Nutrition in surgical patients

Nutrition in surgical patients

1. NUTRITION IN SURGICAL PATIENTS DR. AJAY KUMAR, 3 R D YEAR PG DEPT OF GENERAL SURGERY MKCG, MCH

2. AIMS OF DISCUSSION INTRODUCTION GOAL OF NUTRITIONAL SUPPORT MALNUTRITION NUTRITIONAL ASSESSMENT ESTIMATION OF ENERGY NEEDS NUTRITION ADMINISTRATION FORMULA FOR EN AND PN TAKE HOME MESSAGES

3. INTRODUCTION Nutrition is the process of providing or obtaining the foods necessary for health and growth. The general indications for nutritional support in surgery are in the prevention and treatment of under nutrition. Dietary nutrition supplies carbohydrates, lipids and proteins that drive cellular metabolism .

4. Cont… Chemical processes that maintain cellular viability consist of catabolic (breakdown) and anabolic (synthesis) reactions. Catabolism produces energy, whereas anabolism requires energy. Feeding drives synthesis and storage, whereas starvation promotes the mobilization of energy . Normal functioning of human body requires a balance between nutritional intake and metabolism

5. Cont… Imbalances will manifest as nutritional deficiencies or excess

6. GOAL OF NUTRITIONAL SUPPORT Identify those patients at risk of malnutrition. Prevent or reverse the catabolic effect of disease or injury To meet the energy requirements of metabolic process To maintain a normal core body temperature To provide substrates for adequate tissue repair

7. Metabolic Response to Starvation Low plasma Insulin and high plasma Glucagon Hepatic Glycogenolysis and Gluconeogenesis Protein catabolism Lipolysis Adaptive ketogenesis Reduction in resting energy expenditure ( from 25-30 kcal/kg/day to 15-20 kcal/kg/day.

8. Metabolic response to Trauma and Sepsis Increased counter regulatory hormones like Adrenaline, Noradrenaline, Cortisol, Glucagon and GH. Increased energy requirement up to 40kcal/kg/day Increased Nitrogen requirements Preferential oxidation of lipids Increased Gluconeogenesis and protein catabolism Fluid retention and associated hypoalbunaemia.

9. Who will need nutritional support? Well nourished and mildly malnourished patients who cannot take oral food for more than one week post operatively to avoid prolonged starvation . Severely malnourished patients undergoing general surgery procedures. All critically ill patients (Sepsis patients, Multiple Injury patients, Burn patients, etc.) Patients whom you predict cannot use their gut for prolonged period of time (Short gut syndrome, EC fistula, etc.)

10. When to Start? Preoperatively in severely malnourished patient undergoing a major surgical operation . Immediately postoperatively in severely malnourished patients. Immediately after major trauma, sepsis, major burns . Normal or mildly malnourished patient who is unable to eat on his own by 7 days after surgery.

11. NUTRITIONAL REQUIREMENT Calories provided mainly by carbohydrate and fat - Fat = 9 kcal/ g - Carbohydrate = 4 kcal/ g - Protein = 4 kcal/ g Daily caloric requirements: 30-35kcal/kg /day. Metabolic stress associated with sepsis, trauma, surgery or ventilation lead to increase energy requirement (35-40kcal/kg/day)

12. MALNUTRITION Condition that develops when the body does not get the right amount of the calorie, vitamins , minerals and other nutrients it needs to maintain healthy tissues and organ function . Can occur in people who are either undernourished or over- nourished . Occurs in about 30% of surgical patient with GI disease and in up to 60% of those in whom hospital stay has been prolonged because of post op complications.

13. Impact of poor nutrition in surgical patients Wound infection Sepsis Pneumonia Post operative bleeding Anastomotic leak All these results in prolonged recovery period, prolonged hospital stay and nursing care finally increase the medical cost.

