lecture 2 objectives to discuss the body composition and...

LECTURE 2 – BODY COMPOSITION, INJURY, AND WOUND HEALING IN SURGERY

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Slide 1

Body composition, injury, and wound healing in surgery

Surgical Nutrition Training ModuleLevel 1

Philippine Society of General SurgeonsCommittee on Surgical Training

In this session body composition will be discussed from its normal state to the different states in response to injury. The relationship of body composition to the quality of wound healing in surgery will also be discussed.

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Objectives

• To discuss the body composition and its key components

• To discuss body composition changes in injury particularly in surgery

These are the objectives of the session: • To discuss the body composition and its key components • To discuss body composition changes in injury particularly in surgery


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BASICS AND NORMAL BODY COMPOSITION

Let us discuss the basics in the normal body composition

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The cell and its organelles

Major:

• Cell membrane

• Cytoplasm

• Mitochondria

• Nucleus

• Endoplasmic reticulum

• Golgi apparatus

Illustrations from Guyton’s Textbook of Physiology

The cell is the basic unit of the whole body. What happens in the cell will be reflected by the whole body. It is important to note that understanding the structural and functional aspects of the cell will give the surgeon the means of understanding the basic changes of the body during surgery and how to manage the complications that arise from it.


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Nutrients, structure, function

Structure and function plays a crucial role in the management of surgical patients. As the cell needs energy in order to sustain its normal functions so does the whole body needs energy to fulfill its wound healing requirements like protein synthesis. Inadequate energy and/or structural substrates will lead to problems of wound healing with its attendant complications like infection(s).


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Human body = 100 trillion cells

• Nervous system

• Musculoskeletal system

• Cardiovascular system

• Respiratory system

• Gastrointestinal system

• Genitourinary system

• Reproductive system

• Endocrine system

• Hemopoietic systemENERGY

radicals

The human body is composed of 100 trillion cells. These cells are organized into the different organ systems. One will note the huge requirements (fluid, macronutrients, and micronutrients) needed just to sustain the whole body. Energy is further supplied by the macro and micronutrients that are incorporated in the cell in order to sustain the continuing life processes like structural and enzymatic functions. Energy production also results to free radical production which further requires more nutrients to synthesize antioxidants. There is therefore a balance between structure and function in the human body.


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Body composition, all ages

This balance is represented by body composition analysis which indicates the following key compartments: the first compartment is water, the second compartment is protein or technically the better term, lean body mass, and the third compartment is fat. There are varying patterns of these compartments in the different age groups which are a reflection of the functionality and structural state of the human being at a specific age.


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Muscle and fat mass, all ages

As one ages there will a gradual diminution of the lean body mass compartment and an opposite increase in the fat compartment. At the age beyond 50 the loss of lean body mass becomes more rapid due to factors of aging like sarcopenia, less nutrient intake, and less optimal functional status of the different organ systems. The increasing volume of fat mass appears to be a compensatory mechanism to cover for the decreasing lean body mass through provision of a more energy dense compartment. This means there is a need to avoid losses from the lean body mass to sustain optimum function and status for the surgical patient.


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Slide 9

BODY COMPOSITION IN HEALTH AND DISEASE

Let us discuss the body composition changes in the different disease states. Slide 10

Body compartments in health and disease

WATER (60%)

FAT (25%)

PROTEIN (14%)

WATER (72%)

FAT (15%)

PROTEIN (12%)

WATER (70%)

FAT (23%)

PROTEIN (6%)

CARBO + OTHER (1%)

NORMAL STARVATION CRITICAL CARE

WATER (55%)

FAT (30%)

PROTEIN (14%)

OBESE

In obesity there is more fat mass with similar protein or lean body mass volume compared to normal. It has a greater tendency to undergo pro-inflammatory reactions to injury or to go into the obesity syndrome status. In starvation and cancer cachexia there is loss of protein mass together with the fat mass, however, there is better lean body mass preservation in starvation compared to cancer cachexia. The issue of wound healing and complications become key factors in the recovery of the patient. Protein loss in the critical care state is most severe compared to the rest of the conditions with minimal utilization of fat thus leading to questions of recovery if nutrition is not well managed in this disease state.


