NUTRITIONAL SUPPORT IN SURGICAL PATIENTS

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NUTRITIONAL SUPPORT IN SURGICAL PATIENTS

• M K ALAM MS FRCS
• Professor of Surgery
  

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Objectives

• This presentation will explain
• The need for nutritional support
• Consequences of malnutrition
• Methods of assessing malnutrition
• Types of nutritional support its indications
• Routes of providing nutritional support
• Complications

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• ADEQUATE DIET IS NECESSARY TO MAINATAIN NORMAL
  BODY COMPOSITION AND ORGAN FUNCTIONS

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Definition

• Nutritional support is adjuvant therapy used to
• support the surgical patients until they are
  able
• to sustain themselves with adequate spontaneous
• nutrition by mouth.

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• Malnutrition in hospitalized patients is common
• Up to 50 may have moderate malnutrition
• Malnutrition increases morbidity and mortality
• Damaging effects on psychological status,
  activity level and appearance
• Prolongs hospital stay

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ENDOGENOUS ENERGY STORES
CARBOHYDRATE - GLYCOGEN

• Just enough to last one day
• Liver- 400 kcal
• Muscle- 1600 kcal -- not readily available
• Essential for RBC, WBC, bone marrow, eye , renal
  medulla peripheral nerves
• Brain- normally uses glucose, switches to fat in
  starvation
• 1 Gm. 4 kcal

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ENDOGENOUS ENERGY STORES
FAT- ADIPOSE TISSUE

• Largest fuel reserve
• 120,000 kcal in a 70-kg man
• 1 Gm. 9kcal
• Survival during starvation depends upon the
  amount of endogenous fat reserve
  

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ENDOGENOUS ENERGY STORES
PROTEIN

• Lean body mass- 13 Kg in a 70 Kg man
• 30,000 kcal energy store
• Inefficient source of energy
• Used for essential nitrogenous substances for
  maintenance and growth
• Synthesis requires non protein calorie source

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• SIMPLE
• STARVATION
• ? energy expenditure
• ? use of fat for fuel
• ? lipolysis
• ? nitrogen loss
• ? glucose use by brain
• RBC, WBC, renal medulla,
• neurons, muscles intestinal mucosa supply
  maintained

• POST-SURGERY
  STARVATION
• ? hormonal stimulation
• ? cellular activity
• ? metabolic rate
• ? energy expenditure
• ? gluconeogenesis
• ? protein breakdown
• ? nitrogen loss
• ?Lipolysis

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Aim of nutritional support measures

• The provision of nutrients with therapeutic
  intent
• (prevent / reverse the catabolic effects of
  disease or injury).
• Identify in a timely manner patients in need of
  nutritional support
• Provide nutritional requirements by most
  appropriate route to minimise complications

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MAIN CONSIDERATIONS IN NUTRITIONAL
SUPPORT

• Which patient requires nutritional support
• Select the appropriate substrate
• Obtain and maintain access for delivery

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WHICH PATIENT?

• Severely malnourished due to disease
• Become malnourished due to surgical therapy
• Insufficient intake for more than 5-7 days
• Unable to resume dietary intake within 5-7 days

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ASSESSMENT OF NUTRITIONAL STATUS

• History
• Altered oral intake
• Unintentional weight loss ( 10-15 in
  4-6 months)
• Physical examination
• Body weight / BMI wt. in kg/
  height in m² ( normal- 18.5-24.9)
• Mid arm muscle circumference lt60 ( M
  25.5 cm, F 23 cm )
• Triceps skin fold lt60 ( M 12.5mm, F
  16.5mm )

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ASSESSMENT OF NUTRITIONAL
STATUS

• Laboratory evaluation
• Complete blood count
• Lymphocyte count lt 1800/cmm
• Serum albumin lt 30G/L
• Immune competence
• Delayed cutaneous hypersensitivity to
  intra-dermal antigens
• Functional evaluation
• Ability to do daily functions, hand
  grip

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PREOPERATIVE NUTRITIONAL SUPPORT

• Improves outcome in severely malnourished
• If possible, delay surgery
• 5-7 days nutritional support
• Avoid tumor feeding limit calorie protein to
  match need
• Continue nutritional support postoperatively
  

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ASSESSMENT OF NUTRITIONAL REQUIREMENTS

• Optimal nutrition should provide adequate
  requirements of
• Calories- Carbohydrate fat
• Protein
• Water
• Electrolytes
• Trace elements
• Vitamins

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• Energy requirements in adults
• Energy Uncomplicated patients- 25 Kcal/
  kg/ day
• Complicated/ stressed pts.
  30-35 Kcal/kg/day
• Energy source Carbohydrates 70- 80
• Lipids 20

