NUTRITIONAL SUPPORT IN SURGICAL PATIENTS

INTRODUCTION Nutritional disorders in surgical patients have 2 principal components Starvation – effect of the disease, restriction of oral intake, or both - Metabolic effects of stress/inflammation,increased catabolism,decreased anabolism

ASSESSMENT OF NUTRITIONAL REQUIREMENTS ESTIMATION OF ENERGY AND PROTEIN REQUIREMENTS IN ADULT SURGICAL PATIENTS Uncomplicated Complicated/stressed Energy (Kcal/kg/day) 30 34-40 Protein (g/kg/day) 1.3 1.3-2

CAUSES OF ADEQUATE INTAKE Patient with normal gut cumulative effects of repeated periods of fasting to undergo investigations such as endoscopy or contrast radiology. Patient with intestinal failure * Short bowel syndrome * Fistula formation * Motility disorders * Expensive small bowel disease(e.g.crohn’s disease)

CAUSES OF ANOREXIA IN SURGICAL PATIENTS INTESTINAL OBSTRUCTION ILEUS CANCER ANOREXIA DEPRESSION,STRESS,ANXIETY DRUGS e.g Opiates ORAL ULCERATION/INFECTION GENERAL DEBILITY/WEAKNESS

METHODS OF ADMINISTRATION OF ENTERAL FEEDS NASOGASTRIC OR NASOJEJUNAL TUBES GASTROSTOMY JEJUNOSTOMY

COMPLICATIONS OF ENTERAL NUTRITION DIARRHOEA VOMITING DIFFICULTY IN PLACING THE TUBE

PARENTERAL NUTRITION INDICATION FOR TPN (Total Parenteral Nutrition) COMPOSITION OF TPN

STANDARD PARENTERAL NUTRITION REGIMEN Non-protein energy 2200 kcal Nitrogen 13.5g Volume 2500ml Sodium 115mmol Pottasium 65mmol Calcium 10mmol Magnesium 9.5mmol Phosphate 20mmol Zinc 0.1mmol Chloride 113.3mmol Acetate 135mmol Adequate vitamins and trace elements

COMPLICATIONS OF TPN (Total Parenteral Nutrition) CATHETER PROBLEMS THROMBOPHLEBITIS INFECTION METABOLIC COMPLICATIONS

PERIPHERAL VEIN NUTRITION Lipid emulsion & Isotonic Solutions of Amino Acids infused into peripheral veins Less irritant than TPN Short term usage Complication with long term (Thrombophlebitis)

MONITORING OF NUTRITIONAL SUPPORT DEFICIENCY STATES ASSESS THE ADEQUACY OF ENERGY PROTEIN PROVISION ANTICIPITATE COMPLICATION Pulse rate / Blood Pressure – regularly recorded Accelerate fluid Balance Chart Urine checked for glycosuria daily Body weight measured twice weekly Serum Urea &Electrolyte – daily F.B.C, L.F.T , Serum Albumin , Ca+,Magnesium,Phosphate – once or twice weekly Urine collected over one or two 24 hr periods each week for Nitrogen balance.

NUTRITIONAL SUPPORT IN SURGICAL PATIENTS Clinical Scenarios

1)A 69 year old man presented with significant weight loss and change in bowel habit. A mass was felt per rectum and he underwent a difficult abdomino-perineal resection, with some feacal contamination perioperatively. He has not passed flatus since the operation.Recovery is anticipated to take a long time. Discuss the method of feeding ?

2) A 72 year old woman suffered a left sided cerebrovascular accident during an elective abdominal aortic aneurysm repair. Four weeks later she still has no gag reflex. It is anticipated that she will be unable to feed herself for sometime Discuss the method of feeding?

3) A 71 year old man suffers increasing dysphagia over some months 3) A 71 year old man suffers increasing dysphagia over some months.He has a lower oesophageal carcinoma.It proves impossible to pass a nasogastric tube.He is malnourished and it is decided that he will need nutritional support before surgery. Discuss the method of feeding ?