1. nutritional support in the surgical patient

Nutritional Nutritional Support in the Support in the

Surgical Surgical PatientPatientCelso M. Fidel, MD, FPCS,FPSGSCelso M. Fidel, MD, FPCS,FPSGS

Diplomate Philippine Board of SurgeryDiplomate Philippine Board of SurgeryFellow Philippine Society of General SurgeonsFellow Philippine Society of General SurgeonsFellow Philippine Society for the Surgery of TraumaFellow Philippine Society for the Surgery of TraumaFellow Philippine Fellow Philippine Association ofAssociation of Laparoscopic & Endoscopic Laparoscopic & Endoscopic Surgeons Surgeons

FEUNRMF and OLFUFEUNRMF and OLFU

IntroductionIntroduction Interest in Clinical NutritionInterest in Clinical Nutrition

INTERNAL MEDICINEINTERNAL MEDICINE

PEDIATRICSPEDIATRICS

Renaissance of Interest and Elevation to Renaissance of Interest and Elevation to itsits

present status as a Subspecialtypresent status as a Subspecialty

SURGERYSURGERY

HistoryHistory3,500 years ago3,500 years ago– Nutrient enemaNutrient enema

1600 1600 – Milk, sugar, egg whiteMilk, sugar, egg white– Via feather quill with pig’s bladderVia feather quill with pig’s bladder

17931793– John HunterJohn Hunter– Milk, sugar, wine, jellyMilk, sugar, wine, jelly– Via whale bone covered with eel skinVia whale bone covered with eel skin

Late 1800’sLate 1800’s– U.S. Pres. GarfieldU.S. Pres. Garfield– Whiskey, beef brothWhiskey, beef broth– 79 days with nutrient enema79 days with nutrient enema

HistoryHistory

19521952– Subclavian catheter by Subclavian catheter by

AubaniacAubaniac

19691969– TPN by DudrickTPN by Dudrick

19811981– Kudsk and SheldonKudsk and Sheldon– Enteral route is better for Enteral route is better for

malnourished and for malnourished and for septic peritonitisseptic peritonitis

Nutritional SupportNutritional SupportFundamental goals of nutritional support:Fundamental goals of nutritional support:

1. To meet the energy requirement for metabolic 1. To meet the energy requirement for metabolic processesprocesses

2. To maintain a normal core body temperature2. To maintain a normal core body temperature

3. For tissue repair3. For tissue repair

Surgical Patients that Needs Surgical Patients that Needs Nutritional SupportNutritional Support

To shorten the postoperative recovery To shorten the postoperative recovery phase and minimize the number of phase and minimize the number of complications:complications:

1. Chronically debilitated from their diseases 1. Chronically debilitated from their diseases or malnutrition.or malnutrition.

2. Suffered severe trauma, sepsis or surgical 2. Suffered severe trauma, sepsis or surgical complicationscomplications

Nutritional SupportNutritional Support

Indication of nutritional support:Indication of nutritional support: Pre-morbid statePre-morbid state

Age of the patientAge of the patient

Duration of starvationDuration of starvation

Degree of the insultDegree of the insult

Likelihood of resuming normal Likelihood of resuming normal

intake within a definite periodintake within a definite period

Nutritional SupportNutritional SupportDetermination of Lean Body Determination of Lean Body

Mass:Mass: 1. Displacement1. Displacement

2. Exchange of labeled ions 2. Exchange of labeled ions (radioactive K+)(radioactive K+)

3. Neutron activation analysis3. Neutron activation analysis

4. Total body counter4. Total body counter

5. Nuclear magnetic resonance5. Nuclear magnetic resonance

Nutritional SupportNutritional SupportDetermination of Lean Body Mass:Determination of Lean Body Mass:

6. Clinical history and physical 6. Clinical history and physical examinationexamination

History of weight loss, anorexia and disease History of weight loss, anorexia and disease process that interfered with intakeprocess that interfered with intake

Anthropometric data (skin fold thickness , Anthropometric data (skin fold thickness , arm circumference measurement, thenar arm circumference measurement, thenar eminence)eminence)

Biochemical determination (TP, albumin, Biochemical determination (TP, albumin, globulin, liver profile, kidney function testglobulin, liver profile, kidney function test))

Five IssuesFive Issues Indications for Nutritional SupportIndications for Nutritional Support

Determination of Nutritional StatusDetermination of Nutritional Status

Effectiveness of Nutritional SupportEffectiveness of Nutritional Support In Well-nourished versus Malnourished In Well-nourished versus Malnourished

Route of NutritionRoute of Nutrition Enteral versus ParenteralEnteral versus Parenteral

Appropriate Amount and Composition of DietsAppropriate Amount and Composition of Diets

Who are the patients that needs Who are the patients that needs nutritional support?nutritional support?