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Energy utilization

POST-PRANDIAL Glucose

POST-PRANDIAL: within 24 hours Glycogen

Glycogen

FASTING: within 24 to 72 hours

Gluconeogenesis

Fatty acid: lipolysis(minimal)

Lipogenesis

FASTING: beyond 5 daysFatty acid: lipolysis

(full blast)

Note: Cardiac and skeletal muscle (slow) are mainly dependent on fatty acid for energy source

(preserving protein)

This is how nutrient and energy inter-conversion occur. After feeding glucose is utilized by all the cells (=glycolysis) with a big portion preserved as glycogen in the liver and muscles (=glycogenesis). The rest is converted to fat and placed in reserve in all fat tissues (=lipogenesis). Fatty acid is utilized (=beta oxidation) and then put in reserve as fat tissue (=lipogenesis). Amino acids are utilized and reserved in the muscles, particularly in the skeletal muscles (=protein synthesis with “amino acid pool”). After feeding energy is initially provided by glucose thru glycogenolysis then later by gluconeogenesis and finally by fat, after four to five days of fasting. 90% of energy will be from fat on the second week (=ketoadaptation). Note that cardiac and skeletal muscles are heavy users of fatty acids even on the first week.


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No food intake: glucose utilization

This graph shows the energy utilization of the cell focusing on the nutrient priorities from glucose to fat.

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Surgery, wound healing, and nutritional status

SURGERY

INFLAMMATION

↑WBC + ↑ENERGY

↑CELL MULTIPLICATION + ↑NUTRIENT NEEDS

WOUND HEALING

NORMAL POOR ± COMPLICATIONS

No Malnutrition Malnutrition

Surgery induced inflammation would lead to increased energy requirements mainly from the WBC response, followed by the increased cell multiplication process for wound healing and bone marrow activities. These processes are dependent on nutrient supply for optimum function. The type of recovery will be dependent on the presence or absence of malnutrition together with the presence of complications (e.g. poor wound healing and infection)


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• Catecholamines• Glucagon• Thyroid hormones• Cortisol

The critical care state needs to be emphasized due to the rapid depletion of protein due to its utilization for both energy and substrate needs as a consequence of the endocrine and metabolic response to the injury process. There is no time for the protein sparing phase (i.e. preferential carbohydrate and fat utilization over protein), thus for surgical patients who go into this state the value of nutrition management is crucial to recovery. The status of the lean body mass is a huge issue here.


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Loss of lean body mass = ↑mortality

Loss of Total LBM

Complications Associated Mortality

10% Decreased immunityIncreased infections

10%

20% Decrease in healing, increaseIn weakness, infection

30%

30% Too weak to sit, pressure ulcers,Pneumonia, lack of healing

50%

40% Death, usually from pneumonia 100%

Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9.

LBM=Lean Body Mass

A progression in the severity of lean body mass loss is directly related to mortality as shown through the different complications that arise from the loss of protein. The message: preserve as much lean body mass as possible especially in elderly patients.

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BODY COMPOSITION ANALYSIS

How can we analyze the body composition of the surgical patient? Through the CLINICAL NUTRITION PROCESS.


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The surgical nutrition process

All admitted patients are nutritionally screened

All nutritionally at risk patients are assessed

All high risk patients are given nutrition care plans

Monitoring of the nutrition process is done

Nutrition care plan modification / Discharge

This is the clinical nutrition process recommended by the Sub-Committee on Clinical Nutrition of the Committee on Surgical Training for use by all surgical training programs by the PSGS in the Philippines: • NUTRITION SCREENING is done on all patients on admission. This is usually performed by

the nurses. • The identified NUTRITIONALLY AT RISK patients will undergo NUTRITIONAL ASSESSMENT

AND SURGICAL NUTRITION RISK LEVELING. This is the process that gives a good body composition analysis of the patient. This is usually done by the clinical dietitians.

• Once the patients are identified as NUTRITIONALLY HIGH RISK the NUTRITON CARE PLAN for the patient is performed.

• The NUTRITION CARE PLAN is usually done by the clinical nutrition physicians with support by the clinical dietitians. The implementation is done by the nursing service and the clinical dietitians and pharmacists.

• The MONITORING process is performed by all members of the team.


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Nutritional Assessment

and Risk Level Form

This is the Nutrition Assessment and Risk Level form.

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Complication(s) prediction

Predicting post-operative complications based on surgical nutritional risk level using the SNRAF in colon cancer patients - a Chinese General Hospital & Medical Center experience. Ocampo R B, Kadatuan Y, Torillo MR,

Camarse CM, Malilay RB, Cheu G, Llido LO, Gilbuena AA. Yr 2007.

The NUTRITIONAL ASSESSMENT AND RISK LEVELING TOOL is already validated (=Philippines). The sensitivity was 92% and the positive predictive value (PPV) was 96%. When this was used in one of the institutions in the Philippines (Chinese General Hospital Department of Surgery) the predictive value was verified when the identified high risk patients were the ones which had mortality and increased complications.