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• Carbohydrates Predominant form used- dextrose
• Optimal oxidation _at_
  4-5mg/kg/min.
• Lipids 20 of total calories
• Lipid emulsion mixed with other
  element 3 in 1

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• Protein
• Uncomplicated patients 1 g / kg/ day
• Complicated/ stressed pts. 1.3-2g / kg/ day

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• Electrolytes
• Sodium - 1 - 1.5 mEq / kg
  /day
• Potassium 0.7 - 1 mEq/ kg/ day
• Calcium 0.2-0.3 mEq/ kg/ day
• Magnesium 0.35-0.45 mEq /kg /day
• 
  adjusted daily
• Trace elements
• Vitamins

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• Fluid requirements
• 100 ml/kg/day first 10 kg body wt.
• 50 ml / kg /day- for next 10 kg
• 20 ml / kg /day- for each additional kg
• 1 ml of water / cal. / day
• Adjust in patients
• - who cannot tolerate large volume
• - additional fluid loss
• - febrile or septic

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ROUTES USED FOR NUTRITIONAL SUPPORT

• Enteral nutrition
• Providing liquid formula diet in to a functioning
  
• GIT to maintain or improve nutritional status
• Parenteral nutrition
• Delivering predigested nutrients directly to
  venous system
• Mixed ( enteral parenteral )
• Tolerate low amount of enteral, weaning from
  parenteral

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Routes of enteral feeding

• Nasogastric tube feeding for short periods
• Fine bore nasoenteric tube- positioned in
  stomach, duodenum,
  jejunum, better tolerated
• Gastrostomy/ jejunostomy surgical/ endoscopic /
  radiologic, neurological diseases,
• head/ neck carcinoma,
• major upper GIT surgery

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Enteral feeding

• Intermittent bolus- suitable for stomach feeding
• Continuous - suitable for duodenum/ jejunum
  feeding
• Initiate at a slow rate, advance as tolerated
• Initially dilute feeds, gradually advance to full
  strength
• Feeding in semi-upright position particularly for
  stomach feeds
• Maintain this position for 2 hours after feeds
• Aspirate (stomach feeding) before next feeding.
• If gt150ml, delay next feed.

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Advantages of enteral
feeding

• Simplicity
• Greater availability
• Lower cost
• Well tolerated
• Maintains gut integrity
• Fewer complications

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Contraindications to enteral feeding

• Intestinal obstruction
• Paralytic ileus
• High output entero-cutaneous fistula
• Short bowel syndrome
• Severe acute pancreatitis
• Malabsorption

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Complications of enteral feeding

• Mechanical tracheobronchial intubation, erosion
• blockage,
  displacement, bowel perforation
• Metabolic Fluid/ electrolyte imbalance,
  hyperglycemia
• Refeeding / overfeeding
  syndromes
• Gastrointestinal Diarrhea, vomiting, pain
• Pulmonary Aspiration
• Infection Tube site

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Total parenteral nutrition- TPN

• Delivering predigested nutrients via
  hyperosmolar
• solution into venous system
• CVN ( central venous nutrition )
  Subclavian /
  Internal jugular,
• Catheter tip in SVC
• Most commonly used
• PVN ( peripheral venous nutrition )
  Solution of lower calorie,
  lower dextrose and higher lipid Suitable for
  7-10 days feeding

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TPN -
Indications

• Non-functioning GIT
• Short bowel syndrome
• Intestinal fistula
• Severe pancreatitis
• Intractable vomiting/ diarrhea
• Severe inflammatory bowel disease
• Developmental anomalies
• Multiple organ failure
• Sever malnutrition ( unable to take orally )

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TPN -
Administration

• Check all laboratory values before starting
• Nutrients given as 3in1 or 21
• Vitamin k given separately
• Heparin insulin can be added
• Start with 1 L , increasing to desired level as
  tolerated
• Monitor- CBC, electrolytes, glucose , urea,
  creatinine, Ca., Mg., phosphorus, bilirubin,
  coagulation profile, ALP, ALT,AST
• Best managed by nutritional support team

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Home TPN

• Long term nutritional support
• Majority have malignancy
• Special catheter- e.g. Hickman
• Subclavian vein through subcutaneous tunnel
• Support system

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Complications of
TPN

• Catheter related
• Vessel injury,
  thrombosis,
• Haemo/ pneumothorax,
  
• Brachial plexus
  injury, air embolism, sepsis
• Metabolic Hyperglycemia, hypoglycemia,
  
  Hypertriglyceridemia, fluid
  electrolyte disturbance,
  Hyperosmolar syndrome, steatohepatitis,
• Refeeding and
  overfeeding syndromes
• Others
• Cirrhosis, acalcular
  cholecystitis,
• Gallstone, osteomalacia

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• Principle Practice of
  Surgery
• 5th edition
• Garden, Bradbury, Forsyth Parks

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