Surgical Nutrition

1. Surgical Nutrition By Dr. Abdulaziz Almusallam Moderator Dr. Abhay Patwari .

2. Objectives Our talk will be about: • Introduction to nutrition • Malnutrition • Nutritional requirements • Nutritional assessment • Indications For nutritional support • Routes and types of feeding

3. Nutrition is an important category in the management of surgical patient. • Those who suffer from trauma and sepsis or going for surgery, where the demands for energy is increased. • Effective nutritional support requires appreciation that the metabolic and the nutritional needs of injured and septic patients differ from those of healthy individuals.

4. Nutrition Support • The aim of Nutritional Support is to identify the patients in need of the nutritional requirements and to ensure good support to minimize the risk of complications.

5. Malnutrition • The adverse effects were documented from as early as 1936. • The incidence reaches 50% and is exacerbated by hospital stay. • A suboptimal dietary intake for >14 days is associated with a high morbidity and mortality. • Nutrition screening, assessment and support must become an integral part of the multidisciplinary care of the surgical patient. • High-risk patients, a referral should be made to a dietitian who will arrange the provision of nutrition support as indicated. • If possible, especially in high-risk patients, surgery should be postponed until there is an improvement in the nutritional status.

6. Malnutrition • Impaired immune function • infections • Delayed wound healing • Increased risk of postoperative complications • Apathy, depression and neglect

7. Malnutrition • Muscle wasting and weakness which affects: • Respiratory function • chest infections • cardiac function • heart failure • mobility • deep vein thrombosis • pulmonary embolism • pressure sores

8. What is theNutritional requirements

9. The principal requirements in nutritional regimen are energy protein – nitrogen vitamins, minerals, trace elements and water

10. Energy: • Carbohydrate and lipid are the main dietary sources of energy. • Bodyneeds app 30 kcal/kg/day . (it will be increased to up to 35 – 40 kcal/kg/day in case of any metabolicstress). • lipid can provide 1 g → 9 kcal (H2O +CO2) . • CHO can provide 1 g → 4 kcal (H2O +CO2).

11. Note: CHO is the fuel for glucose dependent tissue such as: bonemarrow. Erythrocyte. braintissue. Daily requirements of glucose : 100 – 150 g will suppress any glyconeogenesis and prevent ketosis.

12. Protein – nitrogen: • requirements are estimated at 0.8 – 1 gm/kg/day. • healthy adult requires 1 gm of nitrogen / 150 kcal/ day. • nitrogen content of protein: • 6.25 g of protein contain 1 g of nitrogen. • protein 1 g → 4 kcal (ammonia).

13. Water: • Daily requirements are from 25 – 40 ml/kcal/day or 1 ml/kcal/day. • Provided that we can add 300 ml for each degree (ºC) of rise in temperature. • Fluid requirements Increased in : • Fever. • Fistulas. • Diarrhea. • Decreased in: • Renal failure. • Congestive heart failure. • Cirrhotic ascites.

14. Vitamins, minerals, trace elements: • Bodyneeds them due to their function as : • Metabolic coenzymes (vit K → factor 2,7,9,10). • Co-function in wound healing (vit C, A). • Antioxidant (vit C, E).

15. Amino acid Glutamine: • Nitrogen carrier among organs. • Soit improves nitrogen balance. • Fuel for lymphocyte and hepatocyte. • Important for maintenance of small bowel mucosa. • Deficiency may cause immune dysfunction. • Supplementation 0.285 g/kg/day. Arginine: • Non essential amino acid. asglutamine.

16. Omega 3 fatty acid: • Derived from fish oil. • Polyunsaturated fatty acid. • Anti-inflammatory. • NB :Omega 6 :ratio between 3&6 differs in sepsis. Nucleotides: • structural units DNA and RNA.For immune system.

17. Electrolytes

18. Vitamins • Naturally derived from food. • Dose : 5 ml by weekly subQ or IM injections.

19. Trace elements( addamel injection )

20. Nutrition Assessement • Difficult in practice as there is no ‘gold standard’ for all Patients.

21. What to Assess • Clinical assessment • Anthropometric assessment • Blood indices

22. Clinical assessment • Weight loss • Useful if no dehydration or odema present • 10% =mild malnutrition • 30% = severe malnutrition • Body mass index (Calculated as = weight /height in m2) • Food intake & appetite • Fever • Rx

23. Anthropometric assessment • Triceps skin fold thickness • minimum is 10 mm in male and • 13 mm in the female. • Mid arm circumference • < 25 cm male or • < 23 cm female • Hand grip strength

24. Blood indices • Reduced : • serum albumin • Normal = > 3.5 g/dl • prealbumin or transferrin • Lymphocyte count • If < 1500/ mm3, it indicates an impaired cellular defense mechanism

25. No index of nutritional assessment shown to be superior to clinical assessment

26. THE MUST TOOL

27. Indications for nutritional support • 1.Diminished food intake in: • Preoperative malnutrition • Coma • Postoperative ileus lasting for > 4 days

