1. Nutritional Support In The Surgical Patient
Upcoming SlideShare
Loading in...5
×
 

1. Nutritional Support In The Surgical Patient

on

  • 9,619 views

 

Statistics

Views

Total Views
9,619
Views on SlideShare
9,597
Embed Views
22

Actions

Likes
5
Downloads
577
Comments
0

2 Embeds 22

http://www.slideshare.net 21
http://translate.googleusercontent.com 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    1. Nutritional Support In The Surgical Patient 1. Nutritional Support In The Surgical Patient Presentation Transcript

    • Nutritional Support in the Surgical Patient Celso M. Fidel, MD, FPCS,FPSGS Diplomate Philippine Board of Surgery Fellow Philippine Society of General Surgeons Fellow Philippine Society for the Surgery of Trauma Fellow Philippine Association of Laparoscopic & Endoscopic Surgeons FEUNRMF and OLFU
    • Introduction
      • Interest in Clinical Nutrition
      • INTERNAL MEDICINE
      • PEDIATRICS
      • Renaissance of Interest and Elevation to its
      • present status as a Subspecialty
      • SURGERY
    • History
      • 3,500 years ago
        • Nutrient enema
      • 1600
        • Milk, sugar, egg white
        • Via feather quill with pig’s bladder
      • 1793
        • John Hunter
        • Milk, sugar, wine, jelly
        • Via whale bone covered with eel skin
      • Late 1800’s
        • U.S. Pres. Garfield
        • Whiskey, beef broth
        • 79 days with nutrient enema
    • History
      • 1952
        • Subclavian catheter by Aubaniac
      • 1969
        • TPN by Dudrick
      • 1981
        • Kudsk and Sheldon
        • Enteral route is better for malnourished and for septic peritonitis
    • Nutritional Support
      • Fundamental goals of nutritional support:
      • 1. To meet the energy requirement for metabolic processes
      • 2. To maintain a normal core body temperature
      • 3. For tissue repair
    • Surgical Patients that Needs Nutritional Support
      •  To shorten the postoperative recovery
      • phase and minimize the number of
      • complications:
        • 1. Chronically debilitated from their diseases or malnutrition.
        • 2. Suffered severe trauma, sepsis or surgical complications
    • Nutritional Support
      • Indication of nutritional support:
      •  Pre-morbid state
      •  Age of the patient
      •  Duration of starvation
      •  Degree of the insult
      •  Likelihood of resuming normal
      • intake within a definite period
    • Nutritional Support
      • Determination of Lean Body Mass:
      • 1. Displacement
      • 2. Exchange of labeled ions (radioactive K+)
      • 3. Neutron activation analysis
      • 4. Total body counter
      • 5. Nuclear magnetic resonance
    • Nutritional Support
      • Determination of Lean Body Mass:
      • 6. Clinical history and physical examination
        • History of weight loss, anorexia and disease process that interfered with intake
        • Anthropometric data (skin fold thickness , arm circumference measurement, thenar eminence)
        • Biochemical determination (TP, albumin, globulin, liver profile, kidney function test )
    • Five Issues
      •  Indications for Nutritional Support
      •  Determination of Nutritional Status
      •  Effectiveness of Nutritional Support
        •  In Well-nourished versus Malnourished
      •  Route of Nutrition
        •  Enteral versus Parenteral
      •  Appropriate Amount and Composition of Diets
      • Who are the patients that needs nutritional support?
      Issue # 1
    • Indications
      • Patients who are nutritionally depleted
      • Patients who are unable to take nutrients by
      • GI Tract
      • Those who should not take nutrients by the GI tract because of an inherent risk or complicate
      • management of their current surgical disease
    • Indications for Nutritional Support
      •  Short gut syndrome
        • <0.5 m jejunum/ileum if with colon
        • <1.0 m of small bowel if without colon
      •  Severely
      • malnourished
        • * All other indications are less clear
    • Indications for Nutritional Support
      • Severely malnourished
      • Short bowel syndrome
      • Patient not expected to feed in 7 days
        •  Prolonged ileus or intestinal obstruction
        •  Entero-cutaneous fistulas
        •  Pancreatitis
        •  Major bowel surgery
          • Esophageal replacement
          • Gastric or colon surgery
          • Whipple’s procedure
