgical patientsNutritional Assessment Postoperative (post-traumatic) malnutrition • Hypercatabolic state. Severe sepsis (subphrenic abscess), • severe trauma (burns) • disturbances of major viscera (pancreatitis) . • Short gut syndrome NEEDS ARE HIGH

27. NB –Pathophysiology of starvation The metabolic changes are directed to minimizing tissue loss and, in some circumstances, humans can survive for about 120 days. Glucose reserves are available only for 24 hours and thereafter are derived principally from muscle, so that catabolism begins almost immediately after food deprivation.

28. NB –Pathophysiology of starvation • In the first 72 hours, there is a rapid weight loss due to loss of sodium and water, then the resting metabolic expenditure falls and daily nitrogen losses over 2 weeks fall from about 10 g to3—4g. • Progressively fat provides most of the energy requirements yielding 38 kJ/g while carbohydrate derived by gluconeogenesis in the liver from amino acids is utilised by the brain, adrenal glands and red cells — all obligatory glucose users. • After about 21 days, the central nervous system adapts to using ketones derived from fat. The gluconeogenesis and ketosis of starvation may be easily inhibited by glucose intake.

29. C-Nutrition in surgical patients Nutritional Assessment a-History b-Clinical examination c-Anthropometric measures • Skin fold thickness [10mm] • Arm circumference[25cm] • Weight

30. C-Nutrition in surgical patients Nutritional Assessment d-LABORATORY MEASURES • 1. Albumin:  [35gm] • 2.  Nitrogen (Protein) Balance: = RDA calls for 0.8g/kg/d. • 3.  Total Lymphocyte Count: <1000-1200 /uL =mod to severe malnutrition. • 4.  Serum Transferrin: < 100-200 = mod to severe malnutrition. • 5. Total Cholesterol:  • 6-candida skin test [altered cell mediated immunity]

31. C-Nutrition in surgical patients Nutritional Assessment General Assessment of Nutritional Status History: 1) Weight change 2) Dietary intake change 3) GI symptoms 4) Functional capacity 5) Underlying disease (+ metabolic demand) Physical Examination: 1) Lossness of subcutaneous fat 2) Muscle wasting 3) Ankle edema 4) sacral edema 5) ascites

32. C-Nutrition in surgical patients Nutritional Assessment Genaeral Assessment of Nutritional Status History and physical examination • Well nourished • Moderately malnourished • Severely malnourished No explicit numerical weighting scheme

33. C-Nutrition in surgical patientsClinical indications -Who Needs Nutritional Support a-Preoperative nutritional depletion; b-Postoperative complications: • Ileus more than 4 days • Sepsis-hyper catabolic state-needs • Fistula formation- • Massive bowel resection-

34. C-Nutrition in surgical patientsClinical indications -Who Needs Nutritional Support Part of management of: • —     Pancreatitis, • —     Malabsorption syndromes, • —     Ulcerative colitis, • —     Radiation enteritis, • —     Pyloric stenosis; • -- Anorexia nervosa;

35. C-Nutrition in surgical patientsClinical indications -Who Needs Nutritional Support Misc. • Intractable vomiting; • Maxillofacial trauma; • Traumatic coma / multiple trauma; • Burns; • Malignant disease; • Renal failure; • liver disease; • Cardiac valve disease.

36. c-Nutrition in surgical patients Modes of administration –[What Route should be used] • Enteral Oral N/G tube Gastrostomy/ jejunostomy • Parenteral TPN:  PPN: 

37. c-Nutrition in surgical patients Modes of administration

38. c-Nutrition in surgical patients Modes of administration Enteral nutrition • Oral supplements • N/G tube feeding • Gastrostomy tube feeding Per-cutaneous Open surgical • Jejunostomy tube feeding Laparoscopy/open surgery

39. c-Nutrition in surgical patients Modes of administration Enteral nutrition- feeding jejunostomy

40. c-Nutrition in surgical patients Modes of administration Enteral nutrition • Simple Home made Diet • Commercial formulae Care Hygiene Timing frequency Tolerance Oral cavity /tube care

41. c-Nutrition in surgical patients Modes of administration Total Par-Enteral Nutrition (TPN): • Define the indication • Calculate the non protein Energy requirement • Calculate protein requirement • Calculate total fluids • Calculate trace elements/minerals/vitamins • Monitor

42. c-Nutrition in surgical patients Modes of administration Total Par-Enteral Nutrition (TPN) TPN-Method -Access Routes • Centrally administered into vena cava at a constant rate.  • Lines:  Tip of catheter should be in the innominate vein or SVC (avoid R atrium and subclavian vein).  • Can be from a peripherally inserted central catheter (PICC).   • Long term catheters (Hickman or Portacath) avoid catheter clotting. 

43. c-Nutrition in surgical patients Modes of administration Total Par-Enteral Nutrition (TPN) Peripheral Parenteral nutrition (PPN) Through a peripheral vein Short period /minimally stressed patients for 3-5d of support

44. c-Nutrition in surgical patients Modes of administration Total Par-Enteral Nutrition (TPN) Standard solution • Glucose =!0%,/25% • Fat emulsions =!0%.20% • Amino Acid Solutions • Mixtures of all e.g Aminoval, intralipid, liposin,Plabolite etc Read the manufacturers advice , contents and values

45. c-Nutrition in surgical patients Modes of administration Total Par-Enteral Nutrition (TPN) • The daily electrolyte requirements for most patients can be met by adding one of the standard electrolyte packages to the PN

46. c-Nutrition in surgical patients The standard Par Enteral electrolyte package • Sodium 25 meq • Potassium 40.6 meq • Calcium 5 meq • Magnesium 8 meq • Acetate 33.5 meq • Gluconate 5 meq • Chloride 40.6 meq

47. c-Nutrition in surgical patients Total Par-enteral Nutrition (TPN) Vitamin & trace elements Standard Parenteral Multivitamin Package Standard Parenteral Trace Elements Package [zinc, copper, chromium, manganese, iodine, iron, and selenium ] Single Par enteral vitamin OR Trace Element Formulations available

48. c-Nutrition in surgical patientsComplications • Major complications rare (<3%) • Minor complications frequent (diarrhea) • Minimizing complications : Perioperative vs. oral supplements • Enteral Hyperosmolar diarrhea Nausea vomiting Re feeding syndrome Dyspepsia

49. c-Nutrition in surgical patientsComplications Par-Enteral A-Technical complications : Air embolism, subclavian artery puncture/Hemotoma /laceration, pneumothorax, hemothorax, carotid artery injury, thromboembolism, catheter embolism, catheter malposition, Horner's syndrome, brachial plexus injury, and phrenic nerve paralysis.

50. c-Nutrition in surgical patientsComplications Par-Enteral B-Metabolic Complications Dehydration /Overhydration Alkalosis / Acidosis Hypocalcemia Hypercalcemia Hyperglycemia Hypoglycemia Hyperlipidemia Cholestasis-Jaundice Coagulation defects