??? ?? (??? ??) Surgical Nutrition

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??? ?? (??? ??)Surgical Nutrition

• ????? ?????
• ???? ??????
• ? ? ?
• Department of General Surgery
• Organ Transplantation Center,
• Inje University, Pusan Paik Hospital
• Byong Wook Lee, M.D.
• bwleemd_at_ijnc.inje.ac.kr potrac_at_thrunet.com

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Inflammatory Response
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Metabolic Response to Injury
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Metabolic Response to Fasting- Glucose
homeostasis
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Metabolic Response to Fasting
60g
120g
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Gluconeogenesis from 3 carbon presursors - Cori
(lactate) and Alanine Cycle (pyruvate)
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Gluconeogenesis from 3 Carbon precursors -
glutamine, pyruvate
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Metabolic Response to Starvation
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Fat metabolism during Starvation
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Metabolism after Injury

• Sustained activities of macroendocrine
  hormones
• Immune cell activation

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Metabolism after Injury- Energy Balance

• Increase in energy balance directly with severity
  of injury
• Increased activity of SNS
• energy required for ion pump action to maintain
  normal transmembrane concentration overcoming
  increased cell membrane sodium permeability

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Metabolism after Injury Substrate Metabolism
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Interorgan Flux of Nutrients after Injury
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Metabolism after Injury- Lipid Metabolism 1

• Free fatty acid predominant energy source afer
  injury
• Increased lipolysis by catecholamine, and other
  stress hormones and reduction in insulin level
• Continuation of net lipolysis during flow phase
  oxidation for cardiac and skeletal muscle energy
  source
• Fatty acid induced inhibition of glcolysis in
  moderate injury
• not in severe injury, hemorrhage, or sepsis
  (persistent glycolysis and net proteolysis)
• Lipoprotein lipase in endothelium
• Cytokine

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Metabolism after Injury- Lipid Metabolism 2

• High concentration of intracellular fatty acids
  and elevated concentration of glucagon
• ? inhibition of fatty acid synthesis
• ? simulate transport of acyl CoA into
  mitochondria for oxidation and
• ketogenesis in liver
• Keotgenesis
• variable and inversely correlated with severity
  of injury
• Decreased after major injury, severe shock and
  sepsis
• Suppressed by increases in levels of insulin and
  other energy substrates
• Suppressed by increased uptake and oxidation of
  free fatty acids
• Suppressed by an associated counter regulatory
  hormone response

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Metabolism after Injury Carbohydrate Metabolism

• A state of relative insulin resistance
• Net gluconeogenic response due to active control
  of glucagon with permissive requirement for
  cortisol Proinflammatory mediators
• Reduced glucose oxidation mediator induced
  reduction of skeletal muscle pyruvate
  dehydrogenase activity ? shunting of 3-carbon
  skeleton to liver
• Increased hepatic gluconeogenesis ? Hyperglycemia
  
• ? energy source of nervous system, wound, RBC,
  WBC
• Wound
• increase in glucose uptake associated with an
  increased in activity of phosphoructokinase
• dereased insulin sensitivity and failed glucose
  uptake and glycogenolysis in response to insulin

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Metabolism after Injury Protein Metabolism

• Net proteolysis
• Skeletal muscle depletion with relative
  preservation of visceral tissue
• Extracellular hormonal millieu, proinflammatory
  cytokines
• Ubiquitin-dependent proteolytic pathway
  upregulated by intracellular oxidative
  intermediates and antioxidants
• Greater release of glutamine and alanine than
  normal concentration of muscle
• Glutamine major energy source for lymphoytes,
  fibroblasts, and GI tract

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Ubiquitin-ATP dependent Proteolysis
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Severity of Injury and Proteolysis
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Nutrition in the Surgical Patients

• Obligatory increases in energy expenditure and
  nitrogen excretion
• Post-injury metabolic environment precluding
  efficient oxidation of fat and ketone production
• ? continued erosion of protein pools
• ? critical organ failure

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Nutritional Supprot of the Surgical Patient-
Protein

• Requirement
• Average normal requirement 0.8 g/Kg/d
• Essential amino acids
• On parenteral nutrition, 200-250 nitrogen/Kg/d

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Nutritional Support of the Surgical Patient
Calories

