nutrition plus.pptx for surgery pt for preoperative management overview

Basics of nuetrition

1. The primary goal of nutritional support: “to provide an adequate energy supply and all the nutrients necessary to support life and function.” The major components: Carbohydrates Lipids Proteins Sabiston 20 th edition

2. Nutritional requirements: ENERGY : Total energy requirement of a stable patient is approximately 20–30 kcal/kg per day. Majority of hospitalised patients - total energy requirements are approximately 1300–1800 kcal/day. Very few patients require in excess of 2000 kcal/day.

3. CARBOHYDRATES Obligatory glucose requirement - Meet the needs of central nervous system and haematopoietic cells - 2 g/kg per day. Physiological maximum to the amount of glucose that can be oxidised - 4 mg/kg per minute Plasma glucose levels - Indication of tolerance - Avoid hyperglycaemia.

4. FATS : Dietary fat contains triglycerides - Mainly 4 long-chain fatty acids & medium chain fatty acids. Two saturated fatty acids - palmitic (C16) & stearic (C18) Two unsaturated fatty acids - oleic (C18 with one double bond) & linoleic (C18 with two double bonds)) & linolenic acid (C18 with three double bonds) . Linoleic and linolenic acid - essential Fatty acids Both soybean and sunfloweroil emulsions are rich sources of linoleic & linolenic acid

5. DUAL ENERGY E nergy should be - Mixture of glucose and fat. Minimises metabolic complications - during parenteral nutrition, reduces fluid retention, enhances substrate utilisation & decreased carbon dioxide production.

6. PROTEINS : Basic requirement for nitrogen - without pre-existing malnutrition and metabolic stress is 0.10–0.15 g/kg per day. In hypermetabolic patients - Increases to 0.20–0.25 g/kg per day.

7. VITAMINS, MINERALS , NUTRIENTS All are essential components of nutritional regimes. Water-soluble vitamins B and C act as coenzymes - collagen formation & wound healing. Postoperatively - vitamin C requirement increases to 60–80 mg/day. Supplemental vitamin B12 is indicated - patients who undergone intestinal resection or gastric surgery & alcohol dependent patients. Absorption - fat-soluble vitamins A, D, E and K is reduced - steatorrhoea and the absence of bile. Sodium, potassium and phosphate subjected to significant losses - diarrhoeal illness.

8. Trace elements - act as cofactors for metabolic processes. Trace element requirements - Met by the delivery of food to the gut - patients on longterm parenteral nutrition are at particular risk of depletion. Magnesium, zinc and iron levels may all be decreased as part of the inflammatory response. Supplementation is necessary to optimise utilisation of amino acids and to avoid refeeding syndrome.

9. Aim of nutrition support is to identify patients at risk for malnutrition and to meet their nutritional requirements Malnutrition has high risk of complications plus mortality

10. METABOLIC RESPONSE TO STARVATION Within 12 hours of fasting… Insulin level and Glucagon level Glycogenolysis (liver glycogen to glucose) Cori’s cycle > 24 hours… Gluconeogenesis in liver 48 – 72hrs : Lipolysis and Adaptive Ketogenesis

11. Metabolic response to injury and trauma: Sabiston 20 th edition

12. Sabiston 20 th edition

13. Sabiston 20 th edition

14. M ALNUTRITION A pathophysiologic dysfunction resulting from a failure to consume or to metabolize sufficient nutrients to support the body’s structural and functional integrity. Subtypes: Starvation-associated malnutrition Chronic disease–associated malnutrition Acute disease–associated or injury-associated malnutrition Sabiston 20 th edition

15. K washiorkor Long-term protein-energy malnutrition secondary to: Gastric surgery, Anorexia nervosa, or Loss of ingested nutrients Sabiston 20 th edition

16. M arasmus Sustained deficiency in dietary calories. The response to energy deficiency is a decrease in basal energy metabolism Sabiston 20 th edition

17. Stress-Induced Changes in Substrate Metabolism Rapid mobilization of fat stores Insulin resistance Peripheral glucose intolerance Hepatic gluconeogenesis Decline in lean body mass Sabiston 20 th edition Energy Expenditure and Caloric Balance After Burn Increased Feeding Leads to Fat Rather Than Lean Mass Accretion : David W. Hart et al, Annals of Surgery: 2002

18. A SSESSMENT & P LANNING

19. Assessment of Nutrition: Midarm Circumference Triceps Skin Fold thickness. Body Mass Index Albumin ( Best of all methods in Surgical Patients)

20. Global Assessment and Nutritional Risk Screening C linical history: preexisting malnutrition, medical conditions and metabolic disorders, malabsorption, dental disease, drug dependency, and alcoholism. P hysical examination, A nthropometric measurements: IBW, BMI, skinfold thickness I ndirect calorimetry O xygen consumption, D etermination of respiratory quotient B ody composition analysis: Dual-energy x-ray absorptiometry B iochemical measurements: Albumin, transferrin, pre-albumin. M easurement of nitrogen balance W ound assessment Sabiston 20 th edition

