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Casuses and consequences of malnutrition in surgical patient.pptx

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Casuses and consequences of malnutrition in surgical patient.pptx

  1. 1. Tips on using my ppt. 1. You can freely download, edit, modify and put your name etc. 2. Don’t be concerned about number of slides. Half the slides are blanks except for the title. 3. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. 4. At the end rerun the show – show blank> ask questions > show next slide. 5. This will be an ACTIVE LEARNING SESSION x three revisions. 6. Good for self study also. 7. See notes for bibliography.
  2. 2. Learning Objectives
  3. 3. Learning Objectives 1. Introduction & History 2. Relevant Anatomy, Physiology 3. Aetiology 4. Pathophysiology 5. Pathology 6. Classification 7. Clinical Features 8. Investigations 9. Management 10. Prevention 11. Guidelines 12. Take home messages
  4. 4. Introduction & History. •
  5. 5. Introduction • The term ‘malnutrition’ has no universally accepted definition. • It has been used to describe a deficiency, excess or imbalance of a wide range of nutrients, resulting in a measurable adverse effect on body composition, function and clinical outcome.1 • Although malnourished individuals can be under- or overnourished, ‘malnutrition’ is often used synonymously with ‘undernutrition’, as in this lecture.
  6. 6. Introduction • Malnutrition is a common, under- recognised and undertreated problem facing patients and clinicians. • It is both a cause and consequence of disease and exists in institutional care and the community.
  7. 7. History
  8. 8. History • In the 1930s surgeons observed that patients who were starved or underweight had a higher incidence of postoperative complications and mortality. • A large number of studies have subsequently supported this original observation.
  9. 9. History • Similar complaints • Urethral instrumentation/ operations • UTIs
  10. 10. Aetiology
  11. 11. Aetiology • Idiopathic • Congenital/ Genetic • Nutritional Deficiency/excess • Traumatic • Infections /Infestation • Autoimmune • Neoplastic (Benign/Malignant) • Degenerative • Iatrogenic • Psychosomatic • Poisoing/ Toxins/ Dtug induced
  12. 12. Aetiology • Poverty • Social isolation • Substance misuse • Reduced dietary intake • Reduced absorption of macro- and/or micronutrients • Increased losses or altered requirements • Increased energy expenditure (in specific disease processes)
  13. 13. Reduced Dietary intake •
  14. 14. Reduced Dietary intake • The single most important aetiological factor • Due to reductions in appetite sensation as a result of changes in cytokines, glucocorticoids, insulin and insulin-like growth factors. • The problem may be compounded in hospital patients by failure to provide regular nutritious meals in an environment where they are protected from routine clinical activities, and where they are offered help and support with feeding when required
  15. 15. Reduced Dietary intake • Dysphagia, • Anorexia nervosa, • Depression, • Alcoholism • NBM perioperative • However, the most common cause of in-hospital malnutrition is poor food served without assistance to frail individuals and timed for the benefit of personnel rather than of the patients. • Patients are also given nothing by mouth for the Most trivial reasons (e.G., Radiologic studies) and diets are often not advanced rapidly even after minor operations.
  16. 16. Reduced absorption
  17. 17. Reduced absorption • Inflammatory bowel disease, • Coeliac disease • Short bowel syndrome, • Protein-losing enteropathies.
  18. 18. Increased losses or altered requirements
  19. 19. Increased losses or altered requirements Excessive and/or specific nutrient losses; their nutritional requirements are usually very different from normal metabolism- • Cancer • Surgery • Sepsis • Enterocutaneous fistulae • Burns
  20. 20. Energy expenditure • .
  21. 21. Energy expenditure • It was thought for many years that increased energy expenditure was predominantly responsible for disease- related malnutrition. • There is now clear evidence that in many disease states total energy expenditure is actually less than in normal health. • The basal hypermetabolism of disease is offset by a reduction in physical activity, with studies in intensive care patients demonstrating that energy expenditure is usually below 2,000 kcal/day. • The exception is patients with major trauma, head injury or burns where energy expenditure may be considerably higher, although only for a short period of time.
  22. 22. Aetiology of Aetiology •
  23. 23. Aetiology of Aetiology • Idiopathic • Congenital/ Genetic • Nutritional Deficiency/excess • Traumatic • Infections /Infestation • Autoimmune • Neoplastic (Benign/Malignant) • Degenerative / lifestyle • Iatrogenic • Psychosomatic • Poisoning/ Toxins/ Drug induced
  24. 24. Pathophysiology
  25. 25. Pathophysiology:Consequences of malnutrition • Malnutrition affects the function and recovery of every organ system.
  26. 26. Metabolic and hormonal changes
  27. 27. Metabolic and hormonal changes • In early starvation body switches from using carbohydrate to using fat and protein as the main source of energy, • Basal metabolic rate decreases by as much as 20-25%.
  28. 28. Metabolic and hormonal changes • During prolonged fasting, hormonal and metabolic changes are aimed at preventing protein and muscle breakdown. • Muscle and other tissues decrease their use of ketone bodies and use fatty acids as the main energy source. • This results in an increase in blood levels of ketone bodies, stimulating the brain to switch from glucose to ketone bodies as its main energy source. • The liver decreases its rate of gluconeogenesis, thus preserving muscle protein. .
  29. 29. Metabolic and hormonal changes • During the period of prolonged starvation, several intracellular minerals become severely depleted. • However, serum concentrations of these minerals (including phosphate) may remain normal. • This is because these minerals are mainly in the intracellular compartment, which contracts during starvation. • In addition, there is a reduction in renal excretion.