14. Nutrition in emergency surgical patients In emergency surgical patients who are malnourished, operative procedure must be done as early as possible as life saving procedure. There is window of opportunity within first 24 to 72 hours following a surgery, in which starting enteral feeding is associated with preserving gut integrity as well as diminishing the activation of inflammatory cytokines. When patient can not tolerate oral/enteral feeding for >7 days then parenteral nutrition should be started mainly TPN, Human Albumin, Amino acid, Lipid emulsion.

15. ESPEN GUIDELINE Under nutrition: - BMI < 18.5 kg/m 2 . - Weight loss >10-15% within 6 months. - Serum albumin <30g/L (with no evidence of hepatic or renal dysfunction). - < 80% of ideal body weight Over nutrition : - BMI > 30kg/m 2 . - Body weight >20% from ideal body weight

16. Malnutrition Universal Screening Tool (MUST) Parameter Range Score 1. BMI: >20kg/m 2 18.5-20kg/m 2 1 <18.5kg/m 2 2 2. Wt. loss in 3-6 mon. <5% 0 5-10% 1 >10% 2 3. No nutritional intake for 2 >5 days

17. Interpretation of MUST Tool SCORE 0: Low risk of undernutrition, needs only routine clinical care with treatment of underlying conditions, repeat screening every week in hospital, every month in care homes, every year for special (old age) groups in community. SCORE 1: Medium risk of undernutrition, document intake for 3 days in hospital or care homes, repeat screening from <1 month to >6 months with dietary advice. SCORE 2 OR MORE: High risk for undernutrition, refer to dietician or implement local policies, need food and food fortification and supplements in hospital, care homes or community.

18. BMI Underweight - <18.5kg/m 2 Normal - 18.5 – 24.9kg/m 2 Overweight - 25.0 – 29.9kg/m 2 Obese Class I - 30.0 – 34.9kg/m 2 Obese Class II - 35.0 – 39.9kg/m 2 Obese Class III - ≥ 40kg/m 2

19. NUTRITIONAL ASSESSMENT History Physical examination Laboratory investigation Nutritional assessment score

20. HISTORY Enquiries about presenting complaints like Vomiting, Diarrhoea and Dysphagia. Specific enquiries pertinent to nutritional status include recent history of Weight fluctuation with attention as to the timing and intent. Enquiries about co-morbidities like Obesity, Malignancy, IBD. Social & Dietary History.

21. Clinical Examination ANTHROPOMETRIC MEASUREMENTS:- - Weight , height & BMI, IBW - Skin-fold thickness (biceps & triceps) - Mid-arm circumference

22. Laboratory Tests CBC – Haemoglobin (HCMC anaemia ), Total Leucocytes count LFT – Serum albumin Serum Transferrin Serum Prealbumin Others - Nitrogen balance – for adequacy of protein intake. - Electrolytes/Creatinine

23. ESTIMATION OF ENERGY NEEDS Indirect calorimetry:- Remains the gold standard in measuring energy expenditure in the clinical setting. Measures CO2 production and O2 consumption during rest and exercise at steady-state to calculate total energy expenditure (TEE ). Indirect calorimetry allows for gas analysis and calculation of RQ . RQ is 1.0, 0.7 and 0.8 for glucose, fat and protein respectively. RQ higher than 1.0 suggests over feeding and lipogenesis.

24. Basal energy expenditure (BEE ):- Can be predicted by using the Harris-Benedict equation (in kilocalories per day ). For men equals 66.5 + [13.7 × weight (kg)] + [5 × height (cm)] – [6.8 × age (years )]. For women equals 655 + [9.6 × weight (kg)] + [1.8 × height (cm)] – [4.7 × age (years)].

