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Surgical Nutrition

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Department of Surgery ... Nutrition in health and Disease, 1994:812-841 Determining Protein Needs: ... Nutrition in health and Disease, ... – PowerPoint PPT presentation

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Title: Surgical Nutrition


1
Surgical Nutrition
Dorothy Sparks Northside Medical
Center Department of Surgery
2
Historical Perspective
  • Rectal feedings
  • Naso-enteral feedings
  • Oral-enteral feedings
  • Enterostomies

3
Rectal Feedings
  • Egyptians
  • Ritual nutrient enemas and emetics
  • Greeks
  • Nutritional support / laxative therapy
  • Wine, milk, whey, wheat, barley
  • Western Europe
  • Beef and chicken broths
  • Raw eggs, brandy

4
Rectal Feedings
  • Great Britain
  • Lancet, 1878 Brown-Seguard recipe
  • 2/3 lb beef and hog pancreas, ground
  • United States
  • President Garfield received peptonized beef broth
    with whiskey x 79 days after being wounded
  • Europe
  • Proctoclysis in WWI and WWII
  • Administered water, N.S., glucose and isotonic
    amino acids

5
Upper GI Feedings
  • 1598 -- Capivacceus
  • First to report esophageal feeds
  • 1617 -- Fabricius ab Aquapendente
  • Nasopharyngeal feeds with silver tube
  • 1646 -- Boerhaave
  • Leather tubes for gastric feeding
  • 1790 -- John Hunter
  • Catheter and syringe for gastric feeds

6
Upper GI Feedings
  • 1800s -- Stomach pump
  • Used for feeding mentally ill patients
  • 1874 -- Ewald and Oser
  • Soft rubber tube for gastric intubation
  • 1876 -- Dukes
  • Nasal feeding of child with rubber tube
  • 1894 -- L. Emmett Holt
  • Gavage feeding acutely ill infants
  • 4-6 oz milk, 1 oz brandy with digitalis

7
Gastrostomy
  • 1822 -- William Beaumont
  • Studied Alexis St. Martin (gastric fistula)
  • 1850s --
  • Gastrostomies in children after caustic ingestion
  • 1894 -- Stamm gastrostomy
  • 1982 -- Gauderer develops PEG
  • 1984 -- Gauderer develops gastrostomy button

8
Small Bowel Feedings
  • 1910 -- Einhorn
  • Weighted tube for duodenal and jejunal feeds
  • 1939 -- Jejunal feeds after gastrostomy
  • 1952 -- Feeding jejunostomy
  • 1950s
  • Polyethylene tubes, elemental and chemically
    defined formulas
  • 1972 -- Feeding tube jejunostomy

9
Measures of Nutrition

  • Half-Life
  • Serum albumin 21 days
  • Serum trasferrin 7-12 days
  • Serum pre-albumin 2-3 days

Calorie requirement 25 to 30 kcal/kg/day
10
Malnutritional Assessment

  • At Risk Level
  • Serum albumin lt3.5 g/dL
  • Total lymphocyte count lt1500 cell/mm3
  • Serum trasferrin lt140 mg/dL
  • Serum pre-albumin lt17 mg/dL
  • Total iron-binding capacity lt250 mg/dL
  • Serum cholesterol lt150 mg/dL
  • Heymsfield SB et al. In
    Nutrition in health and Disease, 1994812-841

11
Determining Protein Needs
  • Body weight
  • Age
  • Type of protein
  • Daily requirements
  • - Healthy
  • ? 0.8-1.0 g/kg/day
  • - Stressed state
  • ? 1.0-2.0 g/kg/day

12
Determining Fat Needs
  • Source of energy and essential fatty acid
  • - Linoleic acid 2-7g/day
  • Provide 20-30 of total calories
  • - 1g/kg/day
  • In special disease management
  • - more than 45 of total calories from fat

13
Determining Lipid Needs
  • Provide 20-35 of total calories
  • Maximum recommendation for intravenous lipid
    infusion 1.0-1.5 g/kg/day
  • Monitor triglyceride level to ensure adequate
    lipid clearance

14
Respiratory Quotient
The respiratory quotient (RQ) is calculated from
the ratio RQ CO2 produced / O2 consumed
15
Interpretation and Use of RQ
  • Value Interpretation
    Nutrition Strategy
  • gt1.0 Overfeeding
    Decrease total kcal
  • 0.9 - 1.0 Carbohydrate oxidation
    Decrease carbohydrate

  • or increase lipids
  • 0.8 - 0.9 Fat, protein and
    Target range
  • carbohydrate oxidation
  • 0.7 0.8 Fat and protein oxidation
    Increase total kcal
  • Starvation

16
Response to Overfeeding
  • Hyperglycemia
  • Hypertriglyceridemia
  • Hypercapnia (?RQ and minute ventilation)
  • Fatty liver
  • Hypophosphatemia
  • Hpomagnesemia
  • Hypokalemia

17
Enteral vs Parenteral Nutrition
  • Indications
  • Comparisons
  • Advantages/Disadvantages

18
Indications for Enteral Nutrition
  • Gastrointestinal Disease
  • Short bowel syndrome
  • Inflammatory bowel disease
  • Intractable diarrhea of infancy
  • Extrahepatic biliary atresia
  • Intestinal pseudo-obstruction
  • Chronic liver disease
  • Glycogen liver disease