  30. 30. Muscle function
  31. 31. Muscle function • Weight loss due to depletion of fat and muscle mass, including organ mass, is often the most obvious sign of malnutrition. • Muscle function declines before changes in muscle mass occur, suggesting that altered nutrient intake has an important impact independent of the effects on muscle mass. • Similarly, improvements in muscle function with nutrition support occur more rapidly than can be accounted for by replacement of muscle mass alone
  32. 32. Muscle function • If dietary intake is insufficient to meet requirements over a more prolonged period of time the body draws on functional reserves in tissues such as muscle, adipose tissue and bone leading to changes in body composition. • With time, there are direct consequences for tissue function, leading to loss of functional capacity and a brittle, but stable, metabolic state
  33. 33. Muscle function • Rapid decompensation occurs with insults such as infection and trauma. • Importantly, unbalanced or sudden excessive increases in energy intake also put malnourished patients at risk of decompensation and refeeding syndrome.
  34. 34. Cardio-respiratory function
  35. 35. Cardio-respiratory function • Reduction in cardiac muscle mass • decrease in cardiac output has a corresponding impact on renal function by reducing renal perfusion and glomerular filtration rate. • Micronutrient and electrolyte deficiencies (eg thiamine) may also affect cardiac function, particularly during refeeding. • Poor diaphragmatic and respiratory muscle function reduces cough pressure and expectoration of secretions, delaying recovery from respiratory tract infections. • Reduced ventilatory performance and prolonged ventilator dependence.
  36. 36. Gastrointestinal function
  37. 37. Gastrointestinal function • Chronic malnutrition results in changes in – Pancreatic exocrine function, – Intestinal blood flow – Villous architecture and intestinal permeability. • The colon loses its ability to reabsorb water and electrolytes, and secretion of ions and fluid occurs in the small and large bowel. • This may result in diarrhoea, which is associated with a high mortality rate in severely malnourished patients..
  38. 38. Immunity and wound healing
  39. 39. Immunity and wound healing • Diminished complement and immunoglobulin production, • Poor cellular immunity, • impairment of variou aspects of leukocyte action including chemotaxis, phagocytosis, and oxidative burst. • Poor tissue repair and wound healing
  40. 40. Clinical outcome
  41. 41. Clinical outcome • Malnourished surgical patients have complication and mortality rates three to four times higher than normally nourished patients • Longer hospital admissions • there is clear evidence that nutrition support significantly improves outcomes in these patients
  42. 42. Psychosocial effects
  43. 43. Psychosocial effects • Apathy • Depression • Anxiety • Self-neglect.
  44. 44. The cost
  45. 45. The cost • Malnutrition is also a major resource issue for public expenditure. • The costs associated with disease-related malnutrition in the UK in 2007 were over £13 billion. • The potential cost savings associated with prevention and treatment of malnutrition are considerable: a saving as small as 1% represents £130 million per year. • There is evidence that for specific situations treating malnutrition produces cost savings of 10–20% or more.
  46. 46. Take home messages
  47. 47. Take home messages • Integration of nutrition into the overall management of the patient • Avoidance of long periods of preoperative fasting • Re-establishment of oral feeding as early as possible after surgery • Start of nutritional therapy early, as soon as a nutritional risk becomes apparent • Metabolic control e.G. Of blood glucose
  48. 48. Take home messages • Reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function • Minimize time on paralytic agents for ventilator management in the postoperative period • Early mobilisation to facilitate protein synthesis and muscle function.
  49. 49. Clinical Features •
  50. 50. Clinical Features • Demography • Symptoms • Signs • Prognosis • Complications
  51. 51. Demography
  52. 52. Demography • Incidence & Prevalence • Geographical distribution. • Race • Age • Sex • Socioeconomic status • Temporal behaviour
  53. 53. Demography • Incidence & Prevalence-
  54. 54. Demography • Geographical distribution.
  55. 55. Demography • Race.
  56. 56. Demography • Age
  57. 57. Demography • Sex
  58. 58. Demography • Socioeconomic status
  59. 59. Demography • Temporal behaviour
  60. 60. Signs
  61. 61. Signs • General Examination • Systemic Examination • Local Examination
  62. 62. Signs • General Examination
  63. 63. Signs • Systemic Examination
  64. 64. Signs • Local Examination
  65. 65. Prognosis
  66. 66. Prognosis • Morbidity • Mortality rate • 5 year survival in Malignancy
  67. 67. Investigations
  68. 68. Investigations • Laboratory Studies – Routine – Special • Imaging Studies • Tissue diagnosis – Cytology • FNAC – Histology – Germ line Testing and Molecular Analysis • Diagnostic Laparotomy.
  69. 69. Investigations in Malignancy •
  70. 70. Investigations in Malignancy • For diagnosis • For staging • For Screening • For Monitoring
  71. 71. Diagnostic Studies
  72. 72. Diagnostic Studies Imaging Studies • X-Ray • USG • CT • Angiography • MRI • Endoscopy • Nuclear scan
  73. 73. Prevention
  74. 74. Prevention • Screening • Risk reduction
  75. 75. Mythbusters Myths Facts
  76. 76. Guidelines
  77. 77. Get this ppt in mobile 1. Download Microsoft PowerPoint from play store. 2. Open Google assistant 3. Open Google lens. 4. Scan qr code from next slide.
  78. 78. Get this ppt in mobile
  79. 79. Get my ppt collection • https://www.slideshare.net/drpradeeppande/ edit_my_uploads • https://www.dropbox.com/sh/x600md3cvj8 5woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl =0 • https://www.facebook.com/doctorpradeeppa nde/?ref=pages_you_manage

Editor's Notes

  • drpradeeppande@gmail.com
    7697305442
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/

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