Nutrition in surgery

1. Nutrition in Surgery Name: Nurzawani Binti Shamsudin Matric No: 0918424

2. Outline of the seminar

3. introduction Definition of nutrition & malnutrition Causes of malnutrition Objectives of nutritional support Assessment of nutritional status Estimating energy requirement Estimating nutritional requirement.

4. nutrition Definition The taking in and metabolism of nutrients (food and other nourishing material) by an organism so that life is maintained and growth can take place . Dorland’s Pocket Medical Dictionary

5. malnutrition Definition A disorder of nutrition or a wasting condition resulting from energy and protein deficiency , sometimes with vitamin and trace element deficiency as well. Dorland’s Pocket Medical Dictionary

6. Malnutrition Causes Reduced food intake anorexia fasting pain on swallowing, physical or mental impairment Malabsorption impaired digestion or absorption excess loss from gut Altered metabolism trauma burns sepsis surgery cancer cachexia

7. Importance of nutrition in surgery Surgical procedures (and subsequent fasting) after admission can cause these patients to go into severe malnutrition quickly, often before the treating team realizes it. There is evidence that patient with severe protein depletion have greater incidence of postoperative complication such pneumonia, wound infection, & prolonged hospital stay.

8. Causes of inadequate intake

9. Objective of nutritional support Provide nutrition support consistent with patient’s medical condition Prevent/ treat macronutrient and micronutrient deficiency Provide doses of nutrient compatible with existing metabolism Avoid/ manage complications related to the technique of nutrient delivery. Improve patient’s outcome such as those related to morbidity To prevent and minimize the effect of catabolism

10. ASSESSMENT OF NUTRITIONAL STATUS

11. Assessment of nutritional status History Diet assessment. Physical Examination. Investigation

12. ASSESSING PATIENT FOR MALNUTRITION Clinical assessment: Lack of nutritional intake for 5 days or more. Clinical appearance – does the patient looked malnourished? Unintentional weight loss for more than 10% from usual body weight for previous 6 months. More than 20% is likely to represent severe malnutrition. BMI less than 18.5. History of poor nutrient intake: anorexia, nausea, vomiting, early satiety and food preference.

13. Clinical nutritional history based on understanding of the etiologies and pathophysiology of malnutrition. History of poor nutrient intake Anorexia Nausea Vomiting Early satiety Food preference Loss of body weight (see table) Weight loss of more than 10-15% during the past 6 months EVALUATION OF MALNUTRITION (HISTORY)

14. Percentage of weight loss and impression % weight loss Impression 5 Normal 10 -15 Risk 15 – 20 Malnutrition 20 – 30 Severe malnutrition 30 - 40 Incompatible

15. Social & economic condition that may lead to poverty & malnutrition Inadequate income Homeless Drug abuse Chronic alcoholism Gastrointestinal symptoms Dysphagia Recurrent vomiting Chronic diarrhea Food intolerance Other chronic medical illnesses Disseminated cancer COPD Chronic inflammatory disease EVALUATION OF MALNUTRITION (HISTORY)

16. EVALUATION OF MALNUTRITION (Physical EXAMINATION ) Findings Interpretation General appearance Weight loss Decreased temporal & proximal extremity muscle mass Decreased “pinch test” Malnutrition < 90% of ideal weight Decreased skeletal protein Decreased body fat stores Skin, nails, hair Easily plucked hair Spooning of nails Protein Iron

17. Findings Interpretation Skin, nails, hair Easy bruising, perifollicular hemorrhage “Flaky paint” of the lower extremity Coarse skin, papular keratitis “goose bumps” Peripheral edema Vitamin C Zink Vitamin A Protein Eyes Conjunctival pallor Bitot spot Opthalmoplegia Anemia (non-specific) Vitamin A Thiamine

18. Papular keratitis Bitot spot Perifollicular hemorrhage Nasolabial seborrhea Flaky paint of lower limb

19. Physical examination anthropometry Definition T he science dealing with measurement of the size, weight and proportions of human body It can assess level of energy reserves by e stimate amount of subcutaneous adipose stores. However it cannot identify specific nutrient deficiency

20. Anthropometric assessment: Triceps skin fold thickness (mm ) Mid arm circumference (cm) : Mid-upper circumference (cm) – ( π x triceps skin fold thickness) (cm ) % standard men women interpretation 100 12.5 16.5 Adequate 50 6 8 Borderline 20 2.5 3 Severe % standard men women interpretation 100 25.5 23 Adequate 80 20 18.5 Borderline 60 15 14 Depletion 40 10 9 Severe

21. Body Mass Index

22. EVALUATION OF MALNUTRITION (LABORATORY INVESTIGATION) To detect subclinical nutritional deficiencies in patients Nitrogen Balance Serum Albumin Creatinine excretion Immunological Function assessment

23. Nitrogen balance Nitrogen balance provides an index of protein gain or loss: 6.25 protein gained is equivalent to 1 g nitrogen Can be assessed by measuring the difference between nitrogen consumed (mouth, enteral tube or IV) and nitrogen excreted in the urine, feces and other intestinal sources. In most cases, total urine nitrogen can be calculated by dividing 24-h urinary urea nitrogen by 0.85 & assuming approximately 2g/d for nitrogen losses in feces & sweat. Blood indices: Nitrogen Intake – loss [90% urine, stool 5%, integument 5%] or [Protein intake (g)/6.25] – urinary urea (g) – 2(for stool & skin) – 2(non-urea nitrogen)

