malnutrition - its effect preop, intraop and postop.pptx

malnutrition and its effect on surgery -pre, intra and post op.

1. Causes and consequences of malnutrition in surgical patiets

2. Diagnosis of malnutrition Global Leadership Initiative on Malnutrition (GLIM) proposes a diagnosis of malnutrition based on the presence of: at least one phenotypic criterion and one aetiological criterion

3. Phenotypical criteria: 1. Weight loss >5% within past 6 month, or >10% beyond 6 month 2. Low BMI: Asia: <18.5 if <70 yr , or <20 if >70 yr 3. Reduced muscle mass – determined using a validated body composition technique.

4. Aetiological criteria: 1. Reduced food intake or assimilation ≤50% of energy requirement >1 wk , or any reduction for >2 wk , or any chronic gastrointestinal condition that has adverse impacts on food absorption 2. Inflammation – acute disease/injury (e.g. major infection, burns, trauma, surgery, closed head injury) or chronic disease related (e.g. malignancy, chronic obstructive pulmonary disorder).

5. Screening of malnutrtion the Malnutrition Universal Screening Tool (MUST) is used to screen malnutrition in adults. A five‐step validated tool used to classify patients as low, medium, or high risk. Others: Subjective Global Assessment (SGA) Mini Nutrition Assessment Clinical Frailty Scale

6. Aetiology of malnutrition in surgical patients Pre-existing Conditions: Increased Nutritional Needs: Inadequate Nutrient Intake: Impaired Nutrient Absorption: Medications: Psychological Factors: Socioeconomic Factors: Age-related Factors:

7. Pre-existing Conditions: Chronic Illnesses: Conditions such as cancer, chronic kidney disease, heart failure, and gastrointestinal disorders can lead to malnutrition. Diabetes: Poor glycemic control can interfere with nutrient absorption and utilization.

8. Increased Nutritional Needs: Metabolic Stress: Surgery and the healing process increase metabolic demands, requiring more nutrients. Infection and Inflammation: These conditions elevate the body's nutrient requirements.

9. Inadequate Nutrient Intake: Reduced Appetite: Anxiety, pain, medications, and the effects of surgery can decrease appetite. Difficulty Eating: Post-surgical pain, nausea, vomiting, and physical restrictions (e.g., facial surgery) can limit food intake. The single most important aetiological factor the most common cause of in-hospital malnutrition is poor food served without assistance to frail individuals. Patients are also given nothing by mouth for the most trivial reason (e.g., Radiologic studies) D iets are often not advanced rapidly even after minor operations Contributing factors: Dysphagia, Anorexia nervosa, Depression, Alcoholism

10. Reduced absorption Inflammatory bowel disease, Coeliac disease Short bowel syndrome, Protein-losing enteropathies. Increased losses or altered requirements: Cancer Surgery Sepsis Enterocutaneous fistulae Burns

11. Impaired Nutrient Absorption Previous gastrointestinal Surgery: Procedures affecting the stomach, intestines, or pancreas can impair nutrient absorption. Medical Conditions: Conditions like celiac disease, Crohn's disease, or chronic pancreatitis can reduce nutrient absorption.

12. Medications and psychological factors Side Effects: Medications such as antibiotics, chemotherapy, and corticosteroids can cause nausea, vomiting, and reduced appetite. Interference with Nutrient Absorption: Some drugs can impair the absorption of essential vitamins and minerals. Depression and Anxiety: Mental health conditions can reduce appetite and motivation to eat. Stress: Surgical stress can negatively impact eating behaviors.

13. Socioeconomic Factors Limited Access to Nutritious Food: Financial constraints can limit the ability to purchase nutrient-dense foods. Lack of Support: Patients without a support system may struggle to prepare and consume adequate meals

14. Age related factors Elderly Patients: Older adults are at higher risk of malnutrition due to decreased appetite, dental problems, and chronic diseases. Children: Pediatric patients have different nutritional needs and may be more susceptible to malnutrition during surgical recovery.