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SURGICAL DECISION MAKING BASED ON BODY COMPOSITION ANALYSIS

Knowing the body composition of the patient whether as severely malnourished or with a high risk of developing nutrition related complications, what would be the surgical decision making steps?


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malnutrition

Scheduled• esophageal resection• gastrectomy• pancreaticoduodenectomy

Enteral nutrition for 10-14 days

oral immunonutrition for 6-7 days

Early oral feeding within 7 days

yes no

within 4 days

yes

“Fast Track”

no

Parenteral hypocaloric

Adequate calorie intake within 14 days

Enteral access (NCJ)

yes no

enteral nutrition immunonutrition for 6-7 days

Oral intake of energy requirements

yes no

combined enteral / parenteral

no slight, moderate severe

SURGERY

PRE-OPERATIVE PHASE

POST-OP

EARLY DAY 1 - 14

LATE DAY 14

Oral intake of energy requirements

yesnosupplemental enteral diet

The surgical nutrition guidelines as recommended by the European Society of Parenteral and Enteral Nutrition (ESPEN) are the following: • Nutritional assessment must be done on all surgical patients. If normal or moderate

malnutrition go ahead with the surgery. • Pre-operative nutrition build-up should be done on the following:

• All severely malnourished patients • Major surgery like: esophageal resection, gastrectomy, and

pancreaticoduodenectomy (with additional immunonutrition supplementation) • During intra-operative phase try to determine if there is a need to place enteral access like

needle catheter jejunostomy if it can be foreseen that patient cannot adequately eat within two to three weeks.

• In the post-operative phase: • If early oral feeding is possible within the first four days do “fast-track” surgery • If not possible to achieve adequate oral/enteral intake give supplemental parenteral

nutrition until adequacy is reached.


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WOUND HEALING ISSUES

Here are some specific wound healing issues.

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Inflammation: part of wound healing

• Cell proliferation

• ↑ nutrient and energy requirements

• Adequacy of response is dependent on the nutrient supply / reserves

• The surgical process involves inflammation. • The wound healing process also involves inflammation. • The resulting cell proliferation in both aspects require increased energy and nutrient

requirements. • The adequacy and rate of recovery is dependent on the available nutrient supply and/or

reserves


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Wound healing

Angiogenesis

Stages of wound healing and repair

Reference: Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003.

The need for nutrients will become more marked during the granulation phase of wound healing where cell proliferation due to both angiogenesis and connective tissue synthesis (e.g. basement membrane and collagen placement) progressively increase exponentially.

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Basement membrane:1. Cell support2. Exchange 3. Transport4. Development5. Repair6. Defense7. Integrity of structure and

environment

Intercellular environment1. Tissue support/shape2. Exchange3. Growth4. Repair5. Defense6. Movement

Wound healing: molecular environment

These are the areas of cellular and connective tissue development in the wound which shows the complex inter-relationship between local and systemic factors.


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Wound healing

Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003.

The wound healing process is shown here where the inflammation process is well coordinated with the cellular proliferation process until continuity is restored.


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Wound healing requirements

• Increased requirements– Energy and protein

– Electrolytes, vitamins, trace elements

– Oxygen and water

• Addition of: – conditional essential amino acids (glutamine)

– Trace elements (selenium in burns)

– Antioxidants

• Continuous supply of the requirements

These are the increased requirements: • Energy and protein • Electrolytes, vitamins, and trace elements • Oxygen and water

There are conditions when there is an increased need of special nutrients: • Conditional essential amino acids like glutamine • Trace elements (like selenium) in burns • Antioxidants

The delivery has to be continuous


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Energy calculations are good enough

Calculations for energy requirements provide values that are consistently between 1000 and 1800 kcal/day for most patients.

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ESPEN Guidelines 2009: Surgery

• Calorie Requirement(s):

– The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements.

– Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weight

– (Grade B)

ESPEN: European Society of Parenteral and Enteral Nutrition

These are the recommended energy requirements (as placed in the guidelines of ESPEN, year 2009): • The usual energy requirement is 25 kcal/kg ideal body weight • The energy requirements increase in severe stress like burns or sepsis (ESPEN) reaching as

much as 30-45 kcal/kg ideal body weight


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Protein synthesis

• Requirements:

– ↑Insulin levels induced by adequate glucose intake

– ↑plasma amino acid levels

– Adequate essential amino acid levels

– Adequate non-protein calories from carbohydrate and fat

For adequate protein synthesis these are the requisites: • Increased insulin levels induced by adequate glucose delivery • Increased plasma amino acid levels with preponderance of essential amino acids • Adequate energy from carbohydrate and fat to enhance the utilization of protein

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• Protein Requirement(s)

– In illness/stressed conditions a daily nitrogen delivery equivalent to a protein intake of 1.5 g/kg ideal body weight (or approximately 20% of total energy requirements) is generally effective to limit nitrogen losses. The Protein:Fat:Glucose caloric ratio should approximate to 20:30:50% (Grade C)


These are the recommended doses for protein with the protein:fat:glucose calorie ratio (grade C).


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Slide 32

Carbohydrate and fat ratios

Stoner et al

McFie et al

The glucose and fat ratios provide the appropriate energy sources during different post-surgical states. In non-septic states, glucose is the preferred source of energy, however when infection and sepsis come in, or when organ failure occurs, fat becomes the preferred source (Stoner et al) Glucose and fat combined results to better protein utilization and nitrogen balance compared to glucose alone (McFie et al)


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Do lipids matter?

LCT = mostly ω6FA (arachdionicacid) content = proinflammatory

MCT = reduces ω6FA (arachidonicacid) content + direct utilization in the liver

The type of fat given also results to the quality of cellular metabolism. Purely long chain PUFA will result to a higher inflammatory environment compared to long chain PUFA with a medium chain triglyceride combination which results to a better energy utilization in a less inflammatory environment. The outcome as shown in this study by Smirniotis et al (Int Care Med 1998) shows better oxygen delivery in the ARDS patient receiving an LCT-MCT combination.

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• Nitrogen sparing; non-protein calories

– Optimal nitrogen sparing has been shown to be achieved when all components of the parenteral nutrition mix are administered simultaneously over 24 hours (Grade A)


As a final note – optimum nitrogen utilization is achieved when all macronutrients (=protein, fat, carbohydrates) are given simultaneously (Grade A, ESPEN guidelines 2009)


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Slide 35

Energy requirements and antioxidants

Glutathione reductase

Glutathione peroxidase

Glutathione peroxidase

Superoxide dismutase

• Munoz C. Trace elements and immunity: Nutrition, immune functions and health; Euroconferences, Paris; June 9-10, 2005;

• Robbins Basic Pathology 7th edition 2003. Kumar, Cotran, Robbins editors.

Oxygen radicalsO•2

Hydrogen peroxideH2O2

ONOO-

Zn

Cu

2H2O

ONO- + H2O

Glutathione reductase

Se

2GSH

2GSH

GSSG

GSSG

Vitamin C

Vitamin C

Catalase

2H2O

Increased cellular proliferation in either inflammation and wound healing require huge amounts of energy. Glycolysis with the corresponding oxidative phosphorylation process results to free radical production which becomes harmful in large quantities. The cell controls this through the production of antioxidants. Shown here are the major enzymes responsible for the antioxidant with their corresponding co-factors (Vitamin C and the trace elements: copper, zinc, and selenium). There are mitochondrial, cytoplasmic, and membrane antioxidants.


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Antioxidants

Nathens AB, Neff MJ, Jurkovich GJ, Klotz P, Farver K, Ruzinski JT, Radella F, Garcia I, Maier RV. Randomized, prospective trial of antioxidant supplementation in critically ill surgical

patients. Ann Surg. 2002; 236(6): 814-22.

1. α-tocopherol 1,000 IU (20 mL) q 8h per naso- or orogastric tube

2. ascorbic acid 1,000 mg given IV in 100 mL D5W q 8h for the shorter of the duration of admission to the ICU or 28 days.

With the understanding that antioxidants are increased in surgery, this study of increased supplementation of vitamin C, E, and trace elements in cancer surgery patients showed decreased risk of developing multi-organ complications. (Nathens et al, Ann Surg 2002)

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Body composition, intake and outcome

Achieving adequate energy and protein intake in surgical patients with delivery of both macro and micronutrients improves mortality in high risk patients thus rendering a non-significant difference in both high risk or low risk surgical patients.


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Slide 38

CONCLUSION

In conclusion:


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Body composition

• Body composition changes occur in surgery

• Quality of body composition determines outcome in surgery

• Analysis of body composition and correction of deficiencies through nutrition improves outcomes in surgery

Conclusion: • Body composition changes occur in surgery • The quality of the body composition determines the outcome of the surgical process • Analysis of body composition and correction of deficiencies through nutrition improves

outcomes in surgery

lecture 2 objectives to discuss the body composition and...

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