Nur Amalina Aminuddin082012100067

NUTRITION AND FLUID THERAPY

30% in surgical patients with GI disease60% in prolonged hospital stay patientsHave higher risk of complications and death

Aim of nutritional support Identify patients at risk of malnutrition Ensure their nutritional requirements are met

MALNUTRITION

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

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

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

Weight loss >10% in 6 months

poor outcomeBMI

<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

British Association of Parenteral and Enteral NutritionMalnutrition Universal Screening Tool (MUST)

3.CLINICAL

Low risk Medium risk High riskHospital Repeat

screening :Weekly

Document dietary and fluid intake for 3 days

Refer dietician

Care homes

Monthly

Community

Yearly Repeat screening and dietary advice

I f BMI or weight loss cannot be established, use recalled value

I f both, use overal l impression of malnutrit ion Clinical impression or Clothes

becoming loose or loss of appetite or any underlying cause

Average Daily Water Balance

Daily electrolytes requirement (mm/d): Sodium 50-90 Potassium 50 Calcium 5 Magnesium 1

FLUID AND ELECTROLYTES

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 28NS ( 0.9% NaCl) 154 154Dextrose saline 30 30Gelofusine 150 <1 150 Gelatin 4%Haemecel 145 5.1 6.2

6145 Polygelin 75g/l

Hetastarch Hydroxyethyl starch 6%

Changes based on condition of patientMonitoring 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

Total energy requirements20-30 kcal/kg/d1300-1800 kcal/d

CarbohydratesObligatory glucose

requirements: 2g/kg/dGlucose 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

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

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

REFERENCE