• Caloric Sources
• Amino acids 15 (BCAA 6-7)
• Fat 70-75
• Carbohydraes 10-15
• Calorie-Nitrogen Ratio
• Normal ratio for protein synthesis 100-1501
• Changes in different disease states
• 1001 for sepsis, 4001 for uremia

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Nutritional Support of the Surgical Patient
Energy Requirement

• BEE
• 66.5 13.7 x weight (Kg) 5.0 x height
  (cm) 6.8 x age (yr.) male
• 655.1 9.56 x wt 1.85 x ht 4.68 x age
  female

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Nutritional Support of the Surgical Patient -
Carbohydrates

• Supplement calories without elevating glucose
  concentration
• Lipid supplementation replacing glucose as
  energy source
• lipid not efficient in severe sepsis

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Nutritional Support of the Surgical Patient - Fat

• Caroric source
• Source of essential fatty acids providing
  precursors of PGs
• Modifying inflammatory and immunologic response
• 25 of nonprotein calories as fat optimal for
  hepatic protein synthesis
• Fat overload syndrome
• lt 2 g/Kg/d for adults
• lt 4 g/Kg/d for infants

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Nutritional Assessment

• Estimate changes in body nutritional composition
  to predict risk for surgery
• Evaluation of nutritional system measurement of
  functional lean body mass (muscular, respiratory,
  cardiac, hepatic, renal, immunologic and host
  defense function)
• Prognostic Nutritional Index (PNI)
• 158- 16.6 alb 0.78 TSF 0.20 TFN 5.8 DH

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Bases of PNI
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Malnourished Patients at Risk

• Recent weight loss gt 10 body weight and/or body
  weight 80-85 ideal body weight
• Serum albumin in a stable, hydrated patient lt 3.0
  g/dl
• Anergy to injected skin recall antigens
• True transferrin lt 200 mg/dl
• History of functional impairment
• Significant deficits in hand dynamometry or
  muscle response to nerve stimulation

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Indication for Nutritional Support

• Premorbid state
• Nuritional status
• Age
• Duration of starvation
• Degree of anticipated insult
• Likelihood of resuming normal intake soon
• Weight loss of 15
• Serum albumin level lt 3.0 g/d

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Route of Administration- Enteral route

• More physiologic
• Costs less
• Protects and improves hepatic function
• Mimics normal ingress of nutrients to liver
• Maintains gut mucosal integrity
• early gut feedings resulting in lower mortality
  and septic complication rates in posttraumatic
  situation
• Prevention of bacteria and/or their products from
  translocating the gut mucosa
• releasig catecholamines and other counter
  regulatory stimuli, ? preventing hypercatabolism
• Increased substrate supply to the liver
• ? improved hepatic acute phase protein synthesis

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Enterocyte-specific Nutritional Substrates-
Glutamine

• Conditionally essential amino acid
• 40 of available glutamine taken up by gut from
  general circulation
• Addition of 2 glutamine to parenteral nutrition
  maintains jejunal or ileal mucosal thickness,
  protein content and DNA
• Prevention or healing of chemotherapeutic or
  radiation toxicity
• Regrowth after massive small bowel resection

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Enterocyte-specific Nutrients Short Chain
Fatty Acids

• Acetoacetate (10), propionic acid (50),
  butyrate (80)
• Produced by fermentation of soluble pectin by
  colonic bacteria
• Disruption of colonic mucosa in deficient state
• BHBA
• wall thickening and increased protein content of
  ileum and colon
• 70 of energy supply to colonic mucosa
• Stimulation of ketogenesis, increased ATP
  generation, lipolysis, absorption of sodium and
  potassium

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Principles of Eneral Feeding

• Stmachprincipal defense against an enteral
  osmotic load
• Duodenum calcium,iron and other metal absorption
• Small bowel principal area for nutreint
  absorption
• Terminal ileum enterohepaic circulation
• Bile and pancreatic juice fat and protein
  absorption
• Immunologic functions of the gut
• largest immunoogic organ in the body GALT,
  secretory Igs
• Secretion of mucin
• Gut mucosal barrier function

