nutrition in surgical patients

1. NUTRITION IN SURGICAL PATIENTS ENTERAL VIS A VIS PARENTERAL NUTRITION DR.BARUN KUMAR UNIT IIA, GENERAL SURGERY

2. AT A GLANCE Basic principles guiding nutrition in surgical patients Enteral nutrition Parenteral nutrition Immuno nutrition

3. GOAL OF NUTRITIONAL SUPPORT PREVENT OR REVERSE THE CATABOLIC EFFEECT 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

4. ESTIMATION OF ENERGY REQUIREMENT ASSESSMENT OF PRE SURGERY NUTRITIONAL STATUS- A] HISTORY, PHYSICAL EXAMINATION, BODY WEIGHT, BMI B] BIOCHEMICAL TESTS: CREATININE EXCRETION, ALBUMIN , TOTAL COUNT, SERUM TRANSFERRIN

5. EVALUATING CALORIC REQUIREMENT: Calculating resting Energy Expenditure (REE ) Harris-Benedict Equation – Variables gender, weight (kg), height (cm), age (years) Men : 66.47 + (13.75 x weight) + (5 x height) – (6.76 x age) Women : 65.51 + (9.56 x weight) + (1.85 x height) – (4.67 x age) Calorie requirement = BEE x Activity factor x Stress factor

6. EVALUATING CALORIC REQUIREMENT: INDIRECT CALORIMETRY: REE (kcal/day)= 1.44(3.9 Vo2 (ml/min) + 1.1 Vco2 ) DUAL ENERGY X-RAY ABSORPTIOMETRY: measure lean body mass, fat mass, bone density

7. Electrolyte requirements Na+ : 100-120 meq/day K+ : 80 – 120 meq/day Mg+ : 12 – 15 mmol/day Ca+ : around 5 mg/day Phosphorus : 14 – 16 mmol/day

8. Micro Nutrients Agent Requirement/day Iron 0 – 2 mg Zinc 1 – 15  g Copper 1 -5  g Chromium 10 – 20  g Selenium 20 – 100  g Manganese 150 -800 mg Vit E 10 – 50 IU Vit A 2500 IU Vit C 300 – 500 mg Vit D 250 IU Agent Requirement/day Vit K 10 mg/week Thiamine 50 – 250 mg Riboflavin 5 mg Niacin 50 mg Pantothenate 15 mg Pyridoxine 5 mg Folic acid 600  g BIZ 12  g Biotin 60  g

9. 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.

10. Administer at least 20% of the caloric and protein requirements enterally while reaching the required goal with additional PN. 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

11. Contraindications to Enteral Nutrition Intractable vomiting, diarrhea refractory to medical management Paralytic ileus Distal high-output intestinal fistulas (too distal to bypass with feeding tube) GI obstruction, ischemia Diffuse peritonitis Severe shock or hemodynamically instability Severe GI hemorrhage Severe short bowel syndrome (less than 100 cm of small bowel remaining) Severe GI malabsorption (e.g., enteral nutrition failed, as evidenced by progressive deterioration in nutritional status) Inability to gain access to GI tract Need is expected for <7 days

12. ENTERAL NUTRITION ROUTES OF ADMINISTRATION : NASOGASTRIC NASODUODENAL NASOJEJUNAL GASTROSTOMY- percutaneous, endoscopic, radiologic JEJUNOSTOMY- percutaneous, endoscopic, radiologic

13. PATIENT MUST BE HEMODYNAMICALLY STABLE BEFORE STARTING ENETERAL 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 PREFFERED NASOENTERIC: PATIENTS WITH INTACT MENTATION AND PROTECTIVE LARYNGEAL REFLEXES HEAD END OF THE BED RAISED TO 35 DEGREES 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.

14. ENTERAL NUTRITION Gastric feeding Jejunal feeding Solution used Hypertonic or isotonic Isotonic Infusion rate Bolus or continuous Continuous Initiation of infusion 25-30mL/hr Increments 25-30 mL/hr daily Intolerance Vomiting Distention, diarrhea, colic, reflux to NGT

15. Enteral formulas: 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 2.Isotonic formula with fibre : Soluble and insoluble fibre Stimulate pancreatic lipase activity Degradation into short chain fatty acids

16. Enteral formulas: (cont) 3. Immune enhancing formulas: Glutamine, arginine, omega-3 fatty acids, nucleotides, beta carotene 4. Calorie dense formula: 2kcal/ml 5.High protein formula 6.Elemental formula: predigested nutrients, Adv: ease 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

17. Advantages of enteral nutrition Provides the advantage of trophic feeding Maintain structural and functional support of int estinal mucosa by providing glutamine, preserving blood supply and promoting peristalsis Maintain integrity of int mucosa- prevents bacterial translocation Cheap, easy to administer, safe.

