1. Nutritional Support Surgical Nutrition Advisory Team Dept of Surgery Yong Loo Lin School of Medicine National University of Singapore

2. Nutritional Support may supplement normal feeding, or completely replace normal feeding into the gastrointestinal tract.

3. Benefits of Nutritional Support Preservation of nutritional status Prevention of complications of protein malnutrition  Post-operative complications

4. Who Requires Nutritional Support? Patients already with malnutrition – surgery / trauma/sepsis Patients at risk of malnutrition

5. Patients at Risk of Malnutrition Depleted reserves Cannot eat for >5 days Impaired bowel function Critical illness Need for prolonged bowel rest

6. How Do We Detect Malnutrition?

7. Nutritional Assessment History Physical examination Anthropometric measurements Laboratory investigations

8. Nutritional Assessment History Dietary history Significant weight loss within last 6 months  > 15% loss of body weight  compare with ideal weight  Beware the patient with ascites/ oedema

9. Physical Examination Evidence of muscle wasting Depletion of subcutaneous fat Peripheral oedema, ascites Features of Vitamin deficiency  e.g. nail and mucosal changes Echymosis and easy bruising Easy to detect >15% loss Nutritional Assessment

10. Anthropometry Weight for Height comparison Body Mass Index ( 10% decrease) Triceps-skinfold Mid arm muscle circumference Bioelectric impedance Hand grip dynamometry Urinary creatinine / height index Nutritional Assessment

11. Lab investigations albumin < 30 mg/dl pre-albumin <12 mg/dl transferrin < 150 mmol/l total lymphocyte count < 1800 / mm3 tests reflecting specific nutritional deficits  e.g. prothrombin time Skin anergy testing Nutritional Assessment

12. Types of Nutritional Support Enteral Nutrition Parenteral Nutrition

13. More physiologic Less complications Gut mucosa preserved No bacterial translocation Cheaper Enteral Feeding Is Best

14. Enteral Feeding Is Indicated When nutritional support is needed Functioning gut present No contra-indications  no ileus, no recent anastomosis, no fistula

15. Types of Feeding Tubes Naso-gastric tubes Oro-gastric tubes Naso-duodenal tubes Naso-jejunal tubes Tubes inserted down the upper GIT, following normal anatomy

16. Gastrostomy tubes  Percutaneous Endoscopic Gastrostomy (PEG)  Open Gastrostomy Jejunostomy tubes Tubes that require an invasive procedure for insertion Types of Feeding Tubes

21. What Can We Give in Tube Feeding? Blenderised feeds Commercially prepared feeds  Polymeric e.g. Isocal, Ensure, Jevity  Monomeric / elemental e.g. Vivonex

23. Complications of Enteral Feeding 12% overall complication rate Gastrointestinal complications Mechanical complications Metabolic complications Infectious complications

24. Gastrointestinal Distension Nausea and vomiting Diarrhoea Constipation Intestinal ischaemia Complications of Enteral Feeding

25. Infectious Aspiration pneumonia Bacterial contamination Complications of Enteral Feeding

26. Mechanical Malposition of feeding tube Sinusitis Ulcerations / erosions Blockage of tubes Complications of Enteral Feeding

27. Parenteral Nutrition

28. Allows greater caloric intake BUT Is more expensive Has more complications Needs more technical expertise

29. Who Will Benefit From Parenteral Nutrition? Patients with/who  Abnormal gut function  Cannot consume adequate amounts of nutrients by enteral feeding  Are anticipated to not be able to eat orally by 5 days  Prognosis warrants aggressive nutritional support

30. Two Main Forms of Parenteral Nutrition Peripheral Parenteral Nutrition Central (Total) Parenteral Nutrition Both differ in  composition of feed  primary caloric source  potential complications  method of administration

31. Peripheral Parenteral Nutrition Given through peripheral vein Short term use Mildly stressed patients Low caloric requirements Needs large amounts of fluid Contraindications to central TPN

32. What to Do Before Starting TPN Nutritional Assessment Venous access evaluation Baseline weight Baseline lab investigations

33. Venous Access for TPN Need venous access to a “large” central line with fast flow to avoid thrombophlebitis Superior Vena Cava Long peripheral lineLong peripheral line Subclavian approachSubclavian approach Internal jugular approachInternal jugular approach External jugular approachExternal jugular approach

36. Baseline Lab Investigations Full blood count Coagulation screen Screening Panel # 1 Ca ++, Mg ++, PO 4 2- Lipid Panel # 1 Other tests when indicated

