1. Surgical Nutrition Dr. Robert Mustard October 4, 2011

2. Does it really matter? US VA TPN Study: NEJM: 325 p 525-532, 1991 459 patients with (primarily) GI malignancies requiring surgical resection Patients stratified into 3 groups; - normally nourished - mild malnutrition - severe malnutrition Patients then randomized to 1-2 weeks preoperative TPN vs control.

3. 1991 VA Trial – Outcome (30 day) Major infections complications NMildSevere TPN12.215.2 12.9 Control 4.0 6.6 10.5 Major non-infections complications TPN14.316.1 22.6 Control 16.022.6 42.1 * No difference in mortality (Editorial by A. Detsky)

4. Further evidence that TPN may be bad for your patients M.J. Sena, et al: Early Supplemental Parenteral Nutrition is Associated with Increased Infectious Complications of Critically Ill Trauma Patients; JACS 207: p 459-467, 2008

5. Why might TPN be bad for your patients? 1)central line 2)hyperglycemia 3) gut atrophy 4)IV lipids 5) query hepatic cholestasis

6. Determining Nutritional Status J.P. Baker, et al: Nutritional Assessment: A Comparison of Clinical Judgment and Objective Measurements. NEJM: 306, p 969-972, 1982. A.S. Detsky, et al: What is Subjective Global Assessment of Nutritional Status? J. Parent. Ent. Nutrition 11: p 8-13, 1987.

7. Subjective Global Assessment of Nutritional Status History: 1) Weight change 2) Dietary intake change 3) GI symptoms 4) Functional capacity 5) Underlying disease (+ metabolic demand) Physical Examination: 1) Lossness of subcutaneous fat 2) Muscle wasting 3) Ankle edema 4) sacral edema 5) ascites

8. Subjective Global Assessment of Nutritional Status Hx + P/E → Well nourished Moderately malnourished Severely malnourished No explicit numerical weighting scheme

9. Who Needs Nutritional Support? 1)Normally nourished or moderately malnourished: 7-10 days NPO well tolerated 2) Severely malnourished: Start feeds ASAP Consider patients underlying disease and the likelihood of rapid recovery following treatment (eg – surgical excision of cancer)

10. How Much Food Is Needed? Enough to avoid complications caused by malnutrition. Guidelines: 1) Calories - estimate BME from Harris-Benedict formula (sex, age, weight, height) - ~ 25 Kcal/kgm/24h - estimate ”stress factor” ~ 25% for general surgical patients as much as 100% for major burn patients 2) Protein - basal requirements ~ 0.7 gm/kgm/24h - with stress factor ~ 1 gm/kg/24hr 3) Electrolytes - trace elements - vitamins - same for all

11. What Route to Use Enteral, if at all possible IGNORE - recent GI surgery - presence or absence of bowel sounds, flatus, etc DO NOT IGNORE - Olgilves Syndrome - constipation - diarrhea

12. Enteral Routes - NG tube (regular or silastic) - NJ tube - surgical G or J – tube - percutaneous G or J – tube - endoscopic G – tube

13. Notes 1)Risk of aspiration pneumonia more or less independent of feeding mechanism 2)Always check gastric residuals with G- tube feeds 3)Beware of complications of J-tube feeds (small bowel necrosis) 4)All tubes are mobile!

14. Parenteral Routes - PVC line - PICC line - Hickman catheter - Porta-cath

15. Case Studies 1)Patient with severe closed head injury. Tracheostomy in place, need for long term feeds – ? Route. 2)Post-op patient who suffered from bowel infarction and is left with 3 feet of small bowel, and a left colon. ? How to feed. 3)Patient in ICU on ventilator with severe acute pancreatitis. ? How to feed. 4)Patient with Crohn’s disease, severe weight loss, and high grade small bowel obstruction. ? How to feed.