clinical nutrition in surgery
TRANSCRIPT
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Role of Parenteral
Nutrition in Surgery
Dr. Veena Singh
Dept. of Surgery
Medical College & Hospital
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20% of ICU patients have malnutrition
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Consequences of Malnutrition
Progressive psychological decline
In addition to its physical effects onpatients ability to recover from illness orinjury, malnutrition has severely deleteriouseffects on the mental state
As the nutritional status declines, the Qualityof Life also reduces.
Wretlind. 1987; 28-29
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Consequences of malnutrition
Ava
ila
bleEnergyan
dN
itrogens
tores
Qua
lityo
fL
ife
100%
0%Normal patients
Clinical changes
Decreased muscle massDecreased visceral proteins
Impaired immune response
Impaired wound healing
and response to trauma
Complete exhaustion
Bedridden
Psychological changes
Fatigue, general weakness
Lack of initiative
ApathyDepression
Changes of behavior
and personality
Total apathy
Death
Catabolic patients
100%
60%
Bo
dywe
ight
weeks0 5 10
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Survival afterintensive care292 ICU patients followed for 5 years
100%
50%
Survival
Years after ICU
0 1 2 3 4 5
>2 yearsRate approximates to ageadjusted norm
R.Griffiths, personal communication
60% of deaths in ICU
87% of deaths occur by 6 months
92% of deathsat 1 year
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Protein deficiency
Catabolism
The body has no protein reserve
Protein - losses
short term: functional protein, e.g. enzymes
long term: structural protein, e.g. muscle
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Insult
infection
trauma
I/R
hypoxemic/
hypotensive
Activation of
PMNs
= oxidative stress
Death
organ = failure
Pathophysiology of Critical Illness
mitochondrial
dysfunction
Role of
GIT
Key nutrient deficiencies(e.g. glutamine, selenium)
activation of coagulation/complement
generation of OFR
(ROS + RNOS)
endothelial dysfunction
elaboration of cytokines,
NO, and other mediators
cellular = energetic
failure
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Metabolic response in thesurgical patient
Modulated by changes in the
neuroendocrine milieu.
Increased levels of : catecholamine,glucocorticoids, glucagon, GH,
aldosterone, ADH.
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Metabolic response in thesurgical patient
Catecholamine increases BMR
Cortisol negative nitrogen balance Aldosterone and ADH sodium and water
retention weight gain
Counter-regulatory hormone stress DM hyperglycemia
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Introduction:
3 basic questions to be answered:
Can we identify which patients willbenefit from nutritional support?
When, and how long should the support
be given?
By what route should support be given?
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Guidelines for the choiceof nutrition support (I)
Nutritional assessment
of the patient
Normally
nourished
Normal/near-normal nutrition
state (but will deteriorate
if support withheld)
Malnourished
Normal feedingNutrition support indicated
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Guidelines for the choiceof nutrition support (2)
Nutrition support indicated
NoYes
Is enteral nutrition possible?
Normal feeding
+ dietary supplements
Supplemental/total PN
(PPN/CPN)
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Pre requisites:
Routine history taking
Assessment of physical status
Comparative assessment of approximateweight & weight loss
Periods of fasting/ starvation
Investigations:- blood urea, serum creatinine,
serum electrolytes and serum proteinsAlbumin level of less than 3.5g/dl is
indicative strongly of sepsis andassociated with high post- abdominal
surgical morbidity and mortality.
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Pre Requisites (cont) :
Nutritional requirements : Protein requirements in
terms of Nitrogen balance (NB)
N.B. = N (in)N (out)* = Protein _ N (out)
6.25 (gm/day)
* N (out) = Urine Urea N/0.8 (gm/day) + GI losses (24
gms/ day) + cutaneous losses (0-4 gm/day)
= Urine Urea N + 4 -- as a constant factor
0.8
NB =(Protein intake)(Urine urea nitrogen + 4)6.25 0.8
keep positive nitrogen balance of 2
4 gm / day
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Peri-operative Nutrition
Pre-operative :- Wt.loss > 10-15% over last 3 months
- Serum albumin
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Post-operative nutrition
Patients unlikely to resume GI feeds within 3-5
days.
Immediate support after extensive surgery.
Previously malnourished patients.
Major trauma/burns.
Usually begun within 48 hours of surgery if
decision is taken.
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Caloric deprivation in Post-Surgical Days
are harmful
CED10000
Kcal
p
Age 53.6 14.8 34.8 17.4 0.024
EE (Kcal/kg/d) 28.4 4.4 28.3 4.8 0.982
Intake(Kcal/kg/d)
26.4 6.6 19.2 5.4 0.044
SIRS (d) 3.6 2.2 8.0 4.2 0.017
ICU LOS(d)
12.5 7.6 23.5 15.1 0.021
Reid & Campbell Clin Nutr2001;20(Suppl 3):52CED= cumulative energy deficit
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Caloric need
Resting Energy ExpenditureKcal/min = 3.94 x VO2 + 1.11 x VCO2
RQ = fat 0.7 protein 0.8 CHO 1.0
Category Studies Patients Range kcal______________________________________
Surgical 7 637 1300-1900
Oncology 5 269 1300-1500
Mixed 2 200 1300-1400______________________________________
Nordenstrm & Thrne, E J Clin Nutr, 1994;48:531-37
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Energy yield
Sources:
Glucose 3.4 kcal/g
Protein 4 kcal/g
Lipids 9 kcal/g
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Energy needs
Energy requirements:
Total daily expenditure25-30 kcal kg-1
- Resting metabolic rate
- Activity energy expenditure
- Diet induced energy expenditure
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Energy needs
Energy requirements:
BMR calculated by Harris-Benedictequation:
66.47 + [13.75 x W] + [5 x H][6.76 x A]
Additional caloric expenditure:Minor operation 1.2 x BMR
Peritonitis 1.3 x BMR
Trauma 1.5 x BMR
Sepsis 1.6 x BMR
Burns 2.1 x BMR
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The ideal formula for the critically ill:
Amino acids including glutamine
Lipids as Structured triglycerides
Glucose (under control)
Omega-3-fatty acids (under control)
Micronutrients
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Glucose
The optimal proportion of the glucosecalories should be ~70% of the total
caloric intake
should be adjusted to maintain a bloodglucose level less than 150 mg/dl,
including administering regular insulin ifnecessary
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Fat
A good energy source during thepostoperative period because of its high
caloric value
Parenteral administration of lipids maybe extended up to approximately 20%
of the total calories and provided as acontinuous infusion
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Protein
1520% can be given as protein or aminoacids
In general, stressed patients with normalhepatic and renal function should
receive approximately 1.5 g/kg/day.
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The Recent Reviews :
Latest guidelines about the enteral nutrition and
parenteral nutrition in terminally ill surgical
patients by Dy SM (2006) confirm
Enteral and parenteral nutrition combined mayhelp improve survival, functional status andquality of life
These benefits appear to be primarily limited tothe patients with good functional status
The risks and the complications as mentioned in
the past are confirmed
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Postoperative parenteral nutrition
support
The effect of postoperative TPN on surgical outcome(meta-analysis)
- decreased complications by 10% with no differences in
the mortality Sandstorm et al, lower complication rate
Consensus conference of NIH,ASCN,ASPEN
- Postoperative nutrition support must beadministered to the patients who are notexpected to resume an oral diet for 3 to 5 days.
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