NUTRITION IN SURGERY

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NUTRITION IN SURGERY:

NUTRITION IN SURGERY DR SUBI V 2 nd Yr DNB Surg Resident KIMS

INTRODUCTION:

INTRODUCTION Malnutrition is common among surgical patients e.g.---major abdominal surgery Malnutrition –associated with: High infection rate Increased hosp. stay Increased morbidity and mortality

METABOLIC RESPONSE TO TRAUMA AND SEPSIS:

METABOLIC RESPONSE TO TRAUMA AND SEPSIS The Ebb Phase “Ashen faces, a thready pulse and cold clammy extremities…” Hypometabolic Hypothermic Hypoinsulinemic Hypoperfusion Hyperglucagonemia Hyperglycemia Hypercatecholemia Hypercortisolism

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The Flow Phase “T he patient warms up, cardiac output increases and the surgical team relaxes…” Hypermetabolic Hyperthermic Catabolic Hyperinsulinism Hypercortisolism Hyperglucagonemia High cardiac output

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Changes in protein met Protein breakdown – amino acids Changes in carbohydrate met Glycogenolysis + Gluconeogenesis – hyperglycemia Changes in fat met Lipolysis – free fatty acids + glycerol

Nutritional requirement:

Nutritional requirement Proteins – 0.8 – 1g/ kg / day Energy – 2800kCal / day in males, 1800kCal / day in females Fat – 9.3 kCal /g Carbohydrates – 4.1 kCal /g Proteins – 4.1 kCal /g Alcohol – 7.1 kCal /g

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Total Energy Expenditure ( TEE) Resting Metabolic Expenditure ( RME) + Activity Energy Expenditure (AEE) + Diet induced energy expenditure

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Additional energy requirement Trauma – 0.3 x RME Elective surgery – 0.1 x RME Sepsis – upto 0.5 x RME Severe sepsis – upto 0.6 x RME Massive burns – 1 x RME

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Vitamins Fat soluble – A, D, E, K Water soluble – B & C Trace elements Zinc Iron Copper Selenium

Assessment of nutrition:

Assessment of nutrition Height and weight – BMI Subcutaneous fat thickness S. proteins – Albumin, Transferrin Nitrogen balance (Dietary protein x 0.16) – (Urine urea nitrogen + 2g skin loss + 2g Stool loss) Bioelectrical impedence

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Immune competence – circulatory TLC, skin tests Muscle functions – Hand grip, respiratory muscle function Nutrition Risk Index = (1.519 x S. Albumin) + (0.417 x {current wgt /usual wgt } x 100) ≤ 83.5 – severely malnourished 83.5 – 97.5 – mildly malnourished 97.5 – 100 – boderline malnourished

Enteral nutritional support:

Enteral nutritional support Route of choice Access – nasogastric tubes - gastrostomy - jejunostomy Nutritional solution – polymeric diet - elemantal diet - special formulations - modular diet

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Delivery Complications GI Mechanical Metabolic Infective

Parenteral support:

Parenteral support Central venous access – SVC via subclavian or int. jugular vein Complications- sepsis , thromboembolism , hemo / pneumothorax , injury to brachial plexus and thoracic duct Peripheral venous access – more incidence of thrombophlebitis

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Feeding solutions- Nitrogen source- crystalline solutions of L aminoacids Energy source- balanced combination of dextrose and fats Complications Glucose disturbance Lipid disturbance Nitrogen disturbance Electrolyte disturbance Liver disturbance Ventilatory problems

monitoring:

monitoring Enteral nutrition Monitor fluid balance and weight daily Twice weekly – RFT, LFT, phosphate, calcium, magnesium, albumins and proteins Regular check on access site

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Parenteral nutrition Daily weighing and assessment of fluid balance Daily – S. electrolytes, urea, creatnine , glucose Twice weekly – LFT, albumin and proteins, calcium, magnesium, phosphate Hb , WBC and hematocrit – twice weekly Circulating glucose levels 4 times a day Catheter site checked regularly Nutritional assessment

Nutritional support in defined clinical situations:

Nutritional support in defined clinical situations PERIOPERATIVE PERIOD In critically ill pts during pre op period nutritional supplementation – decr risk of complications Criteria- S. albumin < 30-32 g/l - ≥ 15% loss of body wght - NPI < 83.5 - severe sepsis and burns - high output enterocutaneous fistulas

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Acute pancreatitis Major catabolic stress Daily nitrogen req - 1.2-2.0g/kg and energy – 28-35 kcal/kg Inflammatory bowel disease Malabsorption d/t decreased absorptive length, bacterial overgrowth, protein loosing enteropathy Incr calorie and nitrogen req if in sepsis TPN with bowel rest may itself be therapeutic

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Enterocutaneous fistula Adequate support spontaneous healing and decrease mortality Burns Severe catabolic and metabolic state > 20% BSA – nutritional support started 20-25g nitrogen /day , fats given as major source of calorie

THANK YOU:

THANK YOU

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