1. Surgical Nutrition B.E.Mostafa, MD Professor of ENT-HNS ASU

2. Malnutrition In 30-50% of Head and Neck Patients Causes:  The tumor itself may present a barrier to deglutition  Tumor metabolism remains constant despite changes in nutritional status. Consequently, starvation responses such as lipolysis are not used by tumor cells, and glucose is continuously derived from protein catabolism.  Cancer cachexia may be induced by catabolic factors secreted by tumor cells.  Finally, tumor treatment may induce anorexia through discomfort, obstruction, and loss of taste.

3. Types of PEM Marasmus:  Fat and muscle catabolism make up for deficient intake without depression of serum albumin level Kwashiorkor:  Visceral protein depletion

4. Consequences Poor wound healing Immune suppression Poor response to therapy Poor survival

5. Scope Nutritional support  Simple starvation Metabolic support:  Hypermetabolism and multiple organ failure  Activation of neuroendocrine pathways NutritionMetabolic SettingMalnutritionOrgan failure BasisStarvationStress FocusProtein synthesis Weight gain Restore organ function Stop catabolism FuelGlucoseMixed

6. Evaluation Clinical Anthropometric Biochemical Immunological

7. Anthropometric measures: Body weight:  > 10% Usual body weight loss in 6 mos  Ideal body weight Mild malnutrition= 80 to 90% IBW Moderate malnutrition = 70 to 79% IBW Severe malnutrition= < 69% IBW  BMI Underweight: BMI < 18.5 Adequate weight: BMI = 18.5 to 24.9 Overweight: BMI = 25 to 29.9 Obese: BMI > 30 Triceps skin fold Mid arm circumference

8. Biochemical Albumin:  Adequate = > 3.5 g/dL  Mild = 2.7 to 3.5 g/dL  Moderate= 2.1 to 2.6 g/dL  Severe = < 2.1 g/dL Transferrin:  Adequate = 200 to 400 mg/dL  Mild = 180 to 200 mg/dL  Moderate = 160 to 180 mg/dL  Severe= < 160 mg/dL Pre-albumin:  Adequate = 18 to 42 mg/dL  Mild = 13 to 17 mg/dL  Moderate = 8 to 12 mg/dL  Severe = ≤ 7 mg/dL

9. Immunocompetence Total lymphocyte count:  Adequate = > 1,800 mm3  Mild = 1,500 to 1,800 mm3  Moderate = 900 to 1,500 mm3  Severe = < 900 mm3 Cutaneous hypersensitivity:  Non reactive = 0  1 < 5mm induration  2 > 5mm induration

10. Requirements Energy requirements Nutrient requirements  Glucose requirements  Fat requirements  Protein requirements  Electrolytes  Vitamins,minerals and trace elements

11. Energy requirements Adult daily calorie requirements 30 to 35 kcal/kg Add 10 kcal/kg to compensate for surgical stress. The Harris-Benedict equation estimate basal energy expenditure (BEE) For men: 66.47 + [13.75 × wt (kg)] + [5.0 × ht (cm)] – [6.76 × age (y)] For women 665.10 + [9.56 × wt (kg)] +[1.85 × ht (cm)] – [4.68 × age (y)] The BEE is multiplied by a stress and activity factor totaling 1.3 to 1.5

12. Nutritional requirements Protein requirements are estimated at  Normal1.0 g/kg/day.  Mildly stressed 1.2 g/kg/day.  Mild to moderate 1.5 g/kg/day  Reconstruction up to 2.0 g/kg/day. Glucose:  20-25 nonprotein Kcal/Kg/day Fat:  < 30 % of non protein calories

13. Route of Administration This is determined by:  Patient's condition  Access available  Skill and preferences of surgeon Oral supplements Enteral feeding:  NGT/NIT  Gastrostomy  Jejunostomy Total parenteral nutrition TPN Combined

14. Enteral feeding Normal functioning GIT Prevents intestinal mucosal atrophy Supports gut associated immunological shield Cheaper with less complications than TPN May be supplemented with IV solutions