IndicationsIndications

Patients who are nutritionally depletedPatients who are nutritionally depleted

Patients who are unable to take nutrients byPatients who are unable to take nutrients by

GI TractGI Tract

Those who should not take nutrients by the Those who should not take nutrients by the GI tract because of an inherent risk or GI tract because of an inherent risk or complicatecomplicate

management of their current surgical diseasemanagement of their current surgical disease

Indications for Nutritional SupportIndications for Nutritional Support Short gut syndromeShort gut syndrome

– <0.5 m jejunum/ileum <0.5 m jejunum/ileum if if with with coloncolon

– <1.0 m of small bowel <1.0 m of small bowel if if withoutwithout colon colon

Severely Severely malnourishedmalnourished

* All other indications are less clear* All other indications are less clear

Indications for Nutritional SupportIndications for Nutritional Support

Severely malnourishedSeverely malnourished

Short bowel syndromeShort bowel syndrome

Patient not expected to feed in 7 daysPatient not expected to feed in 7 days Prolonged ileus or intestinal obstructionProlonged ileus or intestinal obstruction

Entero-cutaneous fistulasEntero-cutaneous fistulas

PancreatitisPancreatitis

Major bowel surgeryMajor bowel surgeryEsophageal replacementEsophageal replacement

Gastric or colon surgeryGastric or colon surgery

Whipple’s procedureWhipple’s procedure


Patient not expected to feed in 7 daysPatient not expected to feed in 7 days– Prolonged ileus or intestinal obstructionProlonged ileus or intestinal obstruction


Patient not expected to feed in 7 daysPatient not expected to feed in 7 days– Entero-cutaneous fistulasEntero-cutaneous fistulas


ESOPHAGECTOMY

COLON REPLACEMENTCAUSTIC INGESTION, ESOPHAGEAL

STRICTURE


Duodenal Leak

Gastro-duodeno-pancreatectomy

Nutritional StatusNutritional StatusNo single “gold standard”No single “gold standard”

Markers of MalnutritionMarkers of Malnutrition1.1. Weight loss Weight loss

2.2. Subjective Global Assessment Subjective Global Assessment

3.3. Transport ProteinsTransport ProteinsAlbuminAlbumin

TransferrinTransferrin

TBPA (thyroxine binding pre-albumin)TBPA (thyroxine binding pre-albumin)

RBP (retinol binding protein)RBP (retinol binding protein)

Nutritional StatusNutritional Status

4. Immune incompetence4. Immune incompetenceTotal Lymphocyte CountTotal Lymphocyte CountDelayed HypersensitivityDelayed Hypersensitivity

5. Prognostic Nutritional Index (PNI)5. Prognostic Nutritional Index (PNI)

6. Prognostic Inflammatory Nutritional 6. Prognostic Inflammatory Nutritional Index (PINI)Index (PINI)

Markers of MalnutritionMarkers of Malnutrition

Unintentional weight loss= ↑ complicationsUnintentional weight loss= ↑ complications– % weight loss= (usual wt – present wt) x 100% weight loss= (usual wt – present wt) x 100

usual wtusual wt

<10% - mild malnutrition, over 1 month <10% - mild malnutrition, over 1 month

10-20%- moderate malnutrition, over 1 month10-20%- moderate malnutrition, over 1 month

>20% - severe, in 6 months>20% - severe, in 6 months>30% - pre-morbid>30% - pre-morbid

>50% - pre-mortality>50% - pre-mortality


Subjective Global AssessmentSubjective Global Assessment– Anthropometry- TSF, MAMC, muscle massAnthropometry- TSF, MAMC, muscle mass– Creatinine-height indexCreatinine-height index– Muscle strengthMuscle strength– Correlates with complication rateCorrelates with complication rate– Correlation with improved outcome ?? Correlation with improved outcome ??


