Nutrition Support of the Surgical Patient Randa Jaroudi, Pharm.D Clinical Coordinator TPN Coordinator KKUH

Nutrition Nutrition allows the body to be provided with all basic nutrients substrates and energy required for maintaining or restoring all vital body functions from carbohydrate and fat and for building up body mass from amino acid.

Malnutrition Malnutrition—come from extended inadequate intake of nutrient or severe illness burden on the body composition and function—affect all systems of the body

Type of Malnutrition Marasmus Protein – calorie malnutrition The patient's oral diet may include an acceptable protein:calorie ratio but is inadequate in quantity and calories. (depleted somatic proteins, normal visceral proteins) Normal Albumin and transferrin Patients look thin and malnourished. e.g. Patients with mild to moderate starvation, common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa 4

Clinical Manifestations Weight loss Reduced basal metabolism Depletion skeletal muscle and adipose (fat) stores Decrease tissue turgor Bradycardia Hypothermia

Type of Malnutrition Kwashiorkor (Kwa-shior-kor) Protein malnutrition the diet contains various amounts of nonprotein calories (inadequate, adequate, or excessive) from carbohydrates and fats, but is deficient in total protein and essential amino acids. (normal somatic proteins depleted visceral proteins) ↓ Serum Albumin and transferrin Patients appear normal or overweight e.g. Hypercatabolic critical care patients, chronic diarrhea, chronic kidney disease, trauma , burns, hemorrhage, and liver cirrhosis

Clinical Manifestations Marked hypoalbuminemia Anemia Edema and ascites Muscle atrophy Delayed wound healing Impaired immune function

Diagnosis Mixed Marasmus-Kwashiorkor: (depleted somatic and visceral proteins) All above data are reduced Patients appear cachexic and severely malnourished. e.g. *Chronic hypercatabolic patients (250 to 500g loss of weight) *Prolonged starvation Marasmic-kwashiorkor is a mixed form of any PCM symptoms. It frequently occurs when the marasmic patient experiences the catabolic stress of illness or trauma. 10

Medical causes (Risk factors for malnutrition) Recent surgery or trauma Sepsis Chronic illness Gastrointestinal disorders Anorexia, other eating disorders Dysphagia Recurrent nausea, vomiting, or diarrhea Pancreatitis Inflammatory bowel disease Gastrointestinal fistulas Cancer

Metabolic Rate Normal range Long CL, et al. JPEN 1979;3:452-6

Protein Catabolism Normal range Long CL. Contemp Surg 1980;16:29-42

The Goals of Preoperative Nutrition Support ↓ surgical mortality ↓surgical complications and infection Reduce the catabolic state and restore anabolism ↓the hospital length of stay Speed the healing/recovery process

Indications Aggressive nutritional support (enteral or parenteral) should be considered in minimum 3 of: Looks clinically malnourished. Has a low serum albumin <3.5g/dL. Has a recent loss of 10% or greater within Has a history of recent poor intake. Who as a consequence of his illness is going to be or has been NPO for 5-7 days. The term “If gut works, use it” remains the golden rule. However, recently this was changed to: If gut works use it; and if gut works partially, use it partially.

Preoperative Nutrition Assessment-1 1. Medical & Nutritional History Medical history includes acute or chronic disease, medication, surgeries, & other therapies (i.e., chemotherapeutics, immunosuppressive) Nutrition History includes recent changes in appetite or weight, activity level, use of diet. Subject Global Assessment (SGA)

Preoperative Nutrition Assessment-2 2. Physical examination Logical assessment from head to toe 3. Anthropometric parameters % of IBW = Actual weight x 100/Ideal body weight Triceps Skinfold Thickness (TSF) for assessing fat reserve. It is decreased when fat stores are depleted. Midarm muscle circumference (MAC) to assess the degree of somatic protein depletion. TSF and Mid Arm Circumference are no more recommended as an accurate measurement. Creatinine Height Index (CHI) to assess somatic protein stores. Serum Protein Determination to assess the degree of visceral protein depletion, e.g. Albumin, Transferring, Prealbumin. Measure Total Lymphocyte Count (TLC) to assess Immune function becomes impaired 4. Lab assessment

Fat, Anthropometric parameters Assessment of body fat Triceps Skinfold Thickness (TSF) for assessing fat reserve. It is decreased when fat stores are depleted.

