Nutrition needs in a Surgical Patient.pptx

Nutrition in a surgical patient

1. Nutrition in a Surgical Patient Dr. Nipun Singhal JR-2, Deptt of Surgery. L.L.R.M. Medical College, Meerut.

2. INTRODUCTION Optimal nutritional status, both pre- and postoperatively, is a key factor in reducing perioperative complications and improving surgical outcomes. However, the pathologies requiring surgical intervention often contribute to malnutrition, and a lack of appreciation of preoperative nutritional status can unnecessar- ily increase the risk of the operation and compromise recovery from surgery. It is therefore imperative that the efects of surgical intervention on the patient’s nutritional status are taken into consideration perioperatively, and appropriate intervention taken as early as possible to correct any nutritional defcits.

3. Physiological response to nutritional impairment Metabolic response to fasting or starvation Metabolic response to trauma and sepsis The effect of the metabolic response to surgery on nutrition

4. Metabolic response to fasting or starvation During short-term fasting periods, when insulin levels fall and glucagon levels rise, glycogenolysis is the main source of glucose, whereby glycogen stores from the l iver and skeletal muscle are converted to glucose via lactate (the Cori cycle). After approximately 24–40 hours of fasting , glycogen reserves are depleted and gluconeogenesis (the de novo synthesis of glucose from non-carbohydrate precursors such as the amino acids glutamine and alanine, as well as fructose ,l actate and glycerol) takes over as the predominant source of glucose production. The generation of amino acids occurs from catabolism of skeletal muscle, in amounts of up to 75   g per day for the average-sized individual . Under conditions of even more prolonged fasting (>48 hours) , glucose production is met by the breakdown of fat stores ( lipolysis ); this provides glycerol, which is then converted to fatty acids and glucose. Fatty acids can be converted to ketones, which can be used as a metabolic substrate by the majority of tissues in circumstances of extended fasting, reducing the need for muscle breakdown. Resting energy expenditure levels signifcantly decrease in starvation, related in part to reduced conversion of inactive thyroxine (T4) to active tri-iodothyronine (T3). Nevertheless, this reduction is insufcient to obviate the need for metabolic substrates, leaving a glucose requirement of approximately 200 g per day even during conditions of prolonged fasting

5. Metabolic response to trauma and sepsis M etabolic response to trauma is infuenced by the early and rapid rises in sympathetic nervous system activity and circulating catecholamines and elevated levels of glucocorticoids, glucagon and growth hormone, as well as insulin. Energy requirements often remain increased to allow tissue repair and infammatory cell function. Elevated stress hormone levels can lead to net catabolism of tissue protein and thus a negative nitrogen balance

6. The effect of the metabolic response to surgery on nutrition The metabolic response to surgery is afected not only by the induced fasting period but also by the phenomenon of insulin resistance, which has been described in surgery and in other similar stresses, including trauma and burn injuries. Insulin resistance causes hyperglycaemia as a result of increased gluconeogenesis and reduced peripheral glycolysis. This is further worsened by reduced transport of glucose into muscle cells owing to reduced activation of the glucose transporter protein GLUT4 . Instead, m uscle protein is broken down to produce amino acids as substrates for gluconeogenesis, inducing a catabolic state with loss of lean muscle mass. The lack of response to insulin means that the catabolic processes induced by fasting or starvation are not resolved with the provision of glucose, and the inappropriate handling of peripheral glucose and breakdown of lean muscle continues for as long as the triggers for insulin resistance persist.

7. Pre-existing comorbidities such as metabolic syndrome, diabetes, cancer and obesity have been shown to contribute to perioperative insulin resistance Increased awareness of perioperative insulin resistance has led to the incorporation of specifc interventions such as preoperative high-carbohydrate drinks to increase insulin sensitivity, adoption of minimally invasive surgery where appropriate (more invasive surgery appears to trigger a greater degree of insulin resistance) and early mobilisation protocols to minimise the impact and duration of insulin resistance on postoperative outcomes and recovery

8. Preoperative Nutritional Assessment. The nutritional status of an individual can be assessed by the ABCD of A nthropometry B iochemistry C linical evaluation D ietary assessment.