Transport ProteinsTransport Proteins tt½½ – Albumin*Albumin* 21 days21 days

– TransferrinTransferrin 8 days*8 days*

– TBPATBPA 2-3 days2-3 days

– RBPRBP 8 hours8 hours


Transport ProteinsTransport Proteins– Albumin, TransferrinAlbumin, Transferrin– Affected by disease Affected by disease

processprocess

MarasmusMarasmus


Transport ProteinsTransport Proteins– Albumin, TransferrinAlbumin, Transferrin– Affected by disease Affected by disease

processprocess

Interleukin-6Interleukin-6– SepsisSepsis– PeritonitisPeritonitis– TraumaTrauma– BurnsBurns

Nutritional StatusNutritional Status

Markers of MalnutritionMarkers of Malnutrition– Prognostic Nutritional Index (PNI)Prognostic Nutritional Index (PNI)= 158 = 158 –– 16.6 (ALB) 16.6 (ALB) –– 0.78 (TSF) 0.78 (TSF) –– 0.2 (Tfn) 0.2 (Tfn) –– 5.8 (DH) 5.8 (DH)

↑ ↑ score = ↑ riskscore = ↑ risk

– Prognostic Inflammatory Nutritional Index (PINI)Prognostic Inflammatory Nutritional Index (PINI)= = [(CRP x AAG) ÷ PA] x ALB[(CRP x AAG) ÷ PA] x ALB

correlates with recovery from injurycorrelates with recovery from injury

Effectiveness of Nutritional SupportEffectiveness of Nutritional Support

Effect of Nutritional SupportEffect of Nutritional Support

Post-op CoursePost-op Course SepsisSepsis

Well-nourishedWell-nourished

Moderately Moderately MalnourishedMalnourished

if supplemented by arginine, RNA, omega-3 fatty acidif supplemented by arginine, RNA, omega-3 fatty acid

if given very early (30-40% increase) if given very early (30-40% increase)

prefer nutritional support 5-10 days post-op prefer nutritional support 5-10 days post-op

Severely Severely MalnourishedMalnourished








SepsisSepsisPost-op CoursePost-op Course


Post-op CoursePost-op Course SepsisSepsis







Route of NutritionRoute of Nutrition

GIT functional?

YES NO

ENTERAL ROUTE PARENTERAL ROUTE

Short term

Long term

Short term

Long term

NGNGTT

Gastrostomy, Jejunostomy

Peripheral PN

Central PN

Decision MakingDecision Making

Enteral versus ParenteralEnteral versus Parenteral

Blunt and penetrating abdominal Blunt and penetrating abdominal traumatrauma

early enteral feeding early enteral feeding (Moore 1986 & 1989, Kudsk 1992, (Moore 1986 & 1989, Kudsk 1992,

1996)1996)

severity = severity = complications if feed complications if feed enterallyenterally

Severe head injurySevere head injury– No benefit No benefit (Rapp 1983, Hadley 1986, Young 1987, Borzotta 1984)(Rapp 1983, Hadley 1986, Young 1987, Borzotta 1984)

– Beneficial Beneficial (Grahm(Grahm 1989) 1989)

Enteral versus ParenteralEnteral versus ParenteralGeneral SurgeryGeneral Surgery– LaparotomyLaparotomy

Enteral better than parenteral Enteral better than parenteral (Level I evidence)(Level I evidence)

– Ulcerative Colitis and CD after resectionUlcerative Colitis and CD after resectionEnteral better than parenteral Enteral better than parenteral (Level I evidence)(Level I evidence)

– Liver transplantationLiver transplantationEnteral = Parenteral Enteral = Parenteral (Wicks 1994 Level I evidence)(Wicks 1994 Level I evidence)

– Acute pancreatitisAcute pancreatitisGastric and duodenal feeding- ↑ Gastric and duodenal feeding- ↑ complication complication (Ragins 1973)(Ragins 1973)

TPN, jejunal feeding TPN, jejunal feeding (Stabile 1984, Bodoky 1991)(Stabile 1984, Bodoky 1991)

Jejunal feeding = TPN Jejunal feeding = TPN (McClave 1997 Level I evidence)(McClave 1997 Level I evidence)

Jejunal feeding better than TPN Jejunal feeding better than TPN (Windsor 1998 Level (Windsor 1998 Level I evidence)I evidence)

Route of Administration:Route of Administration:1.1. ENTERAL ROUTEENTERAL ROUTE

2.2. PARENTERAL ROUTE (TPN)PARENTERAL ROUTE (TPN)

3.3. COMBINATIONCOMBINATION

ENTERALENTERAL

Advantages:Advantages:1.1. more physiological (liver not more physiological (liver not

bypassed)bypassed)

2.2. lesser cardiac work lesser cardiac work

3.3. safer and more efficientsafer and more efficient

4.4. better tolerated by the patientbetter tolerated by the patient

5.5. more economicalmore economical

ENTERAL NUTRITIONENTERAL NUTRITION

Enteral accessEnteral access– NGTNGT– GastrostomyGastrostomy– JejunostomyJejunostomy– PEG (percutaneous PEG (percutaneous

endoscopic gastrostomy)endoscopic gastrostomy)– Trans-gastric jejunostomyTrans-gastric jejunostomy

ENTERALENTERALRoute:Route:1.1. Naso-enteric tube feedingNaso-enteric tube feeding (blended food – Casseinates (blended food – Casseinates

and whole protein formulas)and whole protein formulas) Naso-esophageal or NGT / NJTNaso-esophageal or NGT / NJT..

