This document discusses malnutrition and nutritional support. Some key points: - 30-60% of surgical and hospitalized patients are malnourished, increasing risks of complications and death. - Malnutrition causes metabolic changes like increased protein catabolism and reduced energy expenditure. Trauma/sepsis increases requirements and causes insulin resistance. - Nutritional assessment tools include BMI, weight loss percentage, albumin levels, and MUST screening tool. - Fluid requirements are based on condition and losses. Common IV fluids include Hartmann's, normal saline, dextrose saline, and colloids. Electrolytes like sodium and potassium are also essential. - Nutritional support aims to meet caloric, protein

1. Nur Amalina Aminuddin
082012100067
NUTRITION AND
FLUID THERAPY

2.  30% in surgical patients with GI disease
 60% in prolonged hospital stay patients
 Have higher risk of complications and death
 Aim of nutritional support
 Identify patients at risk of malnutrition
 Ensure their nutritional requirements are met
MALNUTRITION

3.  Metabolic response to
starvation
 Low plasma insulin
 High plasma glucagon
 Hepatic glycogenolysis
 Protein catabolism
 Hepatic gluconeogenesis
 Lipolysis
 Adaptive ketogenesis
 Reduced resting energy
expenditure ( 15-20kcal/kg/d)
PHYSIOLOGY

4.  Metabolic response to trauma and sepsis
 Increased counter- regulatory hormones
 Increased energy requirements ( 40kcal/kg/d)
 Increased nitrogen requirements
 Insulin resistance and glucose intolerance
 Increased gluconeogenesis and protein catabolism
 Loss of adaptive ketogenesis
 Fluid retention

5. 1.Laboratory techniques
 Albumin
 <30g/l : poor prognostic indicator
 Immunity
 Eg.lymphocyte count or skin test for delayed
hypersensitivity
 Not precise/ reliable/ practical
NUTRITIONAL ASSESSMENT

6.  Weight loss
 >10% in 6 months
poor outcome
 BMI
 <18.5 : nutritional
impairment
 < 15 : increased hospital
mortality
 Anthropometric
techniques
 Estimate body fat and
muscle mass
 Indirect measure of
energy and protein
stores
 Bioelectrical impedence
analysis (BIA)
 Estimate intra- and extra
cellular fluid volume
2.BODY WEIGHT AND ANTHROPOMETRY

7.  British Association of Parenteral and Enteral Nutrition
 Malnutrition Universal Screening Tool (MUST)
3.CLINICAL
Low risk Medium risk High risk
Hospital Repeat screening :
Weekly
Document dietary and
fluid intake for 3 days
Refer dietician
Care homes Monthly
Community Yearly Repeat screening and
dietary advice

8.  If BMI or weight
loss cannot be
established, use
recalled value
 If both, use overall impression
of malnutrition
 Clinical impression or Clothes
becoming loose or loss of appetite
or any underlying cause

9.  Average Daily
Water Balance
 Daily electrolytes requirement (mm/d):
 Sodium 50-90
 Potassium 50
 Calcium 5
 Magnesium 1
FLUID AND ELECTROLYTES

10.  Nature and volume of fluids administered are determined by:
 Assessmnet of patient ( pulse,BP,CVP, hydration status, urine,
s.electrolyte and hematocrit)
 Estimation of loss
 Estimation of supplement fluids
 Electrolytes composition
Solution Na K Ca Cl Lactate Colloid
Hartmann’s 130 4 2.7 109 28
NS ( 0.9% NaCl) 154 154
Dextrose saline 30 30
Gelofusine 150 <1 150 Gelatin 4%
Haemecel 145 5.1 6.26 145 Polygelin 75g/l
Hetastarch Hydroxyethyl starch 6%

11.  Changes based on condition of patient
 Monitoring feeding regimens
NUTRITIONAL REQUIREMENTS
Daily Weekly Fortnightly
• Body weight
• Fluid balance
• FBC
• Blood glucose
• Electrolytes
• Urine volume
• Temperature
• Urine and
plasma
osmolality
• Ca ,Mg, Zn,
Phosphate
• Plasma protein
• LFT
• Acid- base
status
• S. Vit B12
• Folate
• Iron
• Lactate

12. Total energy requirements
 20-30 kcal/kg/d
 1300-1800 kcal/d
Carbohydrates
 Obligatory glucose
requirements: 2g/kg/d
 Glucose infusion at
4mg/kg/min
Protein
 Basic: 0.10-0.15g/kg
Fat
 Essential fatty acids
(linoleic, linolenic): 100-
200g/w
 Given as mixture with
glucose at 0.15g/kg/h
 Minimises metabolic
complications during
parenteral nutrition
 Reduces fluid retention
 Increases substrate
utilisation

13. Vitamins, minerals and trace elements
 Vit B and C: collagen formation, wound healing
 B12 supplements for intestinal resection/ gastric surgery/ alcohol
dependence
 Vit A,D,E and K in steatorrhea and in absence of bile
 Necessary to optimise amino acids utilisation

14. Norman William, Christopher, & P.Ronan,
Bailey & Love’s Short Practice of Surgery, 25th
edition
REFERENCE