25. Total Energy Expenditure(TEE):- TEE = BEE x Activity Factor x Stress Factor x Thermal Factor ACTIVITY FACTOR: Bed rest – 1.2 Mobile – 1.3 THERMAL FACTOR: 38 c – 1.1, 39 c – 1.2, 40 c – 1.3, 41 c – 1.4

26. STRESS FACTOR: Starvation - 0.8 Postoperative – 1 to 1.05 Cancer – 1.1 to 1.45 Sepsis – 1.25 to 1.55 Multiple Trauma – 1.25 to 1.55 Burn – 1.5 to 1.7

27. Estimates of Protein Requirements: Non stressed patients should receive 0.8 to1.2 g/kg/day of protein. Critically ill generally require 1.2 to 1.5 g/kg/day Burn, septic, and obese patients may require 1.5 to 2 g/kg/day.

28. ELECTROLYTE REQUIREMENT:- Na + 50-90 mmol/day K + 50-70 mmol/day Mg 2+ 01mmol/day Ca 2+ 05 mmol/day

29. PRINCIPLES GUIDING NUTRITION Use the oral route if the GI tract is fully functional and there are no other contraindications to oral feeding . Initiate nutrition via the enteral route if the patient is not expected to be on a full oral diet within 7 days post surgery and there are no GI tract contraindications If the enteral route is contraindicated or not tolerated, use the parenteral route within 24 to 48 hours in patients who are not expected to be able to tolerate full enteral nutrition (EN) within 7 days.

30. Administer at least 20% of the caloric and protein requirements enterally while reaching the required goal with additional Parenteral nutrition . Maintain PN until the patient is able to tolerate 75% of calories through the enteral route and EN until the patient is able to tolerate 75% of calories via the oral route

31. Nutritional Requirements Caloric goal – S tart with 10-15kcal/kg/d and increased slowly up to 30- 35kcal/kg/day

32. ROUTES & METHODS OF FEEDING Oral Enteral Parenteral Combinations

33. ORAL ROUTE Oral administration of nutrition is the preferred route since it is the most physiologic and the least invasive. Mental Alertness and Orientation Patients who have altered mentation are at increased risk for aspiration and should not begin an oral nutrition regimen. Intact Chewing/Swallowing Mechanism Patients who have had a stroke or undergone pharyngeal surgery may have difficulty swallowing. They may be candidates for modified oral diets.

34. NUTRITION IN POST OPERATIVE PATIENTS Oral/ enteral route is preferred in post operative patients unless contraindicated. Early post operative enteral feeding decreases the incidence of infectious complication and maintain mucosal barrier function. However, in patients who can not tolerate enteral feeds or they are contraindicated, the parenteral route is used.

35. DIET SELECTION Transitional diets minimize digestive stimulation and colonic residue while providing more calories than IV fluids alone in patients recovering from postoperative ileus. Clear liquids provide fluids mostly in the form of sugar and water. For short-term use after an acute illness or surgery (GI procedure ). Regular diet represents an unrestricted regimen that includes various foods designed to meet all caloric, protein, and elemental needs.

36. ENTERAL NUTRITION (EN) Delivery of nutrient into healthy and functioning GI tract. Most preferred when oral route is contraindicated. Advantages are:- 1. Maintain gut mucosal integrity 2. Maintain normal gut flora & pH 3. Cheap & easily available 4. Less complication

37. Indications of EN Oral intake < 50% of required in the previous 7-10 days. Dysphagia or chewing problem due to strokes, brain tumor, head injuries. Major burns. Low output GIT fistulas (< 500 ml/day ).

38. Contraindication of EN Mechanical obstruction of GIT. Prolonged ileus Severe GI haemorrhage Severe diarrhoea Intractable vomiting High output GIT fistula (>500ml/day) Severe enterocolitis

39. ROUTES OF ENTERAL NUTRITION NASOGASTRIC NASODUODENAL NASOJEJUNAL GASTROSTOMY- percutaneous, open, laparoscopic. JEJUNOSTOMY- percutaneous , open surgery, laparoscopic.