15. Equipment Enteral feeding set with bag Formula Graduated cylinder Irrigation container 60 cc syringe with catheter adaptor

16. NGT Local decongestant and anaesthetic Introduce a 16 or 18 Fr tube [silastic.] Either proximal to GEJ or into duedenum Tube should be 30-35 cms from external nares Check tube placement by x-ray or auscultation Change nostril 10-14 days to prevent necrosis

17. Tube feeding Bolus feeding:  250-500 mL 4-6 times/day Intermittent feeding  400 mL by slow drip ½-1 hour 4-6 times/day Continuous infusion  Feeding pump  125 mL/hour for 16-24 hours

18. Important points Elevate head of bed 30-45° Check tube patency Start with 100 mL D5W and wait for 1 hour Increase by 50 to 100 mL / 8h or daily as tolerated Assess gastric residue every 4 hours Flush the feeding tube to clear formula Dilute medications with 30 cc water and administer a few minutes apart if patient is polymedicated The final feed no later than11:00 pm

19. Complications Tube clogging Diarrhoea Nausea and vomiting Formula-drug interactions Refeeding syndrome Aspiration Columellar necrosis

20. Tube clogging Inject 5 mL of warm water and clamp for 5 minutes Inject a bolus (20 to 30 cc) of air Follow with 30 to 50 mL of warm water Flush with:  324 mg sodium bicarbonate tablet  One pancrelipase(Cotazym or Viokase) capsule  5 mL of sterile water.  Clamp it for 5 minutes. Flush the tube with water until clear. The tube should be replaced

21. Diarrhoea 3 or more  500 cc / 24 hours An inappropriate rate of formula infusion, Impaired functional capacity of the GIT Hypoalbuminemia Concurrent use of antibiotics and other medications Altered bacterial flora Enteral formula contamination. Within 48 hours after feedings :  Change to sterile water 50 cc / h/ 12 hours, then resume formula feeding at 50 cc per hour and advance per protocol. After 48 hours:  Antidiarrhoeal medications 3-4 times  Re-evaluate formula and infection

22. Nausea / Vomiting Continuous feeding:  Stop feeding for 1 hour. Resume feeding at the last tolerated rate for the next 12 hours and then increase. Interval feeding:  Stop feeding and hold until next scheduled feeding Administer antacid ± H2 blocker

23. Intolerance Continuous feedings:  If residual is greater than 2 hours of present rate, hold the feeding and recheck in 1 hour. Resume feeding when amount is less than 2 hours of present rate, otherwise continue to check hourly.  When the desired volume of feeding is achieved, discontinue checking residual unless feeding intolerance occurs. Interval feedings:  If more than 100 cc of the previous feeding is aspirated, hold the feeding and recheck in 1 hour. If aspirate remains more than 100 cc, hold feeding until next scheduled time.  When residuals are less than 100 cc for 24 hours, discontinue checking residual unless intolerance occurs.

24. Formula drug interaction Diminished bioavailablity of:  Quinolones, tetracyclines, azithromycin antivirals Increased absorption of antifungals Vitamin B, iron and Ca syrup clog tubes Administer drugs separately Flush after each dose

25. Refeeding syndrome Serious metabolic disturbance that may occur with the initiation of aggressive nutrition support in patient with severely depleted nutrition stores. Significant compartmental shifts in phosphorus, magnesium, and potassium and sodium retention with expansion of the extracellular space. Hypophosphatemia is the most serious single consequence in refeeding syndrome. Cardiopulmonary failure and death may occur within days In patients at risk for refeeding syndrome, normal levels of phosphorus, potassium, and magnesium should be monitored constantly

26. Aspiration Avoid transgressing GEJ Keep patient semi sitting during feeding Avoid feeding while asleep Slow instillation of fluid Check tube location before each feed and after changing sides Add H 2 blockers/PPI