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Practical Enteral Feeding

• Goals of Nutritional Support
• Use the gut if possible
• Administer at least 20 of caloric and protein
  requirement by gut
• Smalllest possible nasgastric tube, tip at the
  duodenum
• Constant infusion except at bed time, head up 30?
• For gastric feeding, first osmolality and then
  volume,
• reversed for jejunal feeding
• Complications
• Malposition and/or aspiration
• Diarrhea, dehydration, hyperglycemia and ions
• Pneumaosis intestinalis with perforation
• Hyperosmolar nonketotic coma
• perforation

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Parenteral Nutrition- Peripheral
Hyperalimentation

• Without protocol
• Lipid system
• 10-20 of caloric need as fat emulsion
• 5 dextrose and amino acids
• Hypocaloric amino acids and 5 dextrose or
  glycerol solution
• Dextrose free amino acids by allowing utilization
  of endogenous fat secondary to low plasma insulin
  level
• Minimize nitrogen breakdown for limited periods
  of time

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Parenteral Nutrition- Central Approach

• Silastic or Teflon-coated catheters
• Percutaneous or open
• Temporal or permanent
• Enforced protocol for TPN
• Nutritional requirements
• 250 mg nitrogen/Kg/d
• 35 Kcal/Kg/d
• 20-25 of nonprotein calories as fat
• Adequate vitamin and trace minerals

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Parenteral Nutrition - Indications

• Primary Therapy
• Efficacy shown
• GI-cutaneous fistula
• Renal failure
• Short bowel syndrome
• Acute burns
• Hepatic Failures
• Efficacy not shown
• Crohns disease
• Anorexia nervosa

• Supportive therapy
• Efficacy shown
• Acute radiation enteritis
• Acute chemotherapy toxicity
• Prolonged ileus
• Weight loss preliminary to major surgery
• Efficacy not shown
• Before cardiac surgery
• Prolonged respiratory support
• Large wound losses

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Complications of Parenteral Nutrition- Technical

• Placement complications
• Pneumothorax
• Arterial lacerations
• Hemothorax
• Mediastinal hematoma
• Nerve injury
• Late complications
• Erosion of catheter
• Subclavian thrombosis
• Septic thrombosis

• Sympathetic effusion
• Thoracic duct injury
• Air embolism
• Hydrothorax
• Catheter embolism

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Complications of Parenteral Nutrition -
Metabolic Complications

• Plasma electrolyte abnormalities
• Trace mineral deficiency
• zinc, copper, chromium, selenium
• Essential fatty acid deficiency
• Disorders of glucose metabolism
• Hypoglycemia
• Hyperglycemia
• Diabetic patient hyperosmolar nonketotic coma
• Liver function derangements

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Parenteral Nutrition Order Form
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Complications of Parenteral Nutrition Septic
Complications

• Catheter Infection
• Absence of proocol
• Degree of colonization of the pericatheter skin
  gt 103
• G() organism from remote site seeding the fibrin
  sleeve along catheter vs G(-) organism
• Candida from the gut
• Management of patient with suspected catheter
  sepsis

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Prevention of Catheter Complications

• Catheter Placement

• Nutritional Support teams and Protocols

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Nutritional Protocol
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Parenteral Nutrition for Pediatric Patients

• More rapid growth
• High proportion of viscera with little fat or
  muscle
• Incompletely developed enzyme system
• Liable to heat loss
• Nutritional Requirements in Pediatric Patients

Protein (g/Kg/d) 0-6 mo 6-12 mo School age Adolescent C/N
Protein (g/Kg/d) 2.5-3.0 2.0-2.5 1.75 1.2 1501
Calories Newborn or premature Infant ( 10Kg) 10-20 Kg gt 20 Kg
120 100 100 50 100 50 20
Fat ? 35 of calories (up to 3.5 g/Kg/d) ? 35 of calories (up to 3.5 g/Kg/d) ? 35 of calories (up to 3.5 g/Kg/d) ? 35 of calories (up to 3.5 g/Kg/d) ? 35 of calories (up to 3.5 g/Kg/d)
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Home Hyperalimentation

• Silastic catheters with long subcutaneous tunnel
• Mean catheter life 7 years
• Overnight PN
• Septic complications

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Nutritional Pharmacology

• Nutritional support to change either the milieu
  or the pathophysiology of a disease process to
  affect outcome
• Arginine
• Glutamine
• Nucleotides
• Omega 3-fatty acids
• Ketone bodies

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