40. Patient must be haemodynamically stable before starting enteral nutrition The contraindications of enteral nutrition as stated earlier must be ruled out. The choice of route must be made, the least invasive ones are preferred

41. NASOENTERIC : Head end of the bed raised to 35 degrees. 20-30 ml/ hr are administered initially and gradually increased. Residual volumes should be checked 1 hour after meal and it should not exceed 50ml/hr. Signs of intolerance should be monitored and rate and osmolarity adjusted accordingly.

42. GASTROSTOMY Placement of a tube through the abdominal wall directly into the stomach. Stamm Gastrostomy (sero-lined) – temporary Janeway Gastrostomy (mucous-lined ) – permanent

43. PER CUTANEOUS ENDOSCOPIC GASTROSTOMY 2 methods of PEG:- Ponsky pull technique Push through technique (Sacks-Vine )

44. JEJUNOSTOMY TUBE Witzel (Open) - permanent Button jejunostomy Roux-en-Y (rarely used) Endoscopic

45. ENTERAL FORMULA 1. LOW RESIDUE ISOTONIC FORMULAS: Calorie density of 1 kcal/ml Non protein-calorie : nitrogen ratio =150:1 No fibre, no bulk, no residue Cheap, first line for stable GI tract

46. Cont… 2. ISOTONIC FORMULA WITH FIBER : Soluble and insoluble fiber Stimulate pancreatic lipase activity Degradation into short chain fatty acids

47. Cont… 3. IMMUNE ENHANCING FORMULAS: Glutamine , arginine, omega-3 fatty acids, nucleotides, beta carotene 4. CALORIE DENSE FORMULA: 2kcal/ml 5. HIGH PROTEIN FORMULA

48. Cont… 6.ELEMENTAL FORMULA: Pre-digested nutrients. Adv: E ase of absorption in gut impairment, pancreatitis. Disadv: Poor in fat, vitamin, trace elements. High osmolarity, high cost. 7. SPECIAL FORMULAS: Renal/Pulmonary/Hepatic failure patients

49. Complication of EN TUBE RELATED:- - Malposition of tube - Displacement of tube - Blockage of tube - Break/Leakage - Aspiration

50. Cont… GASTRO-INTESTINAL:- - Diarrhoea - Nausea, Vomiting - Bloating - Abdominal cramps - Constipation

51. Cont… METABOLIC/BIOCHEMICAL:- - Electrolyte imbalance - Vitamin, Mineral, Trace element deficiency REFEEDING SYNDROME :- - After prolonged fasting period - Leads to sudden rise in insulin and electrolyte abnormalities resp, hepatic and renal dysfunction - Rate of feeding should be slow at starting

52. PARENTERAL NUTRITION Delivery of all nutritional requirements by IV route without the use of GIT (bypass GIT ). Sterile liquid chemical formula are used. May be delivered via : - Central line - Peripheral line The high cost and complications has limited its use.

53. INDICATIONS OF TPN GIT Malfunction 1. OBSTRUCTED: Carcinoma oesophagus/stomach , stricture 2. FISTULATED: Post op entero - cutaneous fistula, high output fistulas 3. INFLAMMED: Crohn’s disease, acute severe pancreatitis 4. TOO SHORT: Massive resection, short gut syndrome. Pre operative : Build up of malnourished patient

54. Cont… Failure of enteral feeding to meet caloric requirement:- Major polytrauma, major burns. Cancer : complication of chemotherapy, radiotherapy Newborns: GIT anomalies NEC

55. PRE OPERATIVE PN Indicated in : -Severely undernourished patients who cannot be adequately enterally fed. -In cancer cachexia patients who are planned for operative procedure. Studies have shown that : - Inadequate oral intake of >14 days => higher mortality - 7-10 days of preoperative PN => improves postoperative outcome in severe undernourished patient.

