Surgical Nutritions

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SURGICAL NUTRITIONS

Prepared By:

Lilibeth C.Tenorio, M.D.


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GOALS

Meet the energy requirements for metabolic

processes, core temperature, maintenance andtissue repair

Meet the substrate requirements for proteinsynthesis

BEE (men)+ 66.47+13.75(W) +5.0(H)- 6.76(A)kcal/d

BEE (women)+ 655.1+9.56(W) +1.85(H)-4.68(A) kcal/d

30 kcal/kg/day will adequately meet energyrequirements in most post surgical patients withlow risk of overfeeding


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Caloric Adjustment Above BEE

Condition kcal/kg/d Adjustment

Above BEE

Grams of

protein/day

Normal 25-30 1.1 1.0

Mild stress 25-30 1.2 1.2

Moderate

stress

30 1.4 1.5

Severe

stress

30-35 1.6 2.0

Burns 35-40 2.0 2.5


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Nutritional Screening

and Assessment


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History

Unusual dietary habit

Medications/vitamin and mineral

supplementation

Dysphagia/Odynophagia

Abdominal pain/distention/diarrhea


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Anthropometrics

Ideal Body Weight

Adult females: 100lb (45kg) for the first 60

(152cm) + 5lbs (2.3kg) for every inch >60.

Adult males: 106lb (48kg) for the first 60

(152cm) + 6lbs (2.7kg) for every inch >60.


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Percent of Usual or Ideal

Body WeightSignificant potential for malnutrition

>5% weight loss in 1 month >7.5% weight loss in 3 months

>10% weight loss in 6 months


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Laboratories

Pre-Albumin- most sensitive marker for total body proteinstatus

- half-life of 2-3 days- elevated in renal failure and suppressed inhepatic failure

Normal 18-24 mg/dlMildly Depleted 16-18 mg/dl

Moderately Depleted 14-16 mg/dl

Severely Depleted


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Serum Transferrin

- may be elevated due to iron deficiency anemia,as an acute phase reactant, during pregnancy,or during the use of oral contraceptives

- suppressed in renal and hepatic failure despiteof adequate protein status

- half life of 8 to 10 days

Normal 200-250 mg/dl

Mildly Depleted 170-200 mg/dl

Moderately Depleted 140-170 mg/dl

Severely Depleted


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Albumin

most widely available laboratory examinations

affected by non-nutritional factors like albumin infusion,

dehydration, renal failure and anabolic steroids causes

elevation. Pregnancy, severe burns, protein losing

enteropathy, nephrotic syndrome, neoplastic disease,

severe infections, trauma or post surgery.

Half life of 14-20 days

Normal 3.5-5.0 g/dl

Mildly Depleted 3.0-3.5 g/dl

Moderately Depleted 2.5-3.0 g/dl

Severely Depleted


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ALL SURGICAL PATIENTS

Assessment of Risk for

Nutritional Complications

Moderate to Severe

Malnutrition

7 to 10 days

Nutritional Support

BMI 18

Screening:

Body Mass Index

Serum Albumin

Total Lymphocyte Count

SGA (Subjective Global

Assessment)

Combined Enteral

And Parenteral Nutrition

As tolerated


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ENTERAL NUTRITION


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Reduces intestinal mucosal atrophy

Reduces infection complications and acute

phase protein production

Indications1. Protein calorie malnutrition

2. CNS disorders: comatose state, CVA,

Parkinsons disease

3. Neoplasms4. Gastrointestinal diseases

5. Psychiatric disorders


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Formula Selection:

Considerations:1. Patients diagnosis, nutritional status andrelated concerns such as presence of

congestive heart failure, renal or hepatic

insufficiency or hypermetabolic state

2. Purpose of the formula

3. Patients digestive and absorptive ability

4. Formula osmolality5. Cost


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Categories of Formula1. Nutritionally Complete (Polymeric) Formula

composed of protein, carbohydrate and fat.Requires normal digestive and lipolytic activityand less expensive

2. Chemically Defined Formula low residue and

use free amino acids or peptides as proteinsource

3. Specialty Formula use in patients with avariety of clinical conditions including renal,

respiratory or hepatic insufficiency, diabetes,hypermetabolic and immunocompromisedstate


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Rate of Administration

1. Continuous- tube feeding in the stomach is initiated at a rate of 40ml/hr

then rate can be increased by 25ml/hr every 8-12 hours as

tolerated

- jejunal feeding may require initial rates as low as 10ml/hr

especially in the immediate post- operative state

2. Intermittent used if there has been no history ofdiarrhea or malabsorption and the gastrointestinal tract is

intact

3. Bolusmost useful with gastrostomy tube and shouldnever be used in jejunal feeding. The formula should be

administered at a drip rate or via syringe injection not

exceeding 240ml/30 minutes. Use a 100ml bolus initially and

increase the volume by 50ml daily as tolerated


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ACCESS FOR ENTERAL

NUTRITIONAL SUPPORT Nasoenteric tubes those with intact mental status and

protective laryngeal reflexes to minimize risk ofaspiration

Percutaneous Endoscopic Gastrostomy those withimpaired swallowing mechanisms, oropharyngeal oresophageal obstruction and major facial trauma

Percutaneous Endoscopic Gastrostomy - Jejunostomyand Direct Percutaneous Endoscopic Jejunostomy forthose who cannot tolerate gastric feedings or havesignificant aspiration risks should be fed directly past the

pylorus Surgical Gastrostomy and Jejunostomy for patient

undergoing complex abdominal or trauma surgery. Itaffords access to the stomach or bowel.