15. Preoperative Nutritional Status Existing Malnutrition: Patients who are already malnourished before surgery are at higher risk of postoperative malnutrition. Obesity: Paradoxically, obese patients can also be malnourished if their diet lacks essential nutrients.  Hospital Food Quality: Poor quality or unappealing hospital food can reduce intake. Feeding Restrictions: Medical procedures and tests often require fasting or dietary restrictions.

16. Consequences of Malnutrition Malnutrition affects the function and recovery of every organ system. Under physiologic conditions: Muscle breakdown prevented by hormonal changes which results in decreased use of ketones by muscles and a decrease in gluconeogenesis by the muscle protein. Under prolonged fasting: draws on functional reserves in tissues leading to loss of functional capacity on muscle, adipose tissue and bone.

17. Cardio-respiratory function Reduction in cardiac muscle mass decrease in cardiac output has a corresponding impact on renal function by reducing renal perfusion and glomerular filtration rate Poor diaphragmatic and respiratory muscle function: reduces cough pressure and expectoration of secretions, delaying recovery from respiratory tract infections Reduced ventilatory performance and prolonged ventilator dependence

18. Gastrointestinal function Chronic malnutrition results in changes in Pancreatic exocrine function, Intestinal blood flow Villous architecture and intestinal permeability. The colon loses its ability to reabsorb water and electrolytes This may result in diarrhoea

19. Immunity and wound healing Diminished complement and immunoglobulin production, Poor cellular immunity, impairment of leukocyte action including chemotaxis, phagocytosis, and oxidative burst. Poor tissue repair and wound healing (lack of Vit C)

20. Factors affecting wound healing

21. Malnutrition causing decreased wound healing Protein Deficiency: Collagen Synthesis: crucial for wound strength and integrity. Without adequate protein, collagen production is impaired, weaker wound tensile strength and increased risk of wound dehiscence. Cellular Repair and Immune Function: Proteins are vital for the proliferation of fibroblasts and keratinocytes. necessary for producing antibodies and immune cells to prevent infection. Vitamin Deficiency: Vitamin C: collagen synthesis and immune function. Deficiency can lead to weakened wound strength and increased susceptibility to infection. Vitamin A: Important for epithelialization and immune function. A deficiency can delay wound closure and increase the risk of infection. Vitamin E: Plays a role in cellular repair and antioxidant protection. Deficiency can lead to prolonged inflammation and poor wound healing.

22. Mineral Deficiency: Zinc: Crucial for DNA synthesis, cell division, and protein synthesis. Zinc deficiency can result in delayed wound healing, impaired immune response, and increased infection risk. Iron: Necessary for oxygen transport and energy production within cells. Iron deficiency can lead to reduced oxygen supply to the wound, impairing wound healing. Carbohydrate Deficiency: A deficiency can lead to reduced energy supply, affecting all stages of wound healing, from inflammation to tissue remodeling.

23. Fats and Fatty Acids: Essential Fatty Acids: Important for cell membrane integrity and the inflammatory response. Deficiency can impair the inflammatory phase of wound healing and lead to prolonged healing times. Calories: Overall caloric intake must be sufficient to meet the increased energy demands of wound healing . Inadequate caloric intake can slow the healing process and increase the risk of wound complications.

24. Renal System Impaired Renal Function: Malnutrition can lead to reduced renal function, affecting fluid and electrolyte balance. Increased Risk of Acute Kidney Injury (AKI): Poor nutritional status increases the risk of AKI, complicating postoperative recovery.

25. Hematologic System: Anemia: Malnutrition often leads to anemia, reducing oxygen transport capacity and impairing wound healing. Coagulation Disorders: Nutritional deficiencies can lead to coagulopathy, increasing the risk of bleeding and clotting disorders.

26. Nervous System Cognitive Impairment: Malnutrition can lead to confusion, delirium, and decreased cognitive function, complicating postoperative care. Peripheral Neuropathy: Deficiencies in essential vitamins and minerals can cause peripheral neuropathy, affecting recovery and rehabilitation.

27. Clinical Outcome Malnourished patient’s mortality rates three to four times higher than normally nourished patients. Longer hospital admissions Psychosocial effects: Apathy Depression Anxiety Self-neglect.

28. Thank You