SURGICAL NUTRITION

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SURGICAL NUTRITION

• ByCol Abrar Zaidi

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Sequence

• A-Introduction
• B-Nutritional elements and
• daily requirements
• C-Nutritional support in surgical
• patients

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• A-Introduction

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A-Introduction

• Important aspects of surgical care
• Treatment of primary disorder
• Antibiotic prophylaxis and treatment
• Analgesia
• Fluid and electrolyte management
• Nutrition

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A-Introduction cont

• Importance
• Malnutrition is common among surgical patients
  e.g.---major abdominal surgery
• Malnutrition associated with
• High infection rate
• Increased hosp. stay
• Increased morbidity and mortality

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A-Introduction cont

• Basic clinical considerations
• whom/What/how much/how To Feed
• Who are the patients in need of support
• What and How Much nutritional elements are
  required- normal vs. disease
• How to make assessment of the needs
• What are the specific needs
• What Route should be used
• How should we monitor

?
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A-Introduction

• Human body is LIKE AN ENGINE.
• It burns fuel to generate energy that, in turn,
  is used to perform work to
• maintains its
• a-Functional integrity
• b-Structural integrity

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A-Introduction cont

• The human body does several kinds of work,
  including mechanical work (e.g., locomotion,
  breathing), transport work (e.g.,
  carrier-mediated uptake of nutrients into cells),
  and synthetic work (biosynthesis of proteins and
  other complex molecules).

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A-Introductioncont

• Indeed, all of these kinds of work are essential
  for life.
• Requires energy - to do this work that comes
  from the energy present in the chemical bonds of
  the nutrients we consume.

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A-Introduction cont

• The goals of nutrition support
• To minimize protein breakdown
• Preserve lean body mass
• Promote protein synthesis
• Optimize immune responses.

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B-ELEMENTS OF NUTRITION CC_1
What and How Much nutritional elements are
required- normal vs. disease
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B-ELEMENTS OF NUTRITION

• Basic elements of nutrition
• WATER
• PROTIENS
• CARBOHYDRATES
• FATS
• VITAMINS
• MINERAL TRACE ELEMENTS

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B-ELEMENTS OF NUTRITION cont Assessment of
requirements - considerations

• Quantitative estimation- principles
• How much is the need -?
• Estimate Average daily Requirement (EAR)
• Recommended Daily Allowance (RDA) to meet the
  
• requirements of persons in a particular
  life-stage
• and gender group. 
• Adequate intake (AI) based on observed or
• experimentally derived estimates of
  nutrient intake by a
• group or groups of healthy people. 
• Tolerable Upper Intake Level (UL) the highest
  level of
• daily nutrient intake likely to pose no
  risks of adverse
• health effects .

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B-ELEMENTS OF NUTRITION Assessment of
requirements - considerations 

• Gender, age stage of life cycle (fetus,
  pregnant, lactating, child, adult, elder),
• Disease states (malabsorption, maldigestion),
  inborn errors of metabolism,
• Lifestyle ( labourer,clerk),
• Medications, bioavailability,

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B-ELEMENTS OF NUTRITION Assessment of
requirements - considerations

• Energy expenditure for caloric requirements.
• Protein requirements
• fluid,electrolyes,trace elements,vits.

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B-ELEMENTS OF NUTRITION cont Caloric
requirements - Energy expenditure

• Harris Benedict Equation  W IBW in kg, A age
  in yrs, H ht in cm.
• BMR for Male 66 (13.7 X W) (5XH) - (6.8 X
  A) kcal/d.
• BMR for Female 55 (9.6 X W) (1.8XH) - (4.7 X
  A).
• Multiply X activity level / stress level  
• Well nourished and unstressed 1. 
• Confined to bed or minor surgery 1.2.   Out
  of bed   1.3.   Mild starvation 0.85-1.  Bone
  trauma 1.35.  Major sepsis 1.6.  Severe burn
  2.1.  

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B-ELEMENTS OF NUTRITION cont Caloric
requirements - Energy expenditure

• Basal
• gt 50 kg male 1485 kcal/d, female 1399. 
• 60 kg male 1630 kcal/d, female 1544. 
• 70kg male 1750 kcal/d, female 1680.  

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B-ELEMENTS OF NUTRITION cont Caloric
requirements - Energy expenditure

• Daily energy required for maintenance BMR X
  stress factor X 1.25 (an additional 25 for
  hospital activity
• Daily energy requirements for wt gain
  maintenance 750 kcal.

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B-ELEMENTS OF NUTRITION cont Caloric
requirements - Energy expenditure

• Source of calories
• Glucose Fats
• Ratio 60 40

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B-ELEMENTS OF NUTRITION cont Protein
requirements

• Normal 0.8-1 g/kg/d protein (up to 60-70g/d).  
• Moderate depletion/ stress 1-1.5 g/kg/d. 
• Severe 1.5-2. 
• Non protein (Gl Lipids)25-30 kcal/kg/d. 
• Calculate grams of nitrogen grams of protein/
  d/ 6.25. 
• Nitrogen-to-calorie ratio is usually 1gN to every
  150 kcal (1150). 
• Need less protein with renal failure before
  dialysis and hepatic encephalopathy.
• Multiple trauma/ burn/ sepsis --gt 30-50 non
  protein and 1.5-3 protein.
• Stress factor 1 gm/kg/24hr

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B-ELEMENTS OF NUTRITION cont
Vitamins, minerals and trace elements

•   Can get catabolism and loss of lean body mass
  if low in K, Mg, Zn, P, sulfur. 