9. A nthropometry Anthropometry uses several diferent parameters to obtain an estimate of body composition as a surrogate for nutritional status. These parameters can include weight percentage weight change body mass index (BMI) (weight [kg]/height [m2]) mid-upper arm circumference (MUAC), skinfold thickness (TSF) mid-arm muscle circumference (MAMC) [MAMC = MUAC (cm) – 3.14   ×   TSF (cm)]

10. These measurements are indirect assessments of energy and protein stores and are not sufciently accurate to facilitate planning of nutritional support regimens. BMI, in particular, has often been used as a quick screening measure to identify those who are malnourished. A BMI of less than 18.5 kg/m2 and unintentional weight loss greater than 10% within the last 3–6 months or a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months are indicators of a need for nutrition support. It is important to note, however, that both BMI and body weight can be altered by major changes in fuid balance, and thus may not be reliable indicators of nutritional status in critically ill patients.

11. B iochemistry Albumin, C-reactive protein and white cell counts can be markers of infection or infammation, which can compromise nutritional status. Hypoalbuminaemia can be associated with malnutrition. Effects of pre-op albumin on post-op morbidity and mortality in major surgeries- < 2 g/dl - 80% mortality and 65% morbidity >3.5 g/dl - < 5% mortality and <20% morbidity Albumin(half life - 20 days) gives long term status while pre-albumin(half life-12 days) can give short term status. However, albumin level is easily afected by fuid balance and is not a reliable parameter of nutritional status in the acute setting. Haemoglobin levels can indicate the presence of anaemia related to a lack of appropriate vitamins. Glycated haemoglobin can refect diabetes and blood glucose control. Electrolytes such as sodium and urea can refect underlying renal function, while calcium and phosphate are useful baseline measurements in anticipation of potential refeeding syndrome (discussed in more detail later).

12. C linical evaluation Clinical assessment of nutritional status should begin by consideration of any important symptoms that may suggest malnutrition. Upper abdominal symptoms such as nausea and vomiting, early satiety, dysphagia, refux or bloating as well as lower gastrointestinal symptoms of diarrhoea or constipation can all indicate inadequate nutritional intake or absorption. A thorough assessment of the past medical history and comorbidities is also essential in assessing nutritional status, as conditions such as cancer, gastrointestinal pathologies (e.g. infammatory bowel disease and liver disease) and neurological conditions (e.g. stroke, Parkinson’s disease and dementia) can all contribute to afect nutritional status. Nutrient absorption can be impaired by conditions directly afecting the bowel such as short bowel syndrome,high-output stoma and enterocutaneous fstulae, and also by disorders more proximally in the gastrointestinal tract such as pancreatic insufciency, in which absorption is impaired because of a lack of pancreatic enzyme secretion into the bowel.

13. D ietary assessment The total daily calorie intake of an individual can be estimated via a diary of their food and fuid intake, taking into account the quality of the food or fuid consumed. For patients who are unwell, we need to take into account any diferences in current food and fuid consumption compared with their typical intake when well. Their caloric intake can be assessed against their calculated energy requirements, estimated with the calculation of 25–35 kcal/kg lean body weight and taking into account any metabolic stresses and activity level. Patients whose caloric intake falls short of their caloric requirements or who are anticipated to eat little or nothing for over 5 continuous days in the near future (e.g. owing to upcoming abdominal surgery) are likely to require nutritional support The Malnutrition Universal Screening Tool (MUST), developed by the British Association for Parenteral and Enteral Nutrition (BAPEN), is a rapid screening tool that can be used in both hospitals and the community

14. PONS (Perioperative Nutrition Screen) tool Parameter Cut-off / Criteria Positive if… BMI < 18.5 kg/m² (or < 20 kg/m² in elderly >65 yrs)- Underweight Serum Albumin < 30 g/L (without hepatic/renal dysfunction)- Hypoalbuminemia Unintentional Weight Loss > 10% body weight in last 6 months- Significant weight loss Food Intake < 50% of estimated needs for > 1 week (or no intake for > 5 days)- Inadequate intake Interpretation: If ≥1 criterion is positive → patient is considered at nutritional risk. Such patients should undergo full nutritional assessment and preoperative optimization (oral nutritional supplements, enteral/parenteral nutrition if required).

