Nutrition%20in%20Surgical%20Patients

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Nutrition in Surgical Patients

• Ronald Merrell, MD
• Chairman of Surgery
• Virginia Commonwealth University

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What?

• Carbohydrate
• Lipid
• Protein
• Trace elements
• Vitamins

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Who?

• Malnourished (gt10 lean body mass)
• Incapable of eating (gt10 days)

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Why?

• Risks of malnutrition including infection, poor
  healing and higher mortality
• Malnutrition is exacerbated by physiological
  stress

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When?

• Preoperative?
• Early?
• Late?
• ---after initial resuscitation following injury
  or surgery

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How?

• Parenteral
• Enteral
• Total
• Partial

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Issues

• Metabolic response to injury
• Cytokines, inflammation, hormones
• Biology of substrates
• Enteral vs. Parenteral

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Ashen faces, a thready pulse and cold clammy
extremities

• The Ebb Phase
• Cuthbertson, Quart. J. Med.25233,1932

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The Ebb Phase

• Hypometabolic
• Hypothermic
• Hypoinsulinemic
• Hypoperfusion

• Hypercortisolism
• Hyperglucagonemia
• Hyperglycemia
• Hypercatecholemia

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The patient warms up,cardiac output increases
and the surgical team relaxes

• The Flow Phase
• Cuthbertson. Lancet 1233, 1942

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The Flow Phase

• Hypermetabolic
• Hyperthermic
• Catabolic

• Hyperinsulinism
• Hypercortisolism
• Hyperglucagonemia
• High cardiac output

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Nutritional Assessment

• Body weight
• Body mass index
• creatinine height index
• Serum proteinsalbumin, prealbumin, transferrin
• Immune competence lymphocytes, DH
• Nitrogen balance

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Caloric Requirement

• Formula
• Indirect calorimetry
• PRN for nitrogen balance
• Approximation

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Nutritional Requirements

• 25 cal/kg/day
• carbohydrate 70
• Lipid 15-30
• Protein 1.5-2.0g/kg/day. Not for calories
• Additional 50 to 100 for stress as in ICU
  patients

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Nutritional Goals

• Nitrogen balance
• Preserve or restore visceral protein
• Reduce morbidity
• Reduce mortality
• Reduce hospital stay

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Early Enteral Feeding a meta-analysis

• Eight prospective randomized trials with trauma
  and high risk surgical patients(118 enteral, 112
  parenteral)
• Septic complicationsenteral 18, parenteral 35
  
  
  
• Moore. Ann. Surg. 216172,1992

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Parenteral requirements

• Dilution in right heart return because of
  hyperosmolarity.Central Venous Line
• Delivery of simple carbohydrate (20glucose)
• Lipid emulsion
• Amino acids

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Enteral Requirements

• Delivery into the GI tract by tube with minimum
  risk of aspiration or patient effort
• Delivery of nutrients with minimal need for
  digestion
• Control of rate to prevent osmotic diarrhea

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Advantages of enteral nutrition

• Easier
• GI bacterial translocation
• Cheaper
• Fewer specific complications

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Nutrients with specific putative contributions

• Branch chain amino acids
• Glutamine
• Arginine
• Nucleotides
• Omega-3 fatty acids

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Immune Enhancing Diet

• Arginine, nucleotide, fish oil
• Shorter stay, fewer infections
• Bower Critical Care Medicine. 23436, 1995

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Parenteral Nutrition Immunosuppressive IF...

• Poorly administered
• Hyperglycemia
• No nucleotides
• No arginine
• No taurine
• Excessive fats

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Overfeeding with parenteral diets

• Carbohydrate hyperglycemia, hypercarbia, fatty
  liver
• Lipids hypertriglyceridemia, hypoxia, infection
• Protein azotemia

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Conclusions

• Nutrition is a powerful determinate of patient
  outcome
• The proper provision of nutrition is a component
  of basic patient care
• Nutrition is a precise and potentially very
  hazardous form of intervention