21. B ody Weight Reflects- fluid balance and nutritional status. Sustained weight gain or weight loss generally indicates a nutrition or malnutrition phenomenon. In the absence of pathologic fluid retention, sustained weight gain is a classic hallmark of a return to anabolism. Sabiston 20 th edition

22. I deal Body Weight: Values for IBW can be found in standardized tables Equations: Men : 48 kg for the first 152 cm and 2.7 kg for each additional 2.54 cm Women : 45 kg for the first 152 cm and 2.3 kg for each additional 2.54 cm Sabiston 20 th edition

23. L ean Body Mass Nonadipose tissue mass Low lean body mass or a persistent decline in lean body mass: malnutrition. Sarcopenic obesity Surgical morbidity and mortality rates correlate far more closely LBM. Sabiston 20 th edition

24. B ody Mass Index Estimate of body fat BMI = weight (in kg) / height 2 (in m 2 ) < 5th percentile – Underweight > 95th percentile – Obese • Severely underweight: < 16.5 kg/m 2 • Underweight: 16.5-18.4 kg/m 2 • Normal weight: 18.5-24.9 kg/m 2 • Overweight: 25-29.9 kg/m 2 • Obesity grade I: 30-34.9 kg/m 2 • Obesity grade II: 35-39.9 kg/m 2 • Obesity grade III: ≥ 40 kg/m 2 Sabiston 20 th edition

25. C linical Imaging Dual-Energy X-Ray Absorptiometry (DEXA) Two X-ray beams, with different energy levels Quantitative measures of the attenuation Used to calculate: lean body mass, fat mass, bone mineral content Computed Tomography and Ultrasound

26. S erum Albumin Level >50% of the total protein Major contributor to colloid osmotic pressure Long half-life of approximately 20 days Preoperative albumin levels- a better prognostic indicator of morbidity and mortality. Hypoalbuminemia Is a Strong Predictor of 30-Day All-Cause Mortality in Acutely Admitted Medical Patients: A Prospective, Observational, Cohort Study Marlene Ersgaard Jellinge Daniel Pilsgaard

27. P ediatric Assessment clinical history, physical examination, and analysis of biochemical markers plotting growth on percentile charts- best tool for acute setting below the fifth percentile- failure to thrive

28. E VALUATING METABOLISM AND E NERGY REQUIREMENTS

29. E nergy Expenditure Equations Harris-Benedict, American College of Chest Physicians, Ireton-Jones (1997), Penn State (2003) Swinamer (1990) equation

30. H arris-Benedict Equation Most often to estimate REE Estimates BMR assuming a normal resting physiologic state Stress factors: Minor elective surgery: 1.1 Major elective surgery: 1.2 skeletal trauma: 1.35 head injury: 1.6 1.1, 1.5, and 1.8, for mild, moderate, and severe infection respectively.

31. I ndirect Calorimetry Bedside metabolic carts Measure REE using expired gas volumes; oxygen consumption (VO2) and carbon dioxide production (VCO2) Predict 24-hour energy expenditure with remarkable accuracy (1) severely burned children (2) ventilator-dependent patients; (3) patients with clinical signs of overfeeding or underfeeding; (4) patients with spinal cord injury or coma; (5) critically ill patients who are morbidly obese; (6) patients with failure to respond adequately to the use of diets

32. N itrogen Balance Adequacy of protein intake Negative nitrogen balance- muscle breakdown Positive nitrogen balance- muscle gain

33. S erum Proteins The usefulness is limited in the acute phase following injury, inflammation, infection, and surgical stress. Fluid shifts and increased capillary permeability lead to protein leakage from the intravascular compartment, which results in hemodilution and false hypoproteinemia .

34. K ey aspects of perioperative nutritional care Integration of nutrition into the overall management of the patient Avoidance of long periods of preoperative fasting Re-establishment of oral feeding Start of nutritional therapy early, as soon as a nutritional risk becomes apparent. Metabolic control e.g. of blood glucose Reduction of factors which exacerbate stress-related catabolism or impair GI function. Minimized time on paralytic agents for ventilator management in the postoperative period. Early mobilization to facilitate protein synthesis and muscle function ESPEN: European Society for Clinical Nutrition and Metabolism Guidelines 2017.

35. N UTRITIONAL SUPPORT The ultimate goal : “to meet caloric and nutrient-specific requirements safely to promote wound healing, diminish risk of infection, and prevent loss of muscle protein”.

36. P reoperative Nutrition N on-malnourished Patients: Clear liquid intake can safely be allowed 2 hours before surgery. Carbohydrate supplementation in the immediate preoperative period Initiation of immunonutrition (5 to 7 days preoperatively).