15. Principles of Nutrition in a Surgical Patient The fundamental aim is to maintain homeostasis in the patient, thereby enabling faster recovery and less morbidity/mortality. The increased loss of fluid as well as substrates during stress and inflammation needs to be compensated. Involves interventions at all stages - pre operative, peri operative and post operative. Is not a case of one blanket covers all. Has to be adapted to the patient’s specific needs. Should take care of macro as well as micronutrients. Close monitoring needed to tackle feeding related complications, if and when they occur.

16. Changes in Hormonal Milieu Divided into two distinct phases - Ebb/catabolic phase & flow/anabolic phase. Understanding the effect of various hormones is important in maintaining homeostasis, especially at the level of electrolytes in the body. Highlights the importance of source control and pain relief in surgical patients.

17. Fluid & Electrolyte Balance Fluid intake consists of liquid ingested in the form of oral fuids as well as fuid released during oxidation of consumed food It must be noted that insensible losses can increase in conditions of pyrexia, exertion or warm environments. Patients with a tracheostomy can lose a larger amount of fuid via insensible losses, emphasising the importance of humidifcation of inspired air. In addition, fuid loss via the faecal route will inevitably increase in diarrhoea or more chronic bowel pathologies, such as high-output stoma, short bowel syndrome and enterocutaneous fstulae.

18. M aintenance fuids should aim to restore fuid losses and provide sufcient water and electrolytes to maintain the intracellular and extracellular fuid compartments, and to enable the kidneys to excrete waste products. The normal volume of water required for daily maintenance in a healthy 70-kg adult is approximately 2.2 litres or 30 mL/kg per day. Accurate assessment of maintenance fuid volumes requires both intake and output to be taken into account, in addition to the patient’s body weight. Fluid replacement should also encompass replacement of key electrolytes. The approximate daily requirements of the main electrolytes are as follows: sodium: 0.9–1.2 mmol/kg per day potassium: 1 mmol/kg per day calcium: 5 mM per day magnesium: 1 mM per day Replacement of fuid and electrolytes should be by the simplest and safest route of administration. Where feasible the oral route should be used via oral rehydration solutions.

19. Intravenous fluid replacement solutions Intravenous fuid replacement may be necessary in conditions of gastrointestinal absorptive impairment or large fuid losses that cannot be quickly replaced via the enteral route . The specifc type of fuid replacement therapy will be determined by the individual patient’s needs. In addition to the crystalloid fuid solutions above, f l uid can also be replaced with colloid solutions, which usually contain a form of modifed gelatin. Examples of these include Gelofusine® or Volplex®, which both contain 4% w/v suc_x0002_cinylated gelatin, or Voluven®, which contains hydroxyethyl s tarch. These solutions are often used as plasma expanders as the larger molecules are thought to be slower to difuse into the extravascular space. Colloids are therefore sometimes used for fuid resuscitation in preference to crystalloids, but they can cause renal failure or coagulopathy. There is ongoing controversy regarding the use of crystalloids or colloids in the setting of f l uid resuscitation. Albumin solutions have also been used in the past for fluid resuscitation; however, increasing evidence shows no beneft for the use of albumin outside of certain specifc indications such as replacement of ascitic fuid losses or in the context of liver insufciency. It is important to remember that if fuid loss is related to haemorrhage then the best form of fluid replacement is blood.

20. N one of the diferent intravenous fuid replacement solutions have electrolyte levels that completely mirror plasma levels, and thus there is no single ideal fuid replacement therapy. The specifc choice of fuid replacement should take into account the nature of f l uid losses and the amount of f l uid replacement necessary in a specifc patient. Such an assessment would include: measurement of the pulse, blood pressure and, if available, the central venous pressure, as an estimate of intravascular f l uid depletion; accurate intake and output charts, especially in inpatients in the acute care setting, taking into account urine output as well as losses from drains, fstulae, nasogastric tubes and faecal losses; measurement of serum electrolytes and haematocrit.

