Surg. Nutritional Supp.

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Surg. Nutritional Supp.

  1. 1. Surgical Nutritional Support
  2. 2. OVERVIEW <ul><li>Artificial Nutrition: Importance and History </li></ul><ul><ul><li>antibiotics, blood transfusion, critical care monitoring, advances in anesthesia, organ transplantation, and cardiopulmonary bypass </li></ul></ul><ul><ul><li>hyperalimentation  moderate nutritional supply </li></ul></ul><ul><ul><li>nutritional pharmacology </li></ul></ul><ul><ul><li>parenteral  parenteral & enteral </li></ul></ul>
  3. 3. OVERVIEW <ul><li>Clinical Sequelae of Impaired Nutrition </li></ul><ul><ul><li>Impaire the body's ability to heal wounds and to support normal immune function </li></ul></ul><ul><ul><li>reduced ventilation due to wasting of muscle </li></ul></ul><ul><ul><li>limiting to all aggressive surgical and medical therapies </li></ul></ul><ul><li>Incidence of Malnutrition in Hospitalized Patients </li></ul><ul><ul><li>as many as 50% of hospitalized patients may be malnourished </li></ul></ul>
  4. 4. <ul><li>Surgical Nutritional Support : Provide adequate and proper nutrients to support the metabolism of the body, and to maintain the function and structure of the organs, to accelerate the recovery. </li></ul>
  5. 5. Questions <ul><li>Why should we provide nutritional support </li></ul><ul><li>When it is provided </li></ul><ul><li>What kind and amount of nutrients </li></ul><ul><li>How to administrate the nutrients </li></ul>
  6. 6. METABOLIC ADAPTATIONS IN CATABOLIC STATES AND REGULATION OF NITROGEN BALANCE
  7. 7. Regulation of Intracellular Protein Synthesis and Degradation
  8. 8. Metabolic Changes in state of starving <ul><li>secretion of insulin declines; </li></ul><ul><li>secretion of glycagon, growth factor, catecholamine increase; </li></ul><ul><li>utilization of glucose is accelerated; </li></ul><ul><li>gluconeogenesis continues </li></ul><ul><li>proteolysis is initiated to provide energy </li></ul><ul><ul><li>lipid is oxidized to ketones </li></ul></ul><ul><ul><li>consume great amount of protein </li></ul></ul>
  9. 10. Metabolic changes in stress (trauma, sepsis) <ul><li>trauma activating the sympathetic nerve </li></ul><ul><li>utilization of carbohydrates are inhibited, hyperglycemia is produced </li></ul><ul><ul><li>the secretion of insulin declines </li></ul></ul><ul><ul><li>the blood level of glycagon, growth factor, catecholamine, thyroid hormone, ACTH, antidiuretic hormone increase </li></ul></ul><ul><li>The lipolysis is activated, gluconeogenesis and proteolysis is accelerated, large amount of protein are consumed to provide energy supply. </li></ul>
  10. 11. FUNDAMENTALS OF ARTIFICIAL NUTRITION
  11. 12. General Indications for Nutrition Support and Choice of Route of Administration <ul><li>The pre-morbid state (healthy or otherwise) </li></ul><ul><li>Poor nutritional status (the current oral intake meets <50% of total energy needs) </li></ul><ul><li>Significant weight loss (initial body weight less than the usual body weight by ≥10%, or a decrease in inpatient weight by >10% of the admission weight) </li></ul><ul><li>The duration of starvation (>7 days' inanition) </li></ul><ul><li>An anticipated duration of artificial nutrition (particularly for total parenteral nutrition [TPN]) of more than 7 days </li></ul><ul><li>The degree of the anticipated insult, surgical or otherwise </li></ul><ul><li>A serum albumin value less than 3.0 g/100 mL measured in the absence of an inflammatory state </li></ul>
