SURGICAL NUTRITIONS

Prepared By: Lilibeth C.Tenorio, M.D.

GOALS
Meet the energy requirements for metabolic processes, core temperature, maintenance and tissue repair Meet the substrate requirements for protein synthesis 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 energy

requirements in most post surgical patients with low risk of overfeeding

Caloric Adjustment Above BEE

Condition Normal Mild stress kcal/kg/d 25-30 25-30 Adjustment Grams of Above BEE protein/day 1.1 1.0 1.2 1.2

Moderate stress
Severe stress

30
30-35

1.4
1.6

1.5
2.0

Burns

35-40

2.0

2.5

Nutritional Screening and Assessment

History
Unusual dietary habit Medications/vitamin and mineral supplementation Dysphagia/Odynophagia Abdominal pain/distention/diarrhea

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.

Percent of Usual or Ideal Body Weight

Significant potential for malnutrition >5% weight loss in 1 month >7.5% weight loss in 3 months >10% weight loss in 6 months

Laboratories
Pre-Albumin
- most sensitive marker for total body protein status - half-life of 2-3 days - elevated in renal failure and suppressed in hepatic failure
Normal Mildly Depleted Moderately Depleted Severely Depleted 18-24 mg/dl 16-18 mg/dl 14-16 mg/dl <14 mg/dl

 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 despite of adequate protein status - half life of 8 to 10 days Normal Mildly Depleted Moderately Depleted Severely Depleted 200-250 mg/dl 170-200 mg/dl 140-170 mg/dl <140 mg/dl

 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 Mildly Depleted Moderately Depleted Severely Depleted 3.5-5.0 g/dl 3.0-3.5 g/dl 2.5-3.0 g/dl <2.5 g/dl

ALL SURGICAL PATIENTS BMI 18 Assessment of Risk for Nutritional Complications

Screening: Body Mass Index

Serum Albumin Total Lymphocyte Count SGA (Subjective Global Assessment)

Moderate to Severe Malnutrition

7 to 10 days Nutritional Support

Combined Enteral And Parenteral Nutrition As tolerated

ENTERAL NUTRITION

Reduces intestinal mucosal atrophy Reduces infection complications and acute phase protein production

Indications
1. Protein calorie malnutrition 2. CNS disorders: comatose state, CVA, Parkinsons disease 3. Neoplasms 4. Gastrointestinal diseases 5. Psychiatric disorders

Formula Selection:
Considerations:
1. Patients diagnosis, nutritional status and related 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 osmolality 5. Cost

Categories of Formula
1. Nutritionally Complete (Polymeric) Formula composed of protein, carbohydrate and fat. Requires normal digestive and lipolytic activity and less expensive 2. Chemically Defined Formula low residue and use free amino acids or peptides as protein source 3. Specialty Formula use in patients with a variety of clinical conditions including renal, respiratory or hepatic insufficiency, diabetes, hypermetabolic and immunocompromised state

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 of

diarrhea or malabsorption and the gastrointestinal tract is intact

3. Bolus most useful with gastrostomy tube and should

never 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

ACCESS FOR ENTERAL NUTRITIONAL SUPPORT

Nasoenteric tubes those with intact mental status and protective laryngeal reflexes to minimize risk of aspiration Percutaneous Endoscopic Gastrostomy those with impaired swallowing mechanisms, oropharyngeal or esophageal obstruction and major facial trauma Percutaneous Endoscopic Gastrostomy - Jejunostomy and Direct Percutaneous Endoscopic Jejunostomy for those who cannot tolerate gastric feedings or have significant aspiration risks should be fed directly past the pylorus Surgical Gastrostomy and Jejunostomy for patient undergoing complex abdominal or trauma surgery. It affords access to the stomach or bowel.