21. The choice of fuid replacement will also be guided by the time of gastrointestinal fuid loss

22. NUTRITIONAL REQUIREMENTS Patients who are considered to be unable to consume enough nutrition via dietary means will need to be considered for either enteral or parenteral nutrition. Provision of enteral and parenteral nutrition should take into account not only macronutrients, such as carbohydrate, fat and protein, but also vitamins, trace elements, electrolytes and water. Planning of the feeding regimen will require the patient’s weight as well as daily energy and protein requirements, which can be calculated based on standard tables. These regimens will need to be assessed on a daily basis and adjusted according to any changes in requirements, as overfeeding is one of the most common causes of complications regardless of the route of nutrient delivery. Regular biochemical monitoring is also mandatory as electrolyte and nutrient requirements can vary based on plasma levels

23. Macronutrient requirements Total energy intake In a normal state of health, the basal metabolic rate (BMR) can be calculated using the Harris–Benedict equation:

24. In the unwell patient population (acute or chronic disease), a degree of hypermetabolism exists, but no more than 120% o f the predicted values. Stable patients with a normal or only moderately increased nutritional need should therefore be provided with a corresponding energy intake of 20–30  kcal for every kilogram of ideal body weight per day. Daily energy expenditure and thus requirements can be severely overestimated in obese patients, hence the ideal body weight should be used in these calculations rather than the actual body weight. Nutrient requirements may increase to 30 kcal/kg ideal body weight per day under conditions of severe stress. However, the introduction of nutrition should be cautious in these patients as well as in those at risk of refeeding syndrome; nutrition should be started at no more than 50% of the estimated target energy needs. This can be increased to the full requirement over 24–48 hours, according to tolerance. Patients at risk of refeeding syndrome should have a maximum of 50% of their target requirements for the frst 48 hours; this is subsequently increased only if clinical and biochemical monitoring shows no evidence of refeeding syndrome

25. Carbohydrate Glucose is the main substrate for the central nervous system and certain haematopoietic cells, which require the equivalent of 2  g/kg of glucose per day. Dietary guidelines therefore recommend that carbohydrates form 45–65% of the total caloric intake per day. Protein In the ill patient population, daily nitrogen requirements increase from approximately 0.15 g/kg per day to 0.25 g/kg per day. This is equivalent to a daily protein intake of 1.5 g/kg ideal body weight or around 20% of total energy requirements, in order to reduce nitrogen losses at times of illness Fat Dietary fat consists of triglycerides of saturated and unsaturated fatty acids. Of these, the unsaturated fatty acids linoleic acid and linolenic acid are particularly notable, as they cannot be synthesised in vivo from non-dietary sources and are therefore considered essential fatty acids. Emulsions of long-chain triglycerides are now routinely used in parenteral nutrition, in which a mixture of glucose (a minimum of 100–200   g per day) and fat (100–200   g per week) is delivered. The combination of fat and glucose delivery minimises metabolic complications associated with parenteral nutrition, improves substrate utilisation and reduces fuid retention and carbon dioxide production.

26. Vitamins, minerals and trace elements Vitamins B and C are important in optimising recovery from illness, in particular for collagen formation and wound healing. Vitamin C requirement in the postoperative period increases to 60–80 mg per day. It is important to consider the need for supplemental vitamin B12, especially in patients who have undergone gastric surgery and in those with a history of alcohol dependence Surgical procedures or medical conditions associated with a reduction in pancreatic or biliary enzymes in the intestinal tract (e.g. obstruction of the biliary or pancreatic ducts) will result in malabsorption of the fat-soluble vitamins A, D, E and K. Increased intestinal losses such as in chronic diarrhoea can cause hyponatraemia, hypokalaemia and hypophosphataemia, which will all need monitoring and r eplacement. Trace elements such as magnesium, zinc and iron are important cofactors in metabolic processes and may be reduced as part of the infammatory response. Replacement of these elements is necessary to ensure appropriate utilisation of amino acids and avoidance of refeeding syndrome.