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• C-Nutrition in surgical patients
• Who Needs
• What and how much is needed
• How to administer
• How to monitor progress

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C-Nutrition in surgical patients

• Major aspects of surgical care
• Treatment of primary cause surgery
• Fluid and electrolytes
• Antibiotics
• Nutrition
• Critical care /monitoring / support

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C-Nutrition in surgical patients
Nutritional Assessment
Malnutrition is common in surgical patients
Pre operative
Postoperative More then 20 loss of average
body wt. is associated with high morbidity
mortality
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C-Nutrition in surgical patients
Nutritional Assessment

• Preoperative malnutrition
• how do the surgical patients become
  malnourished
• starvation or to a failure of digestion.
• Starvation is caused by
• Difficulty in obtaining food poverty/Famine
• -self neglect, elderly,
  alcoholics
• Difficulty in swallowing food -dysphagia
• Difficulty in retaining food vomiting/diarr.
• Failure of Digestion/absorption caused by
• Short gut/Pancreatic or biliary disease
  (carcinoma or jaundice due to stones),
• fistula blind-loop syndrome others

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C-Nutrition in surgical patients
Nutritional Assessment

• Postoperative (post-traumatic) malnutrition
• Usual happening
• Transient nature - short period of starvation
  stress reaction to trauma.
• Recovery -from any nitrogen deficit due to
  protein catabolism will follow on return to
  normal feeding.
• Any delay in return to a normal diet
• makes malnourishment likely to occur
• Nature of disease and operation oesophagectomy
• Complication -paralytic ileus /peritonitis
• Others

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c-Nutrition in surgical patients
Nutritional Assessment

• Postoperative (post-traumatic) malnutrition
• Hypercatabolic state. Severe sepsis (subphrenic
  abscess),
• severe trauma (burns)
• disturbances of major viscera (pancreatitis) .
• Short gut syndrome
• NEEDS ARE HIGH

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NB Pathophysiology of starvation

• The metabolic changes are directed to
  minimizing tissue loss and, in some
  circumstances, humans can survive for about 120
  days. Glucose reserves are available only for 24
  hours and thereafter are derived principally from
  muscle, so that catabolism begins almost
  immediately after food deprivation.

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NB Pathophysiology of starvation

• In the first 72 hours, there is a rapid weight
  loss due to loss of sodium and water, then the
  resting metabolic expenditure falls and daily
  nitrogen losses over 2 weeks fall from about 10 g
  to34g.
• Progressively fat provides most of the energy
  requirements yielding 38 kJ/g while carbohydrate
  derived by gluconeogenesis in the liver from
  amino acids is utilised by the brain, adrenal
  glands and red cells all obligatory glucose
  users.
• After about 21 days, the central nervous system
  adapts to using ketones derived from fat. The
  gluconeogenesis and ketosis of starvation may be
  easily inhibited by glucose intake.

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C-Nutrition in surgical patients
Nutritional Assessment

• a-History
• b-Clinical examination
• c-Anthropometric measures
• Skin fold thickness 10mm
• Arm circumference25cm
• Weight

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C-Nutrition in surgical patients
Nutritional Assessment

• d-LABORATORY MEASURES
• 1. Albumin  35gm
• 2.  Nitrogen (Protein) Balance RDA calls for
  0.8g/kg/d.
• 3.  Total Lymphocyte Count lt1000-1200 /uL mod
  to
• severe malnutrition.
• 4.  Serum Transferrin lt 100-200 mod to severe
  malnutrition.
• 5. Total Cholesterol 
• 6-candida skin test altered cell mediated
  immunity

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C-Nutrition in surgical patients
Nutritional Assessment

• General Assessment of Nutritional Status
• History
• 1) Weight change
• 2) Dietary intake change
• 3) GI symptoms
• 4) Functional capacity
• 5) Underlying disease ( metabolic demand)
• Physical Examination
• 1) Lossness of subcutaneous fat
• 2) Muscle wasting
• 3) Ankle edema
• 4) sacral edema
• 5) ascites

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C-Nutrition in surgical patients
Nutritional Assessment

• Genaeral Assessment of Nutritional Status
• History and physical examination
• Well nourished
• Moderately malnourished
• Severely malnourished
• No explicit numerical weighting scheme

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C-Nutrition in surgical patientsClinical
indications -Who Needs Nutritional Support

• Preoperative nutritional depletion
• Postoperative complications
•  Ileus more than 4 days
• Sepsis-hyper catabolic state- needs
• Fistula formation-
• Massive bowel resection-

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C-Nutrition in surgical patientsClinical
indications -Who Needs Nutritional Support

• Part of management of
•      Pancreatitis,
•      Malabsorption syndromes,
•      Ulcerative colitis,
•      Radiation enteritis,
•      Pyloric stenosis
• -- Anorexia nervosa

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C-Nutrition in surgical patientsClinical
indications -Who Needs Nutritional Support

• Misc.
• Intractable vomiting
• Maxillofacial trauma
• Traumatic coma / multiple trauma
• Burns
• Malignant disease
• Renal failure
• liver disease
• Cardiac valve disease.