28. Indications for nutritional support • 2.Diminished digestion and absorption, eg: • Pyloric stenosis • Pancreatic disease • Biliary disease • Malabsorption syndrome • Short bowel syndrome • Radiation enteritis • Ulcerative colitis • Duodenal fistula

29. Indications for nutritional support • 3.Chronic disease, eg: • Chronic cardiac, hepatic or renal disease • Malignant disease • 4.Hypercatabolic states: • Polytrauma • Burn • Sepsis

30. Things to remember • Use gastrointestinal tract if available • Prolonged post-operative starvation is not required • Early enteral nutrition reduced post-operative morbidity

31. Routes of feeding • Enteral Nutrition • Fine-bore nasogastric tube • Nasojejunal tube • Open surgical gastrostomy or jejunostomy • Percutaneous endoscopic gastrostomy (PEG) • Parenteral Nutrition • Internal jugular or .. • Subclavian vein • PICC (peripheral inserted central catheter PICC)

32. Enteral Nutrition • Benefits • More physiologic • Less complications • Gut mucosa preserved • No bacterial translocation • Cheaper

33. Enteral feeding • Complications : • Diarrhoea • Aspiration pneumonia • Leakage around tubes • Blockage of tubes • Migration of tubes

34. Enteral Feeding • What to be given in feeds ? • Blenderised feeds • Commercially prepared feeds • Polymeric • eg Isocal, Ensure, Jevity • Monomeric / elemental • eg Vivonex

35. Enteral feeding • NG tube : • When to use : • Short term < 30 days • Intact gag reflex • Normal gastric function • Low risk of aspiration • Benefits : • Easy tube placement • Surgery not required • Easy to check gastric residuals • Accomodates bolus or intermittent infusions

36. Enteral feeding • Naso-jejunal tube : • When to use : • Compromised gastric function • Early enteral feeding • Benefits : • May decrease aspiration risk • Surgery not required • Problems : • Transpyloric placement may be difficult • Frequent dislodgement • Tube malposition common

37. Enteral feeding • Gastrostomy Tube : • long term > 30 days • bolus, intermittent or continuous feedings • meal times

38. Enteral feeding • PEG tube • Allows gastric decompression& simultaneous JT feeding

39. Paranteral Nutrition • GI tract is not functioning well enough to meet nutritional needs of patient so nutrients put in bloodstream intravenously. • examples: • Small bowel resection • Bowel obstruction (small or large) • Large output fistula below enteral feeding site

40. Paranteral nutrition Allows greater caloric intake BUT • Is more expensive • Has more complications • Needs more technical expertise

41. Paranteral Nutrition • Indications : • Intestinal failure • Temporary : eg; prolonged ileus post op • Permanent : eg ; small bowl ressection • Indication for home parenteral nutrition .

42. Parenteral Nutrition • Contra-Indication ( not absolute ) • Need to be corrected before starting parenteral nutrition . • Heart Disease • Shock • Blood dyscrasias • Chronic liver disease • Disorders of fat metabolism • Uncontrolled DM

43. Parenteral nutrition • Complications • Associated with placement of a central line • Arterial injury • Nerve injury (vagus nerve / sympathetic plexus) • Pneumothorax OR Haemothorax • Thoracic duct injury • Cardiac arrhythmias • Cardiac tamponade Air embolism • Cerebrovascular injury

44. Paranteral • Metabolic Complications • Hyperosmolar states • Hypo / hypernatraemia • Calcium and magnesium disorders • Fatty acid deficiency • Hyperammonaemia • Hyperglycaemia / reactive hypoglycaemia • Acidosis Zinc / Copper / Chromium deficiency • Cholestatic liver profile  • Sepsis

45. Two main forms of parenteral nutrition • Peripheral Parenteral Nutrition • Central (Total) Parenteral Nutrition Both differ in • composition of feed • primary caloric source • potential complications • method of administration

46. Centeral Paranteral Nutrition • Route of administration • Should be a central great vein • Avoid peripheral vein thrombosis by the irritant hypertonic solution . • Traditionally achieved by subclavian vein cannulation . • Silicone-rubber catheters • Introduced via cephalic vein • Can be left for as long as possible

47. Peripheral Parenteral feeding • If short term feeding ( < 2 weeks) . • possible by using • PICC • short cannula at wrist veins • PPN • cannot use more than D10 • Cannulas to be switched from hand to hand • Every 24-48 hours

48. Parenteral Nutrition • Solutions • Composition • Carbohydrates • Glucose , fructose , sorbitol . • Fats • Amino acids • Na, K , PO4 , Ca , Mg . • Others ( added whenever indicated ) • Minerals • Vitamins • Trace Elements

49. Paranteral nutrition • Preparations : • Vamin 9 Glucose • Synthamin 14 • Aminoplex • Intralipid 20 %

50. Parenteral feeding dosage