    • Indications for Nutritional Support
      • Patient not expected to feed in 7 days
        • Prolonged ileus or intestinal obstruction
    • Indications for Nutritional Support
      • Patient not expected to feed in 7 days
        • Entero-cutaneous fistulas
    • Indications for Nutritional Support ESOPHAGECTOMY COLON REPLACEMENT CAUSTIC INGESTION, ESOPHAGEAL STRICTURE
    • Indications for Nutritional Support Duodenal Leak Gastro-duodeno-pancreatectomy
      • Determination of Nutritional Status
      Issue # 2
    • Nutritional Status
      • No single “gold standard”
      • Markers of Malnutrition
        • Weight loss
        • Subjective Global Assessment
        • Transport Proteins
          • Albumin
          • Transferrin
          • TBPA (thyroxine binding pre-albumin)
          • RBP (retinol binding protein)
    • Nutritional Status
        • 4. Immune incompetence
          • Total Lymphocyte Count
          • Delayed Hypersensitivity
        • 5. Prognostic Nutritional Index (PNI)
        • 6. Prognostic Inflammatory Nutritional
        • Index (PINI)
    • Markers of Malnutrition
      • Unintentional weight loss= ↑ complications
        • % weight loss= (usual wt – present wt) x 100
        • usual wt
        • <10% - mild malnutrition, over 1 month
        • 10-20%- moderate malnutrition, over 1 month
        • >20% - severe, in 6 months
          • >30% - pre-morbid
          • >50% - pre-mortality
    • Markers of Malnutrition
      • Subjective Global Assessment
        • Anthropometry- TSF, MAMC, muscle mass
        • Creatinine-height index
        • Muscle strength
        • Correlates with complication rate
        • Correlation with improved outcome ??
    • Markers of Malnutrition
      • Transport Proteins t ½
        • Albumin* 21 days
        • Transferrin 8 days*
        • TBPA 2-3 days
        • RBP 8 hours
    • Markers of Malnutrition
      • Transport Proteins
        • Albumin, Transferrin
        • Affected by disease process
          • Marasmus
    • Markers of Malnutrition
      • Transport Proteins
        • Albumin, Transferrin
        • Affected by disease process
          • Interleukin-6
            • Sepsis
            • Peritonitis
            • Trauma
            • Burns
    • Nutritional Status
      • Markers of Malnutrition
        • Prognostic Nutritional Index (PNI)
        • = 158 – 16.6 (ALB) – 0.78 (TSF) – 0.2 (Tfn) – 5.8 (DH)
        • ↑ score = ↑ risk
        • Prognostic Inflammatory Nutritional Index (PINI)
        • = [(CRP x AAG) ÷ PA] x ALB
        • correlates with recovery from injury
      • Effectiveness of Nutritional Support
      Issue # 3
    • Effect of Nutritional Support Post-op Course Sepsis Well-nourished   Moderately Malnourished  if supplemented by arginine, RNA, omega-3 fatty acid  if given very early (30-40% increase) prefer nutritional support 5-10 days post-op Severely Malnourished  
    • Effect of Nutritional Support   Severely Malnourished  if supplemented by arginine, RNA, omega-3 fatty acid  if given very early (30-40% increase) prefer nutritional support 5-10 days post-op Moderately Malnourished   Well-nourished Sepsis Post-op Course
    • Effect of Nutritional Support Post-op Course Sepsis Well-nourished   Moderately Malnourished  if supplemented by arginine, RNA, omega-3 fatty acid  if given very early (30-40% increase) prefer nutritional support 5-10 days post-op Severely Malnourished  
    • Effect of Nutritional Support Post-op Course Sepsis Well-nourished   Moderately Malnourished  if supplemented by arginine, RNA, omega-3 fatty acid  if given very early (30-40% increase) prefer nutritional support 5-10 days post-op Severely Malnourished  
      • Route of Nutrition
      Issue # 4
    • Decision Making GIT functional? YES NO ENTERAL ROUTE PARENTERAL ROUTE Short term Long term Short term Long term NGT Gastrostomy, Jejunostomy Peripheral PN Central PN
    • Enteral versus Parenteral
      • Blunt and penetrating abdominal trauma
        •  early enteral feeding (Moore 1986 & 1989, Kudsk 1992, 1996)
        •  severity =  complications if feed enterally
      • Severe head injury
        • No benefit (Rapp 1983, Hadley 1986, Young 1987, Borzotta 1984)
        • Beneficial (Grahm 1989)
    • Enteral versus Parenteral
      • General Surgery
        • Laparotomy
          • Enteral better than parenteral (Level I evidence)
        • Ulcerative Colitis and CD after resection
