Ahmed Mayet Associate Professor King Saud University Done by : 428 surgery team surgery team

Nutrition  Nutrition—provides with all basic nutrients and energy required for maintaining or restoring all vital body functions from carbohydrate, fat and protein surgery team

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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 surgery team

Types of malnutrition  Kwashiorkor: (kwa-shior-kor) is protein malnutrition  Marasmus: (ma-ras-mus) is protein-calorie malnutrition “overall malnutrition” surgery team

Kwashiorkor  Protein malnutrition - caused by inadequate protein intake in the presence of fair to good calories intake in combination with the stress response  Common causes - chronic diarrhea, chronic kidney disease”b/c there will be leaking out of protein”, infection, trauma, burns, hemorrhage, liver cirrhosis “b/c the liver can not synthesis any protein so, we have a –ve protein ” and critical illness surgery team

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

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Marasmus  The patient with severe malnutrition characterized by calories deficiency  Common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa and starvation protein-calorie surgery team

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

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Risk factors for malnutrition  Medical causes  Psychological and social causes surgery team

Medical causes (Risk factors for malnutrition) RRecent surgery or trauma SSepsis CChronic illness GGastrointestinal disorders AAnorexia, other eating disorders DDysphagia RRecurrent nausea, vomiting, or diarrhea PPancreatitis IInflammatory bowel disease GGastrointestinal fistulas surgery team

Psychosocial causes AAlcoholism, drug addiction PPoverty, isolation DDisability AAnorexia nervosa FFashion or limited diet 1g Alcohol = 7 kcal surgery team

Consequences of Malnutrition  Malnutrition places patients at a greatly increased risk for morbidity and mortality  Longer recovery period from illnesses  Impaired host defenses  Impaired wound healing  Impaired GI tract function surgery team

Cont:  Muscle atrophy “in renal diseases and liver cirrhosis”  Impaired cardiac function  Impaired respiratory function  Reduced renal function  mental dysfunction  Delayed bone callus formation  Atrophic skin surgery team

Results: Of the 5051 study patients, 32.6% were defined as ‘at- risk’ At-risk’ patients had more complications, higher mortality and longer lengths of stay than ‘not at-risk’ patients. International, multicentre study to implement nutritional risk screening and evaluate clinical outcome Sorensen J et al ClinicalNutrition(2008)27, “Not at risk” = good nutrition status “At risk” = poor nutrition status surgery team

Metabolic Rate Long CL, et al. JPEN 1979;3:452-6 Normal range Patients with major burn, their metabolic rate is very high so, they consume a lot of calorie and u have to replace these calories or u will end up having a malnutrition.. Same thing with sepsis and trauma patients surgery team

Protein Catabolism Long CL. Contemp Surg 1980;16:29-42 Normal range Also here patients with major burn, trauma or sepsis their protein catabolism or consumption rate is very high, and u have to give extra amount of protein or otherwise the body will catabolize his self and people will end up with malnutrition surgery team

Laboratory and other tests  Weight  BMI  Fat storage  Somatic and visceral protein surgery team

Height Small Frame Medium Frame Large Frame 4'10" '11" '0" '1" '2" '3" '4" '5" '6" '7" '8" '9" '10" '11" '0" Standard monogram for Height and Weight in adult-male surgery team

Percent weight loss 129 lbs – 110 lbs = 19 lbs 19/129 x 100 = 15% 139 lbs – 110 lbs = 29 lbs 29/139 x 100 = 20% Small frame Medium frame 50kg x 2.2 = 110 lbs 3-5% == mild malnutrition 5-9%== moderate malnutrition >10 % == severe malnutrition We took a person who is 5.9’’ and his weight is 50 kg: First we have to convert into lbs, then we take the ideal weight regarding his height from the previous chart.. Then, (ideal weight”129” – his weight”110”) = 19 lbs 19 / (ideal weight”129” )= (malnutrition percentage) surgery team

Laboratory and other tests  Weight  BMI  Fat storage  Somatic and visceral protein surgery team