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Contraindications:

1. Distal intestinal obstruction

2. Severe edema of the intestinal wall

3. Radiation enteritis4. Inflammatory bowel disease

5. Ascites

6. Severe immunodeficiency7. Bowel ischemia


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Means to Prevent Complications Before initiating feeding, confirm placement of

feeding tube by X-ray Keep the patients head and shoulder elevated at

30-45C at all times during feeding and and forone hour after

Use a 30-35ml syringe to check gastric residualsevery 4 hours

Maintain accurate intake and output records

Record patients weight at least 3 times weekly

Observe the patient for abdominal distention,pain, diarrhea or dyspnea


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PARENTERAL NUTRITION


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- Continuous infusion of a hyperosmolar

solution containing carbohydrates,proteins, fat and other necessary nutrients

through an indwelling catheter.

- fundamental goals are to provide sufficientcalories and nitrogen substrate to promote

tissue repair and to maintain the integrity

or growth of lean tissue mass.


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Total parenteral nutrition- Referred to as central parenteral nutrition,

requires access to large-diameter vein todeliver the entire nutritional requirements ofthe individual

Components:1. Dextrose

2. Protein (Amino acids)

3. Lipid emulsion4. Electrolytes

5. Vitamins, minerals and trace elements


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Monitoring

Initial measurement of weight and height dailyweight thereafter

Strict intake and output record

Temperature every 8 hours

Blood glucose 2 hours after each rate increase

and every 6 hours once stable

Baseline blood tests: glucose, CBC, platelet

count, PT, total protein, albumin BUN, Crea Laboratory tests weekly or biweekly: AST, ALT,

bilirubin, total protein, albumin, CBC,platelet


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Peripheral parenteral nutrition- Lower osmolality of the solution is used to

allow its administration via peripheral veins- Not appropriate for repleting patients with

severe malnutrition

- Used for short periods (


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INDICATIONS:1. Newborn infants with catastrophic gastrointestinal

anomalies such as tracheoesophageal fistula,gastroschisis, omphalocoele, or massive intestinalatresia

2. Infants who fail to thrive due to gastrointestinalinsufficiency associated with short bowel syndrome,malabsorption, enzyme deficiency, meconium ileus, or

idiopathic diarrhea.3. Adult patient with short bowel syndrome secondary to

massive small bowel resection (7-10 days), multipleinjuries, blunt or open abdominal trauma, or patients

with reflex ileus complicating various medical diseases


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6. Adult patients with functional gastrointestinal disorders

such as esophageal dyskinesia followingcerebrovascular accident, idiopathic diarrhea,psychogenic vomiting, or anorexia nervosa

Patients with granulomatous colitis, ulcerative colitis,and tuberculous enteritis, in which major portions are

of the absorptive mucosa are diseased.8. Patients with malignancy, with or without cachexia, in

whom malnutrition might jeopardize successfuldelivery of a therapeutic option

Failed attempts to provide adequate calories by enteraltube feedings or high residuals

Critically ill patients who are hypermetabolic for morethan five days or when enteral nutrition is not feasible

INDICATIONS:


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CONTRAINDICATIONS:

1. Lack of specific goal fir patient management,

or in cases in which instead of extending a

,meaningful life, inevitable dying is delayed

2. Periods of hemodynamic instability or severemetabolic derangement (e.g., severe

hyperglycemia, azotemia, encephalopathy,

hyperosmolality, and fluid electrolyte

disturbances) requiring control or correctionbefore attempting hypertonic intravenous

feeding


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CONTRAINDICATIONS:

3. Feasible gastrointestinal tract feeding; in thevast majority instances, this is the best routeby which to provide nutrition

4. Patients with good nutritional status

5. Infants with less than 8cm of small bowel,since virtually all have been unable to adaptsufficiently despite prolonged periods of

parenteral nutrition6. Patients who are irreversibly decerebrate orotherwise dehumanized


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COMPLICATIONS1. Technical sepsis secondary to contamination of

the central venous catheter. Earliest signs ofsystemic sepsis maybe the sudden development of

glucose intolerance. Other complications include the

development of pneumothorax, hemothorax,

hydrothorax, subclavian artery injury, thoracic duct

injury, cardiac arrhythmia, air embolism, catheter

embolism and cardiac perforation with tamponade.

2. Intestinal atrophy lack of intestinal stimulation isassociated with intestinal mucosal atrophy,

diminished villous height, bacterial overgrowth,

reduced IgA production and impaired gut immunity.


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COMPLICATIONS3. Metabolic hyperglycemia may develop with

normal rates of infusion patients with impairedglucose tolerance or in any patient if the hypertonicsolutions are administered too rapidly treatment ofthe condition consists of volume replacement with

correction of electrolyte abnormalities and theadministration of insulin. Overfeeding is notadvised in depleted patient in whom excess calorieinfusion may result in carbon dioxide retention and

respiratory insufficiency.Hepatic steatosis or marked glycogen

deposition, cholestasis and formation of gallstonesare common in patients receiving long term

parenteral nutrition.


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MUSCLE

Protein

75mg

FAT STORES

Triglycerides160g

Gluconeogenesis

Oxidation

BRAIN

RBC

WBC

NERVE

KIDNEY

MUSCLE

HEART

KIDNEY

MUSCLE

Amino

acids

Glycerol

16g

Fatty

Acid

160g

LIVER

Glycogen75g

Glucose180g

Lactate and Pyruvate


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MUSCLEProtein

250g

FAT STORESTriglycerides

170g

KIDNEY

Gluconeogenesis

Gluconeogenesis

LIVER

Oxidation

WOUND

RBC

WBC

NERVE

KIDNEY

MUSCLE

HEARTKIDNEY

MUSCLE

Amino

Acids

Glycerol

Fatty

Acid

170g

Glucose

Ketone

Fatty Acid

130g

Lactate + pyruvate


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Surgical Nutritions

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