18. PARAMETER ACUTE PATIENT STABLE PATIENT Electrolytes Daily 1-2×/week Complete blood count Daily 1-2×/week Glucose level 3×/day; more often if poor control 3×/day; less often if good control Creatinine and urea levels Daily Weekly or twice weekly Nitrogen balance Daily 2-3×/week Input and output Daily 2-3×/week Body weight Daily 2-3×/week Urine output Hourly every 4 hours Stool Per motion Daily Monitoring schedule for enteral feeding

19. Complications : Local problems: epistaxis, sinustis, nasal necrosis Mechanical problems: tube malpositioning, dislodgement Gastroparesis: vomiting, aspiration REFEEDING SYNDROME: after prolonged fasting period leads to sudden rise in insulin and electrolyte abnormailities resp, hepatic and renal dysfunction rate of feeding should be slow at starting

20. Solute overload: Diarrhoea, dehydration, electrolyte disturbance, hyperglycemia, Loss of trace elements In severe cases, pneumatosis intestinalis with bowel necrosis and perforation

21. PROBLEM COMMON CAUSES MANAGEMENT Diarrhea Medications (e.g., antibiotics, H 2 blockers, laxatives, hyperosmotic, hypertonic solutions), feeding intolerance (osmolarity, fat), acquired lactase deficiency Measure stool output. Rule out infection (bacterial, viral, parasitic). Supply fibre. Change medication or formula. Check osmolarity and infusion rate. Administer antimotility medications (e.g., loperamide, codeine). Nausea and vomiting Delayed stomach emptying, constipation, abdominal distention, odor and appearance of formulations Administer feedings at room temperature. Use isotonic formulations. Use a closed system when possible. Reduce doses of narcotics. Use gastroprokinetic agents (metoclopramide). Monitor gastric residuals and stool output.

22. Constipation, fecal impaction Dehydration, lack or excess of fibre Monitor fluid balance daily. Carry out rectal disimpaction. Consider the use of cathartics, stool softeners, laxatives, or enemas. Aspiration pneumonitis Long-term supine position, delayed stomach emptying, altered mental status, malpositioned feeding tube, vomiting Place head of bed at 45 degrees during feedings. Stop EN if gastric residual volume exceeds 200 mL. Use nasoduodenal or nasojejunal tubes in patients at risk. Hyponatremia, overhydration Excess fluid intake, refeeding syndrome, organ failure (e.g., liver, heart, kidney) Monitor fluid balance and body weight daily. Consider fluid restriction. Change formula (avoid low- sodium intake). Initiate diuretic therapy

23. Hypernatremia Dehydration, inadequate fluid intake Increase free water. Dehydration Diarrhea, inadequate fluid intake Determine cause. Increase fluid intake. Hyperglycemia High content of carbohydrate in feedings, insulin resistance Evaluate and adjust feeding formula. Consider insulin regimen. Hypokalemia, hypomagnesemia, hypophosphatemia Diarrhea, refeeding syndrome Correct electrolyte abnormalities. Determine cause. Reduce rate if refeeding syndrome is present and monitor patient. Hyperkalemia Excess potassium intake, renal impairment Change feeding formula. Reduce potassium intake. Consider insulin regimen.

24. TOTAL PARENTERAL NUTRITION IV INFUSION OF NUTRIENTS IN ELEMENTAL FORM THE HIGH COST AND COMPLICATIONS HAS LIMITED ITS USE FOR PATIENTS IN WHICH CONTRAINDICATIONS TO ENTERAL FEEDING ARE PRESENT PATIENT MUST BE HEMODYNAMICALLY STABLE BEFORE ITS USE

25. CONDITIONS REQUIRING CAREFUL USE OF TPN CONDITION SUGGESTED CRITERIA Hyperglycemia Glucose >300 mg/dL Azotemia BUN >100 mg/dL Hyperosmolality Serum osmolality >350 mOsm/kg Hypernatremia Na >150 mEq/L Hypokalemia K <3 mEq/L Hyperchloremic metabolic acidosis Cl >115 mEq/L Hypophosphatemia Phosphorus <2 mg/dL Hypochloremic metabolic alkalosis Cl <85 mEq/L

26. FORMULATIONS 2IN 1 SOLUTION : 60-70% DEXTROSE 10-20% AMINO ACIDS 3 IN 1 SOLUTION : IN ADDITION HAS 10-30% LIPID EMULSIONS IN ADDITION – STERILE WATER, ELECTROLYTE, MINERAL AND VITAMINS