27. Feeding formulas Custom processed formulas Commercially available Combination

28. Commercially available formulas:  Polymeric formulas Protein 12 to 20% Carbohydrates, 40 to 60%; Fats 30 to 40%. Ratio of nonprotein calories to nitrogen is 150 to 1 Polymeric formulas contain whole proteins isolated from casein, whey, lactalbumin, and egg white. The source of carbohydrate is usually glucose polymerspolymers from starch and its hydrolysates. Formulas are l;actose-free The fats are from vegetable sources. Essential vitamins and minerals  Monomeric formulas: Require less digestion, rarely used

29. Sustagen ® Calories / mL1 CarbohydrateSucrose,corn syrup 140 g/L ProteinSoy protein isolate 61 g/L FatSoy oil 23 g/L Non protein Calories79:1 Na/K mEq/L40/53 Vitamins for 100% RDA1080 mL

30. Custom prepared formula Breakfast 1 cup Citrus juice 2 tsps sugar 3 glasses:  ½ cup strained refined cereal [Cerelac]  1 cooked egg  1 ½ cup milk  ¼ corn syrup  1 tablespoon vegetable oil  ½ cup water Lunch & Dinner 1 cup juice 2 tspns sugar 3 glasses:  1 cup strained meat  ½ cup strained vegetable  2 cups warm milk  2 tbsp vegetable oil

31. Custom prepared formula Provides 2800 Kcal Should be warmed, blended and strained Given at body temperature The glass should be stirred to mix components Keep only 24 hrs in refrigerator Some coffee may be added to stimulate appetite In case of lactose intolerance lactose-free milk may be used A commercially formula may be added to provide extra nutrients

32. Remember Adequate free water Formula at room temperature Encourage activity Oral feeding allowed if possible. Supplement with minerals and vitamins

33. Indications of TPN Absolute indications  Enterocutaneous fistulae Relative indications  Moderate or severe malnutrition  Acute pancreatitis  Abdominal sepsis  Prolonged ileus  Major trauma and burns  Severe inflammatory bowel disease

34. Parenteral nutrition The intravascular administration of carbohydrates, protein, fat, vitamins, and minerals. Total parenteral nutrition  Nutrient administration into the superior vena cava, Peripheral partial nutrition  Supplements enteral feeding  Through a peripheral vein 10% glucose solution, Amino acids Fat emulsion

35. Hyperosmolar, low pH and irritant to vessel walls 14g nitrogen as L amino acids 250g 25 % glucose 5mg/Kg/Min 500 ml 20% lipid emulsion Electrolytes:  100 mmol Na+  100 mmol K+  150 mmol Cl­-  15 mmol Mg2+  13 mmol Ca2+  30 mmol PO42-  0.4 mmol Zn2+ Vitamins / Trace elements / Insulin Typical content / 2.5 L soln

36. Preparations Aminosteril10% AA solutions Panamine Aminoleban Haes-sterileHydroxyethyl starch Intralipid20% lipid emulsion

37. Complications Problems of insertion  Failure to cannulate  Pneumothorax  Haemothorax  Arterial puncture  Brachial plexus injury  Mediastinal haematoma  Thoracic duct injury Problems of care  Line and systemic sepsis  Air embolus  Thrombosis / thrombophlebitis  Catheter breakage

38. Metabolic complications Hypo / hyper glycaemia Excess CO 2 production Hyperlipedimia Abnormal liver functions Cholestasis Hypo / hypervolaemia Disturbances in Na, K, Mg PO 4, Ca Acid/base disturbances

39. Care of TPN lines Strict asepsis in care Do not use for sampling Do not use for drug administration Check for signs of sepsis

40. Monitoring of TPN Clinical evaluation twice daily Urine sugar or glucocheck / 6 hrs Daily  Weight  Fluid chart Twice weekly  Electrolytes,  BUN, Weekly  Blood count,  Liver functions

41. Final Aim Restore body weight Improve anthropometric parameters Improve biochemical parameters Improve immunological parameters Prevent organ failure and catabolism