19
Indications for Enteral Nutrition
  • Preterm infants
  • Neurologic
  • Static encephalopathy
  • Dysphagia
  • CNS tumor
  • Cardiorespiratory
  • Cystic fibrosis
  • Bronchopulmonary dysplasia
  • Congenital heart disease

20
Indications for Enteral Nutrition
  • Malignancy
  • Poor intake radiation / chemotherapy
  • Terminal support
  • Hypermetabolic states
  • Burns
  • Trauma / head injury
  • Other
  • Anorexia nervosa
  • Chronic renal disease

21
Enteral Nutrition vs Parenteral Nutrition
  • Advantages
  • Economy
  • Ease
  • Safety
  • Physiology

22
Advantages of Enteral Nutrition
  • Physiology
  • Promotes mucosal growth and function
  • Decreased bacterial translocation
  • Improved nutrient utilization
  • Less hepatobiliary complications

23
Enteral Nutrition
  • Contraindications
  • Peritonitis
  • Obstruction
  • Ileus
  • Vomiting
  • Enteric fistulae

24
Gastrostomy Feedings
  • Possible Possible
  • Advantages Disadvantages
  • Simulates normal feeding Aspiration
  • Intermittent bolus regimen GE Reflux
  • PEG placement Dumping

25
Transpyloric Feedings
  • Indications
  • Gastroesophageal reflux
  • Altered mental status
  • Intractable emesis
  • Delayed gastric emptying
  • Abnormal swallowing

26
Enteral Feeding Supplies
  • Feeding tubes
  • Enteral containers
  • Enteral pumps

27
Enterostomies
  • Approaches and Devices
  • Stamm gastrostomy vs PEG
  • Low profile devices
  • Jejunostomy Surgical vs PEJ

28
Enteral Feedings
  • Formula Selection
  • Blenderized
  • Polymeric
  • Chemically defined
  • Elemental
  • Modular

29
Enteral Diets
  • Type Indication
  • Polymeric Normal GI function
  • Chemically defined Malabsorption
  • Elemental Predigested nutrients
    Usually contains MCT
  • Modular Special requirements

30
Tube Feeding Formulas
  • Inability to meet full nutritional needs by oral
    route (intact GI tract)
  • Infants
  • Breast milk, Similac, Enfamil, SMA, Premie
    formula
  • Children
  • Pediasure (1 - 6 years of age)
  • Osmolite, Isocal, Ensure, Enrich

31
Tube Feeding Formulas
  • Inborn Errors of Metabolism
  • Glycogen storage disease
  • Vivonex
  • Dietary Protein Changes
  • Renal failure
  • Travasorb Renal, Nepro
  • Hepatic failure
  • Travasorb Hepatic, Hepatic-aid

32
GI Complications
  • Vomiting
  • Diarrhea
  • Constipation
  • Abdominal pain / bloating
  • Gastric irritation
  • Aspiration

33
Mechanical Complications
  • Tube occlusion
  • Nasopharyngeal effects
  • Tube fractures
  • Leakage
  • Dislodgment
  • Obstruction
  • Irritation

34
Metabolic Complications
  • Hypovolemia
  • Hyperkalemia
  • Hypophosphatemia
  • Hypertonic dehydration
  • Fluid overload

35
Liquid Incompatibilities
  • Product Effect
  • Dimetapp elixir Formula breaks down
  • Robitussin expectorant Precipitate
    forms
  • Sudafed syrup Gelatinous formation
  • Feosol elixir Complete gel forms
  • KCl liquid Interface incompatible
  • MCT oil Gelatinous formation
  • Neo-Calglucon syrup Gelatinous formation

36
Incompatibility of Liquids
  • Osmolite / Osmolite HN
  • Product Effect
  • Amphogel Thickens on contact
  • Mylanta II Thickens on contact
  • Riopan Thickens on contact
  • Tagamet Thickens on contact

37
PEG Indications
  • Swallowing dysfunction
  • CNS disease, oropharyngeal or laryngotracheal
    abn, metabolic disorders, myopathy
  • Supplemental feedings
  • CHD, BPD, malignancy, esophageal dysmotility,
    biliary atresia, AIDS, cystic fibrosis
  • Small bowel disease
  • Crohn disease, short gut syndrome, intestinal
    pseudo-obstruction

38
PEG Contraindications
  • Significant gastroesophageal reflux
  • Failure to transilluminate
  • Epigastric anatomic malformations
  • Scoliosis

39
PEG Advantages
  • Shorter procedure time
  • No ileus
  • Minimal discomfort
  • Relatively inexpensive
  • Sedated procedure
  • Early re-feeding
  • Accomplished in high-risk patients

40
PEG Complications
  • Gastrocolic fistula
  • Infection
  • External migration
  • Intestinal obstruction
  • Gastric separation
  • Development of GE reflux
  • Death

41
Low Profile Gastrostomy Tubes
  • Advantages
  • Simplified care
  • Cosmetically pleasing
  • Decreased skin irritation
  • Low risk migration and dislodgement
  • Comfortable and well tolerated
  • Minimal leakage

42
Low Profile Gastrostomy Tubes
  • Disadvantages
  • Mature gastrostomy site required
  • Valve leaks, limited sizes
  • More expensive than conventional tubes
  • Tube may dislodge during feeds
  • Inappropriate sizing may result in pressure
    necrosis

43
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