27. CARBOHYDRATE CONTENT dextrose provide 3.4kcal/kg Concentrated hypertonic solutions given via central line Contraindications – alcohal withdrawal dehydrated patient, suspected ntracranial hemorrhage Sufficient carbohydrate prevents glycogen breakdown, protein sparing effect Suggested guideline of 25% dextrose at a rate of 7mg/kg/min LIPID CONTENT Dense source of energy 9kcal/gm Prevents essential fatty acid deficiency Soyabean oil(Omega-6 fatty acids) (linoleic acid) : pro inflammatory potential Fish oil (omega-3 fatty acids) (eicosapentaenoic acid): lacks pro-inflammatory potential

28. PROTEIN CONTENT: RDA = 0.8G/KG/DAY 20% of total energy requirements must be met by protein Fasted surgical patients – 1.5 to 2 gm protein/kg/day Severely injured patients – 3g/kg/day Nitrogen to calorie ratio (1:150) Low protein preparations in renal and hepatic failure FLUID AND ELECTROLYTES: Fluid : 30 to 40ml/ kg Sod and pot- 1to 2 mEq/kg Calcium- 10 to 15 mEq/kg Magnesium- 8 to 20 mEq/kg Phosphate- 20 to 40 mmol

29. COMPLICATIONS OF TPN A.TECHNICAL PROBLEMS: Sepsis sec to contamination of the central venous catheter earliest sign may be glucose intolerance Fever without any other septic focus for more than 48 hours removal of catheter and reintroduction at new site Pneumo/hydro/hemothorax Cardiac arrhythmias, cardiac tamponade Air embolism, thoracic duct injury

30. COMPLICATIONS OF TPN(cont) B.METABOLIC COMPLICATIONS: HYPERGLYCEMIA ELECTROLYTE ABNORMALITY OVERFEEDING – co2 retention and repiratory insufficiency, hepatic steatosis, Cholestasis and gall stones Raised liver enzymes C.INTESTINAL ATROPHY

31. 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

32. ARGININE Semi essential amino acid Relative deficiency in metabolic stress Metabolic role : a. collagen synthesis b.secretagouge for insulin, prolactin, growth harmone c.nitric oxide donor Counteract myeloid suppressor cells alongwith omega-3 fatty acids Zeta chain in t cell receptor complex is arginine sensitive Evidence based role in patients following burns Pro inflammatory role: might be counterproductive in sepsis Dosage : 12gm/1000 calorie

33. GLUTAMINE Semi essential amino acid Fuel for enterocyte , colonocyte, lymphocyte Component of glutathione, precursor of nucleotide synthesis, neoglucogenesis Synthesis of mucin protecting gut mucosa Downregulate toll-like receptor, reduce inflammatory cytokines Proven benefit in post-burn Early studies shows beneficial effects in critically ill patients Unstable in solution – packed in dipeptide form, powder/granule form Dosage: eneteral- 3.5gm/100 gm of protein parenteral- 0.285 to 0.4 g/kg/day

34. OMEGA-3 FATTY ACIDS ALPHA-LINOLEIC ACID, EICOSAPENTANOIC ACID, DOCOSAHEXAENOIC ACID As discussed earlier omega-6 FA has pro and omega-3 FA has anti inflammatory effects Anti-inflammatory effects of O3FA Displaces arachadonic acid from memb phospholipids Inhibits conversion of linoleic to arachdonic acid Activates peroxisomal receptors Stabilise nf-kb, suppress pro-inflammatory genes Reduce expression of icam-1 & E-SELECTINS Stabilise myocardium, reduce arrhythmia Reduced risk of ards

35. NUCLEOTIDES Essential for dna and rna synthesis Proliferation and normal functioning of phagocytes Protects guts from mucosal atrophy Most standard enteral and parenteral formulas lacks nucleotides

36. TAKE HOME MESSAGE The role of nutrition in surgical patients with increased metabolic demands cannot be over-emphasized A clear understanding of body’s energy, fluid, electrolytes and micro nutrients is essential Whenever the gut is available for use, USE IT!!!! Parenteral nutrition should be reserved for the patients in whom a clear contraindication to enteral nutrition is present

37. Even with parenteral nutrition, 20% of the total energy requirement should be tried to meet with enteral nutrition for the trophic effect on gut A careful watch for possible complications should be kept on patients receiving both enteral and parenteral nutrition overfeeding should be avoided for its dangerous complications in critically ill patients The role of immuno nutrients are still under study and till then, its use can be reserved for the patients in which proven efficacy has been shown in studies.

38. Thank you