2.2. Gastrostomy tubeGastrostomy tube (blended food)(blended food) Stamm (sero-lined) – temporaryStamm (sero-lined) – temporary Glassman (mucous-lined) – permanentGlassman (mucous-lined) – permanent Percutaneous endoscopic gastrostomyPercutaneous endoscopic gastrostomy

3.3. Jejunostomy tubeJejunostomy tube (elemental diet)(elemental diet) Roue-en-y - permanentRoue-en-y - permanent Witzel - permanentWitzel - permanent EndoscopicEndoscopic

ENTERALENTERAL

Hyperosmolar solution are better tolerated Hyperosmolar solution are better tolerated by the stomach:by the stomach:

– Gastric feedingGastric feeding – increase osmolality first then – increase osmolality first then the volumethe volume

– Small bowelSmall bowel – volume first is increase then – volume first is increase then osmolalityosmolality

ENTERALENTERAL Precautions to be observe to prevent Precautions to be observe to prevent

reflux/aspiration:reflux/aspiration:1.1. 30 degree angle30 degree angle

2.2. ConsciousConscious

3.3. Stop feeding at 11 pmStop feeding at 11 pm

Use French 10 and after administration of Use French 10 and after administration of food =Clean the tubefood =Clean the tube

Prolonged use render the cardia Prolonged use render the cardia incompetent and sometimes causes strictureincompetent and sometimes causes stricture

Gastric AnatomyGastric Anatomy


Gastric feedingGastric feeding Jejunal feedingJejunal feeding

Solution usedSolution used Hypertonic or Hypertonic or isotonicisotonic IsotonicIsotonic

Infusion rateInfusion rate Bolus or Bolus or continuouscontinuous ContinuousContinuous

Initiation of Initiation of infusioninfusion 25-30mL/hr 25-30mL/hr

IncrementsIncrements 25-30 mL/hr daily25-30 mL/hr daily

IntoleranceIntolerance VomitingVomiting Distention, diarrhea, Distention, diarrhea, colic, reflux to NGTcolic, reflux to NGT


Nutritional Support Needed?


Nutritional Support Needed

ENTERAL NUTRITIONENTERAL NUTRITIONOral SupplementsOral Supplements Ensure, SustagenEnsure, Sustagen

Tube FeedingsTube Feedings– Blenderized dietBlenderized diet– Polymeric-Polymeric- Isocal, OsmolyteIsocal, Osmolyte– High caloric density-High caloric density- MagnacalMagnacal– Monomeric-Monomeric- Vivonex TENVivonex TEN– Disease-specific-Disease-specific- AminAid, HepaticAidAminAid, HepaticAid

Complication of Enteral FeedingComplication of Enteral Feeding1.1. Malposition of the catheterMalposition of the catheter ( (pharynx/trachea):pharynx/trachea):

Inadvertently movedInadvertently moved Reinsert ideally w/ fluoroscopic guidanceReinsert ideally w/ fluoroscopic guidance

2.2. AspirationAspiration due to:due to: OverloadingOverloading Supine position / unconsciousSupine position / unconscious Change in gastric motilityChange in gastric motility

3.3. Solute overloadingSolute overloading --> --> diarrhea, dehydration, diarrhea, dehydration, electrolyte imbalance (hypokalemia, electrolyte imbalance (hypokalemia, hypomagnesemia), hyperglycemia (hyperosmolar, hypomagnesemia), hyperglycemia (hyperosmolar, nonketotic coma)nonketotic coma)

Avoided by gradual increase in the osmolality of the fluidAvoided by gradual increase in the osmolality of the fluid

4.4. PerforationPerforation (rare)(rare)


Metabolic ComplicationsMetabolic Complications– HyperglycemiaHyperglycemia– HypophosphatemiaHypophosphatemia– Potassium ↑ or ↓Potassium ↑ or ↓– HypomagnesemiaHypomagnesemia– Sodium ↑ or ↓Sodium ↑ or ↓

_ (_ (hyperosmolar, hyperosmolar,

nonketotic coma)nonketotic coma)

Avoided by gradual Avoided by gradual increase in the increase in the osmolality of the fluidosmolality of the fluid

– Re-feeding syndrome-Re-feeding syndrome- intracellular mobilization of K, intracellular mobilization of K, POPO44

– Small bowel necrosis Small bowel necrosis – Pneumatosis Pneumatosis

intestinalisintestinalis


DISEASE-SPECIFIC FORMULAS

Nutritional Support?Nutritional Support?

