NUTRITION IN SURGERY

NUTRITION IN SURGERYDR PRAJWAL

MODERATOR: DR ELROY

Aim of nutrition support is to identify patients at risk for malnutrition and to meet their nutritional requirements

Malnutrition has high risk of complications plus mortality

Metabolic response to starvationWithin 12 hours of fastingInsulin level and Glucagon level Glycogenolysis (liver glycogen to glucose)Coris cycle> 24 hours Gluconeogenesis in liver48 72hrs : Lipolysis and Adaptive Ketogenesis

glycogen in muscle is broken down(glycogenolysis) to lactate, converted to glucose in liver (Coris cycle)

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In trauma/ sepsis..Increased counterregulatory hormones Increased energy requirement( 15- 25% more)Increased nitrogen requirementInsulin resistance / stress induced hyperglycemiaPreferential oxidation of lipidsIncreased gluconeogenesis / protein catabolismLoss of adaptive ketogenesisFluid retention with hypoalbuminemia

INSULIN RESISTANCE DUE TO INCREASED CYTOKINES AND DECREASED GLUCOSE TRANSPORTER PROTEINS, FOLLOWING SURGERY 2 WEEKS OF INSULIN RESISTANCE WILL BE THERE,. DEGREE OF INSULIN RESISTANCE PROPORTIONAL TO MAGNITUDE OF INJURY5

Energy requirements

One g carbohydrate provides about 3.4 KCal, whereas 1 g fat provides about 9 KCal. Protein 4 KCal for each g.

An average adult needs 30--35 KCal/Kg/day

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Nutritional AssessmentDietary History and History of weight loss

Physical Examination: General appearance( emaciated, apathetic look)Assessment of body fat stores (Skin fold examination over biceps and triceps, subscapular region)Assessment of protein stores (Muscle bellies of biceps, triceps, supra and infraspinatus)Assessment of metabolic stress (indirect calorimetry , temp, wbc count, pulse, positive blood culture, abscess)Physiological fn poor wound healing, early fatiguability, grip strength, resp muscle fn test

RQ 1 : carbohydrate utilization. 0.8 : pure protein oxidation 0.7 :pure fat utilization7

Body weight and Anthropomentry

Laboratory tests: Serum albumin levels, Lymphocyte count, Skin hypersensitivity tests

THE MUST TOOL BMI, WT LOSS IN 3-6 MTHS, ACUTE DISEASE.

MALNUTRITION UNIVERSAL SCREENING TOOL8

Nutrition support given to..Past medical historyInvoluntary lossBlood loss >500mlBMI < 18.5 kg/m2Serum albumin 75 % small bowel resectedIf ileocaecal removedIf remaining bowel is diseased with impaired absorption

Decrease in intestinal surface area, decrease in intestinal transit time, decrease in intestinal absorptionGastric acid hypersecretionD Lactic acidosisNephrolithiasis

Diarrhoea, hypovolemia, hypokalemia67

TREATMENTImmediate Post op period: Adequate replacement of IV fluid, electrolytes with zinc and H2 receptor antagonists

Bowel adaptation period: Enteral feeding started as soon as possible once stool output is less than 1000ml/day. Glutamine and medium chain triglycerides to maintain mucosal healing

Long term treatment: Small and frequent oral feeds started, in intact colon diet rich in complex carbohydrates are given. If terminal ileum resected, vitamin b12 given monthly and in patients with d lactic acidosis carbohydrate diet is reduced

Gastrointestinal fistulaDiversion of intestinal contents commonly to skinCommon causes: Crohns, Bowel injury, Bowel surgery, Radiation injuryHigh output fistulas: >500ml fluid loss

REFERENCESBAILEY AND LOVE 26 TH EDITIONSABSITON 17TH EDITIONS.DAS OPERATIVE SURGERY 5 TH EDITIONPYES SURGICAL HANDICRAFT NUTRITION SUPPORT THEORY AND THERAPEUTICS- SCOTT A SHIKORA, GEORGE L.BLAKBURNPRACTICAL GUIDELINES ON FLUID THERAPY 2ND EDITION SANJAY PANDYAMEDSCAPE ONLINE RESOURCES