          • Enteral better than parenteral (Level I evidence)
        • Liver transplantation
          • Enteral = Parenteral (Wicks 1994 Level I evidence)
        • Acute pancreatitis
          • Gastric and duodenal feeding- ↑ complication (Ragins 1973)
          • TPN, jejunal feeding  (Stabile 1984, Bodoky 1991)
          • Jejunal feeding = TPN (McClave 1997 Level I evidence)
          • Jejunal feeding better than TPN (Windsor 1998 Level I evidence)
    • Route of Administration:
      • ENTERAL ROUTE
      • PARENTERAL ROUTE (TPN)
      • COMBINATION
    • ENTERAL
      • Advantages:
        • more physiological (liver not bypassed)
        • lesser cardiac work
        • safer and more efficient
        • better tolerated by the patient
        • more economical
    • ENTERAL NUTRITION
      • Enteral access
        • NGT
        • Gastrostomy
        • Jejunostomy
        • PEG (percutaneous endoscopic gastrostomy)
        • Trans-gastric jejunostomy
    • ENTERAL
      • Route:
      • Naso-enteric tube feeding (blended food – Casseinates and whole protein formulas)
        • Naso-esophageal or NGT / NJT .
      • Gastrostomy tube (blended food)
        • Stamm (sero-lined) – temporary
        • Glassman (mucous-lined) – permanent
        • Percutaneous endoscopic gastrostomy
      • Jejunostomy tube (elemental diet)
        • Roue-en-y - permanent
        • Witzel - permanent
        • Endoscopic
    • ENTERAL
      • Hyperosmolar solution are better tolerated by the stomach:
        • Gastric feeding – increase osmolality first then the volume
        • Small bowel – volume first is increase then osmolality
    • ENTERAL
      • Precautions to be observe to prevent reflux/aspiration:
        • 30 degree angle
        • Conscious
        • Stop feeding at 11 pm
      • Use French 10 and after administration of food =Clean the tube
      • Prolonged use render the cardia incompetent and sometimes causes stricture
    • Gastric Anatomy
    • ENTERAL NUTRITION
    • ENTERAL NUTRITION Gastric feeding Jejunal feeding Solution used Hypertonic or isotonic Isotonic Infusion rate Bolus or continuous Continuous Initiation of infusion 25-30mL/hr Increments 25-30 mL/hr daily Intolerance Vomiting Distention, diarrhea, colic, reflux to NGT
    • ENTERAL NUTRITION Nutritional Support Needed?
    • ENTERAL NUTRITION Nutritional Support Needed
    • ENTERAL NUTRITION
      • Oral Supplements Ensure, Sustagen
      • Tube Feedings
        • Blenderized diet
        • Polymeric- Isocal, Osmolyte
        • High caloric density- Magnacal
        • Monomeric- Vivonex TEN
        • Disease-specific- AminAid, HepaticAid
    • Complication of Enteral Feeding
      • Malposition of the catheter ( pharynx/trachea):
        • Inadvertently moved
        • Reinsert ideally w/ fluoroscopic guidance
      • Aspiration due to:
        • Overloading
        • Supine position / unconscious
        • Change in gastric motility
      • Solute overloading --> diarrhea, dehydration, electrolyte imbalance (hypokalemia, hypomagnesemia), hyperglycemia (hyperosmolar, nonketotic coma)
        • Avoided by gradual increase in the osmolality of the fluid
      • Perforation (rare)
    • ENTERAL NUTRITION
      •  Metabolic Complications
        • Hyperglycemia
        • Hypophosphatemia
        • Potassium ↑ or ↓
        • Hypomagnesemia
        • Sodium ↑ or ↓
      • _ ( hyperosmolar,
      • nonketotic coma)
        •  Avoided by gradual increase in the osmolality of the fluid
        • Re-feeding syndrome- intracellular mobilization of K, PO 4
        • Small bowel necrosis
        • Pneumatosis intestinalis
    • ENTERAL NUTRITION
    • ENTERAL NUTRITION DISEASE-SPECIFIC FORMULAS
    • Nutritional Support? TPN X ?
    • Nutritional Support? TPN ? ☺
    • Nutritional Support? TPN ? ☺
      • As Supportive Therapy :
        • Nutritional support can be achieved but alteration in the disease process have not been established.
      •  New born GIT anomalies ( gastrochisis,
      • omphalocele)
      •  Alimentary tract obstruction (achalasia, stricture, carcinoma, pyloric obstruction)
      •  Prolonged ileus
      •  Prolonged respiratory support
      •  Large wound losses
      Parenteral Nutrition
    • PARENTERAL NUTRITION
      •  Proven efficacy
      • Radiation & Chemoenteritis,
      • Hyperemesis gravidarum
      •  Efficacy not yet established
      • Pre-op, cardiac cachexia, pancreatitis,
      • Ventilatory support, prolonged ileus
