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Surgical Nutrition

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Surgical Nutrition Dr. Robert Mustard October 4, 2011 Does it really matter? US VA TPN Study: NEJM: 325 p 525-532, 1991 459 patients with (primarily) GI malignancies ... – PowerPoint PPT presentation

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Title: Surgical Nutrition


1
Surgical Nutrition
  • Dr. Robert Mustard
  • October 4, 2011

2
Does it really matter?
  • US VA TPN Study NEJM 325 p 525-532, 1991
  • 459 patients with (primarily) GI malignancies
    requiring surgical resection
  • Patients stratified into 3 groups
  • - normally nourished
  • - mild malnutrition
  • - severe malnutrition
  • Patients then randomized to 1-2 weeks
    preoperative TPN
  • vs control.

3
1991 VA Trial Outcome (30 day)
  • Major infections complications
    N Mild Severe
  • TPN 12.2 15.2 12.9
  • Control 4.0 6.6 10.5
  • Major non-infections complications
  • TPN 14.3 16.1 22.6
  • Control 16.0 22.6 42.1

  • No difference in mortality
  • (Editorial by A. Detsky)

4
Further evidence that TPN may be bad for your
patients
  • M.J. Sena, et al Early Supplemental Parenteral
    Nutrition is Associated with Increased Infectious
    Complications of Critically Ill Trauma Patients
  • JACS 207 p 459-467, 2008

5
Why might TPN be bad for your patients?
  • 1) central line
  • 2) hyperglycemia
  • 3) gut atrophy
  • 4) IV lipids
  • 5) query hepatic cholestasis

6
Determining Nutritional Status
  • J.P. Baker, et al Nutritional Assessment A
    Comparison of Clinical Judgment and Objective
    Measurements.
  • NEJM 306, p 969-972, 1982.
  • A.S. Detsky, et al What is Subjective Global
    Assessment of Nutritional Status?
  • J. Parent. Ent. Nutrition 11 p 8-13, 1987.

7
Subjective Global 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

8
Subjective Global Assessment of Nutritional Status
  • Hx P/E ? Well nourished
  • Moderately malnourished
  • Severely malnourished
  • No explicit numerical weighting scheme

9
Who Needs Nutritional Support?
  • 1) Normally nourished or moderately
    malnourished
  • 7-10 days NPO well tolerated
  • 2) Severely malnourished Start feeds ASAP
  • Consider patients underlying disease and the
    likelihood of rapid recovery following
    treatment (eg surgical excision of cancer)

10
How Much Food Is Needed?
  • Enough to avoid complications caused by
    malnutrition.
  • Guidelines
  • 1) Calories
  • - estimate BME from Harris-Benedict formula
  • (sex, age, weight, height)
  • - 25 Kcal/kgm/24h
  • - estimate stress factor
  • 25 for general surgical patients
  • as much as 100 for major burn patients
  • 2) Protein
  • - basal requirements 0.7 gm/kgm/24h
  • - with stress factor 1 gm/kg/24hr
  • 3) Electrolytes
  • - trace elements
  • - vitamins
  • - same for all

11
What Route to Use
  • Enteral, if at all possible
  • IGNORE - recent GI surgery
  • - presence or absence of bowel sounds,
  • flatus, etc
  • DO NOT IGNORE - Olgilves Syndrome
  • - constipation
  • - diarrhea

12
Enteral Routes
  • - NG tube (regular or silastic)
  • - NJ tube
  • - surgical G or J tube
  • - percutaneous G or J tube
  • - endoscopic G tube

13
Notes
  1. Risk of aspiration pneumonia more or less
    independent of feeding mechanism
  2. Always check gastric residuals with G-tube feeds
  3. Beware of complications of J-tube feeds (small
    bowel necrosis)
  4. All tubes are mobile!

14
Parenteral Routes
  • - PVC line
  • - PICC line
  • - Hickman catheter
  • - Porta-cath

15
Case Studies
  • Patient with severe closed head injury.
  • Tracheostomy in place, need for long term feeds
  • ? Route.
  • Post-op patient who suffered from bowel
    infarction and is left with 3 feet of small
    bowel, and a left colon. ? How to feed.
  • Patient in ICU on ventilator with severe acute
    pancreatitis. ? How to feed.
  • Patient with Crohns disease, severe weight loss,
    and high grade small bowel obstruction. ? How to
    feed.
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