외과적 영양 ( 外科的 營養 ) Surgical Nutrition

1. 외과적 영양 (外科的 營養)Surgical Nutrition 인제대학교 부산백병원 일반외과 · 장기이식센터 이 병 욱 Department of General Surgery & Organ Transplantation Center, Inje University, Pusan Paik Hospital Byong Wook Lee, M.D. bwleemd@ijnc.inje.ac.krpotrac@thrunet.com

2. InflammatoryResponse POTraC 2000

3. Metabolic Response to Injury POTraC 2000

4. Metabolic Response to Fasting- Glucose homeostasis POTraC 2000

5. Metabolic Response to Fasting 60g 120g POTraC 2000

6. Gluconeogenesis from 3 carbon presursors - Cori (lactate) and Alanine Cycle (pyruvate) POTraC 2000

7. Gluconeogenesis from 3 Carbon precursors - glutamine, pyruvate POTraC 2000

8. Metabolic Response to Starvation POTraC 2000

9. Fat metabolism during Starvation POTraC 2000

10. Metabolism after Injury • Sustained activities of macroendocrine hormones • Immune cell activation POTraC 2000

11. Metabolism after Injury- Energy Balance • Increase in energy balance directly with severity of injury • Increased activity of SNS • energy required for ion pump action to maintain normal transmembrane concentration overcoming increased cell membrane sodium permeability POTraC 2000

12. Metabolism after Injury – Substrate Metabolism POTraC 2000

13. Interorgan Flux of Nutrients after Injury POTraC 2000

14. Metabolism after Injury- Lipid Metabolism 1 • Free fatty acid; predominant energy source afer injury • Increased lipolysis by catecholamine, and other stress hormones and reduction in insulin level • Continuation of net lipolysis during flow phase; oxidation for cardiac and skeletal muscle energy source • Fatty acid induced inhibition of glcolysis in moderate injury; not in severe injury, hemorrhage, or sepsis (persistent glycolysis and net proteolysis) • Lipoprotein lipase in endothelium • Cytokine POTraC 2000

15. Metabolism after Injury- Lipid Metabolism 2 • High concentration of intracellular fatty acids and elevated concentration of glucagon  inhibition of fatty acid synthesis  simulate transport of acyl CoA into mitochondria for oxidation and ketogenesis in liver • Keotgenesis • variable and inversely correlated with severity of injury • Decreased after major injury, severe shock and sepsis • Suppressed by increases in levels of insulin and other energy substrates • Suppressed by increased uptake and oxidation of free fatty acids • Suppressed by an associated counter regulatory hormone response POTraC 2000

16. Metabolism after Injury – Carbohydrate Metabolism • A state of relative insulin resistance • Net gluconeogenic response due to active control of glucagon with permissive requirement for cortisol + Proinflammatory mediators • Reduced glucose oxidation; mediator induced reduction of skeletal muscle pyruvate dehydrogenase activity  shunting of 3-carbon skeleton to liver • Increased hepatic gluconeogenesis  Hyperglycemia  energy source of nervous system, wound, RBC, WBC • Wound; • increase in glucose uptake associated with an increased in activity of phosphoructokinase • dereased insulin sensitivity and failed glucose uptake and glycogenolysis in response to insulin POTraC 2000

17. Metabolism after Injury – Protein Metabolism • Net proteolysis • Skeletal muscle depletion with relative preservation of visceral tissue • Extracellular hormonal millieu, proinflammatory cytokines • Ubiquitin-dependent proteolytic pathway upregulated by intracellular oxidative intermediates and antioxidants • Greater release of glutamine and alanine than normal concentration of muscle • Glutamine; major energy source for lymphoytes, fibroblasts, and GI tract POTraC 2000

18. Ubiquitin-ATP dependent Proteolysis POTraC 2000

19. Severity of Injury and Proteolysis POTraC 2000

20. Nutrition in the Surgical Patients • Obligatory increases in energy expenditure and nitrogen excretion • Post-injury metabolic environment precluding efficient oxidation of fat and ketone production  continued erosion of protein pools  critical organ failure POTraC 2000