Protein (Somatic Protein) Assessment of the fat-free muscle mass (Somatic Protein) depletion Mid-upper-arm circumference (MAC) TSF and MAC are no more recommended as an accurate measurement

Creatinine-height index (CHI ) [measured urinary creatinine (24hr)/ Ideal urinary creatinine for a given height] Ideal Cr = IBW x 23 mg/kg male = IBW x 18 mg/kg female CHI > 80 mild depletion CHI 60 – 80 moderate CHI < 60 severe

Average Body Mass Index (BMI) for Adult Classification BMI (kg/m2) Obesity Class Underweight <18.5   Normal 18.5-24.9 Overweight 25.0-29.9 Obesity 30.0-34.9 I Moderate obesity 35.0-39.9 II Extreme obesity >40.0 III

Nutrition Provides Energy Amino Acid Fluid & Electrolyte Trace minerals (elements) Vitamin Certain drugs

Fluid Requirement

Fluid Requirement Amount of fluid requirement needed depend on age Pediatric: 1st 10kg = 100ml/kg 2nd 10kg = 50ml/kg 3rd 10kg & up 20ml/kg Adult: 30-35ml/kg Additional fluid for vomiting, nasogastric tube output, diarrhea, large open wound, fever, hyperventilation, fistula drainage.

Fluid Requirements Special situation for fluid restriction: Fluid overload, Cardiac, Renal, or Liver failure Elderly Medication NRC* recommends 1 to 2 ml of water for each kcal of energy expenditure *NRC= National research council

Energy Requirements

Total Energy Expenditure TEE (kcal/day) = BEE x stress/activity factor BEE: The Harris-Benedict equation is a mathematical formula used to calculate BEE

Harris-Benedict Equation Women = 655 + (9.6 x wt) + (1.7 x ht) - (4.7 x age) Men = 66 + (13.7 x wt) + (5 x ht) - (6.8 x age) Calories Multiply by stress factor

A correlation factor that estimates the extent of hyper-metabolism 1.15 for bedridden patients 1.10 for patients on ventilator support 1.25 for normal patients The stress factors are: 1.3 for low stress 1.5 for moderate stress 2.0 for severe stress 1.9-2.1 for burn

Calories Requirements Obesity: 18-20kcal/kg/day of IBW Normal need: 25-30kcal/kg/day Elective surgery: 28-30kcal/kg/day Severe injury: 30-40kcal/kg/day Extensive trauma/burn: 40-45kcal/kg/day

Carbohydrate Primary energy substrate The amount of carbohydrate is determined by patient’s calorie requirement glucose oxidation rate optimal balance of carbohydrate and fat Maximum oxidized rate 4 - 7mg/kg/min (adult).

Carbohydrate Provide from a non nitrogen source Energy requirement depends on number of factors! Stress factors, increase calories requirements 60% - 80% of caloric requirement as glucose

CHO Oxidation Rate 1gm = 3.4kcal Kcl ÷ 3.4 x 1000 ÷ 1440 ÷ wt kg = not more than 5mg/kg/min e.g. 1700 ÷ 3.4 x 1000 ÷ 1440 ÷ 70 = 4.9mg/kg/min or 5 mg x 3.4 ÷ 1000 x wt x 1440 5 x 3.4 ÷ 1000 x 70 x 1440 = ~ 1700 kcal

Carbohydrate Source Starting with: 200 - 250 gm or 15% dextrose solution started or 2.5 mg/kg/min 100 - 150 gm or 10% - 15% dextrose solution in stress & DM Increase gradually up to 5 mg/kg/min, Max 7 mg/kg/min

How to Calculate Percentage Total volume of fluid x 3.4 x % e.g. 2000ml x 3.4 x 0.20 = 1360 kcal. Or 1400 ÷ 3.4 ÷ 2000ml = 20% as started then 1700 ÷ 3.4 ÷ 2000ml = 25% full requirement

Protein (Amino Acid) AAs are the vital components of body protein. The primary aim of providing AAs to the body is to prevent:   Disease related catabolic state. The development of manifest protein deficiency with subsequent impaired wound healing. Disturbances of blood clotting. The impairment of hepatic and renal function. A reduced immuno-competence.

Protein (Amino Acid) 1g of protein = 4 Kcal 1g of nitrogen is equivalent to 6.3g of protein Non-protein k.cal: nitrogen 150-200: 1 (normal patient)  Note: In renal and hepatic failure the ratio is 1:300-400. Adult dose: Normal patients requirement 0.8-1.0 g/kg max. 2.5g/kg depend on patient status Renal failure patient 0.6 g/kg

Protein (Amino Acid) 12% - 16% of calories as protein Note: Products containing only essential Aas have been formulated for renal failure. BCAA (Branched Chain Amino Acids) are used for Hepatic Encephalopathy or in severely stressed patients.