27. Name Importance Deficiency Sources Supplementation Vit A Collagen synthesis, epithelialization, mucosal function Impaired immunity, xerophthalmia, corneal damage Carrot, spinach, fish, milk, egg yolk, liver severe deiciency- 2,00,000 IU/day(capsule form preferred) maintenance dose - 50,000 IU/day (risk of toxicity: headache, nausea, alopecia, hepatotoxicity) Vit D Bone health, calcium & phosphate absorption, immunomodulation Bone deformity, impaired calcium absorption , generalised weakness Sun exposure, ergocalciferol, cholecalciferol 1st month- 60,000 IU/week 2nd month- 60,000 IU/15 days 3-6 months- 60,000 IU/month ; toxicity possible in overdose Vit E Antioxidant Increased fragility of RBC, neuromuscular disorders Almonds, spinach, broccoli, vegetable oils , papaya, mango tolerable upper limit is 1500 IU standard dose is 400 IU BD in capsule form Vit K Coagulation, wound healing Bleeding, hemorrhage Cabbage, cauliflower Loading dose 5–10 mg slow IV Maintenance dose: 1–10 mg/day (depending on INR) ampoule- 10 mg/ml Vit B1 (Thiamine) collagen cross-linking , glucose metabolism Beri-beri, Wernicke encephalopathy Cereal, dals, pulses, legumes, nuts Needed in alcoholics, prolonged starvation Vit B2 (Riboflavin) Cellular metabolism Angular stomatitis, glossitis, seborrheic dermatitis Milk, peanuts, fish, meat Supplement when deficiency present Vit B6 (Pyridoxine) major enzyme cofactor Anemia, dermatitis, neuropathy, seizures Spinach, meat, fish, eggs, bananas Required in INH therapy Vit B12 (Cobalamin) Hematopoiesis, nervous system Anemia, demyelination, neuropathy Eggs, mushrooms, meat Supplement required in vegetarians Vit C Antioxidant, collagen cross-linking, immune function, wound healing Poor wound healing, scurvy, fragile capillaries Citrus fruits, tomato, leafy vegetables 500–1000 mg/day recommended oral- 500 mg BD in chronic disease 500 mg od in other cases iv- 1000 mg/ampoule once a day oral vitamin B complex capsule once daily

28. Mineral Function Deficiency RDA Sources Supplementation Iron O2 transport, RBC formation Anemia, fatigue, reduced immunity 8 mg (male) 18 mg (female) Cereals, spinach, pulses, meat oral- 60 mg iron + 500 ug FA combination twice a day in IDA Magnesium Protein & c ollagen synthesis Neuromuscular weakness, tremor, seizures 420 mg Cereals, spinach, beans, legumes Supplement when required Selenium Antioxidant, thyroid function Hypothyroidism, myopathy 55 μg Cereals, fish, meat, eggs Required in deficiency Zinc Protein synthesis, wound healing, immune function Growth retardation, taste loss, wound healing issues 11 mg Cereals, beans, peanuts, milk, fish Therapeutic dose: 20 mg/day for 14 days Iron and Zinc required by phagocytes → essential during disease.

29. Parenteral Iron Indications Intolerance to oral iron (GI side effects). Poor absorption (IBD, celiac disease, post-gastrectomy, bariatric surgery). Severe deficiency needing rapid correction (late pregnancy, pre-op anemia, CKD on dialysis). Non-compliance with oral therapy. Preparations Iron sucrose (IV) Ferric carboxymaltose (IV) Iron dextran (IV/IM, rarely used due to anaphylaxis risk) Iron gluconate (IV) Dosage Calculation (Ganzoni Formula) Total iron deficit (mg)=Body weight (kg)×(Target Hb – Actual Hb)×2.4 +Depot iron (mg) Depot iron: ~500 mg for adults. Usual total requirement: 1000–1500 mg.

30. Artificial Nutritional Support Required for patients who have had inadequate nutritional intake for 5 or more days. Patients due to undergo major surgery for head and neck or abdominal cancers (such as laryngeal or pharyngeal resections, oesophagectomies, gastrectomies and pancreaticoduodenectomies) are more likely to have difficulty consuming any or sufcient oral nutrition postoperatively because of oedema, obstruction, delayed gastric emptying and paralytic ileus. These patients are also more likely to have nutritional depletion preoperatively owing to the efects of the underlying disease. Forethought should be given preoperatively in these patients regarding the placement of intravenous access, nasojejunal tubes or feeding jejunostomies intraoperatively to facilitate postoperative nutrient delivery

31. Nutrition given via GI Tract 1. Sip feeding 2. Tube feeding • Nasogastric tube ( Ryles tube) • Naso jejunal tube • Feeding Gastrostomy • Feeding Jejunostomy Nutrition given via Veins 1. Central Parenteral 2. Peripherally Inserted Central Catheter