56. POST OPERATIVE PN Indicated in: Undernourished patients and enteral nutrition is not feasible / not tolerated Patients with postoperative complications with impairing gastrointestinal function = > unable to receive and absorb adequate amounts of oral/enteral feeding for at least 7 days Post operative PN is life saving in patients with prolonged gastrointestinal failure.

57. Advantages of TPN Can be used for longer periods with hyperosmolar fluids at larger volumes Survival rate is improved and morbidity reduced. Weight loss and tissue breakdown are minimized Wound healing is enhanced Resistance to infection and general immunity are improved Formation of RBCs and plasma proteins is maintained

58. Total Parenteral Nutrition Partial Parenteral Nutrition Central line Peripheral line Supplies all daily nutritional requirement Only part of the daily nutritional requirements supplied, supplementing oral intake ~ 50-70% of patient’s energy needs Long term support (>10 days) Short term support (10-14 days) Hypertonic solutions with high osmolarity (1000-1900mOsm/L) Formulation with low osmolarity (< 900 mOsm/L )

59. FORMULA FOR PN 2 in 1 solution : 60-70% dextrose, 10-20% amino acids (Nutriflex Peri, Nutriflex Plus ). 3 in 1 solution : In addition it has 10-30% lipid emulsions ( NuTRIflex Lipid Peri, NuTRIflex Lipid Plus, Kabiven). In addition – sterile water, electrolyte, mineral and vitamins.

60. COMPLICATIONS OF PARENTERAL NUTRITION ACUTE:- Refeeding syndrome Hyper/ hypoglycaemia Fluid or electrolyte abnormalities Catheter leak Air embolism Catheter related sepsis

61. LATE:- Metabolic bone diseases : osteoporosis Hepatic complications : fatty liver, liver failure, hyperammonemia Gallbladder complications: cholestatic jaundice Venous thrombosis Catheter related sepsis Vitamin and traced element deficiency

62. REFEEDING SYNDROME Characterised by severe fluid and electrolyte shift in malnourished patients undergoing refeeding. More common with parenteral nutrition. Results in Hypophosphataemia, Hypocalcaemia, Hypomagnesaemia. These can results in altered myocardial function, arrhythmia, deteriorating respiratory function, liver function, seizure, confusion, coma, tetany, death. High risk patients are alcohol dependent and severe malnutrition. T /t – Avoiding overfeeding, vit administration, correction of electrolyte.

63. IMMUNO NUTRITION Nutrients affecting the immune system Recognised: arginine, glutamine, omega-3 fatty acids, nucleotides Potential : vit C and E, selenium copper zinc, taurine , branched chain amino acids, n acetyl-cysteine.

64. IMPACT ON OUTCOME For well nourished or mildly malnourished general surgery patients, peri-operative nutritional support did not improve outcome and actually is associated with increased septic complications after surgery. For severely malnourished patients before a major surgical procedure, peri-operative nutritional support reduced postoperative complications (wound complications, prolonged hospital stay, ICU days, use of hospital resources) by about 10%, without significant increase in infectious complications.

65. TAKE HOME MESSAGES Malnutrition leads to prolong stay, prolong recovery period and increased medical cost Normal caloric requirement = 30-35kcal/kg/day, Metabolic stress = 35-40kcal/kg/day Use enteral feeding unless contraindicated Low osmolarity PN (<900mOsm/L) given via peripheral line In high risk patient to develop re feeding syndrome, we should start with low calories Parameters that required daily monitoring are glucose, electrolytes, I/0 and temperature

66. REFERRENCES Williams, Norman S., P. Ronan O’Connell, and Andrew McCaskie. Bailey & Love’s Short Practice of Surgery, 27th Edition: The Collector’s Edition . CRC Press, 2018. Townsend, Courtney M., R. Daniel Beauchamp, B. Mark Evers, and Kenneth L. Mattox. Sabiston Textbook of Surgery E-Book . Elsevier Health Sciences, 2016. ESPEN Guidelines on Enteral/Parenteral Nutrition: Surgery 2012 edition

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