Contraindications:
1. 2. 3. 4. 5. 6. 7. Distal intestinal obstruction Severe edema of the intestinal wall Radiation enteritis Inflammatory bowel disease Ascites Severe immunodeficiency Bowel ischemia

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 for one hour after Use a 30-35ml syringe to check gastric residuals every 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

PARENTERAL NUTRITION

- Continuous infusion of a hyperosmolar solution containing carbohydrates, proteins, fat and other necessary nutrients through an indwelling catheter. - fundamental goals are to provide sufficient calories and nitrogen substrate to promote tissue repair and to maintain the integrity or growth of lean tissue mass.

Total parenteral nutrition

Referred to as central parenteral nutrition, requires access to large-diameter vein to deliver the entire nutritional requirements of the individual

Components:
1. 2. 3. 4. 5. Dextrose Protein (Amino acids) Lipid emulsion Electrolytes Vitamins, minerals and trace elements

Monitoring
Initial measurement of weight and height daily weight 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

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 (<2 weeks)

INDICATIONS:
1. Newborn infants with catastrophic gastrointestinal anomalies such as tracheoesophageal fistula, gastroschisis, omphalocoele, or massive intestinal atresia Infants who fail to thrive due to gastrointestinal insufficiency associated with short bowel syndrome, malabsorption, enzyme deficiency, meconium ileus, or idiopathic diarrhea. Adult patient with short bowel syndrome secondary to massive small bowel resection (<100cm without colon or ileocecal valve, or <50cm with intact ileocecal valve and colon) Enteroenteric, enterocolic, enterovesical, or high output enterocutaneous fistula (>500ml/d) Surgical patients with prolonged paralytic ileus following major operations (>7-10 days), multiple injuries, blunt or open abdominal trauma, or patients with reflex ileus complicating various medical diseases

2.

3.

4. 5.

INDICATIONS:
6. Adult patients with functional gastrointestinal disorders such as esophageal dyskinesia following cerebrovascular 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. Patients with malignancy, with or without cachexia, in whom malnutrition might jeopardize successful delivery of a therapeutic option Failed attempts to provide adequate calories by enteral tube feedings or high residuals Critically ill patients who are hypermetabolic for more than five days or when enteral nutrition is not feasible

8.

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 severe metabolic derangement (e.g., severe hyperglycemia, azotemia, encephalopathy, hyperosmolality, and fluid electrolyte disturbances) requiring control or correction before attempting hypertonic intravenous feeding

CONTRAINDICATIONS:
3. Feasible gastrointestinal tract feeding; in the vast majority instances, this is the best route by 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 adapt sufficiently despite prolonged periods of parenteral nutrition 6. Patients who are irreversibly decerebrate or otherwise dehumanized

COMPLICATIONS
1. Technical sepsis secondary to contamination of the central venous catheter. Earliest signs of systemic 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 is associated with intestinal mucosal atrophy, diminished villous height, bacterial overgrowth, reduced IgA production and impaired gut immunity.

COMPLICATIONS
3. Metabolic hyperglycemia may develop with
normal rates of infusion patients with impaired glucose tolerance or in any patient if the hypertonic solutions are administered too rapidly treatment of the condition consists of volume replacement with correction of electrolyte abnormalities and the administration of insulin. Overfeeding is not advised in depleted patient in whom excess calorie infusion may result in carbon dioxide retention and respiratory insufficiency. Hepatic steatosis or marked glycogen deposition, cholestasis and formation of gallstones are common in patients receiving long term parenteral nutrition.

MUSCLE Protein 75mg

Amino acids

BRAIN LIVER Glycogen 75g Gluconeogenesis Glucose 180g

Glycerol 16g FAT STORES Triglycerides 160g Fatty Acid 160g

RBC WBC NERVE KIDNEY MUSCLE

Oxidation Lactate and Pyruvate

HEART KIDNEY MUSCLE

KIDNEY MUSCLE Protein 250g Amino Acids Gluconeogenesis

WOUND

Gluconeogenesis
Glycerol

Glucose

FAT STORES Triglycerides 170g

RBC WBC NERVE KIDNEY MUSCLE

LIVER
Fatty Acid 170g Oxidation Ketone Fatty Acid 130g HEART KIDNEY MUSCLE Lactate + pyruvate