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Surgical Nutrition Raymundo F. Resurreccion, MD, FPCS.

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Presentation on theme: "Surgical Nutrition Raymundo F. Resurreccion, MD, FPCS."— Presentation transcript:

1 Surgical Nutrition Raymundo F. Resurreccion, MD, FPCS

2 Objectives  Differentiate metabolic responses to starvation and trauma  Explain the energy utilization in patients undergoing injury and stress  Recognize the role of nutritional support in patients undergoing stress and surgery

3 Objectives  Determine basic nutritional requirements in the surgical patient  Determine the appropriate route for delivery of nutrition  Recognize the dangers of overfeeding

4 Metabolic Response to Injury

5 Physiological responses to Injury Injury, infection Diminished intake Increased expenditure Tissues / blood mononuclear cells, endothelium Brain SNSHPA NER Cytokines Metabolic response Inflammatory response Immune response

6 Mediators in SIRS/Sepsis MEDIATOREFFECTSInterleukin-1 Fever, proteolysis ProstaglandinsVasodilation CorticosteroidsHypermetabolism GlucagonGluconeogenesis NorepinephrineHypermetabolism Growth, thyroid hormones Acute catabolism Complement, anaphylatoxins Microcirculatory damage Kinin system, serotonin histamine Vasodilation Oxygen free radicals Membrane damage Tumor necrosis factor Tissue injury, shock Myocardial depressant factor Cardiac dysfunction Nitric oxide Vasodilation, hypotension

7 Stress Response to Injury AFFERENT ARC EFFERENT ARC

8 Neuro-endocrine Response  Massive receptor stimulus  Hypothalamo–pituitary axis  Catecholamines  Gluco + mineralo corticoids  Glucagon  ADH  Insulin

9 Hormonal Response to Injury Hormonal Levels Glucose Production Proteolysis Protein Synthesis Catechols                        Cortisol                         Glucagon           Insulin      HGH           Testosterone     —

10 Starvation vs. Severe Stress Starvation  Continuum  Stress Starvation  Continuum  Stress Resting energy expenditure       Respiratory quotient Counter regulatory hormones —          Primary fuel Fat Fat + amino acids Proteolysis++++ Branched-chain oxidation ++++

11 Starvation vs. Severe Stress Starvation  Continuum  Stress Starvation  Continuum  Stress Hepatic protein synthesis ++++ Acute-phase protein production —+++ Constitutive protein production           Urinary nitrogen losses ++++ Gluconeogenesis++++ Ketone body production +++++

12 Metabolic Response to Injury  Rapid glycogenolysis  H 2 O + NaCl retention  edema  Glucose intolerance  Gluconeogenesis  Protein synthesis redirected to acute phase proteins + wound healing  Muscle wasting

13 Metabolic Response to Injury  Increased energy expenditure Pain, anxiety, feverPain, anxiety, fever Muscular effort-work of breathing, shiveringMuscular effort-work of breathing, shivering  Physiologic stress response: Catabolic phase increased caloric needs, inadequate intakeincreased caloric needs, inadequate intake gluconeogenesis  wasting of endogenous protein stores, increased urinary nitrogen lossesgluconeogenesis  wasting of endogenous protein stores, increased urinary nitrogen losses

14 Energy Utilization  Hypermetabolic state  increases demands  less efficient use of nutrients for energy  more nutrients used to meet the demands  Negative energy balance is highly correlated to complications in critically ill patients

15  Surgical trauma is accompanied by a negative nitrogen balance  Nitrogen balance is more negative than during pure fasting Effects of Surgical Trauma on Resting Energy Expenditure Long CL, et al. JPEN 1979;3:

16 Substrate Utilization Muscle is metabolized as gluconeogenic substrate to supply the brain, kidney, tumor etc Glutamine

17 Weight Loss after Surgical Trauma  Where? MuscleMuscle FatFat  Why? Reduced food intakeReduced food intake Increased energy expenditureIncreased energy expenditure Derangements in protein/fat metabolismDerangements in protein/fat metabolism

18 Oxidation of Carbohydrate and Fat in Sepsis Sepsis score 0 Fat oxidation g/m 2 /h Stoner et al Br J Surg 1983 Glucose oxidation g/m 2 /h Sepsis score