24. Serum Albumin Serum albumin level falls during the acute stress of surgery, sepsis or other acute inflammatory illness because of increased circulating extravascular volume TNF- α mediated inhibition of albumin synthesis The measurement of serum proteins, in particular albumin, is often used as an index of malnutrition (< 35g/L) Sensitive but non-specific . The half-life of albumin is 14 to 18 days. Prealbumin (half-life, 3 to 5 days) or transferrin (<200 mg/ dL ; half-life, 7 days), have been proposed as more sensitive indicators of rapid changes in nutritional status. Blood indices

25. Creatinine Excretion Creatinine is a metabolic product of skeletal muscle creatine . It is produced constantly in an amount directly proportional to skeletal muscle mass. With steady state a day-to-day renal function, each gram of creatinine in the 24-h urine collection represents 18.5g of fat free skeletal muscle. Measurement of creatinine in 24-h urine collection can be used as a relative measure of this body compartment. Blood indices

26. Immunological assessment Delayed cutaneous hypersensitivity or anergy , most commonly tested by delayed reaction to skin recall antigens, was widely used in early studies of nutritional assessment and is a manifestation of cell-mediated immunity Total Lymphocyte count is often <1000 / μ L in PCM and may accompany anergy to common skin test antigens. However, not all malnourished patients are at risk and the defect is immunologic, not nutritional . Blood indices

27. Adverse effect of protein or calories depletion Impaired wound healing and higher rate of wound breakdown. Impaired immune function and the ability to against infection . Skeletal muscle mass is lost , reducing muscular strength and general physical activity as well as causing fatigue. Thoracic muscle mass depletion depresses respiratory efficiency and increase risk of pneumonia. Albumin becomes depleted leading to generalized edema.

28. Adverse effect cont. Small bowel mucosa atrophy reduces its ability to absorb nutrient and may lead to bacterial translocation into bloodstream because loss of mucosal integrity. Impaired mental function leads to apathy, depression and low morale. Post operative complication rates are higher. Prolonged recovery times and longer hospital stay.

29. ASSESSMENT OF NUTRITIONAL REQUIREMENT Energy and protein requirement vary depending on weight, body composition, clinical status, mobility and dietary intake . Few patients require more than 2500 kcal/day. Additional calories are unlikely to be used effectively and may constitute a metabolic stress. Refeeding the chronically starved patient must be cautious because of the dangers of hypokalemia and hypophosphatem.ia uncomplicated Complicated/stressed Energy (kcal/kg/day) 25 30 – 35 Protein (g/kg/day) 1.0 1.3 – 1.5

30. REFERENCES Garden’s Principles & Practice of Surgery, 5 th edition. Burkitt’s Essential Surgery, 4 th edition. Medical Nutrition Therapy Guidelines for nutrition support in critically ill adult by Ministry of Health, Malaysia

31. Metabolic Response to Starvation After 12 hours of not feeding Plasma insulin level falls Glucagon rises Hepatic glycogen is gradually converted into glucose With prolong starvation, muscle glycogen is broken down and converted into lactate which is taken to the liver and converted to glucose After 24 hours Hepatic gluconeogenesis from amino acids precursors start with loss of about 75g of skeletal muslce protein per day.

32. Metabolisms in starvation and stressed state Muscle Protein 75g Fat stores Tryglicerides Amino acid Glycerol Fatty acid Liver Glycogen 75g gluconeogenesis Oxidation Fatty acid Glucose 180g brain RBC WBC Neurons Kidney muscle Lactate +pyruvate Ketone Heart Kidneys muscle Fig :Metabolism during fasting (<5 days)

33. Muscle Protein 250g Fat stores Tryglicerides Amino acid Glycerol Fatty acid KIDNEY gluconeogenesis Gluconeogenesis LIVER oxidation Fatty acid Glucose 360g Wound RBC WBC Nerve Muscle Kidney Lactate + pyruvate Ketone Heart Kidney Muscle Fig: Fuel utilization following trauma In Acute injury, significant alteration in substrate utilization. T here is enhanced nitrogen loss indicative of protein catabolism.

34. Energy requirement BEE (men) = 66.47 + 13.75 (weight) + 5.0 (height) – 6.76 (age) x (activity factor) x (injury factor) kcal/day BEE (women) = 655.1 + 9.56 (weight) + 1.85 (height) – 4.68 (age) x (activity factor) x (injury factor) kcal/day BEE = Basal Energy Expenditure = quantity of energy required to satisfy the requirements of the body at rest Equation adjusted for type of surgical stress Suitable for estimating energy requirement in >80% of patients Provision of 30kcal/kg/day will adequately meet energy requirement ( reduce risk of overfeeding) Activity factor confined to bed :1.2 out of bed :1.3 Injury Factor minor operation :1.20 skeletal trauma :1.35 Major sepsis :1.60 severe thermal burn :1.5

35. Estimation of energy and protein requirement: Uncomplicated Complicated Energy 30 34 – 40 (kcal/kg/day) Protein 1.0 1.3 – 2 (g/kg/day) 24-hour urinary urea excretion Common method for assessing protein requirement