21. Nutritional Supprot of the Surgical Patient- Protein • Requirement • Average normal requirement; 0.8 g/Kg/d • Essential amino acids • On parenteral nutrition, 200-250 nitrogen/Kg/d POTraC 2000

22. Nutritional Support of the Surgical Patient – Calories • Caloric Sources • Amino acids 15% (BCAA 6-7%) • Fat 70-75% • Carbohydraes 10-15% • Calorie-Nitrogen Ratio • Normal ratio for protein synthesis; 100-150:1 • Changes in different disease states; 100:1 for sepsis, 400:1 for uremia POTraC 2000

23. Nutritional Support of the Surgical Patient – Energy Requirement • BEE =66.5 + 13.7 x weight (Kg) + 5.0 x height (cm) – 6.8 x age (yr.) [male] = 655.1 + 9.56 x wt + 1.85 x ht – 4.68 x age [female] POTraC 2000

24. Nutritional Support of the Surgical Patient - Carbohydrates • Supplement calories without elevating glucose concentration • Lipid supplementation; replacing glucose as energy source • lipid not efficient in severe sepsis POTraC 2000

25. Nutritional Support of the Surgical Patient - Fat • Caroric source • Source of essential fatty acids providing precursors of PG’s • Modifying inflammatory and immunologic response • 25% of nonprotein calories as fat; optimal for hepatic protein synthesis • Fat overload syndrome < 2 g/Kg/d for adults < 4 g/Kg/d for infants POTraC 2000

26. Nutritional Assessment • Estimate changes in body nutritional composition to predict risk for surgery • Evaluation of nutritional system; measurement of functional lean body mass (muscular, respiratory, cardiac, hepatic, renal, immunologic and host defense function) • Prognostic Nutritional Index (PNI) • = 158- 16.6 alb – 0.78 TSF – 0.20 TFN – 5.8 DH POTraC 2000

27. Bases of PNI POTraC 2000

28. Malnourished Patients at Risk • Recent weight loss > 10% body weight and/or body weight 80-85% ideal body weight • Serum albumin in a stable, hydrated patient < 3.0 g/dl • Anergy to injected skin recall antigens • True transferrin < 200 mg/dl • History of functional impairment • Significant deficits in hand dynamometry or muscle response to nerve stimulation POTraC 2000

29. Indication for Nutritional Support • Premorbid state • Nuritional status • Age • Duration of starvation • Degree of anticipated insult • Likelihood of resuming normal intake soon • Weight loss of 15% • Serum albumin level < 3.0 g/d POTraC 2000

30. Route of Administration- Enteral route • More physiologic • Costs less • Protects and improves hepatic function • Mimics normal ingress of nutrients to liver • Maintains gut mucosal integrity • early gut feedings resulting in lower mortality and septic complication rates in posttraumatic situation • Prevention of bacteria and/or their products from translocating the gut mucosa releasig catecholamines and other counter regulatory stimuli,  preventing hypercatabolism • Increased substrate supply to the liver  improved hepatic acute phase protein synthesis POTraC 2000

31. Enterocyte-specific Nutritional Substrates- Glutamine • Conditionally essential amino acid • 40% of available glutamine taken up by gut from general circulation • Addition of 2% glutamine to parenteral nutrition maintains jejunal or ileal mucosal thickness, protein content and DNA • Prevention or healing of chemotherapeutic or radiation toxicity • Regrowth after massive small bowel resection POTraC 2000

32. Enterocyte-specific Nutrients – Short Chain Fatty Acids • Acetoacetate (10%), propionic acid (50%), butyrate (80%) • Produced by fermentation of soluble pectin by colonic bacteria • Disruption of colonic mucosa in deficient state • BHBA • wall thickening and increased protein content of ileum and colon • 70% of energy supply to colonic mucosa • Stimulation of ketogenesis, increased ATP generation, lipolysis, absorption of sodium and potassium POTraC 2000