19 Surgery Anesthesia Patient OperativeRisk Magnitude of Risk

20 Risk factors associated with death, analyzed by a multiple regression model Risk Factor OR 1 Confidence interval Malnutrition Presence of cancer Age ≥ 60y/o Surgical treatment 0.16* * p < OR = odds ratio 2 Moderate and severe malnutrition Correia and Waitzberg, Clin Nutr 2003; 22:

21 Consequences of Malnutrition  Loss of lean body mass  Poor wound healing, anastomotic breakdown  Compromised immune defense  Impaired organ function  Increased mortality rates

22 Predictors of Poor Surgical Outcome ParameterPredictorAge Increased (>70 years) Type of Surgery Emergent, contaminated, open abdominal, thoracic or aortic surgery, prolonged surgery ASA > Class 3 Cardiac Presence of S3 gallop, jugular venous distention, MI within 6 mos, > 5 PVC, aortic stenosis, unstable angina, absence of beta-blockade Pulmonary COPD, FEV 1, 1.0, L PaO 2 50, fatigue with walking (steps) Neurologic Impairment, decreased function, nonambulatory status Renal Decreased creatinine clearance, BUN > 50 mg/dl Nutrition Hypoalbuminemia, hypokalemia Frailty Weakness, early exhaustion, dependency American College of Physicians

23 Loss of Lean Mass and Mortality *assuming no preexisting loss Complications Relative to Loss of Lean Body Mass* Lean Body Mass (% loss of total) Complications (related to lost lean mass) Associated Mortality (%) 10 Impaired immunity, increased infection Decreased healing, weakness, infection 30 Too weak to sit, pressure sores, pneumonia, no healing Death, usually from pneumonia 100

24 Goals of Surgical Nutritional Support  Maintain host defenses  Support metabolic response  Reduce the catabolic state and preserve lean body mass  Support the depleted patient throughout the catabolic phase of recovery

25 Goals of Surgical Nutritional Support  Improve patient outcomes Decrease surgical mortalityDecrease surgical mortality Decrease surgical complications and infectionDecrease surgical complications and infection  Prevent/treat macro/micronutrient deficiencies  Speed the healing / recovery process (Decrease the LOS)

26 Surgery Full Wound healing Full Restoration of metabolic and immune homeostasis Endocrine, metabolic, and immunologic alterations Nutrition Support in Surgery Adequate Adequate body reserves body reserves food intake food intake

27 Nutrition Support in Surgery Surgery Wound healing Restoration of metabolic and immune homeostasis Endocrine, metabolic, and immunologic alterations Incomplete restoration of organ functions Multiple organ dysfunction, failure, and death Inadequate body reserves Inadequate food intake Nutrition Support

28 Prospective randomized studies 2-3 days: No improvement in outcome 5-7 days: Influence in outcome 7-10 days: Benefits outcome Reduction of postop morbidity and mortality Reduction of postop morbidity and mortality Meguid: Am J Surg 1990; 159:345 **ENDPOINTS: Monitor nutrient intake (Calorie Count) Total lymphocyte count Necessary Length of Preoperative Nutrition in Malnourished Patients

29 ASPEN Guidelines  Preoperative SNS should be administered to moderately or severely malnourished patients undergoing major gastrointestinal surgery for days if the operation can be safely postponed.  Postoperative SNS should be administered to patients whom it is anticipated will be unable to meet their nutrient needs orally for a period of 7 to 10 days. A. S.P.E.N. Board of Directors, JPEN 2002

30 Nutritional Assessment  Body composition (anthropometric measurements)  Biochemical data  Clinical assessment Subjective Global Assessment (SGA)  Indirect calorimetry

31 Computing Nutritional Requirement  Total caloric requirement (TCR)  Total protein requirement (TPR)  Fluid requirements  Micronutrient/Vitamin requirements

32 Nutritional Requirements Nutrients  Carbohydrate  Protein  Fat  Vitamins  Minerals  Water Calories Provided 4 kcal/g 9 kcal/g - National Research Council: Recommended Dietary Allowances,10th ed National Academy Press, 1989

33 Nutritional Requirements  Calculations are based on: ageage sexsex weight and heightweight and height stress factorstress factor activity levelactivity level

