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SURGICAL NUTRITION

By;Col 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

1) Treatment of primary disorder2) Antibiotic prophylaxis and treatment3) Analgesia4) Fluid and electrolyte management5) 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 Feed1. Who are the patients in need of support2. What and How Much nutritional

elements are required- normal vs. disease

3. How to make assessment of the needs 4. What are the specific needs5. What Route should be used6. 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-Introduction[cont]

• 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 NUTRITIONBasic 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  1. Gender, age & stage of life cycle

(fetus, pregnant, lactating, child, adult, elder),

2. Disease states (malabsorption, maldigestion), inborn errors of metabolism,

3. Lifestyle ( labourer,clerk), 4. 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 expenditureBasal• > 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 (1:150). • Need less protein with renal failure before

dialysis and hepatic encephalopathy. • Multiple trauma/ burn/ sepsis --> 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

1. Nature of disease and operation –oesophagectomy2. Complication -paralytic ileus /peritonitis 3. 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 to3—4g.

• 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 measuresi. Skin fold thickness [10mm]ii. Arm circumference[25cm]iii. 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: <1000-1200 /uL =mod to severe malnutrition.

• 4.  Serum Transferrin: < 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 change2) Dietary intake change3) GI symptoms 4) Functional capacity5) Underlying disease (+ metabolic demand)

Physical Examination:1) Lossness of subcutaneous fat2) Muscle wasting3) Ankle edema4) sacral edema5) ascites

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C-Nutrition in surgical patients Nutritional Assessment Genaeral Assessment of Nutritional Status

History and physical examination1. Well nourished2. Moderately malnourished 3. 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 (<3%)• 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 ComplicationsPar-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

Markers[Transthyretin ] 4. Evaluating Acid/Base Balance 5. Vitamins and Minerals 6. Liver Dysfunction

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THANKS