TPNX?

Nutritional Support?Nutritional Support?

TPN

?☺

As Supportive TherapyAs Supportive Therapy::

Nutritional support can be achieved but Nutritional support can be achieved but alteration in the disease process have not alteration in the disease process have not been established.been established.

New born GITNew born GIT anomaliesanomalies ( gastrochisis, ( gastrochisis,

omphalocele)omphalocele)

Alimentary tract obstruction (achalasia, Alimentary tract obstruction (achalasia, stricture, carcinoma, pyloric obstruction) stricture, carcinoma, pyloric obstruction)

Prolonged ileusProlonged ileus

Prolonged respiratory supportProlonged respiratory support

Large wound lossesLarge wound losses

Parenteral NutritionParenteral Nutrition

PARENTERAL NUTRITIONPARENTERAL NUTRITION Proven efficacyProven efficacy

Radiation & Chemoenteritis, Radiation & Chemoenteritis,

Hyperemesis gravidarum Hyperemesis gravidarum

Efficacy not yet establishedEfficacy not yet established

Pre-op, cardiac cachexia, pancreatitis, Pre-op, cardiac cachexia, pancreatitis,

Ventilatory support, prolonged ileusVentilatory support, prolonged ileus

Under investigationUnder investigation– Cancer, sepsisCancer, sepsis

Indications:Indications: Principal indication is found in seriously illPrincipal indication is found in seriously ill

patients suffering frompatients suffering from Malnutrition, Sepsis,Malnutrition, Sepsis, severe surgical or accidentalsevere surgical or accidental traumatrauma when the when the use of the Gastrointestinal tract for feeding isuse of the Gastrointestinal tract for feeding is not possiblenot possible..

Can be supplemental in patients with Can be supplemental in patients with inadequate oral intakeinadequate oral intake


PARENTERAL NUTRITIONPARENTERAL NUTRITION

IndicationsIndications

Primary TherapyPrimary Therapy– Proven efficacyProven efficacy

GI fistulasGI fistulas

Short bowel syndromeShort bowel syndrome

ATN, Hepatic insufficiencyATN, Hepatic insufficiency

– Efficacy not establishedEfficacy not establishedIBD, Anorexia nervosaIBD, Anorexia nervosa

Parenteral NutritionParenteral NutritionContraindication of TPN:Contraindication of TPN:

1.1. Lack of specific goal for severe metabolic Lack of specific goal for severe metabolic management (inevitable dying).management (inevitable dying).

2.2. Cardiovascular instability / severe Cardiovascular instability / severe metabolic derangement.metabolic derangement.

3.3. Feasible GIT feedingFeasible GIT feeding

4.4. Patient with good nutritional statusPatient with good nutritional status

5.5. Infants with less than 3cm of small bowelInfants with less than 3cm of small bowel

6.6. Irreversible decerebrate (dehumanized)Irreversible decerebrate (dehumanized)


Peripheral TPNPeripheral TPN– 3% AA in 10% dextrose + 10% lipid3% AA in 10% dextrose + 10% lipid

– Used when central line is contraindicatedUsed when central line is contraindicated

– Short-termShort-term

Central TPNCentral TPN– 15-25% dextrose = standard formula15-25% dextrose = standard formula

– 47% dextrose = special formula47% dextrose = special formula

Venous AccessVenous Access

Subclavian AccessSubclavian Access

Venous AccessVenous Access


PeripheralPeripheral CentralCentral

Dextrose contentDextrose content < 5%< 5% > 10> 10

Calorie deliveryCalorie delivery LessLess MoreMore

Volume deliveryVolume delivery MoreMore LessLess

Calorie source*Calorie source* Mostly fatsMostly fats Mostly CHOMostly CHO

Calorie distributionCalorie distribution CHO 30% CHON CHO 30% CHON 20% Fats 50%20% Fats 50%

