Dr. Mahamed Hussein General Surgery Azadi Teaching Hospital Nutrition Dr. Mahamed Hussein General Surgery Azadi Teaching Hospital

Nutrition and Surgery Reported 40% incidence of malnutrition in acute hospital setting Malnutrition may compound the severity of complications related to a surgical procedure A well-nourished patient usually tolerates major surgery better than a severely malnourished patient Malnutrition is associated with a high incidence of operative complications and death.

The five steps to optimal nutrition support are: Begin when the benefits are likely to exceed the risk, Set protein and calorie goals, Choose and establish a method for administering the nutrients, enteral (site and route) or parenteral (peripheral or central) Choose or design a formula suitable for the particular patient Monitor the patient for adequacy of nutrient intake and to avoid or minimize complications

Sources of energy (Calories) There are three major sources of energy: Carbohydrates. Fat Protein Of normal daily energy expenditure, 85 per cent is from fat and carbohydrates, and 15 per cent from protein

Carbohydrates Limited storage capacity, needed for CNS (glucose) function Yields 4 kcal/gm Recommended 45-65% of total caloric intake Simple vs Complex

Fats Major endogenous fuel source in healthy adults Yields 9 kcal/gm Too little can lead to essential fatty acid (linoleic acid) deficiency and increased risk of infections Recommended 20-30% of total caloric intake

Protein Needed to maintain anabolic state (match catabolism) Yields 4 kcal/gm Must adjust in patients with renal and hepatic failure Recommended 10-35% of total caloric intake

Normal Nutrition Requirements Healthy male & female ( for weight maintenance ) -------------- Caloric intake= 25-30 kcal/kg/day Protein intake= 0.8-1gm/kg/day (max=150gm/day) Fluid intake= ~30 ml/kg/day If patient’s BMI is >30, use IBW in kg to determine calorie and protein needs. Don’t want to feed the fat. Fluid intake needs to be adjusted for patients in ESRD (especially those not on dialysis) and hepatic failure.

Nutrition Comparison HEALTHLY 70 kg MALE SURGERY PATIENT 1) Caloric intake 25-30 kcal/kg/day 2) Protein intake 0.8-1gm/kg/day (max=150g) 3) Fluid intake 30 ml/kg/day SURGERY PATIENT 1) Caloric intake *Mild stress 25-30 kcal/kg/day *Moderate stress 30-35 kcal/kg/day *Severe stress 30-40 kcal/kg/day 2) Protein intake 1-2 gm/kg/day 3) Fluid intake INDIVIDUALIZED Mild stress (in the hospital, inpatient) Moderate stress (ICU patient) Severe stress (burn patient)

Reasons for Malnutrition Inadequate nutritional intake Metabolic response Nutrient losses Protein/energy store depletion Prevalence of ileus, anorexia, malabsorption Extraordinary stressors (surgical stress, hypovolemia, bacteremia, medications) Wound healing Anabolic state May require appropriate vitamins

ENTERAL NUTRITION ADVANTAGES 1.Maintains git integrity and positive effect on immunity of small intestine. 2. Enhanced utilization of nutrients. 3. More efficient plasma insulin response. 4. Ease and safety of administration. 5. Less cost than TPN . 6. Mechanical, infectious and metabolic complications less severe than with TPN.

ENTERAL NUTRITION INDICATIONS Any condition which requires nutritional support and in which the GIT is functional. CONTRAINDICATIONS 1.Generalized peritonitis 2. Shock 3. Complete intestinal obstruction 4. Intractable vomiting/severe diarrhoea 5. Paralytic ileus 6. Severe git bleeding 7. High output fistula 8. Early stages of short bowel syndrome 9. Acute severe pancreatitis

Complications Of Enteral Nutrition 1.Gastro-intestinal : diarrhoea, vomiting, bloating, abdominal cramps. 2. Metabolic: glucose intolerance, excess CO2 production, electrolyte imbalances 3. Mechanical: Blocked tube, tube dislodgement, nasopharyngeal discomfort, nasalerosions and necrosis (esp. children) 4. Complications of surgery ( gastrostomy; jejunostomy) Perforation ,Haemorrhage, Wound infection, Bowel obstruction/necrosis, Stomal leakage 5. Infection : Aspiration pneumonia, contaminated feeds - gastroenteritis

PARENTERAL NUTRITION If enteral nutrition is not possible in the malnourished or at-risk patient, the parenteral route must be utilized. Parenteral nutrition may be used for either primary or supportive (Secondary) therapy.

Indications for Parenteral Nutrition Primary therapy Gastrointestinal fistula Short bowel syndrome Acute renal failure Hepatic insufficiency Inflammatory bowel disease

Indications for Parenteral Nutrition Secondary therapy Radiation enteritis/chemotherapy toxicity Hyperemesis gravidarum Prolonged ileus Preoperative therapy Cardiac cachexia Pancreatitis insufficiency Cancer Sepsis

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