NUTRITIONAL SUPPORT IN SURGICAL PATIENTS

1. NUTRITIONAL SUPPORT IN SURGICAL PATIENTS M K ALAM MS ; FRCS Professor of Surgery & Consultant Surgeon

2. Objectives This presentation will explain: • The need of nutritional support in surgical patients • Consequences of malnutrition in surgical patients. • Methods of assessing malnutrition • Types of nutritional support, its indications • Routes of providing nutritional support • Complications of nutritional support.

3. ADEQUATE DIET IS NECESSARY TO MAINATAIN NORMAL BODY COMPOSITION AND ORGAN FUNCTIONS

4. Aim of nutritional support • The provision of nutrients with therapeutic intent(prevent or reverse the catabolic effects of disease or injury). • Identify in a timely manner patients in need of nutritional support • Provide nutritional requirements by most appropriate route to minimise complications

5. Malnutrition in hospitalized patients is common • Up to 50% may have moderate malnutrition • Malnutrition increases morbidity and mortality • Damaging effects on psychological status, activity level and appearance • Prolongs hospital stay

6. ENDOGENOUS ENERGY STORESCARBOHYDRATE - GLYCOGEN • Just enough to last one day • Liver- 400 kcal • Muscle- 1600 kcal, not readily available • Essential for RBC, WBC, bone marrow, eye , renal medulla & peripheral nerves • Brain- normally uses glucose, switches to fat in starvation • 1 Gm. = 4 kcal

7. ENDOGENOUS ENERGY STORESFAT- ADIPOSE TISSUE • Largest fuel reserve • 120,000 kcal in a 70-kg man • 1 Gm. = 9kcal • Survival during starvation depends upon the amount of endogenous fat reserve

8. ENDOGENOUS ENERGY STORES PROTEIN • Lean body mass- 13 Kg in a 70 Kg man • 30,000 kcal energy store • Inefficient source of energy • Used for essential nitrogenous substances for maintenance and growth • Synthesis requires non protein calorie source

9. SIMPLE STARVATION ↓ energy expenditure ↑ use of fat for fuel ↑ lipolysis ↓ nitrogen loss ↓ glucose use by brain* * RBC, WBC, renal medulla, neurons, muscles & intestinal mucosa supply maintained POSTOP. STARVATION ↑ hormonal stimulation ↑ cellular activity ↑ metabolic rate ↑ energy expenditure ↑ gluconeogenesis ↑ protein breakdown ↑ nitrogen loss ↑Lipolysis

10. MAIN CONSIDERATIONS IN NUTRITIONAL SUPPORT • Which patient requires nutritional support • Select the appropriate substrate • Obtain and maintain access for delivery

11. WHICH PATIENT? • Severely malnourished • Insufficient intake for more than 5-7 days • Unable to resume dietary intake within 5-7 days

12. ASSESSMENT OF NUTRITIONAL STATUS • History : Altered oral intake Unintentional weight loss- 10-15% in 4-6 months • Physical examination: Body weight / BMI ( normal- 18.5-24.9) Mid arm muscle circumference <60% ( M 25.5 cm, F 23 cm ) Triceps skin fold <60% ( M 12.5mm, F 16.5mm )

13. ASSESSMENT OF NUTRITIONAL STATUS • Laboratory evaluation: Complete blood count Lymphocyte count < 1800/cmm Serum albumin < 30G/L • Immune competence: Delayed cutaneous hypersensitivity to intra-dermal antigens • Functional evaluation: Ability to do daily functions, hand grip

14. PREOPERATIVE NUTRITIONAL SUPPORT • Improves outcome in severely malnourished • If possible, delay surgery • 5-7 days nutritional support • Avoid tumor feeding: limit calorie & protein to match need • Continue nutritional support postoperatively

15. ASSESSMENT OF NUTRITIONAL REQUIREMENTS Optimal nutrition should provide adequate requirements of : Calories- Carbohydrate & fat Protein Water Electrolytes Trace elements Vitamins

16. Energy requirements in adults • Energy : Uncomplicated patients- 25 Kcal/ kg/ day Complicated/ stressed pts. 30-35 Kcal/kg/day • Energy source : Carbohydrates 60-70% Lipids 20-30 %