CHO 55-60% CHON CHO 55-60% CHON 15-20% Fats 25%15-20% Fats 25%


MonitoringMonitoring– Vital signs q 6hVital signs q 6h

– Blood or urine sugarBlood or urine sugar

– I & O q 8hI & O q 8h

– Weight q 2dWeight q 2d

– Electrolytes, PT, PTT, SGPT*, Short turn-Electrolytes, PT, PTT, SGPT*, Short turn-over proteinsover proteins


Basic Composition of FormulationsBasic Composition of Formulations– Carbohydrate = 15-47% dextroseCarbohydrate = 15-47% dextrose– Amino AcidsAmino Acids– Lipid EmulsionsLipid Emulsions– Vitamins, trace elements, electrolytesVitamins, trace elements, electrolytes

Parenteral NutritionParenteral NutritionComponents:Components:1.1. CHON:CHON:

Mixture of single amino acid of synthetic origin, Mixture of single amino acid of synthetic origin, largely produced from “intelligent bacteria” largely produced from “intelligent bacteria” culturescultures

2.2. CHO:CHO: Provides calories; hypertonic dextroseProvides calories; hypertonic dextrose

3.3. Fat emulsion:Fat emulsion: 10 or 20% emulsion of soy or safflower oil 10 or 20% emulsion of soy or safflower oil

emulsions, usually emulsified and stabilized with emulsions, usually emulsified and stabilized with egg phosphatides and lecithinegg phosphatides and lecithin

As Primary Therapy:As Primary Therapy:– TPN influence the disease process:TPN influence the disease process:

1.1. GIT fistulaGIT fistula

2.2. Renal failure (ATN)Renal failure (ATN)

3.3. Short Bowel SyndromeShort Bowel Syndrome

4.4. Acute Burn (severe trauma)Acute Burn (severe trauma)

5.5. Hepatic failureHepatic failure

6.6. With normal bowel length but with malabsorption With normal bowel length but with malabsorption syndrome due to SPRUE, enzymatic or pancreatic syndrome due to SPRUE, enzymatic or pancreatic insufficiency, Ulcerative colitis, regional enteritisinsufficiency, Ulcerative colitis, regional enteritis

7.7. Anorexia nervosaAnorexia nervosa


Parenteral NutritionParenteral NutritionRoute of TPN:Route of TPN: Central Central

hyperalimentationhyperalimentation– Subclavian veinSubclavian vein– Internal jugular veinInternal jugular vein– Femoral veinFemoral vein

Gauge 16, 8-12 inches Gauge 16, 8-12 inches radio-opaque catheter radio-opaque catheter end at SVCend at SVC

Check position w/ Check position w/

x-rayx-ray

Parenteral NutritionParenteral NutritionComplications of TPN:Complications of TPN:

I. Technical complications:I. Technical complications: A. EarlyA. Early: - : - related to catheter insertionrelated to catheter insertion

1.1. PneumothoraxPneumothorax

2.2. Arterial lacerationArterial laceration

3.3. HemothoraxHemothorax

4.4. Mediastinal hematomaMediastinal hematoma

5.5. Nerve injury to the brachial plexusNerve injury to the brachial plexus

6.6. Hydrothorax Hydrothorax

7.7. Air embolismAir embolism

8.8. Catheter embolismCatheter embolism

Parenteral NutritionParenteral NutritionComplications of TPN:Complications of TPN:

I. Technical complications:I. Technical complications:A.A. Late:Late:

Erosion of the catheterErosion of the catheter to the bronchus or right atrium to the bronchus or right atrium

Thrombosis:Thrombosis: Upper arm swelling and pain at the base of the neckUpper arm swelling and pain at the base of the neck Streptokinase / heparin ---> coumadinStreptokinase / heparin ---> coumadin

Septic thrombosis:Septic thrombosis: Antibiotic therapyAntibiotic therapy Fogarty catheter embolectomyFogarty catheter embolectomy Excision of the subclavian vein and superior Excision of the subclavian vein and superior

venacavavenacava


Complications of TPN:Complications of TPN:

II. Metabolic complications:II. Metabolic complications:A.A. Inadequate administration of certain Inadequate administration of certain

nutrientnutrient1. Trace metal deficiency:1. Trace metal deficiency:

a)a) Zinc deficiency:Zinc deficiency: perioral pustular rashperioral pustular rash darkening of the skin creasesdarkening of the skin creases neuritisneuritis

b)b) Copper deficiency:Copper deficiency: microcytic anemiamicrocytic anemia



II. Metabolic complications:II. Metabolic complications:A. Inadequate cont’dA. Inadequate cont’d

2. Essential Fatty Acid deficiency:2. Essential Fatty Acid deficiency: Dry flaky skin w/ small reddish papules and Dry flaky skin w/ small reddish papules and

alopeciaalopecia

B.B. Disorder of Glucose metabolism:Disorder of Glucose metabolism: 1. Hypoglycemia 1. Hypoglycemia – unexpected slowing of the – unexpected slowing of the

glucose infusion / excessive insulin administrationglucose infusion / excessive insulin administration

Parenteral NutritionParenteral NutritionComplications of TPN:Complications of TPN: II.II. Metabolic complications:Metabolic complications:

B.B. Disorder of Glucose metabolism:Disorder of Glucose metabolism: 2. Hyperglycemia2. Hyperglycemia – – most dangerous metabolism most dangerous metabolism

complication in TPNcomplication in TPN Due to rapid infusion (60 ml/hr the increase of Due to rapid infusion (60 ml/hr the increase of

20ml/hr every 24-48 hrs)20ml/hr every 24-48 hrs) DM ( Hyperosmolar nonketotic coma)DM ( Hyperosmolar nonketotic coma) due to due to

osmotic diuresis ---> dehydration, fever, osmotic diuresis ---> dehydration, fever, obtundation and coma ---> death.obtundation and coma ---> death.

Tx: insulin 200 units/day and administration of Tx: insulin 200 units/day and administration of large dextrose free hypo=osmolar solution large dextrose free hypo=osmolar solution (0.45% NSS w/ K+).(0.45% NSS w/ K+).



II. Metabolic complications:II. Metabolic complications:C.C. Liver function derangement:Liver function derangement:

Abnormalities in SGOT / SGPT / Alk. Abnormalities in SGOT / SGPT / Alk. PO4PO4

Fatty infiltrate of liver ----> fat emulsionFatty infiltrate of liver ----> fat emulsion

Parenteral NutritionParenteral NutritionComplications of TPN:Complications of TPN: III. Septic complications:III. Septic complications:

A.A. Catheter infection:Catheter infection: most lethal complication of TPNmost lethal complication of TPN Bacterial / fungal (candida)Bacterial / fungal (candida) Site of entry of the organism ---> site of catheterSite of entry of the organism ---> site of catheter Symptom: - sudden spike of feverSymptom: - sudden spike of fever Management:Management:

− Change TPN bottle, tubes and filter – culture / Change TPN bottle, tubes and filter – culture / investigate for presence of pneumonia, UTI, investigate for presence of pneumonia, UTI, wound infection, etc.wound infection, etc.

− If fever persist after 8 hrs. ---> removed If fever persist after 8 hrs. ---> removed catheter and culture the tip of the tube. catheter and culture the tip of the tube.


Peripheral

Central

Proper Amount and Composition of DietProper Amount and Composition of Diet

Nutritional Requirements in StressNutritional Requirements in Stress

Basic NeedsBasic Needs– 25-30 kcal/kg/day25-30 kcal/kg/day– 30% fat,1 gm protein/kg/day30% fat,1 gm protein/kg/day

Caloric Needs in StressCaloric Needs in Stress– 35 kcal/kg/day rough estimate35 kcal/kg/day rough estimate– MultipliersMultipliers

1.2 1.2 minor or restingminor or resting1.35 1.35 fracturefracture1.6 1.6 sepsissepsis2.1 severe burn2.1 severe burn

Calculation of Caloric NeedsCalculation of Caloric Needs

ConditionCondition Kcal/kg/dayKcal/kg/day Protein/kg/dayProtein/kg/day NPC : N ratioNPC : N ratio

Normal to moderate Normal to moderate malnutritionmalnutrition 25 - 30 25 - 30 11 150 : 1150 : 1

Moderate stressModerate stress 25 - 3025 - 30 1.51.5 120 : 1120 : 1

Hypermetabolic, Hypermetabolic, stressedstressed 30 - 3530 - 35 1.5 – 2.01.5 – 2.0 90-120 : 190-120 : 1

BurnsBurns 35 - 4035 - 40 2.0 – 2.5 2.0 – 2.5 90-120 : 190-120 : 1

Calculation of Caloric NeedsCalculation of Caloric Needs

For malnourished or well nourished For malnourished or well nourished – Actual body weightActual body weight

For obese For obese – Adjusted body weightAdjusted body weight

– = Ideal wt x 0.25 (actual wt – ideal wt)= Ideal wt x 0.25 (actual wt – ideal wt)