ClassificationBMI (kg/m 2 )Obesity Class Underweight<18.5 Normal Overweight Obesity I Moderate obesity II Extreme obesity>40.0III Average Body Mass Index (BMI) for Adult Our patient BMI = 16.3 kg/m surgery team

Laboratory and other tests  Weight  BMI  Fat storage  Somatic and visceral protein surgery team

Fat  Assessment of body fat  Triceps skinfold thickness (TSF)  Waist-hip circumference ratio  Waist circumference  Limb fat area  Compare the patient TSF to standard monogram surgery team

Laboratory and other tests  Weight  BMI  Fat storage  Somatic and visceral protein surgery team

Protein (Somatic Protein)  Assessment of the fat-free muscle mass (Somatic Protein) Mid-upper-arm circumference (MAC) Mid-upper-arm muscle circumference Mid-upper-arm muscle area Compare the patient MAC to standard monogram surgery team

Protein (visceral protein) Assessment of visceral protein depletion  Serum albumin <3.5 g/dL  Serum transferrin <200 mg/dL  Serum cholesterol <160 mg/dL  Serum prealbumin <15 mg/mL  Creatinine Height Index (CHI) <75% Cont; Our patient has albumin of 2.2 g/dl In visceral protein we look for albumin surgery team

Vitamins deficiency  Vitamin Bs (B1,B2, B6, B 9, B12, )  Vitamin C  Vitamin A  Vitamin D  Vitamin K surgery team

Trace Minerals deficiency  Zinc  Copper  Chromium  Manganese  Selenium  Iron surgery team

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BEE  Basal Metabolic Rate (BMR) or Basal Energy Expenditure (BEE) accounts for the largest portion of total daily energy requirements surgery team

Total Energy Expenditure  TEE (kcal/day) = BEE x stress/activity factor surgery team

BEE  The Harris-Benedict equation is a mathematical formula used to calculate BEE surgery team

Harris–Benedict Equations  Energy calculation Male  BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) Female  BEE = (9.6 x actual wt in kg) + (1.7 x ht in cm) – (4.7 x age in y) surgery team

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  for burn surgery team

Calculation Our patient Wt = 50 kg Age = 45 yrs Height = 5 feet 9 inches (175 cm) BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) = 66 + (13.7 x 50 kg) + (5 x 175 cm) – (6.8 x 45) =66 + ( 685) + (875) – (306) = 1320 kcal TEE = 1320 x 1.25 (normal activity) = 1650 kcal surgery team

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Calories  60 to 80% of the caloric requirement should be provided as glucose, the remainder 20% to 40% as fat  To include protein calories in the provision of energy is controversial surgery team

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Fluid  The average adult requires approximately ml/kg/d  NRC* recommends 1 to 2 ml of water for each kcal of energy expenditure *NRC= National research council Fluid replacement either: Weight distributed1-2ml/kcal expended surgery team

Fluid  1 st 10 kilogram 100 cc/kg  2 nd 10 kilogram 50 cc/kg  Rest of the weight 20 to 30 cc/kg Example: Our patient 1 st 10 kg x 100cc = 1000 cc 2 nd 10 kg x 50cc = 500cc Rest 30 kg x 30cc = 900cc total = 2400 cc surgery team

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Protein  The average adult requires about 1 to 1.2 gm/kg 0r average of grams of protein per day surgery team

Protein Stress or activity level Initial protein requirement (g/kg/day)  Baseline 1.4 g/kg/day  Little stress 1.6 g/kg/day  Mild stress 1.8 g/kg/day  Moderate stress 2.0 g/kg/day  Severe stress 2.2 g/kg/day surgery team

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 The nutritional needs of patients are met through either parenteral or enteral delivery route surgery team

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Enteral  The gastrointestinal tract is always the preferred route of support (Physiologic)  “If the gut works, use it”  EN is safer, more cost effective, and more physiologic that PN surgery team

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 surgery team

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

Safety ”complications”  Catheter sepsis  Pneumothorax  Catheter embolism  Arterial laceration surgery team

