3.
Surgical nutrition is important in
Well nourished and mildly malnourished patients
who cannot take oral food for more than one week
post operatively to avoid prolonged starvation.
Severely malnourished patients undergoing general
surgery procedures.
All critically ill patients (Sepsis patients, Multiple
Injury patients, Burn patients, etc).
Patients whom you predict cannot use their gut for
prolonged period of time (Short gut syndrome, EC
fistula, etc).
Introduction
5.
There are two broad classes of nutrients:
◦ Those that provide energy
Carbohydrates, fats and proteins
◦ Those that are incorporated in tissue synthesis
Proteins, vitamins, electrolytes, trace elements and water
◦ Carbohydrates
30-60%
Stores depleted in 48hrs after starvation but within 24 hrs of
stress
◦ Proteins
Not stored; 2.5% daily turnover
2-4g/day is depleted in starvation but 30-50g/d after severe
stress
◦ Lipids
25-40% of total calories
Depleted in prolonged starvation and stress
Review of Physiology
7.
ENERGY/NUTRIENT REQUIREMENT
Energy requirement is increased in catabolic state.
Neonates/infants require about 3X energy
requirements in adults.
The basal requirements are:
◦ Energy J/kg 125-146
◦ Proteins [g] 0.7-1.0
◦ Carbohydrates [g] 4.2-6
◦ Fat [g] 1.5-2
◦ Water [ml] 30-35 [45 -50]
◦ Electrolytes
◦ Vitamins
8.
ESTIMATION OF ENERGY REQUIREMENT
Harris-Benedict equation estimates BEE at rest.
Men 66 + (13.7x weight) + (5x height) –(6.8 x age).
Women 65 + (9.6 x weight) + (1.7 x height) – (4.7 x
age)
Most require 25-35 kcal/kg/day.
Stress increases these values.
Requirements are increased by activity, surgery,
trauma, fever, infection, burns, head injury, renal
failure.
Decreased by sedation, paralysis, B blocker
9.
Short term starvation
During the first 48-72 hrs increased use of fat
stores, and most tissues except RBCs, WBCs,
and renal medulla oxidize lipid stores.
Brain has an obligate glucose requirement, over
3-5 days uses fatty acids for energy.
Reserves can maintain this demand for 12hrs
but this can elongated by gluconeogenesis from
lactate, glycerol and amino acids.
Prolonged starvation
Hepatic and renal gluconeogenesis drops
Brain cells use ketone bodies for energy.
Human catabolism
10. Protein
Proteolysis and synthesis [energy and acute phase reactant
proteins by the liver]; negative nitrogen balance
Nitrogen loss:
5-8 gm/d normally
2-4 gm/d after several days of unstressed starvation
30-50 gm/d under severe stress (multiple trauma, sepsis,
burns)
Lipids
Lipolysis
Carbohydrates
Glycogenolysis and gluconeogenesis
Insulin resistance
This response is stimulated by:
Hormones ACTH, GH, glucagon
Catecholamines
Cytokines associated with acute stress response
Human catabolism [stress]
11.
Anthropometric measurement
◦ Length/ height; Weight/BMI; MUAC/skin fold thickness
◦ Weight [<10%BW, <80% Ideal, 5% in 1month]
Biochemical findings
◦ Serum protein [<30g/l]
◦ FBC [PCV-anemia; Lymphocyte count <1500/mm3]
◦ Immune competence [delayed hypersensitive reaction, antigen tests]
Clinical findings
◦ History-weight loss, persistent nausea, anorexia, vomiting,
diarrhoea, malaise, dysphagia
◦ Signs: fluffy hair, pallor, skin rash, cheilosis, glossitis, neuropathy,
dementia, muscle wasting, edema, Ascites
Dietary recall
How often, how much, how well
1. Indirect calorimetry
Oxygen consumption, determination of respiratory quotient
1. Measurement of nitrogen balance
2. Measurements of immunologic function
Nutritional assessment –
‘ABCD’
13. Aims
◦ To provide energy, protein, trace elements and vitamins; To
supply fluids and electrolytes
Routes
◦ Enteral
Oro-enteric
Naso-enteric [NGT-NDT-NJT]
Needle catheter jejunostomy
Percutaneous endoscopic Gastrostomy/Jejunostomy
◦ Parenteral
Peripheral /Central
Supplementary/Total
Temporary/permanent
Nutritional support
14.