32. ENTERAL NUTRITION The term ‘enteral feeding’ means delivery of nutrients into the gastrointestinal tract. The alimentary tract should be used whenever possible. Benefts of enteral nutrition include preservation of the gut mucosal barrier and immunity and prevention of gut atrophy. The use of enteral nutrition is also associated with reduced infection rates, better wound healing and a reduced length of stay compared with parenteral nutrition. This can be achieved with normal food, oral supplements (sip feeding) or with a variety of tube feeding techniques delivering food into the stomach, duodenum or jejunum. A variety of nutrient formulations are available for enteral feeding. These vary with respect to energy content, osmolarity, fat content,nitrogen content and nutrient complexity; most contain up to 1–2 kcal/mL and up to 0.6 g/mL of protein. Newer feeding formulations are available that include glutamine and fibre to optimise intestinal nutrition, or immunonutrients such as arginine and fish oils, but these are expensive and their use is controversial.

33. SIP FEEDING Commercially available supplementary sip feeds are used in patients who can drink but whose appetites are impaired or in whom adequate intakes cannot be maintained with ad libitum intakes, supplying around 200   kcal and 2   g of nitrogen per 200-mL carton There is good evidence to demonstrate that these sip-feeding techniques are associated with a significant overall increase in calorie and nitrogen intakes without detriment to spontaneous nutrition. These can be used to increase daily caloric intakes in addition to that provided by diet alone, and are useful when weaning patients of tube-feeding regimens.

34. TUBE-FEEDING TECHNIQUES Ryles Tube: • Average Length- 1 05 cm in adults . Usual size - 14-18 Fr • NEX rule ( Nose, Ear to Xiphisternum) in Adults, • NEMU rule ( Nose, Ear, Midpoint of Epigastrium to Umbilicus) Ideal method to insert Ryles Tube: • Sitting with Neck flexed • Fowler’s Position Once desired length mark has reached, confirm its position by: ▪ Auscultating with stethoscope in epigastric region by simultaneously pushing air in an empty syringe through the external port of tube. ▪ Look for reflux of gastric contents in the tube ▪ Aspiration of secretion and test with litmus paper for pH. Patients who are unable to maintain adequate nutritional intake with oral supplements will need administration of enteral feed via tube feeding

35. Nasojejunal Tube ( Freka Tube) • Inserted with help of Flouroscopy or with help of Endoscopy ( Invasive Procedure) • Indications for NG to NJ tube: - Duodenal Fistula - Acute Pancreatitis Not tolerating NG tube. Maximum Time we can use Nasal Tubes is for 4 weeks only If you want to give > 4 weeks- Go for Surgical Tubes like PEG , Jejunostomy

36. Feature Ryle’s Tube Freka Tube Type Polyvinyl chloride (PVC) nasogastric tube Polyurethane (PU) or silicone nasojejunal feeding tube Length ~100 cm 150–175 cm (longer, reaches jejunum) Caliber Larger bore (12–16 Fr) Smaller bore (6–10 Fr) Tip Closed, rounded with side holes Weighted/tungsten tip to facilitate duodenal passage Radiopacity Radio-opaque line throughout Radiopaque with distal markers Use Mainly nasogastric feeding & aspiration (short-term: <4–6 weeks) Nasojejunal feeding (long-term >4–6 weeks; critically ill, post-surgery, pancreatitis, gastric outlet obstruction) Insertion Simple bedside insertion Requires endoscopic/fluoroscopic guidance (sometimes can self-migrate to jejunum) Duration of Use Short-term Medium–long term (up to 6–8 weeks) Complications Sinusitis, aspiration, gastric irritation, displacement Blockage (smaller bore), migration, kinking, diarrhea from jejunal feeds

37. Feeding Gastrostomy Gastrostomy tubes are generally reserved for patients who require longer term feeding. Based on techique used, it can be- ( percutaneous endoscopic gastrostomy (PEG) radiological (radiologically inserted gastrostomy [RIG]) surgical

38. DIRECT STAB TECHNIQUE Direct-stab’ technique in which the endoscope is passed and the stomach filled with air. The endoscopist then watches a cannula entering the stomach having been inserted directly through the anterior abdominal wall.A guidewire is then passed through the cannula into the stomach. A gastrostomy tube (commercially available) may then be introduced into the stomach through a ‘peel away’ sheath. PEG tube ( 4-6 weeks nutrition) Techniques :(no surgical incision or general anaesthesia needed) Pull through/Transoral - guidewire or suture is brought out of the stomach by the endoscope after transabdominal percutaneous insertion and is either attached to a gastrostomy tube or the tube is pushed over a guidewire.The abdominal end of the wire is then pulled, advancing thegastrostomy tube through the oesophagus and into the stomach.Continued pulling abuts it up against the abdominal wall.