34 Total Caloric Requirement (kcal/ day) 1. Harris-Benedict Equation (BEE) Male: (13.75 x BW) + (5 x height) - (6.76 x Age) x AF x SF (6.76 x Age) x AF x SF Female: (9.56 x BW) + (1.85 x height) - (4.67 x age) x AF x SF (4.67 x age) x AF x SF TCR = BEE x AF x SF Nutritional Requirements

35  Activity factors Confined to bed = 1.2Confined to bed = 1.2 Ambulatory = 1.3Ambulatory = 1.3  Stress Factors Minor surgery = 1.2 Trauma = Sepsis = Burns =

36 2. Short Method Non stressed: kcal/kgNon stressed: kcal/kg Stressed: kcal/kgStressed: kcal/kg Underweight: Actual BW x kcal/kg Overweight: Ideal BW x kcal/kg TCR = wt (kg) x kcal TCR = wt (kg) x kcal Nutritional Requirements

37 Conditions Affecting Caloric Needs REE Change Fever (per°C) +10 to 15% Sepsis +20 to 60% Trauma +20 to 50% Burn +40 to 80% Treatments  Mech. Ventilation -25 to -35%  Nutritional support +20% Agitation +50 to 100% Chiolero R, Nutrition 1997

38 Drugs Affecting Caloric Needs Drug REE Change Opiates-9% Sedation -20 to -55% Barbiturates-32% Muscle relaxants -42% Catecholamines+32% β-blockers -6 to -7% +20% Agitation +50 to 100% Chiolero R, Nutrition 1997

39 3. Indirect calorimetry Gold standard for measuring REEGold standard for measuring REE Calculated by measuring O consumption (VO) and COproduction (VCO) using the abbreviated Weir equation: REE = [3.9 (VO) (VCO)] x 1.44.Calculated by measuring O 2 consumption (VO 2 ) and CO 2 production (VCO 2 ) using the abbreviated Weir equation: REE = [3.9 (VO 2 ) (VCO 2 )] x Performs better than predictive equations with added stress factorsPerforms better than predictive equations with added stress factors Measurements made over min and 24hr EE is extrapolatedMeasurements made over min and 24hr EE is extrapolated Nutritional Requirements

40  Non-Stressed: gm/kg/day  Mild-Moderately Stressed: gm/kg/day  Severely Stressed - > gm/kg/day Lefor et al.Critical Care Lefor et al.Critical Care Protein should comprise approximately 20% of the total calories during stress Protein Requirements

41 Non-Protein Calories  Carbohydrate  Fats NPC combinationsNPC combinations acute stress: 70% carbo 30% fat usual: 60% carbo 40% fat infections: 50% carbo 50% fat pulmonary: 40% carbo 60% fat

42 HYPERGLYCEMIA (Effects in stressed patients) Impaired wound healing Insulin resistance Risk of LBM loss  Skeletal muscle proteolysis  Risk of infection  Oxidative stress (proinflammatory) Supplying Large Amounts of Carbohydrates Leads to Hyperglycemia

43 Vitamins Fat Soluble Vitamin AVitamin A Vitamin DVitamin D Water Soluble Folic AcidFolic Acid Pantothenic AcidPantothenic Acid BiotinBiotin NiacinNiacin RiboflavinRiboflavin Vitamin E Vitamin K Thiamine Vitamin B 6 Vitamin B 12 Vitamin C

44 Electrolytes Sodium Potassium Chloride Calcium Phosphorus Magnesium Zinc Copper Chromium Manganese Selenium Iodine Iron

45 Fluid Requirements  How much volume to give?  Cater for maintenance & on going losses  Normal maintenance requirements By body weightBy body weight Alternatively, 30 to 50 ml/kg/dayAlternatively, 30 to 50 ml/kg/day

46 Maintenance Water Requirements Weight (kg) mL/kg/hrmL/kg/day 1 – – – n 120  Children  Adults 30 ml/kg/day

47 Water losses  Add on-going losses based on I/O chart Urine: 800 to 1500 ml/dayUrine: 800 to 1500 ml/day Stool: 250 ml/dayStool: 250 ml/day  Consider insensible fluid losses also 8-12 ml/kg/day8-12 ml/kg/day Cutaneous insensible losses increase by 10% for every 1°C above >37°CCutaneous insensible losses increase by 10% for every 1°C above >37°C