For significant fluid overload For significant fluid overload – Estimated body weightEstimated body weight

Calculation of Caloric NeedsCalculation of Caloric Needs ProteinProtein gm/kg/daygm/kg/day 70 kg patient per day70 kg patient per day

– Well-nourishedWell-nourished 0.8 – 1.00.8 – 1.0 56 – 70 gms56 – 70 gms

– Stress, sepsisStress, sepsis 1.5 – 2.01.5 – 2.0

– CRF, ARFCRF, ARF 1.21.2

– Liver failure Liver failure 0.5 – 0.8 0.5 – 0.8

GlucoseGlucose– Well-nourishedWell-nourished 7.27.2 504 gms 504 gms

FatFat– Well-nourished Well-nourished 1.01.0 70 gms70 gms

– Critically illCritically ill 1.01.0

– Brittle diabetesBrittle diabetes 2.52.5

Immune EnhancersImmune Enhancers

GlutamineGlutamine– Conditionally essentialConditionally essential– Heat labileHeat labile– Main fuel for GIT, ISMain fuel for GIT, IS

ArginineArginine– Promotes T cell prolif’nPromotes T cell prolif’n– Precursor of NO, NO3, Precursor of NO, NO3,

NO4, putrescine, spermine, NO4, putrescine, spermine, spermidinespermidine

– Secretagogue for GH, I, Secretagogue for GH, I, Glucagon, PRL, Glucagon, PRL,

O-3 FA, O-4 FA (PUFA)O-3 FA, O-4 FA (PUFA)– Via cyclooxygenase and Via cyclooxygenase and

lipooxygenase pathway lipooxygenase pathway PGI3, TxA3, LTB5PGI3, TxA3, LTB5

– ↓ ↓ bacterial translocation bacterial translocation and mortalityand mortality

NucleotidesNucleotides– RNA, DNA formationRNA, DNA formation– ↓ ↓ = T helper fxn, IL2, = T helper fxn, IL2,

increased mortality after increased mortality after Candida & Staphylococcus Candida & Staphylococcus infectioninfection

BCAABCAA– Stress Stress Protein Protein

degradationdegradation

The FutureThe Future

Growth HormoneGrowth Hormone wound healingwound healing infection rateinfection rate catabolismcatabolism– May be harmful to May be harmful to

critically-ill patientscritically-ill patients

Oxandrolene (Oxandrin)Oxandrolene (Oxandrin) wound healing in wound healing in

critically-ill patientscritically-ill patients

Anabolic agentsAnabolic agents

Five IssuesFive Issues Indications for Nutritional SupportIndications for Nutritional Support


Effectiveness of Nutritional SupportEffectiveness of Nutritional Support In Well-nourished versus Malnourished In Well-nourished versus Malnourished

Route of NutritionRoute of Nutrition Enteral versus ParenteralEnteral versus Parenteral

Appropriate Amount and Composition of DietsAppropriate Amount and Composition of Diets

Surgical NutritionSurgical Nutrition

Roberto B. Acuña, Roberto B. Acuña, MD, FPCS, FPSGS, MD, FPCS, FPSGS, FPSLSFPSLSGeneral and Cancer SurgeryGeneral and Cancer SurgeryLaparoscopic SurgeryLaparoscopic SurgeryHepato-biliary SurgeryHepato-biliary Surgery

FEU-NRMF MEDICAL CENTERFEU-NRMF MEDICAL CENTER

NUTRITIONAL ASSESSMENT

FUNCTIONING GI TRACT?

ENTERAL NUTRITION

YES NO

PARENTERAL NUTRITION

Short Term Long TermOr

Fluid Restriction

Peripheral PN Central PN

GI Function Returns?

YES NO

GI FUNCTION

Long TermGastrostomyJejunostomy

Short TermNasoGastric

NasoDuodenalNasoJejunal

NORMAL COMPROMISED

StandardNutrients

SpecialtyFormulas

NUTRIENT TOLERANCE

Adequate Inadequate Adequate

ProgressTo

OralFeedings

ProgressTo More Complex Dietand Oral Feedings As

Tolerated

PNSupplementation

Progress toTotal Enteral

Feedings

Clinical DecisionMakingAlgorithm forNutritionalSupport

Source: ASPEN Boardof Directors

1. nutritional support in the surgical patient

Health & Medicine

days postopseverely

days postopmoderately

days transferrin

days rbp

sheldon enteral route

enteral feedingmoore

sepsis peritonitis trauma

surgical patients