39. Jejunostomy : In recent years, the use of jejunal feeding has become increasingly popular. This can be achieved using nasojejunal tubes or by placement of jejunostomy at the time of laparotomy. In most patients it is appropriate to commence with i nventional nasogastric feeding and progress to post-pyloric feeding if the former is unsuccessful. Nasojejunal tubes often necessitate the use of fluoroscopy or endoscopy to achieve placement, which may delay commencement of feeding. Surgical jejunostomies, even using commercially available needle-insertion techniques, do involve creating a defect in the jejunum. Due to which there can be leak or be associated with tube displacement; both of these complications result in peritonitis.

40. Complications of Enteral Nutrition Tube related Complications are Most Common

41. Total parenteral nutrition (TPN) is defined as the provision of all nutritional requirements by means of the intravenous route and without the use of the gastrointestinal tract. Parenteral nutrition is indicated when energy and protein needs cannot be met by the enteral administration of these substrates. The most frequent clinical indications relate to those patients who have undergone massive resection of the small intestine, who have intestinal fistula or who have prolonged intestinal failure for other reasons. Parenteral nutrition formulation- 3-litre bag containing a lipid emulsion with a mixture of essential and non-essential amino acids, glucose, electrolytes, trace elements and vitamins. The energy content of parenteral nutrition is in the ratio of 150–250   kcal per gram of protein nitrogen, with usually 30–50% of the energy coming from fat. Parenteral nutrition This can be either in addition to enteral feeding (supplemental parenteral nutrition) or the sole source of nutrition (TPN)

42. Folic acid is supplemented in the solution once or twice a week at a dose of 15 mg and other vitamins are given daily. Patients requiring long-term parenteral nutrition (over many months) would also beneft from a single-dose injection of vitamin B12. Phosphate is an essential component of parenteral nutrition regimens: 20–30 mmol phosphate is required daily to ensure phosphorylation of glucose and prevent hypophosphataemia. The specifc composition of parenteral nutrition can be changed daily to refect the patient’s needs and tailored to address any electrolyte defciencies and ongoing energy requirements. This is guided by daily assessments (including weight and electrolytes). In addition, the protein content will difer in patients who are critically ill (requiring more protein) compared with those with chronic renal failure (requiring less protein). Micronutrients such as zinc, copper, selenium, ferritin, folate and vitamins B12 and D will need to be checked in patients on parenteral nutrition for more than 28 days and every 3 months in patients on long-term parenteral nutrition

43. Peripheral PN Central PN DURATION Short duration ( < 2 weeks) Long term nutritional support PATIENT CRITERIA Post op patients Central line contraindicated Critically ill patients OSMOLARITY < 900 mOsm /L ( low concentration dextrose – 5-10% ) 1000-1900 mOsm /L ( dextrose – 50 -70% and amino acids – 10%) ADVANTAGES Cost effective, easy Avoids complications of central line High calorie formulation Low volume DISADVANTAGES Large volume infusion Thrombophlebitis of peripheral veins Expensive Risk of sepsis

44. Central Parenteral Nutrition Most effective method Sites for insertion : Subclavian – best tolerated and easy to dress Jugular – less chances of pneumothorax Femoral – not preferred due to greater risk of catheter infection. Post insertion ,correct placement is checked by a chest xray.

45. Peripherally Inserted Central Catheter Inserted through the arm vein and threaded into subclavian vein, with catheter tip in SVC. Can administer concentrated dextrose Disadvantage – flow can be position related Post insertion ,correct placement is checked by a chest xray.

