NUTRITIONAL SUPPORT IN SURGICAL PATIENTS

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NUTRITIONAL SUPPORT IN SURGICAL PATIENTS
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INTRODUCTION

• Nutritional disorders in surgical patients have 2
  principal components
• Starvation effect of the disease, restriction
  of oral intake, or both
• - Metabolic effects of stress/inflammation,inc
  reased catabolism,decreased
  
• 
  
  anabolism

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ASSESSMENT OF NUTRITIONAL REQUIREMENTS

• ESTIMATION OF ENERGY AND PROTEIN REQUIREMENTS IN
  ADULT SURGICAL PATIENTS
• Uncomplicated
  Complicated/stressed
• Energy
• (Kcal/kg/day) 30
  34-40
• Protein
• (g/kg/day) 1.3
  1.3-2

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CAUSES OF ADEQUATE INTAKE

• Patient with normal gut
• cumulative effects of repeated
  periods of fasting to undergo investigations such
  as endoscopy or contrast radiology.
• Patient with intestinal failure
• Short bowel syndrome
• Fistula formation
• Motility disorders
• Expensive small bowel
  disease(e.g.crohns disease)

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CAUSES OF ANOREXIA IN SURGICAL PATIENTS

• INTESTINAL OBSTRUCTION
• ILEUS
• CANCER ANOREXIA
• DEPRESSION,STRESS,ANXIETY
• DRUGS e.g Opiates
• ORAL ULCERATION/INFECTION
• GENERAL DEBILITY/WEAKNESS

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METHODS OF ADMINISTRATION OF ENTERAL FEEDS

• NASOGASTRIC OR NASOJEJUNAL TUBES
• GASTROSTOMY
• JEJUNOSTOMY

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COMPLICATIONS OF ENTERAL NUTRITION

• DIARRHOEA
• VOMITING
• DIFFICULTY IN PLACING THE TUBE

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PARENTERAL NUTRITION

• INDICATION FOR TPN (Total Parenteral Nutrition)
• COMPOSITION OF TPN

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STANDARD PARENTERAL NUTRITION REGIMEN

• Non-protein energy
  2200 kcal
• Nitrogen
  13.5g
• Volume
  2500ml
• Sodium
  115mmol
• Pottasium
  65mmol
• Calcium
  10mmol
• Magnesium
  9.5mmol
• Phosphate
  20mmol
• Zinc
  0.1mmol
• Chloride
  113.3mmol
• Acetate
  135mmol
• Adequate vitamins and trace elements

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COMPLICATIONS OF TPN (Total Parenteral Nutrition)

• CATHETER PROBLEMS
• THROMBOPHLEBITIS
• INFECTION
• METABOLIC COMPLICATIONS

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PERIPHERAL VEIN NUTRITION

• Lipid emulsion Isotonic Solutions of Amino
  Acids infused into peripheral veins
• Less irritant than TPN
• Short term usage
• Complication with long term (Thrombophlebitis)

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MONITORING OF NUTRITIONAL SUPPORT

• DEFICIENCY STATES
• ASSESS THE ADEQUACY OF ENERGY
• PROTEIN PROVISION
• ANTICIPITATE COMPLICATION
• Pulse rate / Blood Pressure regularly recorded
• Accelerate fluid Balance Chart
• Urine checked for glycosuria daily
• Body weight measured twice weekly
• Serum Urea Electrolyte daily
• F.B.C, L.F.T , Serum Albumin , Ca,Magnesium,Phosp
  hate once or twice weekly
• Urine collected over one or two 24 hr periods
  each week for Nitrogen balance.

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NUTRITIONAL SUPPORT IN SURGICAL PATIENTS

• Clinical Scenarios

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• 1)A 69 year old man presented with significant
  weight loss and change in bowel habit. A mass was
  felt per rectum and he underwent a difficult
  abdomino-perineal resection, with some feacal
  contamination perioperatively. He has not passed
  flatus since the operation.Recovery is
  anticipated to take a long time.
• Discuss the method of feeding ?

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• 2) A 72 year old woman suffered a left sided
  cerebrovascular accident during an elective
  abdominal aortic aneurysm repair. Four weeks
  later she still has no gag reflex. It is
  anticipated that she will be unable to feed
  herself for sometime
• Discuss the method of feeding?

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• 3) A 71 year old man suffers increasing dysphagia
  over some months.He has a lower oesophageal
  carcinoma.It proves impossible to pass a
  nasogastric tube.He is malnourished and it is
  decided that he will need nutritional support
  before surgery.
• Discuss the method of feeding ?