clinical nutrition in surgery

7/30/2019 Clinical Nutrition in Surgery

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Role of Parenteral

Nutrition in Surgery

Dr. Veena Singh

Dept. of Surgery

Medical College & Hospital


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20% of ICU patients have malnutrition


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Consequences of Malnutrition

Progressive psychological decline

In addition to its physical effects onpatients ability to recover from illness orinjury, malnutrition has severely deleteriouseffects on the mental state

As the nutritional status declines, the Qualityof Life also reduces.

Wretlind. 1987; 28-29


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Consequences of malnutrition

Ava

ila

bleEnergyan

dN

itrogens

tores

Qua

lityo

fL

ife

100%

0%Normal patients

Clinical changes

Decreased muscle massDecreased visceral proteins

Impaired immune response

Impaired wound healing

and response to trauma

Complete exhaustion

Bedridden

Psychological changes

Fatigue, general weakness

Lack of initiative

ApathyDepression

Changes of behavior

and personality

Total apathy

Death

Catabolic patients

100%

60%

Bo

dywe

ight

weeks0 5 10


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Survival afterintensive care292 ICU patients followed for 5 years

100%

50%

Survival

Years after ICU

0 1 2 3 4 5

>2 yearsRate approximates to ageadjusted norm

R.Griffiths, personal communication

60% of deaths in ICU

87% of deaths occur by 6 months

92% of deathsat 1 year


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Protein deficiency

Catabolism

The body has no protein reserve

Protein - losses

short term: functional protein, e.g. enzymes

long term: structural protein, e.g. muscle


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Insult

infection

trauma

I/R

hypoxemic/

hypotensive

Activation of

PMNs

= oxidative stress

Death

organ = failure

Pathophysiology of Critical Illness

mitochondrial

dysfunction

Role of

GIT

Key nutrient deficiencies(e.g. glutamine, selenium)

activation of coagulation/complement

generation of OFR

(ROS + RNOS)

endothelial dysfunction

elaboration of cytokines,

NO, and other mediators

cellular = energetic

failure


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Metabolic response in thesurgical patient

Modulated by changes in the

neuroendocrine milieu.

Increased levels of : catecholamine,glucocorticoids, glucagon, GH,

aldosterone, ADH.


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Metabolic response in thesurgical patient

Catecholamine increases BMR

Cortisol negative nitrogen balance Aldosterone and ADH sodium and water

retention weight gain

Counter-regulatory hormone stress DM hyperglycemia


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Introduction:

3 basic questions to be answered:

Can we identify which patients willbenefit from nutritional support?

When, and how long should the support

be given?

By what route should support be given?


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Guidelines for the choiceof nutrition support (I)

Nutritional assessment

of the patient

Normally

nourished

Normal/near-normal nutrition

state (but will deteriorate

if support withheld)

Malnourished

Normal feedingNutrition support indicated


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Guidelines for the choiceof nutrition support (2)

Nutrition support indicated

NoYes

Is enteral nutrition possible?

Normal feeding

+ dietary supplements

Supplemental/total PN

(PPN/CPN)


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Pre requisites:

Routine history taking

Assessment of physical status

Comparative assessment of approximateweight & weight loss

Periods of fasting/ starvation

Investigations:- blood urea, serum creatinine,

serum electrolytes and serum proteinsAlbumin level of less than 3.5g/dl is

indicative strongly of sepsis andassociated with high post- abdominal

surgical morbidity and mortality.


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Pre Requisites (cont) :

Nutritional requirements : Protein requirements in

terms of Nitrogen balance (NB)

N.B. = N (in)N (out)* = Protein _ N (out)

6.25 (gm/day)

* N (out) = Urine Urea N/0.8 (gm/day) + GI losses (24

gms/ day) + cutaneous losses (0-4 gm/day)

= Urine Urea N + 4 -- as a constant factor

0.8

NB =(Protein intake)(Urine urea nitrogen + 4)6.25 0.8

keep positive nitrogen balance of 2

4 gm / day


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Peri-operative Nutrition

Pre-operative :- Wt.loss > 10-15% over last 3 months

- Serum albumin


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Post-operative nutrition

Patients unlikely to resume GI feeds within 3-5

days.

Immediate support after extensive surgery.

Previously malnourished patients.

Major trauma/burns.

Usually begun within 48 hours of surgery if

decision is taken.


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Caloric deprivation in Post-Surgical Days

are harmful

CED10000

Kcal

p

Age 53.6 14.8 34.8 17.4 0.024

EE (Kcal/kg/d) 28.4 4.4 28.3 4.8 0.982

Intake(Kcal/kg/d)

26.4 6.6 19.2 5.4 0.044

SIRS (d) 3.6 2.2 8.0 4.2 0.017

ICU LOS(d)

12.5 7.6 23.5 15.1 0.021

Reid & Campbell Clin Nutr2001;20(Suppl 3):52CED= cumulative energy deficit


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Caloric need

Resting Energy ExpenditureKcal/min = 3.94 x VO2 + 1.11 x VCO2

RQ = fat 0.7 protein 0.8 CHO 1.0

Category Studies Patients Range kcal______________________________________

Surgical 7 637 1300-1900

Oncology 5 269 1300-1500

Mixed 2 200 1300-1400______________________________________

Nordenstrm & Thrne, E J Clin Nutr, 1994;48:531-37


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Energy yield

Sources:

Glucose 3.4 kcal/g

Protein 4 kcal/g

Lipids 9 kcal/g


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Energy needs

Energy requirements:

Total daily expenditure25-30 kcal kg-1

- Resting metabolic rate

- Activity energy expenditure

- Diet induced energy expenditure


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Energy needs

Energy requirements:

BMR calculated by Harris-Benedictequation:

66.47 + [13.75 x W] + [5 x H][6.76 x A]

Additional caloric expenditure:Minor operation 1.2 x BMR

Peritonitis 1.3 x BMR

Trauma 1.5 x BMR

Sepsis 1.6 x BMR

Burns 2.1 x BMR


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The ideal formula for the critically ill:

Amino acids including glutamine

Lipids as Structured triglycerides

Glucose (under control)

Omega-3-fatty acids (under control)

Micronutrients


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Glucose

The optimal proportion of the glucosecalories should be ~70% of the total

caloric intake

should be adjusted to maintain a bloodglucose level less than 150 mg/dl,

including administering regular insulin ifnecessary


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Fat

A good energy source during thepostoperative period because of its high

caloric value

Parenteral administration of lipids maybe extended up to approximately 20%

of the total calories and provided as acontinuous infusion


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Protein

1520% can be given as protein or aminoacids

In general, stressed patients with normalhepatic and renal function should

receive approximately 1.5 g/kg/day.


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The Recent Reviews :

Latest guidelines about the enteral nutrition and

parenteral nutrition in terminally ill surgical

patients by Dy SM (2006) confirm

Enteral and parenteral nutrition combined mayhelp improve survival, functional status andquality of life

These benefits appear to be primarily limited tothe patients with good functional status

The risks and the complications as mentioned in

the past are confirmed


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Postoperative parenteral nutrition

support

The effect of postoperative TPN on surgical outcome(meta-analysis)

- decreased complications by 10% with no differences in

the mortality Sandstorm et al, lower complication rate

Consensus conference of NIH,ASCN,ASPEN

- Postoperative nutrition support must beadministered to the patients who are notexpected to resume an oral diet for 3 to 5 days.


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clinical nutrition in surgery

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