Surgery and Trauma

8/12/2019 Surgery and Trauma

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Surgery and Trauma

I. Definition1. Surgerytreatment of disease by manual or instrumental operations2. Trauma

*severe injury caused by an accident or injury of the central nervous system and heart affected by shock*severe injury caused by an accident or injury, violent disruption, or ingestion of a toxic substance

Classification according to etiology:a. Thermal (burns)b. Neurologic (central nervous system or brain)c. Severe emotional shockd. Chemical (toxic agent)e. Physical (multiple fracture, major surgery)

3. Sepsisuncontrolled infection from fungal or bacterial agents*the spread of infection from one part of the body to the other areas via the circulatory system is calledsepticemia

4. Bacterial translocationmigration of bacteria from wound infection sites into other sites via portalcirculation, leading to sepsis or multiple organ failure

5. Multiple Organ Dysfunction Syndrome (MODS)may occur following trauma, thermal injury, infection,pancreatitis, and shock; it generally begins with lung failure followed by failure of the liver, intestine, kidney,hematologic, and myocardial functions

II. Metabolic Response to StressA. Ebb phaseimmediately following injury; initial response to bodily insult

Characteristics: lower blood pressure, cardiac output, body temperature and oxygen consumption

associated with hypovolemia, hypoperfusion, and lactic acidosis

B. Flow phasea neuroendocrine response to physiologic stress that follows the ebb phasefollows after fluid resuscitation and restoration of oxygen transport

1. Acute Response (Catabolism)Characteristics: increased cardiac output, oxygen consumption, body temperature, energy

expenditure, and total protein catabolism; increased production of glucose, freefatty acid release, circulating levels of insulin, catecholamines, glucagons, andcortisol

2. Adaptive Response (Anabolism)Characteristics: associated with recovery, decreased metabolic rate, hormonal response graduallydiminishes, restoration of protein status, wound healing


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Characteristics of metabolic phases occurring after severe injury

Flow Phase

Ebb-Phase Response Acute Response Adaptive Response

Hypovolemic ShockDecreased

Tissue perfusionMetabolic rateOxygen consumption

Blood pressureBody temperature

Catabolism predominatesIncreased

GlucocorticoidsGlucagonCatecholamines

Excretion of nitrogenMetabolic rateOxygen consumption

Release of cytokines, lipid mediatorsProduction of acute-phase proteinsImpaired use of fuels

Anabolism predominatesHormonal response gradually

diminishesDecreased hypermetabolic rateAssociated with recovery

Potential for restoration of body proteinWound healing depends on nutrient

intake

III. Nutritional CareAim: to improve the preoperative nutritional state in preparation for the stress of surgery, to hasten

recovery, and to maintain good nutrition and rapid healing in the postoperative period

A. Preoperative Diet1. High kilocalorie, high protein at least 7 days prior to surgery to improve nutritional status if

malnourished2. Regular consistency 8 -12 hours prior to surgery3. Low residue or clear liquid diet 2436 hours prior to surgery if bowel preparation is indicated4. NPO the night before surgery5. Enteral and parenteral nutrition as needed

B. Postoperative Diet1. NPO for 2449 hours2. Clear liquids to soft, then regular as bowel movement returns3. High protein to promote wound healing4. Vitamins and minerals as needed to promote wound healing5. If surgery involves the GIT, further modifications may be needed

Cleft Lip and Palate (CLAP)

Cleft lip (harelip)a congenital cleft of the upper lipCleft palatecongenital deformity characterized by incomplete closure of the lateral halves of the palate or roof ofthe mouth

I. Etiology: inbornII. Feeding difficulties

1. Inability to suck adequately2. Food passes through the roof of the mouth into the nasal cavity3. Food may back up in the nose and can cause choking

III. Treatment: Surgical repair


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IV. DietA. For newborn infants

1. A medicine dropper or a plastic bottle and a soft nipple with enlarged hole may be used due toinability to suck

2. Small feedings are given, slowly in an upright position to prevent aspiration3. Frequent burping to expel large amount of air swallowed

B. For older infants*supplementary foods are mixed with milk and given by bottle with large nipple holes

Gastrectomysurgical removal of all or part of the stomachNutritional Care

Aim: to provide a nutritionally adequate diet and reduce the symptoms of dumping syndrome to a level thatthe patient finds tolerable