  12. 13. Route of Administration <ul><li>Enteral nutrition (EN) </li></ul><ul><ul><li>more physiologic, and safe </li></ul></ul><ul><li>PARENTERAL ROUTE </li></ul><ul><ul><li>Parenteral nutrition (PN) </li></ul></ul><ul><ul><li>Total parenteral nutrition (TPN) </li></ul></ul>
  13. 14. Mulnutrtion <ul><li>Kwashiorkor (Protein Malnutrition) </li></ul><ul><ul><li>Adequate fat reserves with significant protein deficits </li></ul></ul><ul><ul><li>Slight or no weight loss </li></ul></ul><ul><ul><li>Low visceral proteins (albumin, prealbumin, transferrin) </li></ul></ul><ul><ul><li>Edema often present </li></ul></ul><ul><ul><li>Seen in acutely stressed patients </li></ul></ul><ul><li>Marasmus (Protein—Calorie Malnutrition) </li></ul><ul><ul><li>Weight loss with fat and muscle wasting </li></ul></ul><ul><ul><li>Visceral proteins normal or slightly low </li></ul></ul><ul><ul><li>Seen in chronic malnutrition </li></ul></ul>
  14. 15. Nutritional Assessment <ul><li>Clinical History </li></ul><ul><li>Body Composition Analysis </li></ul><ul><li>Indirect Calorimetry </li></ul><ul><li>Anthropomorphic Measurements </li></ul><ul><li>Functional Studies of Muscle Function </li></ul><ul><li>Biochemical Measurements </li></ul>
  15. 16. Nitrogen Balance <ul><li>total nitrogen intake – nitrogen expiration </li></ul><ul><li>(most of it are excreted from urine, plus approximately 2~3gm for fecal and others lost of nitrogen) </li></ul>
  16. 17. Plasma proteins <1.6 1.6~1.8 1.8~2.0 2.0~2.5 Transferrin (g/L) <21 21~27 28~34 >35 Albumin (g/L) Severe Moderate Light Malnutrition Normal
  17. 18. Estimation of Energy Needs
  18. 19. Harris-Benedict equation <ul><li>BEE = 66.5 + (13.7 X weight [kg]) + (5.0 X height [cm]) - (6.8 X age [yr] [male]) </li></ul><ul><li>BEE = 655.1 + (9.56 X weight [kg]) + (1.85 X height [cm]) - (4.68 X age [yr] [female]) </li></ul><ul><li>(BEE = basal energy expenditure) </li></ul>
  19. 20. Calories Requirements <ul><li>The three major sources of energy are protein, carbohydrate, and fat. </li></ul><ul><ul><li>amino acids, 15% </li></ul></ul><ul><ul><li>fat, 25 to 50% </li></ul></ul><ul><ul><li>Carbohydrate, 35 to 65% </li></ul></ul>
  20. 21. Nutrients <ul><li>Specific Fuels </li></ul><ul><ul><li>Carbohydrate </li></ul></ul><ul><ul><li>Lipid </li></ul></ul><ul><ul><li>Protein </li></ul></ul><ul><li>Plasma Electrolytes </li></ul><ul><li>Vitamins and Micronutrients </li></ul>
  21. 22. Protein Requirements <ul><li>70-kg man has between 10 and 11 kg of protein. </li></ul><ul><li>Daily protein turnover is 250 to 300 g, or 3% </li></ul><ul><li>the gut , blood system, skin </li></ul><ul><li>daily requirement 0.8 to 1.0 grams per kg per day, or 150 mg of nitrogen per kg per day </li></ul><ul><li>200 to 250 mg of nitrogen per kg of body weight or 1.7 g of protein per kg per day for patients in stress state </li></ul>
  22. 23. Calorie-Nitrogen Ratio <ul><li>150:1 (150 nonpro-tein calories per gram of nitrogen) is required for protein synthesis in healthy persons </li></ul><ul><ul><li>100:1 in sepsis </li></ul></ul><ul><ul><li>300:1 ~ 400:1 in uremia </li></ul></ul>
  23. 24. PRACTICAL APPROACH TO ARTIFICIAL NUTRITION
  24. 25. Enteral Nutrtion <ul><li>Indications for Enteral Feeding </li></ul><ul><li>Routes for Administration of Enteral Feeding </li></ul><ul><li>Administration </li></ul><ul><li>Enteral Formulas </li></ul>