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c-Nutrition in surgical patients Modes of
administration What Route should be used

• Enteral
• Oral
• N/G tube
• Gastrostomy/ jejunostomy
• Parenteral
• TPN  PPN 

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c-Nutrition in surgical patients Modes of
administration
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c-Nutrition in surgical patients Modes of
administration

• Enteral nutrition
• Oral supplements
• N/G tube feeding
• Gastrostomy tube feeding
• Per-cutaneous
• Open surgical
• Jejunostomy tube feeding
• Laparoscopy/open surgery

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c-Nutrition in surgical patients Modes of
administration
Enteral nutrition- feeding jejunostomy
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c-Nutrition in surgical patients Modes of
administration

• Enteral nutrition
• Simple Home made Diet
• Commercial formulae
• Care
• Hygiene
• Timing frequency
• Tolerance
• Oral cavity /tube care

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c-Nutrition in surgical patients Modes of
administration

• Total Par-Enteral Nutrition (TPN)
• Define the indication
• Calculate the non protein Energy requirement
• Calculate protein requirement
• Calculate total fluids
• Calculate trace elements/minerals/vitamins
• Monitor

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c-Nutrition in surgical patients Modes of
administration

• Total Par-Enteral Nutrition (TPN) TPN-Method
  - Access Routes
• Centrally administered into vena cava at a
  constant rate. 
• Lines  Tip of catheter should be in the
  innominate vein or SVC (avoid R atrium and
  subclavian vein). 
• Can be from a peripherally inserted central
  catheter (PICC).  
• Long term catheters (Hickman or Portacath) avoid
  catheter clotting. 

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c-Nutrition in surgical patients Modes of
administration

• Total Par-Enteral Nutrition (TPN)
• Peripheral Parenteral nutrition (PPN)
• Through a peripheral vein
• Short period /minimally stressed patients for
  3-5d of support

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c-Nutrition in surgical patients Modes of
administration

• Total Par-Enteral Nutrition (TPN)
• Standard solution
• Glucose !0,/25
• Fat emulsions !0.20
• Amino Acid Solutions
• Mixtures of all
• e.g Aminoval, intralipid, liposin,Plabolite etc
• Read the manufacturers advice , contents and
  values

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c-Nutrition in surgical patients Modes of
administration

• Total Par-Enteral Nutrition (TPN)
• The daily electrolyte requirements for most
  patients can be met by adding one of the standard
  electrolyte packages to the PN

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c-Nutrition in surgical patients

• The standard Par Enteral electrolyte package
• Sodium 25 meq
• Potassium 40.6 meq
• Calcium 5 meq
• Magnesium 8 meq
• Acetate 33.5 meq
• Gluconate 5 meq
• Chloride 40.6 meq

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c-Nutrition in surgical patients

• Total Par-enteral Nutrition (TPN)
• Vitamin trace elements
• Standard Parenteral Multivitamin Package
• Standard Parenteral Trace Elements Package
• zinc, copper, chromium, manganese, iodine, iron,
  and selenium
• Single Par enteral vitamin OR
• Trace Element Formulations available

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c-Nutrition in surgical patients Complications

• Major complications rare (lt3)
• Minor complications frequent (diarrhea)
• Minimizing complications
• Perioperative vs. oral
  supplements
• Enteral
• Hyperosmolar diarrhea
• Nausea vomiting
• Re feeding syndrome
• Dyspepsia

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c-Nutrition in surgical patients Complications

• Par-Enteral
• A-Technical complications
• Air embolism, subclavian artery
  puncture/Hemotoma
• /laceration, pneumothorax, hemothorax, carotid
  artery injury, thromboembolism, catheter
  embolism, catheter malposition, Horner's
  syndrome, brachial plexus injury, and phrenic
  nerve paralysis.

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c-Nutrition in surgical patients
Complications

• Par-Enteral
• B-Metabolic Complications
• Dehydration /Overhydration
• Alkalosis / Acidosis
• Hypocalcemia Hypercalcemia
• Hyperglycemia Hypoglycemia
• Hyperlipidemia
• Cholestasis-Jaundice
• Coagulation defects

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c-Nutrition in surgical patients Complications

• Par-Enteral
• C-Infective complications
• D-Others
• Drug interactions
• Sampling errors
• Re feeding syndrome

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c-Nutrition in surgical patients Monitoring-
Gains and complications

• A. Physical Examination
• B. Functional Assessment
• C. Laboratory Tests
• 1. Basic Test Schedule
• 2. Nitrogen Balance TUN
• 3. Protein-Energy Balance
  MarkersTransthyretin
• 4. Evaluating Acid/Base Balance
• 5. Vitamins and Minerals
• 6. Liver Dysfunction

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THANKS