Diet1. Small, frequent meals to decrease intestinal distention. Preferably easy to digest, soft, low-fiber diet2. Simple CHO restricted to prevent the formation of hyperosmolar intestinal content3. Milk and other lactose-containing foods should be regulated depending on tolerance4. Fluids should not be taken with meals to delay emptying of solids, preferably taken with 4560 minutesbefore or after meals; important to prevent dehydration5. High protein, high kilocalories to maintain weight6. Fat: moderate to low due to malabsorption7. MCT oil for better fat absorption8. Vitamin B12 supplementation (100g IM monthly) to correct macrocytic anemia in the absence of intrinsic

factor; may also be given parenterally9. Supplemental vitamins and minerals: folate, iron, calcium, and vitamin D

Ostomythe surgical procedure of creating an opening, or stoma, in the wall of the abdomen

I. Conditions usually requiring Ostomy Procedurea. Colon and rectal cancersb. Ulcerative colitisc. Crohns diseased. Severe diverticulitise. Familial polyposis

II. Types of Feeding Ostomiesa. Esophagostomysurgical opening into the esophagus (not common)b. Gastrostomysurgical opening into the stomachc. Jejunostomysurgical opening into the jejunum

III. Nutritional CareAim: to maintain or improve nutritional status, to avoid or reduce gas, odor, or obstruction of the ostomy

Diet1. to avoid obstruction

a. drink plenty of fluids c. chew foods thoroughlyb. avoid high-fiber foods d. avoid corn, coleslaw, lettuce, fruits

2. to avoid flatulence or undesirable odorAvoid gas-forming foods such as cabbage, beans, beer, carbonated beverages, fish, and onions


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Short Bowel Syndrome (SBS)set of symptoms resulting from massive resection of the small intestine; it is life-threatening especially if more than 50% of the organ is removed

I. Etiologya. Treatment of cancerb. Diverticulitisc. Local abscessd. Fistulae. Ulcerative colitisf. Crohns disease

g. Perforationh. Sclerodermai. Mesenteric vascular accidentj. Obstructionk. Radiation enteritis

II. Characteristicsa. Maldigestionb. Malabsorptionc. Electrolyte abnormalities

d. Dehydratione. Nutrient deficiencies

III. Complications of SBSa. Malabsorption of micronutrients and macronutrientsb. Fluid and electrolyte imbalancesc. Weight lossd. Growth failure (in children)

IV. Nutritional CareAim: to provide nutrition parenterally and/or enterally; to enable the remaining small bowel to increase its

absorptive surface area through hyperplasia and the formation of higher villi and deeper crypts ofLieberkuhn

Diet1. Removal of >100 cm of small bowel usually requires total parenteral nutrition (TPN) for nutrition support2. TPN initially required for several weeks until patient can tolerate feeding per orem or enteral diet

3. High protein, high kilocalories to restore protein losses and stabilize weight within normal4. Supplements, specifically calcium, magnesium, iron, zinc, fluids, and fat-soluble vitamins and multivitamins

when shifted to an oral diet5. Six small meals daily for better tolerance6. Restrict fiber, lactose, and fat to reduce stool output7. Glutamine-enriched enteral feeding solutions

Post-surgical Phasesa. 710 days of severe diarrhea, fluid losses, and electrolyte imablancesb. 2 months or more of anorexia, mild diarrhea, steatorrhea, and weight lossc. Up to 2 years of continued bowel adaptation after surgery, with accompanying consequences

including anemia, osteomalacia, gallstone formation, gastric hyperacidity, dehydration, diarhea,steatorrhea, hypocalcemia, hypomagnesemia, vitamin deficiencies (A, D, E, K, B12) and PEM

Tonsillectomy and Adenoidectomy (T & A)surgery to remove diseased tonsils and/or to correct adenoidal impairment

Diet1. Full liquid diet for the first meal2. Mechanical soft diet for the second and third meals3. Regular or general diet for subsequent meals4. Avoid foods that are irritating to the throat like citrus fruits and juices5. Avoid dry foods (ex. Toasts) and very hot liquids


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Burnstissue injury or destruction caused by excessive heat, caustics (acids or alkalis), friction, electricity, or radiation