  25. 26. Indications and Routes of EN <ul><li>Indications </li></ul><ul><ul><li>Gut works </li></ul></ul><ul><ul><li>Oral intake not possible—altered mental state, ventilator, oral/pharyngeal/esophageal disorders </li></ul></ul><ul><ul><li>Oral intake not sufficient for metabolic requirements—anorexia, sepsis, severe trauma/burns </li></ul></ul><ul><ul><li>Presence of malnutrition and wasting </li></ul></ul><ul><li>Routes of administration </li></ul><ul><ul><li>Nasogastric tube, ending in stomach, duodenum or intestine; gastrostomy ; jejunostomy </li></ul></ul>
  26. 30. <ul><li>Administration </li></ul><ul><ul><li>Osmolality , volume , and speed </li></ul></ul><ul><li>Enteral Formulas </li></ul><ul><ul><li>All nutrients, degraded products of protein </li></ul></ul><ul><li>Complications of Enteral Administration </li></ul><ul><ul><li>Tube, infection, diarriah, dilatation </li></ul></ul>
  27. 31. Parenteral Nutrtion <ul><li>Indications for Parenteral Feeding </li></ul><ul><li>Practical Approach to Calculation of the Ideal Parenteral Formula </li></ul><ul><li>Catheter Issues in Parenteral Nutrition </li></ul><ul><li>Metabolic Complications of Long-Term Parenteral Nutrition Administration </li></ul>
  28. 32. Indications of PN <ul><ul><li>Enteral feeding not possible—GI obstruction, ileus </li></ul></ul><ul><ul><li>Enteral intake not sufficient for metabolic requirements—chronic diarrhea/emesis, malabsorption, fistulas, chemotherapy, irradiation therapy </li></ul></ul><ul><ul><li>Risk of aspiration </li></ul></ul><ul><ul><li>Adjunctive support necessary for managing disease—pancreatitis, hepatic failure, renal failure, chylothorax </li></ul></ul><ul><ul><li>Presence of malnutrition and wasting </li></ul></ul>
  29. 33. Routes of PN <ul><li>Peripheral Administration </li></ul><ul><ul><li>Peripheral vein. </li></ul></ul><ul><li>Central Approach </li></ul><ul><ul><li>Subclavian vein </li></ul></ul><ul><ul><li>internal jugular vein </li></ul></ul>
  30. 34. Formula <ul><li>Glucose, 35~65% of energy expenditure. </li></ul><ul><li>Lipid, 25~50% of energy expenditure. </li></ul><ul><li>Amino acid, non protein energy: nitrogen=150: 1 </li></ul><ul><li>Electrolyte: k, Na, Cl, Ca, Mg, P </li></ul><ul><li>Vitamin: Vit A, Vit Bs, Vit E </li></ul><ul><li>Trace metals: Zinc, Copper, Iron </li></ul><ul><li>Water: 2500~3000ml </li></ul>
  31. 35. Complications of Parenteral and Enteral Nutrition <ul><li>Due to improper formula and administration </li></ul><ul><li>Catheter relative </li></ul><ul><li>Metabolic complications of long-term PN </li></ul><ul><ul><li>If the gut can be used, use it. </li></ul></ul>
  32. 36. Summary <ul><li>History of artificial nutrition </li></ul><ul><li>Metabolism </li></ul><ul><li>Nutritional Assessment and Administration </li></ul>
  33. 37. Metabolism <ul><li>Metabolism of protein, carbohydrate, fat and energy production </li></ul><ul><li>Stress metabolism </li></ul>
  34. 38. Nutritional Assessment <ul><li>Types of malnutrition </li></ul><ul><li>Evaluation of the preexisting deficits </li></ul><ul><li>Estimation of caloric and protein requirements </li></ul>
  35. 39. Administration of nutrition <ul><li>Indications </li></ul><ul><li>Enteral Nutrition </li></ul><ul><li>Parenteral Nutrition </li></ul>
  36. 40. Complications <ul><li>Due to improper formula and administration </li></ul><ul><li>Catheter relative </li></ul><ul><li>Metabolic complications of long-term PN </li></ul>
  37. 41. <ul><li>Thank You For Attention </li></ul>

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