Fat Emulsion Essential linoleic acid stabilized by egg yolk phospholipids Delivered in the form of an emulsion fat emulsion has no isotonicity by itself, glycerol is added to render emulsion isotonic (300 mosm/l). Concentrated source of calories Source of essential fatty acids (EFAs) Substitute for carbohydrate in diabetic & fluid restricted patients

Fat Emulsion Fat should provide 20-40% of total calories. Fat provides a concentrated caloric source. 1g provide 10 Kcal. Also fat is an alternative source to dextrose to the patients with compromised respiration since it does produce little CO2 in its metabolism. While dextrose, when oxidized, it produces CO2 which must be eliminated via lungs. Start with 0.5g/kg/d  gradually up to1.5g/kg/d. Administer over 12hr or max rate 15ml/hr

Fat Emulsion The caloric density 10% FE is 1.1 kcal/ml Writing TPN Order 23/07/1438 Fat Emulsion The caloric density 10% FE is 1.1 kcal/ml 20% FE is 2 kcal/ml 30% FE is 3 kcal/ml There is LCT, and MCT/LCT products 1gm = 9kcal of fat Each 1ml = 2kcal Lipid emulsions contain glycerol, so lipid emulsion does not have 9 kcal per gram as it would if it were pure fat. Some use 10 kcal/gm for lipid emulsions. Propofol: Soybean oil in water emulsion, 1ml - 1.112kcal randa911@yahoo.com Randa Jaroudi

Fat Emulsion Contraindications Hyperlipdemia Acute pancreatitis Previous history of fat embolism Severe liver disease Allergies to egg, soybean oil or safflower oil

Electrolytes Na, K, CL, Ca, Mg, PO4, & acetate. Writing TPN Order 23/07/1438 Electrolytes Na, K, CL, Ca, Mg, PO4, & acetate. Electrolytes given to maintain normal serum concentration or to correct deficit. Requirements for specific electrolytes will vary according to the patients disease state randa911@yahoo.com Randa Jaroudi

Restrict electrolytes Writing TPN Order 23/07/1438 Restrict electrolytes Severe renal dysfunction. Edema & congestive heart failure. Patients on corticosteroids. Metabolic acidosis, acute pancreatitis fistulas, or diarrhea. Metabolic alkalosis, vomiting. randa911@yahoo.com Randa Jaroudi

Multivitamins B – Complex: Co-enzyme in absorptive and metabolic processes, transfer of energy from protein, fat and carbohydrate to the cells and their storage as ATP. Ascorbic Acid: Required for collagen synthesis, wound healing. An additional amount may be required in major burns, traumas, and extensive surgeries. Vitamin A: Essential for vision, the production of mucus-secreting epithelial cells and bone growth. Vitamin D: For calcium and phosphate hemeostasis and boncalcification. Vitamin K: For prothrombin generation (Fibrin Fibrinogen).

Vitamin K TPN solution does not contain vitamin K and it can predispose patient to deficiency Vitamin K 10 mg should be given weekly IV or IM if patient is on long-term TPN

Multivitamin and Trace Minerals Writing TPN Order 23/07/1438 Multivitamin and Trace Minerals Standard form of multivitamin & trace mineral use. Zinc, copper, manganese & chromium. Additional of trace mineral required depend on GI losses. Renal failure patients reduce dose Biliary stasis disease, avoid copper & manganese randa911@yahoo.com Randa Jaroudi

Additives INSULIN: For hyperglycemia when glucose is spilling in urine.   HEPARIN: To promote blood circulation (especially with peripheral TPN) and to prevent thrombophlebitis. HYDROCORTISONE: To prevent thrombophlebitis in patients receiving peripheral TPN. ACETATE: For acidosis. ZINC: Extra amount is needed for patient with severe stress, diarrhea, and ileostomy.

