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Surgical Nutrition

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by

Leon Foo

on 10 June 2014

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Transcript of Surgical Nutrition

Thank You!
Leon Foo Jing En
Surgical Nutrition
Objectives
Indications for Nutritional Support
Determination of Nutritional Status
Route of Nutrition
Enteral Vs Parenteral
Who are the patients that needs nutritional support?
Indications
Patient who are nutritionally depleted
Patients who are unable to take nutrients by GI Tract
Those who should not take nutrient by the GI Tract because of an inherent risk or complicate management of their current surgical disease
Examples
Severely Malnourished
Short Bowel Syndrome
Patient not expected to feed in 7 days
Prolonged ileus or intestinal obstruction
Entero-cutaneous fistulas
Pancreatitis
Major bowel surgery
Esophageal replacement
Gastric or Colon surgery
Whipple's procedure
Nutritional Assessment
Laboratory Techniques
Route
of
Nutrition
GIT Functional?
Enteral Route
Parenteral Route
YES
NO
Advantages
More physiological (liver not bypassed)
Lesser cardiac work
safer and more efficient
better tolerated by patient
more economical
Enteral Access
Nasogastric Tube (Ryle's)
Gastrostomy
Jejunostomy
PEG (Percutaneous Endoscopic Gastrostomy)
Trans-gastric Jejunostomy)
Complications of Enteral Feeding
Tube related:
Malposition
Displacement
Blockage
Breakage / Leakage
Local Complications:( e.g. erosion of skin/ mucosa)

Gastrointestinal:
Diarrhoea
Bloating, nausea, vomiting
Abdominal cramps
Aspiration
Constipation

infective:
Exogenous (handling contamination)
Endogenous (patient)

Metabolic complications
Route of delivery
TPN can be administered either by a catheter inserted in the central vein or via a peripheral line.
Peripheral
For short term feeding up to 2 weeks
Using a conventional short cannula in the wrist veins or peripherally inserted central venous catheter (PICC) line
Disadvantage - thrombophlebitis
Central
the catheter can be inserted via the subclavian vein or internal or external jugular vein.
Safest to insert line under ultrasound guildance
Disadvantage of jugular vein approach: the exit site is situated inconveniently on the side of neck, where repeated movements redult in disruption of dressing with attendant risk of sepsis
infraclavicular subclavian approach is more suitable for feeding as catheter then lies flat on chest wall, which optimises nursing care.
Complications
Related to nutrient deficiency
Hypoglycemia/ Hypocalcemia/ Hypophophataemia/ hypomagnesaemia (Refeeding Syndrome)
Chronic deficiency syndromes (essential fatty acids, zinc, mineral and trace elements)

Related to ovefeeding
Excess glucose: hyperglycemia, hyperosmolar dehydration, hepatic steatosis, hypercapnia, increased sympathetic activity, fluid retention, electrolyte abnormalities
Excess fat: hypercholesterolaemia and formation of lipoprotein X, hypertriglyceridaemia, hypersensitivity reactions
Excess amino acids: hyperchloraemic metabolic acidosis, hypercalcaemia, aminoacidaemia, uraemia
Related to Sepsis:
Catheter-related sepsis
Possible increased predisposition to systemic sepsis

Related to Line
On insertion: pneumothorax, damage to adjacent artery, air embolism, thoracic duct damage, cardiac perforation or tamponade, pleural effusion, dromediastinum
Long term use: occlusion, venous thrombosis
No single biochemical measurement
low serum albumin level (<30) is an indicator of poor prognosis
Hypoalbuminaemia occurs because of alterations in body fluid composition & increased capillary permeability related to on-going sepsis

Defective immune function - measurement of Lymphocyte count and delayed hypersensitivity
Body Weight & Anthropometry
Simple method to assess nutritional status is to estimate weight loss.
Unintentional weight loss >10% of patient weight in the preceding 6 months is a good prognostic indicator of poor outcome.
Body Mass Index (BMI - body weight in Kg divided by height in metres squared)
BMI <18.5 indicates nutritional impairment; BMI <15 is associated with significant hospital mortality
Anthropometric techniques - indirect measures of energy and protein stores
Use of Bioelectrical impedence analysis (BIA) permits estimation of intra- and extracellular fluid volumes
Clinical
A clinical assessment of nutritional status (Subjective global assessment) involves:
Focused history and physical examination
an assessment of risk of malabsorption or inadequate dietary intake
selected laboratory tests aimed at detecting specific nutrient deficiencies.
Delivery of nutrients into the gastrointestinal tract
Achieved with oral supplements (Sip Feeding)or with a variety of Tube feeding techniques delivering food into the stomach, duodenum or jejunum.
Electrolyte disorders
Vitamin, Mineral, Trace element deficiencies
Drug interactions
Total parenteral nutrition (TPN) is defined as the provision of all nutritional requirements by means of the intravenous route.
Parenteral nutrition is indicated when energy and protein needs cannot be met by the enteral administration of these substrates.
Enteral Nutrition
Oral supplements
Ensure, Sustagen

Tubal feedings
Blenderized Diet
Polymeric - Osmolite, Isocal
High Caloric Density - Magnacal
Monomeric - Vivonex Ten
Disease Specific - AminAid, Hepatic Aid
Parenteral Nutrition
Reference
Bailey & Love 25th Edition
Subjective Global Assessment Form - www.health.qld.gov.au/nutrition/.../hphe_sga.pdf
Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition National Institute for Clinical Excellence
http://emedicine.medscape.com/article/110152-overview#showall

Increased counter-regulatory hormones: adrenaline, noradrenaline, cortisol, glucagon and growth hormone
Increased energy requirements (up to 40 kcal/kg/day)
Increased nitrogen requirements
Insulin resistance and glucose intolerance
Preferential oxidation of lipids
Increased gluconeogenesis and protein catabolism
Loss of adaptive ketogenesis
Fluid retention with associated hypoalbuminaemia

Metabolic response to trauma and sepsis
Prolonged period without caloric intake
Functional GI tract
Inadequate oral intake
Avoid gut mucosal atrophy, preventing intestinal bacterial translocation and related sepsis
Major burns and trauma.


Indications
Product for enteral feeding
Polymeric feeds- intact protein; require digestion
Monomeric/Elemental feeds – contains nitrogen (free amino acids or peptides).
Newer feeding formulations:
(a) glutamine and fibre -to optimise intestinal nutrition or
(b) immunonutrients such as arginine and fish oils - expensive and their use is controversial.

when energy and protein needs cannot be met by enteral administration of these substrates.
who have undergone massive resection of small intestine (short bowel syndrome)
who have intestinal fistula or
who have prolonged intestinal failure for other reasons.


Indications
Peripheral TPN
3% amino acid in 10% dextrose + 10% lipid

Central TPN
15-25% dextrose = standard formula
47% dextrose = special formula
Vital signs – every 6h for initial 24-48 h.
Fingerstick glucose determinations every 6h to monitor for hyperglycaemia.
Weight check every other day.
Twice-weekly blood work:
Electrolytes, glucose, liver enzymes, Ca⁺⁺, PO₄̄̄, prothrombin, pTT, CBC, short-turnover proteins, if available.



Monitoring
Full transcript