17. Protein requirements in adults • Uncomplicated patients 1 g/ kg/ day • Complicated/ stressed pts. 1.3-1.5 g/ kg/ day • Calorie: nitrogen ratio - 150 : 1 Stress state- 100 : 1

18. Electrolytes:* * adjusted on a daily basis Sodium - 1 - 1.5 mEq / kg /day Potassium 0.7 - 1 mEq/ kg/ day Calcium 0.2-0.3 mEq/ kg/ day Magnesium 0.35-0.45 mEq /kg /day • Trace elements • Vitamins

19. Fluid requirements • 100 ml/kg/day – first 10 kg body wt. 50 ml / kg /day- for next 10 kg 20 ml / kg /day- for each additional kg • 1 ml of water / cal. / day • Adjust in patients : - who cannot tolerate large volume - additional fluid loss - febrile or septic

20. ROUTES USED FOR NUTRITIONAL SUPPORT Enteral nutrition: Providing liquid formula diet in to a functioning GIT to maintain or improve nutritional status Parenteral nutrition: Delivering predigested nutrients directly to venous system Mixed ( enteral + parenteral ): Tolerate low amount of enteral, weaning from parenteral

22. Routes of enteral feeding • Nasogastric tube feeding – for short periods • Fine bore nasoenteric tube- positioned in stomach, duodenum, jejunum, better tolerated • Gastrostomy/ jejunostomy– surgical/ endoscopic / radiologic, neurological diseases, head/ neck carcinoma, major upper GIT surgery

23. Enteral feeding • Intermittent bolus- suitable for stomach feeding • Continuous - suitable for duodenum/ jejunum feeding • Initiate at a slow rate, advance as tolerated • Initially dilute feeds, gradually advance to full strength • Feeding in semi-upright position particularly for stomach feeds • Maintain this position for 2 hours after feeds • Aspirate (stomach feeding) before next feeding. If >150ml, delay next feed.

24. Advantages of enteral feeding • Simplicity • Greater availability • Lower cost • Well tolerated • Maintains gut integrity • Fewer complications

25. Contraindications to enteral feeding • Intestinal obstruction • Paralytic ileus • High output entero-cutaneous fistula • Short bowel syndrome • Severe acute pancreatitis • Malabsorption

26. Complications of enteral feeding • Mechanical: tracheobronchial intubation, erosion blockage, displacement, bowel perforation • Metabolic: Fluid/ electrolyte imbalance, hyperglycemia • Gastrointestinal: Diarrhea, vomiting, pain • Pulmonary: Aspiration • Infection: Tube site

27. Total parenteral nutrition- TPN Delivering predigested nutrients via hyperosmolar solution into venous system • CVN ( central venous nutrition ) : Subclavian / Internal jugular, Catheter tip in SVC Most commonly used • PVN ( peripheral venous nutrition ): Solution of lower calorie, lower dextrose and higher lipid Suitable for 7-10 days feeding

28. TPN - Indications • Non-functioning GIT Short bowel syndrome Intestinal fistula Severe pancreatitis Intractable vomiting/ diarrhea Severe inflammatory bowel disease Developmental anomalies Multiple organ failure • Sever malnutrition( unable to take orally )

29. TPN - Administration • Check all laboratory values before starting • Nutrients given as 3in1 or 2+1 • Vitamin k given separately • Heparin & insulin can be added • Start with 1 L , increasing to desired level as tolerated • Monitor- CBC, electrolytes, glucose , urea, creatinine, Ca., Mg., phosphorus, bilirubin, coagulation profile, ALP, ALT,AST • Best managed by nutritional support team

30. Home TPN • Long term nutritional support • Majority have malignancy • Special catheter- e.g. Hickman • Subclavian vein through subcutaneous tunnel • Support system

31. Complications of TPN Catheter related: Vessel injury, thrombosis, Haemo/ pneumothorax, Brachial plexus injury, air embolism, sepsis Metabolic: Hyperglycemia, hypoglycemia, Hypertriglyceridemia, fluid & electrolyte disturbance, Hyperosmolar syndrome, steatohepatitis, Others: Cirrhosis, acalcular cholecystitis, Gallstone, osteomalacia

32. Principle & Practice of Surgery 5th edition Garden, Bradbury, Forsyth & Parks

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