Status of Organic failure Hypermetabolism Tachycardia, Tachypnea, Fever, Leucocytosis Hypercatabolism Hyperglycemia, Uremia, Hypertriglyceridemia, -NB

Renal Failure Considerations Writing TPN Order 23/07/1438 Renal Failure Considerations Present with problems of volume limitation and poor tolerance of nitrogen wastes. Treated with 0.5-0.6g/kg amino acid, higher glucose and lipid concentration. Limit amounts of sodium, potassium, magnesium, and phosphate. randa911@yahoo.com Randa Jaroudi

Liver Failure Considerations Writing TPN Order 23/07/1438 Liver Failure Considerations Inability to tolerate large fluid volume and difficulty with nitrogen loads Maintain glucose Supply moderate protein(1.0-1.3g/kg) and fat intake up to 30% of T.k.calorie Restrict fluid and salt intake BCAA randa911@yahoo.com Randa Jaroudi

Fluid Restricted Considerations Writing TPN Order 23/07/1438 Fluid Restricted Considerations As pulmonary, cardiac failure, head injuries, and elderly. Special concentrated TPN solution. High fat emulsion, low glucose. Normal protein requirement. Normal electrolyte. randa911@yahoo.com Randa Jaroudi

Writing TPN Order 23/07/1438 Respiratory Failure Non-protein calories to nitrogen ration is not a major consideration. Major problem total calories, either from CHO or fat or both Protein increases oxygen consumption demands and that is not indicated to reducing protein randa911@yahoo.com Randa Jaroudi

Going to surgery In postoperative surgical patients; TPN is indicated if the patient is indicated to stay NPO for 5 – 7 days in malnourished patients, and 7 – 10 days in well-nourished patients. In preoperative patients; TPN should be considered in patients who cannot or should not eat for more than 3 – 5 days.

Practice Guidelines Preoperative NS should be administered for 7-14 days to moderately or severely malnourished patients undergoing major GI surgery PN should NOT be routinely given in the immediate postoperative period to patients undergoing major GI procedures

OR Patient Hold TPN during OR if it more than 1 1/2 hrs Writing TPN Order 23/07/1438 OR Patient Hold TPN during OR if it more than 1 1/2 hrs 2hrs pre-operation: ↓ TPN rate 50% for 1hr Hold TPN Start D10% infusion at same TPN rate 6hrs post – operation Start new TPN bottle at 50% of TPN rate for 1hr ↑ TPN rate as in order MONITORING BLOOD SUGAR randa911@yahoo.com Randa Jaroudi

Routes of Nutrition Support

Enteral Nutrition

Enteral Nutrition Indication Inability to consume or absorb adequate nutrition e.g. who do not eat or receive nutrition support for ≥10-14 days after hospital admission Functional or partially functional gut e.g. who are unable or not allowed to eat, or partial functional gut

Potential benefits of EN over PN Nutrients are metabolized and utilized more effectively via the enteral than parenteral route Gut and liver process EN before their release into systemic circulation Gut and liver help maintain the homeostasis of the AA pool and skeletal muscle tissue

EN (Immunologic) Gut integrity is maintained by enteral feeding and prevent the bacterial translocation from the gut and minimize risk of gut related sepsis

Enteral nutrition (EN) Long-term nutrition: Gastrostomy Jejunostomy Short-term nutrition: Nasogastric feeding Nasoduodenal feeding Nasojejunal feeding

Benefits of EN Physiological/metabolic benefits Safety benefits The gut can be used for administration of complex nutrients that cannot be given intravenously e.g. intact protein, peptides, fiber Safety benefits Safer than PN and less side effects Cost benefits

Contraindication to EN Terminal illness Short bowel Obstruction GI bleeding Vomiting and diarrhea Fistulas GI ischemia Illues GI inflammation A. pancreatitis

Enteral Nutrition Complications Mechanical complication During placement of feeding tube Airway injury, infection, ↑ICP Presence of a feeding tube Tube clogging Declogging methods Aspiration GI complication Gastroesophageal reflux duodenal gastric reflux Diarrhea Metabolic complication

Enteral Nutrition Complications Metabolic complication Hyperglycemia Electrolyte and mineral deficiences Refeeding syndrome

Total Parentral Nutrition

Total Parenteral Nutrition Indication When normal oral feeding is not possible. e.g.: Chron’s disease, gastric & esophageal carcinoma, paralytic ileus, generalized peronitis, GI. obstruction, intractable vomiting. When food is incompletely absorbed. e.g.: Major burns, multiple injuries, radiation therapy, ulcerative colitis, chemotherapy treatment, short bowel syndrome. When food intake is undesirable, in case it is prudent to rest the bowel. e.g.: Post GIT surgery, chronic inflammatory diseases, intractable diarrhea.

Total Parenteral Nutrition Indication In patients who are able to ingest food, but refuse to do so. e.g.: Geriatric post-operative patients, adolescents with anorexia nervosa, some psychiatric patients with prolonged depression. In patients who, as a consequence of their illness are going to be, or have been NPO for 5 – 7 days.