37. Decide how much fat & carbohydrate to give Determine Total Fluid Volume Determine Non-N Caloric needs Determine Protein requirements Determine Electrolyte and Trace element requirements Determine need for additives Steps to Ordering TPN

38. Decide how much fat & carbohydrate to give Determine Total Fluid Volume Determine Non-N Caloric needs Determine Protein requirements Determine Electrolyte and Trace element requirements Determine need for additives Steps to Ordering TPN

39. How Much Volume to Give? Cater for maintenance & on going losses Normal maintenance requirements  By body weight  alternatively, 30 to 50 ml/kg/day Add on going losses based on I/O chart Consider insensible fluid losses also e.g. add 10% for every o C rise in temperature

40. Steps to Ordering TPN Determine Total Fluid Volume Determine Caloric needs Determine Protein requirements Decide how much fat & carbohydrate to give Determine Electrolyte and Trace element requirements Determine need for additives

41. Caloric Requirements Based on Total Energy Expenditure  Can be estimated using predictive equations TEE = REE + Stress Factor + Activity Factor  Can be measured using metabolic cart

42. Stress Factor Malnutrition- 30% Peritonitis+ 15% Soft tissue trauma+ 15% Fracture+ 20% Fever (per o c rise)+ 13% Moderate infection+ 20% Severe infection + 40% <20% BSA burns+ 50% 20-40% BSA burns+ 80% >40% BSA burns+ 100% Caloric Requirements

43. Activity Factor n Bed-bound+ 20% n Ambulant + 30% n Active + 50% Caloric Requirements

44. REE Predictive equations Harris-Benedict Equation Males: REE = 66 + (13.7W) + (5H) - 6.8A Females: REE= 655 + (9.6W) + 1.8H - 4.7A Schofield Equation 25 to 30 kcal/kg/day Caloric Requirements

45. How Much CHO & Fats? “Too much of a good thing causes problems”  Not more than 4 mg / kg / min Dextrose (less than 6 g / kg / day) Rosmarin et al, Nutr Clin Pract 1996,11:151-6  Not more than 0.7 mg / kg / min Lipid (less than 1 g / kg / day) Moore & Cerra, 1991

46. Fats usually form 25 to 30% of calories  Not more than 40 to 50%  Increase usually in severe stress  Aim for serum TG levels < 350 mg/dl or 3.95 mmol/L CHO usually form 70-75 % of calories How Much CHO & Fats?

47. Steps to Ordering TPN Determine Total Fluid Volume Determine Caloric needs Determine Protein requirements Decide how much fat & carbohydrate to give Determine Electrolyte and Trace element requirements Determine need for additives

48. How Much Protein to Give? Based on calorie : nitrogen ratio Based on degree of stress & body weight Based on Nitrogen Balance

49. Calorie : Nitrogen Ratio Normal ratio is 150 cal : 1g Nitrogen Critically ill patients 85 to 100 cal : 1 g Nitrogen in

50. Based on Stress & BW Non-stress patients0.8 g / kg / day Mild stress 1.0 to 1.2 g / kg / day Moderate stress1.3 to 1.75 g / kg / day Severe stress2 to 2.5 g / kg / day

51. Based on Nitrogen Balance Aim for positive balance of 1.5 to 2g / kg / day

52. Steps to Ordering TPN Decide how much fat & carbohydrate to give Determine Total Fluid Volume Determine Protein requirements Determine Non-N Caloric needs Determine Electrolyte and Trace element requirements Determine need for additives

53. Electrolyte Requirements Cater for maintenance + replacement needs Na + 1 to 2 mmol/kg/d (or 60-120 meq/d) K + 0.5 to 1 mmol/kg/d (or 30 - 60 meq/d) Mg ++ 0.35 to 0.45 meq/kg/d(or 10 to 20 meq /d) Ca ++ 0.2 to 0.3 meq/kg/d(or 10 to 15 meq/d) PO 4 2- 20 to 30 mmol/d

54. Trace Elements Total requirements not well established Commercial preparations exist to provide RDA Zn2-4 mg/day Cr10-15 ug/day Cu0.3 to 0.5 mg/day Mn0.4 to 0.8 mg/day

55. Decide how much fat & carbohydrate to give Determine Total Fluid Volume Determine Protein requirements Determine Non-N Caloric needs Determine Electrolyte and Trace element requirements Determine need for additives Steps to Ordering TPN