Cost (EN)  Cost of EN formula is less than PN  Less labor intensive surgery team

Contraindications  Gastrointestinal obstruction  Severe acute pancreatitis  High-output proximal fistulas  Intractable nausea and vomiting or osmotic diarrhea v. imp surgery team

Enteral nutrition (EN)  Long-term nutrition: “like in esophagus cancer”  Gastrostomy  Jejunostomy  Short-term nutrition:  Nasogastric feeding  Nasoduodenal feeding  Nasojejunal feeding surgery team

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Intact food Predigested food surgery team

 We can’t use polymeric food in patient with naso doudenal or nasojejunal b/c there will be no breaking down of the food by stomach, but we need a predigested”monomeric” food for them..  U never ever start feeding a malnurished patient with full calorie >> start gradually surgery team

TF = tube feeding surgery team

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Purpose  To maintain positive nitrogen balance through the intravenous administration of required nutrient such as glucose, IL, AA, electrolytes, vitamins, minerals and trace elements  Patients who didn’t eat for 4-5 days u have to feed them PN first surgery team

PN Goal  Provide patients with adequate calories and protein to prevent malnutrition and associated complication  PN therapy must provide:  Protein in the form of amino acids  Carbohydrates in the form of glucose  Fat as a lipid emulsion  Electrolytes, vitamin, trace elements, min surgery team

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General Indications  Requiring NPO > days  Unable to meet all daily requirements through oral or enteral feedings  Severe gut dysfunction or inability to tolerate enteral feedings.  Can not eat ”intestinal restriction”, will not eat ”nausea & vomitting”, should not eat ”pancreatitis” surgery team

Special Indications (can not eat) surgery team

Cont:  When enteral feeding can’t be established  After major surgery  Pt with hyperemesis gravidarum  Pt with small bowel obstruction  Pt with enterocutaneous fistulas (high and low) surgery team

Cont:  Hyper-metabolic states:  Burns, sepsis, trauma, long bone fractures  Adjunct to chemotherapy  Nutritional deprivation  Multiple organ failure:  Renal, hepatic, respiratory, cardiac failure  Neuro-trauma  Immaturity surgery team

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Fat Emulsion  Concentrated source of calories  Source of essential fatty acids (EFAs)  Substitute for carbohydrate in diabetic & fluid restricted patients surgery team

Fat (Intralipid) contraindications:  Hyperlipdemia  Acute pancreatitis  Previous history of fat embolism  Severe liver disease  Allergies to egg, soybean oil or safflower oil surgery team

Not to be memorized surgery team

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Diabetic  DM is not contraindication to TPN  Use sliding-scale insulin to avoid hyperglycemia surgery team

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Central PN (TPN)  Central PN (TPN) is a concentrated formula and it can delivered large quantity of calories via subclavian or jugular vein only  Peripheral PN provides limited calories surgery team

 There are two types of enteral nutrition: 1. Central: through subclavian vein or jugular vein for pt who needs a lot of calories. 2. Peripheral: through peripheral veins for pt who needs limited calories because of the osmolarity surgery team

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 surgery team

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

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Complications Associated with PN  Mechanical complication  Septic complication  Metabolic complication surgery team

Mechanical Complication  Improper placement of catheter may cause pneumothorax, vascular injury with hemothorax, brachial plexus injury or cardiac arrhythmia  Venous thrombosis after central venous access surgery team

Infectious Complications PN imposes a chronic breech in the body's barrier system  The mortality rate from catheter sepsis as high as 15%  Inserting the venous catheter  Compounding the solution  Care-giver hanging the bag  Changing the site dressing surgery team

Metabolic Complications  Early complication -early in the process of feeding and may be anticipated  Late complication - caused by not supplying an adequate amount of required nutrients or cause adverse effect by solution composition surgery team

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Iron  Iron is not included in TPN solution and it can cause iron deficiency anemia  Add 100mg of iron 3 x weekly to PN solution or give separately surgery team

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 surgery team

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