33. Principles of Eneral Feeding • Stmach;principal defense against an enteral osmotic load • Duodenum; calcium,iron and other metal absorption • Small bowel: principal area for nutreint absorption • Terminal ileum; enterohepaic circulation • Bile and pancreatic juice; fat and protein absorption • Immunologic functions of the gut • largest immunoogic organ in the body; GALT, secretory Ig’s • Secretion of mucin • Gut mucosal barrier function POTraC 2000

34. Practical Enteral Feeding • Goals of Nutritional Support • Use the gut if possible • Administer at least 20% of caloric and protein requirement by gut • Smalllest possible nasgastric tube, tip at the duodenum • Constant infusion except at bed time, head up 30 • For gastric feeding, first osmolality and then volume, reversed for jejunal feeding • Complications • Malposition and/or aspiration • Diarrhea, dehydration, hyperglycemia and ions • Pneumaosis intestinalis with perforation • Hyperosmolar nonketotic coma • perforation POTraC 2000

35. Parenteral Nutrition- Peripheral Hyperalimentation • Without protocol • Lipid system; 10-20% of caloric need as fat emulsion + 5% dextrose and amino acids • Hypocaloric amino acids and 5% dextrose or glycerol solution • Dextrose free amino acids by allowing utilization of endogenous fat secondary to low plasma insulin level • Minimize nitrogen breakdown for limited periods of time POTraC 2000

36. Parenteral Nutrition- Central Approach • Silastic or Teflon-coated catheters • Percutaneous or open • Temporal or permanent • Enforced protocol for TPN • Nutritional requirements • 250 mg nitrogen/Kg/d • 35 Kcal/Kg/d • 20-25% of nonprotein calories as fat • Adequate vitamin and trace minerals POTraC 2000

37. Parenteral Nutrition - Indications • Primary Therapy • Efficacy shown • GI-cutaneous fistula • Renal failure • Short bowel syndrome • Acute burns • Hepatic Failures • Efficacy not shown • Crohn’s disease • Anorexia nervosa • Supportive therapy • Efficacy shown • Acute radiation enteritis • Acute chemotherapy toxicity • Prolonged ileus • Weight loss preliminary to major surgery • Efficacy not shown • Before cardiac surgery • Prolonged respiratory support • Large wound losses POTraC 2000

38. Complications of Parenteral Nutrition- Technical • Placement complications • Pneumothorax • Arterial lacerations • Hemothorax • Mediastinal hematoma • Nerve injury • Late complications • Erosion of catheter • Subclavian thrombosis • Septic thrombosis • Sympathetic effusion • Thoracic duct injury • Air embolism • Hydrothorax • Catheter embolism POTraC 2000

39. Complications of Parenteral Nutrition - Metabolic Complications • Plasma electrolyte abnormalities • Trace mineral deficiency • zinc, copper, chromium, selenium • Essential fatty acid deficiency • Disorders of glucose metabolism • Hypoglycemia • Hyperglycemia • Diabetic patient; hyperosmolar nonketotic coma • Liver function derangements POTraC 2000

40. Parenteral Nutrition Order Form POTraC 2000

41. Complications of Parenteral Nutrition – Septic Complications • Catheter Infection • Absence of proocol • Degree of colonization of the pericatheter skin; > 103 • G(+) organism from remote site seeding the fibrin sleeve along catheter; vs G(-) organism • Candida from the gut • Management of patient with suspected catheter sepsis POTraC 2000

42. Prevention of Catheter Complications • Catheter Placement • Nutritional Support teams and Protocols POTraC 2000

43. Nutritional Protocol POTraC 2000

44. Parenteral Nutrition for Pediatric Patients • More rapid growth • High proportion of viscera with little fat or muscle • Incompletely developed enzyme system • Liable to heat loss • Nutritional Requirements in Pediatric Patients POTraC 2000

45. Home Hyperalimentation • Silastic catheters with long subcutaneous tunnel • Mean catheter life; 7 years • Overnight PN • Septic complications POTraC 2000

46. Nutritional Pharmacology • Nutritional support to change either the milieu or the pathophysiology of a disease process to affect outcome • Arginine • Glutamine • Nucleotides • Omega 3-fatty acids • Ketone bodies POTraC 2000