Administration

Parenteral Nutrition Central Nutrition Subclavian line Long period Hyperosmolar solution Full requirement Minimum volume Expensive More side effect Peripheral nutrition Peripheral line Short period < 14days Low osmolality < 900 mOsm/L Min. requirement Large volume Thrombophlebitis

Routes of TPN Central TPN (usual osmolarity = 2000 mosmol/L) Advantages: Can provide full nutritional support (No limits in concentration of dextrose and amino acids) No risk of thrombophlebitis, No pain. Disadvantages: Requires surgery More risk of sepsis than peripheral TPN High risk of mechanical complications

Routes of TPN maximum osmolarity; Peripheral TPN maximum osmolarity; neonates = 1100/L, Pediatrics = 1000/L, Adults = 900/L Advantages: Does not require surgery Less risk of sepsis than central TPN No risk of mechanical complications Disadvantages: High risk of thrombophlebitis Painful Does not provide full nutrition support. Needs more fluids to provide more nutrition. (maximum dextrose = 7.5% and AA = 2.5%).

Note PPN can infuse through central line but central TPN can NOT infuse through the peripheral line

Calculating the Osmolarity of a Parenteral Nutrition Solution Writing TPN Order 23/07/1438 Calculating the Osmolarity of a Parenteral Nutrition Solution Multiply the grams of dextrose per liter by 5. Example: 100 g of dextrose x 5 = 500 mOsm/L Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L Multiply the (mEq per L sodium + potassium + calcium + magnesium) X 2 Example: 80 X 2 = 160 Total osmolarity = 500 + 300 + 160 = 960 mOsm/L randa911@yahoo.com Randa Jaroudi

Monitoring

Monitoring Avoid overfeeding Avoid respiratory problem Writing TPN Order 23/07/1438 Monitoring Avoid overfeeding Avoid respiratory problem Promote nitrogen retention Triglyceride clearance Fluid and electrolyte Weight Liver function randa911@yahoo.com Randa Jaroudi

Monitoring for Complications Writing TPN Order 23/07/1438 Monitoring for Complications Malnourished patients at risk for refeeding syndrome should have serum phosphorus, magnesium, potassium, and glucose levels monitored closely In patients with diabetes or risk factors for glucose intolerance, insulin infusion should be initiated with a low dextrose infusion rate and blood and urine glucose monitored closely. Blood glucose should be monitored frequently upon initiation, any change in insulin dose, and until measurements are stable. randa911@yahoo.com Randa Jaroudi

Monitoring for Complications Writing TPN Order 23/07/1438 Monitoring for Complications Serum electrolytes (sodium, potassium, chloride, and bicarbonate) should be monitored frequently until measurements are stable. Patients receiving intravenous fat emulsions should have serum triglyceride levels monitored until stable and when changes are made in the amount of fat administered. Liver function tests should be monitored periodically in patients receiving PN. randa911@yahoo.com Randa Jaroudi

Complications of TPN

Writing TPN Order 23/07/1438 Complication Mechanical: occlusion, catheter removal, improper rate, thromboses, pneumothorax. Infection: catheter related Metabolic: re-feeding syndrome, hyperglycemia, fluid & electrolyte disturbance (cont..) randa911@yahoo.com Randa Jaroudi

Complication Organic system: hepatobiliary complication respiratory Writing TPN Order 23/07/1438 Complication Organic system: hepatobiliary complication respiratory cardiovascular renal randa911@yahoo.com Randa Jaroudi

Writing TPN Order 23/07/1438 Transitional Feeding Maintain full PN support until pt is tolerating 1/3 of needs via enteral route Decrease TPN by 50% and continue to taper as the enteral feeding is advanced to total TPN can reduce appetite if >25% of calorie needs are met via PN TPN can be tapered when pt is consuming greater than 500 calories/d and d-c’d when meeting 60% of goal TPN can be rapidly d-c’d if pt is receiving enteral feeding in amount great enough to maintain blood glucose levels randa911@yahoo.com Randa Jaroudi

Defense Against NS Complications Writing TPN Order 23/07/1438 Defense Against NS Complications Select appropriate patients to appropriate nutrition Aseptic technique Do not overfeed Maintain glycemic control <150-170 mg/dl Limit lipids to 1 gm/kg and monitor TG levels Adjust protein based on metabolic demand and organ function Monitor fluid/electrolyte/mineral status Provide standard vitamin and trace element preps daily randa911@yahoo.com Randa Jaroudi

Thank you