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Nutritional management in surgical patients

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ByDr Pirah Korai

Pg, SU-2CMC LARKANA

Nutritional management in surgical patients

OUTLINES IntroductionFundamental goals of nutritional support ERAS CriteriaWho require nutritional support? Post operative complications Criteria of malnutritionDaily fluid maintenance requirement Routes of administration of nutrition ASPEN Guidelines Enteral v/s parenteralPrinciples of TPNStandard regime and energy requirement

Nutrition

“THE BASIC DRUG”

Traumatized Man

Fundamental goals of Nutritional support:

To meet the energy requirement for metabolic processes

To maintain a normal core body temperature

For tissue repair

ERAS CriteriaAvoidance of long periods of pre-operative fasting;

Re-establishment of oral feeding as early as possible after surgery; Integration of nutrition into the overall management of the patient; Reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function; Metabolic control, e.g. of blood glucose; Early mobilisation

WHO REQUIRE NUTRITIONAL SUPPORT?

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A) Patients already with malnutrition

B) Patients at risk of malnutrition

WHO CANT EAT:

ESOPHAGEAL/GASTRIC OUTLET OBSTRUCTION, HEAD & NECK INJURY/SURGERY, SHOCK

WHO CANT EAT ENOUGH:

SEVERE BURNS, MAJOR TRAUMA , SEPSIS

WHO WONT EAT:

ANOREXIA, DEPRESSION & EATING DISORDERS

WHO SHOULD NOT EAT:

BOWEL OBSTRUCTION/LEAKAGE, GI FISTULAS, SEVERE PANCREATITIS, IBD, RADIATION ENTERITIS, PROLONGED ILEUS

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POST-OP COMPLICATIONS

• Impaired defenses– decreased immunity– decreased phagocytosis– decreased chemotaxis

• Increased post-op infections• Impaired wound healing• Longer recovery period• Prolonged hospital stay

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IMPAIRED NUTRITION

40%

60%

40% of hospitalized patients have an impaired nutritional status

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33%

67%

33% of all gastrointestinal surgery patients are malnourished

IMPAIRED NUTRITION

Criteria of Malnutrition

• O/H: Wt loss >10-15% within 6months

• BMI: <18.5 kg/m2

• Subjective global assessment: Grade C

• S-Albumin: <30g/L (with no evidence of hepatic or renal

dysfunction)

1/3rd to 1/4th part of fluid to be provided by Normal saline while rest through 5%

Dextrose

Daily maintenance requirement:

Routes of ADMINISTRATION OF NutritionS

--- Enteral

---Parenteral

---Combined

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ASPEN NUTRITION SUPPORT ALGORITHM

Functional GITYes No

Enteral nutrition Parenteral nutrition

Short term Long term/fluid restriction

PPN Central PN

GI Function returns

No

GI Function

Standard Nutrients

Speciality Formulas

Normal Compromised

Adequate progress to oral feeding

Adequate progress to more complex diet

and oral feedings as tolerated

Inadequate PN supplementation

Nutrient tolerance

Progress to total enteral feedings Yes

Nutrition Assessment

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Principles of TPN• Used only when indicated • All devices must be managed by staff trained in

aseptic • Cyclical feeds better than continuous infusion

(Infusion over 10-18 hrs) • Adequate adjustments in standard solutions as &

when required• Stop TPN when not needed • Never discontinue at once ( Ramp down) (Rate of infusion reduce to one half for 2 hrs, then half

again for 2 hrs & then discontinue)• Careful monitoring & watch for complications

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Parenteral nutritionstandard regimens

• Energy 30 kcal/kg/day (as energy and fat)• Amino acids 1.5g/kg/day• Electrolytes basal amounts• Vitamins and trace elements basal amounts

Above are maintenance requirements. Additional fluid and electrolytes may be required

Basic Energy Requirements:

-Esimated total caloric need of the patient : 25-35kcal/kg/day

( so, 1800-2100 kcal/day for a 70-kg man)

-Generally 30% of calories should be via lipid (fat) and the rest by glucose (carbohydrates)

-1.5 L of 20% dextrose contains 300g of Glucose and will provide 1200kcal

0.5 L of 20% Lipid emulsion contains 100g of lipids and will provide 900kcal.

-Thus , a combination will provide 2100kcal in 2L of fluids

Protein Requirement:

-Estimated daily requirement : 1-2g/kg/day

( so, 70g/day for a 70kg man)

-0.5 L of amino acid solution can thus complete the usual nutritional requirement within daily fluid allowance.

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Enteral vs Parenteral

Parenteral ‘guaranteed’ intake ‘never’ rejectedcan be used with short gut or absent gut

function

Less nutritionally effective than ENHyperglycaemia Electrolyte imbalanceHyperlipidemiaConstant supervisionNeeds long term CVCSterility and infection considerationsCostly

Enteral Requires functional gut can cause solute overloadVomiting, DiarrheaCan cause perforation(rarely)

Can be used to continue oral medsMore effective – on-line to portal system Encourages gut motility Normalises gut flora Electrolyte imbalance unusualLess supervisionLess infectionCheap(er)

SUMMARY