48 Maintenance Water Requirements Change in Fluid Requirements IncreasedDecreased Fever Renal failure Fistulas Congestive heart failure Diarrhea Cirrhotic ascites NG suction Pulmonary disease

49 NUTRITIONAL ASSESSMENT Functioning GI Tract? YESNO ENTERAL NUTRITIONPARENTERAL NUTRITION Tube feeding for more than 6 weeks? YESNO Nasoenteric TubeEnterostomy Risk for pulmonary aspiration? YES NO Nasogastric Tube Nasoduodenal or Nasojejunal Tube Gastrostomy Jejeunostomy Clinical Decision Making Algorithm for Nutritional Support GI FUNCTION NORMALCOMPROMISED Standard FormulaSpecialty Formula FORMULA TOLERANCE PN for more than 4 weeks? YESNO Central PN Peripheral PN GI FUNCTION RETURNS? YESNO Adequate Inadequate Progress to More Complex Diet and Oral Feedings as Tolerated PN Supplementation Progress to Total Enteral Feedings Oral Formula Supplements

50 Preferential Use of Enteral Nutrition  EN delivery has two main routes: gastric and post-pyloric  Use of the gut stimulates GALT & MALT → enhanced immune response  Early feeding can trigger gut immunity and thereby improve outcomes McClave, J Clin Gastro, Sept 2002

51 Preferential Use of Enteral Nutrition  Delay or failure may promote a proinflammatory state with ↑ disease severity & morbidity  Early EN in the post-operative period is a viable option to address recuperation needs, malnutrition and its complications  Reduce morbidity and cost compared with parenteral nutrition

52 Limitations Of EN Delivery  Deranged motility  Reduced exocrine pancreatic function  Intestinal hypoperfusion/ bowel ischemia Gastric reflux Aspiration Nausea, vomiting Abdominal distention and cramps Diarrhea Malabsorption

53 Parenteral Nutrition  Essential form of sustenance for patients who cannot tolerate the oral or tube feeding administered intravenously.

54 Indications: Parenteral Nutrition  General Indications Patients requiring long-term (>10 days) supplemental nutrition because they are unable to receive all of their daily energy, protein, and other nutrient requirements through oral or enteral feedingPatients requiring long-term (>10 days) supplemental nutrition because they are unable to receive all of their daily energy, protein, and other nutrient requirements through oral or enteral feeding Severe gut dysfunction or inability to tolerate enteral feedingsSevere gut dysfunction or inability to tolerate enteral feedings

55 Indications: Parenteral Nutrition  Inability to use the gastrointestinal tract intestinal obstructionintestinal obstruction peritonitisperitonitis intractable vomitingintractable vomiting severe diarrheasevere diarrhea high-output enterocutaneous fistulahigh-output enterocutaneous fistula short bowel syndromeshort bowel syndrome severe malabsorption.severe malabsorption.  Need for bowel rest  Palliative use in terminal patients is controversial ASPEN Board of Directors. JPEN 2002; 26 Suppl 1: 83SA

56 Composition of Formulas Parenteral Nutrition DextroseLipidsElectrolytes Trace Elements VitaminsWater Amino acids

57 Parenteral Access

58 Nutrition Care Plan  Computed calorie and protein requirements based on disease, labs, current complications  Determine form & route of feeding Type of feedingType of feeding Oral Enteral - NGT, PEG, Surgical tubes Parenteral - peripheral, central Delivery method (pump or bolus)Delivery method (pump or bolus)

59 Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press, 1992 Monitoring Metabolic  Glucose  Fluid and electrolyte balance  Renal and hepatic function  Triglycerides and cholesterol Assessment  Body weight  Nitrogen balance  Plasma protein

60 Monitoring FLUID BALANCES CALORIE COUNT

61 Dangers of Overfeeding  Secretory diarrhea (with EN)  Volume overload, CHF  CO2 production: ventilatory demand  COCO2 production: ventilatory demand  O2 consumption

62 Dangers of Overfeeding  Electrolyte problems: PO4, K, Mg  Hyperglycemia, glycosuria, dehydration, lipogenesis, fatty liver, liver dysfunction  Increased mortality (in adult studies)

63 Thank you for your attention.


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