      •  Under investigation
        • Cancer, sepsis
      • Indications:
      • Principal indication is found in seriously ill patients suffering from Malnutrition, Sepsis, severe surgical or accidental trauma when the use of the Gastrointestinal tract for feeding is not possible .
      • Can be supplemental in patients with inadequate oral intake
      Parenteral Nutrition
    • PARENTERAL NUTRITION
      • Indications
      • Primary Therapy
        • Proven efficacy
          • GI fistulas
          • Short bowel syndrome
          • ATN, Hepatic insufficiency
        • Efficacy not established
          • IBD, Anorexia nervosa
    • Parenteral Nutrition
      • Contraindication of TPN:
      • Lack of specific goal for severe metabolic management (inevitable dying).
      • Cardiovascular instability / severe metabolic derangement.
      • Feasible GIT feeding
      • Patient with good nutritional status
      • Infants with less than 3cm of small bowel
      • Irreversible decerebrate (dehumanized)
    • PARENTERAL NUTRITION
      • Peripheral TPN
        • 3% AA in 10% dextrose + 10% lipid
        • Used when central line is contraindicated
        • Short-term
      • Central TPN
        • 15-25% dextrose = standard formula
        • 47% dextrose = special formula
    • Venous Access
    • Subclavian Access
    • Venous Access
    • PARENTERAL NUTRITION Peripheral Central Dextrose content < 5% > 10 Calorie delivery Less More Volume delivery More Less Calorie source* Mostly fats Mostly CHO Calorie distribution CHO 30% CHON 20% Fats 50% CHO 55-60% CHON 15-20% Fats 25%
    • PARENTERAL NUTRITION
      • Monitoring
        • Vital signs q 6h
        • Blood or urine sugar
        • I & O q 8h
        • Weight q 2d
        • Electrolytes, PT, PTT, SGPT*, Short turn-over proteins
    • PARENTERAL NUTRITION
      • Basic Composition of Formulations
        • Carbohydrate = 15-47% dextrose
        • Amino Acids
        • Lipid Emulsions
        • Vitamins, trace elements, electrolytes
    • Parenteral Nutrition
      • Components:
      • CHON:
        • Mixture of single amino acid of synthetic origin, largely produced from “intelligent bacteria” cultures
      • CHO:
        • Provides calories; hypertonic dextrose
      • Fat emulsion:
        • 10 or 20% emulsion of soy or safflower oil emulsions, usually emulsified and stabilized with egg phosphatides and lecithin
      • As Primary Therapy:
        • TPN influence the disease process:
      • GIT fistula
      • Renal failure (ATN)
      • Short Bowel Syndrome
      • Acute Burn (severe trauma)
      • Hepatic failure
      • With normal bowel length but with malabsorption syndrome due to SPRUE, enzymatic or pancreatic insufficiency, Ulcerative colitis, regional enteritis
      • Anorexia nervosa
      Parenteral Nutrition
    • Parenteral Nutrition
      • Route of TPN:
      • Central hyperalimentation
        • Subclavian vein
        • Internal jugular vein
        • Femoral vein
      • Gauge 16, 8-12 inches radio-opaque catheter end at SVC
      • Check position w/
      • x-ray
    • Parenteral Nutrition
      • Complications of TPN:
      • I. Technical complications:
        • A. Early : - related to catheter insertion
          • Pneumothorax
          • Arterial laceration
          • Hemothorax
          • Mediastinal hematoma
          • Nerve injury to the brachial plexus
          • Hydrothorax
          • Air embolism
          • Catheter embolism
    • Parenteral Nutrition
      • Complications of TPN:
      • I. Technical complications:
        • Late:
          •  Erosion of the catheter to the bronchus or right atrium
          •  Thrombosis:
            • Upper arm swelling and pain at the base of the neck
            • Streptokinase / heparin ---> coumadin
          •  Septic thrombosis:
            • Antibiotic therapy
            • Fogarty catheter embolectomy
            • Excision of the subclavian vein and superior venacava
    • Parenteral Nutrition
      • Complications of TPN:
      • II. Metabolic complications:
        • Inadequate administration of certain nutrient
          • 1. Trace metal deficiency:
            • Zinc deficiency:
              • perioral pustular rash
              • darkening of the skin creases
              • neuritis
            • Copper deficiency:
              • microcytic anemia
    • Parenteral Nutrition
      • Complications of TPN:
      • II. Metabolic complications:
