surgical nutritions
TRANSCRIPT
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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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