56. Other Additives Vitamins  Give 2-3x that recommended for oral intake  us give 1 ampoule MultiVit per bag of TPN  MultiVit does not include Vit K can give 1 mg/day or 5-10 mg/wk

57. Other Additives Medications Insulin can give initial SI based on sliding scale according to hypocount q6h (keep <11 mmol/l) once stable, give 2/3 total requirements in TPN & review daily alternate regimes  0.1 u per g dextrose in TPN  10 u per litre TPN initial dose Other medications

58. TPN Monitoring Clinical Review Lab investigations Adjust TPN order accordingly

59. Clinical Review Clinical examination Vital signs Fluid balance Catheter care Sepsis review Blood sugar profile Body weight

60. Lab investigations 3 Full Blood Count 3 Renal Panel # 1 3 Ca++, Mg++, PO42- 3 Liver Function Test 3 Iron Panel 3 Lipid Panel 3 Nitrogen Balance 3 Full Blood Count 3 Renal Panel # 1 3 Ca++, Mg++, PO42- 3 Liver Function Test 3 Iron Panel 3 Lipid Panel 3 Nitrogen Balance 3 weekly, unless indicated 3 daily until stable, then 2x/wk 3 weekly 3 1-2x/wk 3 weekly 3 weekly, unless indicated 3 daily until stable, then 2x/wk 3 weekly 3 1-2x/wk 3 weekly

61. Nutritional Balance Nutritional Balance = N input - N output 1 g N= 6.25 g protein N input = (protein in g  6.25) N output = 24h urinary urea nitrogen + non- urinary N losses (estimated normal non-urinary Nitrogen losses about 3-4g/d)

62. Complications Related to TPN Mechanical Complications Metabolic Complications Infectious Complications

63. Mechanical Complications Related to vascular access technique pneumothoraxpneumothorax air embolismair embolism arterial injuryarterial injury bleedingbleeding brachial plexus injurybrachial plexus injury catheter malplacementcatheter malplacement catheter embolismcatheter embolism thoracic duct injurythoracic duct injury

64. Mechanical Complications Venous thrombosis Catheter occlusion Related to catheter in situ

65. Metabolic Complications Abnormalities related to excessive or inadequate administration  hyper / hypoglycaemia  electrolyte abnormalities  acid-base disorders  hyperlipidaemia

66. Metabolic Complications Hepatic complications Biochemical abnormalities Cholestatic jaundice  too much calories (carbohydrate intake)  too much fat Acalculous cholecystitis

67. Infectious Complications Insertion site contamination Catheter contamination  improper insertion technique  use of catheter for non-feeding purposes  contaminated TPN solution  contaminated tubing Secondary contamination  septicaemia

68. Stopping TPN Stop TPN when enteral feeding can restart Wean slowly to avoid hypoglycaemia Monitor hypocounts during wean  Give IV Dextrose 10% solution at previous infusion rate for at least 4 to 6h  Alternatively, wean TPN while introducing enteral feeding and stop when enteral intake meets TEE

69. Case Study 1 A 48 year old man was admitted after a road traffic accident in which he suffered multiple fractures to his lower limbs and head injuries. He is scheduled for an operation to fix his fractures tomorrow. How would you feed this man?

70. Case Study 2 54 year old man was admitted into the hospital for treatment after a stroke. He has problems with swallowing and tends to choke whenever he is given fluids to drink. How would you feed him?

71. Case Study 3 A 20 year old (65kg) man is admitted with blunt abdominal trauma. At surgery a liver laceration is repaired  What are his nutritional requirements  How should nutritional therapy be delivered

72. A 50 year old man (60)kg had a bowel resection. On the 8th POD he developed a enterocutaneous fistula and was septic. His urine N loss was 14 g/dl. Case Study 4  What are his nutritional problems  How can nutritional therapy help in his recovery ?

73. Case Study 5 Mdm X is a 54 year old Chinese lady who underwent a laparotomy for volvulus of the small bowel. At operation, resection of the gangrenous bowel was carried out. Only 20 cm of midgut remained.  How do you propose to feed her?

74. Case Study 5 (continued) Mdm X weighed 50 kg before operation. She is well hydrated with good urine output Her lab investigation results included the following: Na 140 mmol/lTotal Bilirubin 4 mmol/l K 3.0 mmol/lAlbumin 35 mg/l Rest of electrolytes normalALP and GGT normal