This should consider the following:
1. The patient's premorbid state (healthy or
otherwise)
2. Poor nutritional status (current oral intake
meeting <50% of total energy needs)
3. Significant weight loss (initial body weight
less than usual body weight by 10% or more or
a decrease in inpatient weight by more than
10% of the admission weight
4. The duration of starvation (>7 days' inanition)
Indications for nutritional support
15.
5. An anticipated duration of artificial
nutrition (particularly total parenteral
nutrition [TPN]) of longer than 7 days
6. The degree of the anticipated insult, surgical
or otherwise
7. A serum albumin value less than 3.0 g/dL
measured in the absence of an inflammatory
state
8. A transferrin level of less than 200 mg/dL
9. Anergy to injected antigens
Indications for nutritional support
17.
Advantages
◦ Cheap, more physiological, more efficacious in traumatized
and burns patient
Options
◦ Blenderised
◦ Chemically defined
◦ Special purpose formulation
◦ Modular
Routes
◦ Oro-enteral
◦ Nasoenteral
◦ Needle Catheter Jejunostomy
◦ Percutaneous endoscopic gastrostomy/jejunostomy PEG/PEJ
Complications
◦ Tube –displacement, dislodge, blockage; bowel perforation,
reflux and aspiration pneumonia
◦ Feed-high osmolar feed cause severe diarrhoea
Enteral
18.
PEM with inadequate oral intake
Dysphagia except for fluids
Prolonged return to normal dietary intake after
trauma/ surgery
Inflammatory Bowel Disease (IBD)
Distal, low output enterocutaneous fistulas
To enhance adaptation after massive enterectomy
Indications for enteral
feeding
19.
Mesenteric ischemia
Small Bowel obstruction
Sepsis
Pancreatitis
Fistula proximal small intestinal
SBS
Severe diarrhoea
Contraindications
22.
When nutritional support is appropriate but
effective enteral nutrition is not possible
Proximal intestinal fistula
IBD (especially in the perioperative period)
Massive intestinal resection (<100cm of small
bowel remains)
Ileus
Severe pancreatitis
Acute burns
Hepatic failure (acute decompensation on
cirrhosis
Indications
23.
Standard
Glucose 250g 4200J
Protein 500ml 4200J
Amino acids 14g
Na 100mmol
K 100mmol
Cl 191mmol
Mg 19mmol
Folic acid
Water
Standard TPN
24.
Access
Peripheral
Central
Protocol
‘Daily dose method’
Calculate energy required
Calculate VOLUME requirements/24h.
Determine PROTEIN requirements g/kg/d.
Calculate daily CALORIES kcal/kg/d.
Determine % to be given as protein, CHO, fats.
Add electrolytes, trace elements.
Co-administer Lipids to prevent fatty acid deficiency.
TPN
26.
Advantages
◦ Improved survival
◦ Wound healing
◦ Resistance to infection
◦ Immunity is improved
◦ Synthesis of blood elements RBC, plasma proteins
Successful outcome
◦ GI fistula
◦ Bowel failure
◦ Burns
◦ Persistent ileus
◦ Pancreatic pseudocyst/ascites/fistulae
TPN
27. 1. Can be used for longer periods with hyperosmolar
fluids at larger volumes
2. Survival rate is improved and morbidity reduced.
3. Weight loss and tissue breakdown are minimized
4. Wound healing is enhanced
5. Resistance to infection and general immunity are
improved
6. Formation of RBCs and plasma proteins is
maintained
Advantages of TPN
29.
Nutritional supplementation reduces the risk of
complications if given to severely malnourished patients
undergoing major surgical procedures and in patients
with severe sepsis, trauma and burns.
One of the most important therapeutic modalities of the
20th century has been nutritional support, in particular,
IV feeding.
The ability to intervene in and correct nutritional
deprivation states that cause significant mortality in
patients is germane hence it should not counted as a
luxury.
Conclusion