I. ClassificationA. Partial or full thickness burns

1. Partial thickness (PT) burns (first and second degree burns): not all of the epithelium is destroyed,therefore these wounds can regenerate

2. Full thickness (FT) burns (third degree burns): all epithelial remnants are destroyed andautografting is required

B. Burn injury severity1. Minor Adults: PT20% TBSA; FT


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2. No attempt is made to meet nutritional requirements at this stage3. Feeding should be initiated once resuscitation is complete (within 4 to 12 hours)

B. Recovery Period48 to 72 hours postburnFluid balance is gradually re-established

C. Secondary feeding Periodtowards the end of the first postburn week; as adequate bowel functionreturns, vigorous feeding must be initiated

V. Nutrient ModificationsA. High Energy

1. Requirements may vary according to the size of the burn2. May be calculated using various formulas (ex. Curreri formula)3. Additional calories may be required due to fever, sepsis, multiple trauma

B. Protein1. High requirements due to losses through the urine and wounds; increased used in

gluconeogenesis and wound healing2. 20 to 25% of total kilocalories3. High biologic value4. 2.5 to 3.0g/kg body weight for children

C. Carbohydrates1. Main energy source for protein-sparing2. Maximum glucose load of 7 mg/kg/min3. Excessive glucose can aggravate hyperglycemia

D. Fats1. 1520% of non-protein kilocalories2. Too high levels may cause deleterious immunologic response and increased susceptibility to

infections3. Use of MCT ad structured lipids are currently under investigation

E. Vitamins and Minerals1. Increased needs but exact requirements have not been established2. Vitamin C is increased for wound healing; 500 mg twice daily is recommended3. Vitamin A for immune function and epithelialization; 5000 IU per 1000 calories of enteral nutrition is

recommended4. Increased Na and K to correct hyponatremia5. Ca supplements to treat symptomatic hypocalcemia or losses due to immobalization or treatment

with silver nitrate soaks

6. Phosphorus and magnesium given parenterally to avoid GI irritation7. Zinc supplementation with 220mg of zinc sulfateTrauma

I. Characteristicsa. Hypermetabolismb. Hypercatabolismc. Lipolysisd. Skeletal muscle proteolysis


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II. Metabolic and Endocrine Response*elevated serum concentration of cortisol, catecholamines, glucagons, growth hormone, aldosterone, andantidiuretic hormone

III. Nutritional careAim: to provide adequate nutrition support; to minimize infection during a prolonged course of healing,hypermetabolism, and immobilization

Diet1. Energy: 3035 kilocalories/kg IBW/day is often sufficient to achieve anabolism and positive nitrogenbalance

*requirements of severely stressed patients are higher2. Protein: 1.0-1.5 g/kg IBW/day for moderately stressed patients; 1.5-2.0g/kg IBW/day for severely stressed

patients3. Vitamin and mineral requirements are elevated, however, no specific levels have been established4. Daily supplements of

Vitamin A: 5,000 to 20,000 IUVitamin C: 250 to 1000 gZinc: 220 mg zinc sulfate bid

B-complex vitamin supplement daily is essential to energy/carbohydrate metabolism5. Adjunct enteral and parenteral nutrition in malnourished patients

Transplantationinvolves the transfer of a graft (organ tissues) from one body area or person to another site or person toreplace a disease organ or tissue

Kidney transplantthe surgical implantation of a kidney from a living related donor, a living non-related donor, or acadaver

Nutritional care1. provide adequate calories and protein to counteract the catabolic effects of surgery during the early post-transplant period

2. Manage nutritional side effects of immunosuppressive drugs

Dieta. Up to one 1 month post-transplant

Initial diet depends on function of the transplanted kidney1. Liquid to solid diet, progressive depending on tolerance2. Protein: 1.3 to 1.5 g/kg to promote nitrogen balance3. Calories: 3035 kcal/kg/day to spare protein for anabolism and meet increased needs due to surgery

b. After 1-month post-transplantManagement of nutritional side effects of immunosuppressive therapy and kidney functions1. Protein 1g/kg/day to promote nitrogen balance and prevent damage to transplanted kidney by

excessive dietary protein2. Calories sufficient to control weight to counteract increased appetite and weight gain caused byimmunosuppressive therapy

3. CHO preferably complex to minimize hyperglycemia due to steroid-induced diabetes4. Low cholesterol:

Surgery and Trauma

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