Nutrition in Surgery

Dr. Murali. U. M.S; M.B.A.Asso. Prof. of SurgeryIMS / MSU / Malaysia.

‘A slender and restricted diet is always dangerous in chronic and in acute diseases’Hippocrates 400 B.C.

Learning Outcomes

• Outline the indications & complications of EN• Outline the indications & complications of TPN• Illustrate with diagrams about Tube-feeding

techniques

Definition

• Nutritional support is the provision of nutrients to patients who cannot meet their nutritional requirements by eating standard diets.

Nutritional Support – Fundamental Goals

• To meet the energy

requirement

for metabolic

processes.

• To maintain a normal

core body

temperature.

• For tissue repair.

Principles of Nutrition• Avoiding of malnutrition• Enteral nutrition – Ideal one•Overfeeding to be avoided• Timing & Type of nutrition•Nutrition therapy protein wasting• Immunomodulators – glutamine, arginine, omega 3 fatty acids – very useful

Nutritional Assessment• No single “ Gold Standard ”• Body wt.loss > 10% - 6mths – prognostic index Body mass index : weight (kg)/ height (m2) [ <18 .5 – nutritional impairment ]• Anthropometric measures – Indirect measures - TSF / MAC – muscle & fat mass • Transport proteins –(Sr.alb.-30mg/dl, prealb.-12g/dl,transferrin-150mmol/L)• Immune incompetence – TLC / Delayed Hypersensitivity• MUST - Tool

Indications for Nutritional Support

Severely Malnourished

Post – op complications

Trauma

Burns

Malignant disease

Renal & Liver failure

Short bowel syndrome

Indications for Nutritional Support• Patient not expected to feed in 7 days Prolonged ileus or intestinal obstruction

Entero - cutaneous fistulas Pancreatitis, U C, Pyloric stenosis

Major bowel surgery• Esophageal replacement• Gastric or colon surgery• Whipple’s procedure

Indications for Nutritional Support

Duodenal Leak Gastro-duodeno-pancreatectomy

Indications for Nutritional Support

ESOPHAGECTOMY COLON REPLACEMENTCAUSTIC INGESTION, ESOPHAGEAL STRICTURE

Nutritional Requirements • Basic Needs * 25-30 kcal/kg/day• Hospitalized patients -

TER * 1300 - 1800 kcal/day – rough• Basic Nutritional

Requirements * Carbohydrates, fat, proteins, vitamins minerals & trace elements• Feeding regimen –

planned * Standard tables - available

Nutritional Requirements • For Carbohydrates - Glucose

[40-50%] * 100-200 g/day

• For Fat - EFA [30-40%] * 100-200 g/week

• For Protein – N2 [10-15%] * 0.10-0.15g/kg/day (1.25g/kg/day)

• Vitamins / Minerals & Trace elements

Monitoring Feeding Regimes

Nutrition

Daily

Weekly

Fortnightly

Body wt. / Temp CBC / RBS / BUN I-O / electrolytes Plasma proteins LFT/ Acid-base status Ca / Mg / Zn / Po4 U & P osmolality

Sr-Vit B12 / Iron / Folate

Sr-Lactate Trace elements

Routes of nutrition support

• Enteral nutrition

• Parenteral nutrition

Enteral Nutrition

Enteral Nutrition-Advantages

• More physiological

(liver not bypassed)• Lesser cardiac work • Safer and more efficient• Better tolerated by the patient• More economical

Enteral Nutrition-Access • Sip feeding• NGT/ NDT/ NJT• Gastrostomy• Jejunostomy• PEG (percutaneous endoscopic gastrostomy)

Contraindications of EN• Hemodynamic instability

• Intestinal Obstruction / GI bleed / Ileus

• Intractable vomiting / Diarrhoea

• High output proximal fistula

• Inability to gain access

• Anticipating complications

Complications

Severity

Tube – related

Gastro-intestinal

Metabolic

Infective

Malposition / Displacement

Block / Break / Leakage

Local complications

N V D Aspiration

Constipation Electrolyte disorders Vitamins / minerals

Def. Drug interactions

> Exogenous / Endogenous

Parenteral Nutrition

Definition

Total parenteral nutrition (TPN) is defined as the provision of all nutritional requirements by means of the I.V route & without the use of GIT.

Indications for TPN

Patient not expected to feed in 7 -10 days

Massive resection of small bowel

High output fistulas

Prolonged intestinal failure – some reasons

TPN - Access

Central

Peripheral

Central Access• Central – Catheter is

placed using a needle & guide wire via - • Subclavian approach• Internal jugular approach• External jugular approach

SuperiorVena Cava

Peripheral Access • Peripheral Parenteral

Nutrition

* Through a peripherally

inserted central venous

catheter. [PICC] Catheter.

* Through a formal peripheral

venous line.

Contraindications of TPN

• Cardiac failure

• Blood dyscrasias

• Altered fat metabolism

Complications

Severity

Nutrition

Over - feeding

Sepsis

Line

Hypoglycaemia/Ca/P/Mg (refeeding syndrome)

Chronic deficiency syndromes (EFA, Zn, mineral and trace elements)

Glucose- Hyperglycaemia, fluid

retention, electrolyte abn. Fat- Hypertriglyceridemia A.A- Aminoacidaemia, uraemia,

metabolic acidosis

Catheter related Systemic sepsis Drug interactions

> On insertion – PT / AE / bleeding > Long-term use - occlusion, VT

Advantages - Enteral v/s PN• Preserves gut integrity

• Possibly decreases bacterial translocation

• Preserves immunological function of gut

• Reduces costs

• Fewer infectious complications in critically ill

patients

• Safer and more cost effective in many settings

Refeeding Syndrome • Is occurrence of severe fluid & electrolyte imbalance in severely

malnourished pts. while starting {RE-FEEDING} EN/TPN. More common in TPN.

• Causes - * ↓ Mg, ↓ Ca, & ↓ Po4 → myocardial dysfn., resp.changes, altered liver fns, convulsions & death.

• Commonly seen → chronic starvation, severe anorexia & alcoholic pts.

• Gradual feeding & correction of Mg, Po4 & ca. & other electrolytes & vitamins is important.

Home Parenteral Nutrition • It is becoming popular in Western countries. • Indicated in Pts. who require nutrients for long term – extensive Crohn’s, mesenteric infarction etc.• Pt. uses the TPN fluids as advised at home. A indweling Silastic catheter is designed for long term use. • Pt. should attend TPN clinic weekly – follow-up or any complications. • Pt. is psychologically comfortable & can attend his job also.

ICU Nutrition through the ages

Overfeeding1980s

References

“Less you eat, you are malnourished More you eat, more you are diseased”