        • A. Inadequate cont’d
          • 2. Essential Fatty Acid deficiency:
            • Dry flaky skin w/ small reddish papules and alopecia
        • Disorder of Glucose metabolism:
          • 1. Hypoglycemia – unexpected slowing of the glucose infusion / excessive insulin administration
    • Parenteral Nutrition
      • Complications of TPN:
      • II. Metabolic complications:
        • Disorder of Glucose metabolism:
          • 2. Hyperglycemia – most dangerous metabolism complication in TPN
            • Due to rapid infusion (60 ml/hr the increase of 20ml/hr every 24-48 hrs)
            • DM ( Hyperosmolar nonketotic coma) due to osmotic diuresis ---> dehydration, fever, obtundation and coma ---> death.
            • Tx: insulin 200 units/day and administration of large dextrose free hypo=osmolar solution (0.45% NSS w/ K+).
    • Parenteral Nutrition
      • Complications of TPN:
      • II. Metabolic complications:
        • Liver function derangement:
          • Abnormalities in SGOT / SGPT / Alk. PO4
          • Fatty infiltrate of liver ----> fat emulsion
    • Parenteral Nutrition
      • Complications of TPN:
      • III. Septic complications:
        • Catheter infection:
          • most lethal complication of TPN
          • Bacterial / fungal (candida)
          • Site of entry of the organism ---> site of catheter
          • Symptom: - sudden spike of fever
          • Management:
            • Change TPN bottle, tubes and filter – culture / investigate for presence of pneumonia, UTI, wound infection, etc.
            • If fever persist after 8 hrs. ---> removed catheter and culture the tip of the tube.
    • Parenteral Nutrition
    • Parenteral Nutrition Peripheral Central
      • Proper Amount and Composition of Diet
      Issue # 5
    • Nutritional Requirements in Stress
      • Basic Needs
        • 25-30 kcal/kg/day
        • 30% fat,1 gm protein/kg/day
      • Caloric Needs in Stress
        • 35 kcal/kg/day rough estimate
        • Multipliers
          • 1.2 minor or resting
          • 1.35 fracture
          • 1.6 sepsis
          • 2.1 severe burn
    • Calculation of Caloric Needs Condition Kcal/kg/day Protein/kg/day NPC : N ratio Normal to moderate malnutrition 25 - 30 1 150 : 1 Moderate stress 25 - 30 1.5 120 : 1 Hypermetabolic, stressed 30 - 35 1.5 – 2.0 90-120 : 1 Burns 35 - 40 2.0 – 2.5 90-120 : 1
    • Calculation of Caloric Needs
      • For malnourished or well nourished
        • Actual body weight
      • For obese
        • Adjusted body weight
        • = Ideal wt x 0.25 (actual wt – ideal wt)
      • For significant fluid overload
        • Estimated body weight
    • Calculation of Caloric Needs
      •  Protein gm/kg/day 70 kg patient per day
        • Well-nourished 0.8 – 1.0 56 – 70 gms
        • Stress, sepsis 1.5 – 2.0
        • CRF, ARF 1.2
        • Liver failure 0.5 – 0.8
      •  Glucose
        • Well-nourished 7.2 504 gms
        •  Fat
        • Well-nourished 1.0 70 gms
        • Critically ill 1.0
        • Brittle diabetes 2.5
    • Immune Enhancers
      • Glutamine
        • Conditionally essential
        • Heat labile
        • Main fuel for GIT, IS
      • Arginine
        • Promotes T cell prolif’n
        • Precursor of NO, NO3, NO4, putrescine, spermine, spermidine
        • Secretagogue for GH, I, Glucagon, PRL,
      • O-3 FA, O-4 FA (PUFA)
        • Via cyclooxygenase and lipooxygenase pathway  PGI3, TxA3, LTB5
        • ↓ bacterial translocation and mortality
      • Nucleotides
        • RNA, DNA formation
        • ↓ = T helper fxn, IL2, increased mortality after Candida & Staphylococcus infection
      • BCAA
        • Stress  Protein degradation
    • The Future
      • Growth Hormone
        •  wound healing
        •  infection rate
        •  catabolism
        • May be harmful to critically-ill patients
      • Oxandrolene (Oxandrin)
        •  wound healing in critically-ill patients
      • Anabolic agents
    • Five Issues
      •  Indications for Nutritional Support
      •  Determination of Nutritional Status
      •  Effectiveness of Nutritional Support
        •  In Well-nourished versus Malnourished
      •  Route of Nutrition
        •  Enteral versus Parenteral
      •  Appropriate Amount and Composition of Diets
    • Surgical Nutrition Roberto B. Acuña, MD, FPCS, FPSGS, FPSLS General and Cancer Surgery Laparoscopic Surgery Hepato-biliary Surgery FEU-NRMF MEDICAL CENTER
    •  
    • Thank You