46. TPN bag : • Components of TPN: - Dextran ( 60%) - Fat ( 20%) - Amino acids ( 20%) - All essential nutrients, minerals and Vitamins • Fat Free TPN- 75% Dextran+ 25%Amino acid ( Ratio 3:1) The parenteral nutrition bag should be covered at all times, including during infusion, with an opaque protective bag to prevent the vitamins from degradation. If the parenteral nutrition infusion is disconnected from the line for any reason during administration the bag will need to be discarded.

47. Lab Values to be monitored in patient on TPN long term • Weekly Twice- Blood Sugar and Electrolytes • Weekly once- RFT and LFT • Change the catheter only if there is catheter related sepsis. (Both Tip C/S and Blood C/S are showing same organism)- Put a new catheter on opposite side.

48. Complications of Parenteral Nutrition

49. Insertion complications The most common complication of line insertion is an inadvertent pneumothorax, which occurs in around 0.5–1% of cases, most commonly during insertion of subclavian lines. It is managed by insertion of a chest drain, which can be removed once the pneumothorax has resolved. Line misplacement can also occur and is diagnosed on chest radiograph, which is mandatory following central line insertion. The line is considered to be in the correct place if the tip is in the inferior third of the SVC or at the atriocaval junction

50. Line complications One of the most important line complications is line sepsis, which can occur in up to 15% of patients and is associated with signifcant morbidity and mortality. Insertion of the line and administration of parenteral nutrition requires strict aseptic technique as line infections can rapidly progress to septicaemia. Catheter entry sites should be checked daily. Fungal line infections in particular can be associated with uveitis and bacterial endocarditis. Line thrombosis is not uncommon and can occasionally occur in major veins in association with line infection, causing serious complications such as SVC occlusion and pulmonary embolism. Treatment is by anticoagulation, rarely requiring fbrinolysis for acute SVC occlusion and endovascular intervention in the longer term. Line blockage is relatively common and can be prevented by regular line fushing after manipulation and the use of a dedicated parenteral nutrition line . Blocked lines can be unclogged by flushing the afected line with heparin–saline or thrombolytic agents

51. Metabolic complications REFEEDING SYNDROME

52. This syndrome is characterised by severe fluid and electrolyte shifts in malnourished patients undergoing refeeding. It can occur with either enteral or parenteral nutrition, but is more common with TPN. It results in hypophosphataemia , hypocalcaemia and hypomagnesaemia. These electrolyte disorders can result in altered myocardial function, arrhythmias, deteriorating respiratory function, liver dysfunction, seizures, confusion, coma, tetany and death. Patients at risk include those with alcohol dependency, those suffering severe malnutrition, anorexics and those who have undergone prolonged periods of fasting. Treatment involves matching intakes, avoiding overfeeding. Calorie delivery should be increased slowly and vitamins administered regularly. Electrolyte imbalance needs to corrected. Laboratory tests will reveal low levels of phosphate, potassium, calcium and magnesium and lactic acidosis. Nutritional support in this group of patients should be started at a maximum of 10   kcal/kg per day, aiming to increase levels slowly to meet full needs by 4–7 days

53. Blood sugar derangement . In patients with diabetes and those with impaired blood glucose control owing to critical illness, administration of parenteral nutrition should coincide with a variable insulin infusion regimen to avoid hyperglycaemia. Conversely, insulin dosing should be reduced accordingly when parenteral nutrition is interrupted to avoid hypoglycaemia. Osteoporosis or osteomalacia are both known complications of long-term parenteral nutrition, leading to fractures or kidney stones. Supplementation of calcium, phosphate, vitamin D and sometimes bisphosphonates can both prevent and treat this complication Metabolic bone disease and vitamin defciencies

54. Liver dysfunction Long-term use of parenteral nutrition is associated with derangement of liver function tests in at least 25% of patients. Fatty liver is a common complication. This is worse in children, and the degree can be reduced by modifying the parenteral nutrition solution, such as alternating the use of lipid-free parenteral nutrition solutions. A smaller percentage of patients may subsequently develop liver fbrosis and cirrhosis. Once liver disease is established in these patients the term ‘intestinal failure-associated liver disease’ (IFALD) is used. Factors such as a lack of colonic continuity, extreme short bowel, lack of enteral intake and high energy and fat content in feed have all been associated with a higher risk of the development of IFALD.

55. Thank you