37. M alnourished Patients: 7 days of goal-directed EN or parenteral nutrition (PN). Factors to consider: (1) the patient’s level of malnutrition (2) the nutritional options available to the patient preoperatively (3) the likelihood of the malnutrition responding to preoperative nutrition (4) the relative risk of delaying the particular surgery considered.

38. CRITICALLY ILL PATIENTS : Chronically ill patients - preoperative nutrition is vital to improve postoperative outcomes. Important proven aspects of preoperative nutrition for underweight surgical patients - omega-3 fatty acids and arginine These reduced hospital stays and infection rates postoperatively.

39. POST OPERATIVE NUTRITION In absence of contraindications for enteral feeding - intestinal discontinuity, enteral nutrition (EN) can begin within 24 hours Early nutrition decreases mortality - compared to intravenous fluids alone & additionally may decrease nausea and vomiting. In the absence of contraindications to solid food, clear liquid diets have been found to have no physiologic advantage over solids.

40. The American Society for Parenteral and Enteral Nutrition guidelines recommends - early EN despite possible lack of bowel function. Absence of bowel function - due to atrophy of mucosa and immune barrier dysfunction. Initiation of enteral feeds - Improve postoperative GI dysfunction and decrease ileus. EN or parenteral nutrition should be continued - at least 60% of their caloric needs can be met by oral intake.

41. GI anastomoses - previously thought that nil per oral must be maintained for several days - Recent literature - EN is beneficial to anastomotic healing. Hemodynamic instability/ vasopressor - EN should be held due to lack of perfusion to the gut and possible intestinal necrosis.

42. Nutrition Support in Acute and Chronic Pancreatitis Patients with complicated pancreatitis - historically fasted until the episode of inflammation “cooled off.” Metanalysis shows low-fat diets started within 48 hours are safe in patients with severe acute pancreatitis R educes rates of multiple organ failure. But not mortality

43. E nteral feeding regimens include peptide based formulas, low long-chain fatty acid, medium-chain fatty acid enriched, and hypertonic solutions given to the jejunum. If enteral feedings are not tolerated - parenteral feeding - crystalline amino acids and hypertonic glucose, enough lipid to meet essential fatty acids.

44. Nutrition support in sepsis : EN - provide benefits in septic patients - maintains epithelial lining of the gut & prevents translocation of bacteria. Recommended amount of protein for septic patients during acute resuscitation - 1.0 g/kg/day. Recommended amount of nonprotein calories is approximately 15 kcal/kg/day.

45. NUTRITION SUPPORT IN HEPATIC ENCEPHALOPATHY : Loss of the glycemic control - provided by liver through glycogenesis, glycogenolysis & gluconeogenesis Glycogen stores in muscle - rapidly depletes and insulin resistance develops. Proteins and lipids become sources of energy, causing decreases in peripheral reserves. A catabolic condition - increased concentrations of TNF-α, IL-1, and IL- 6 - potential cause for protein-calorie malnutrition.

46. Diets high in BCAAs - reduces protein wasting. To improve oral intake - encourage uninterrupted meals, increasing meal frequency, decreasing meal sizes, fortifying meals with high-protein. protein restriction - <40 g/day is indicated before more invasive measures such as hepatorenal shunts. If ascites present - treatment - sodium restriction and diuresis or paracentesis.

47. Principles Guiding Routes of Nutrition:

48. ESPEN : European Society for Clinical Nutrition and Metabolism Guidelines 2017 . Recommendation 1: Preoperative fasting from midnight is unnecessary in most patients. Patients undergoing surgery, who are considered to have no specific risk of aspiration, shall drink clear fluids until two hours before anaesthesia. Solids shall be allowed until six hours before anaesthesia

49. Recommendation 2: In order to reduce perioperative discomfort including anxiety oral preoperative carbohydrate treatment (instead of overnight fasting) the night before and two hours before surgery should be administered

50. Recommendation 3: In general, oral nutritional intake shall be continued after surgery without interruption. Recommendation 4: It is recommended to adapt oral intake according to individual tolerance and to the type of surgery carried out with special caution to elderly patients.

51. Recommendation 5: Oral intake, including clear liquids , shall be initiated within hours after surgery in most patients. Recommendation 6: It is recommended to assess the nutritional status before and after major surgery.

52. Recommendation 7: Perioperative nutritional therapy is indicated in patients with malnutrition and those at nutritional risk. Perioperative nutritional therapy should also be initiated, if it is anticipated that the patient will be unable to eat for more than five days perioperatively. It is also indicated in patients expected to have low oral intake and who cannot maintain above 50% of recommended intake for more than seven days. In these situations, it is recommended to initiate nutritional therapy

53. Recommendation 8: If the energy and nutrient requirements cannot be met by oral and enteral intake alone (<50% of caloric requirement) for more than 7 days , a combination of enteral and parenteral nutrition is recommended. Parenteral nutrition shall be administered as soon as possible if nutrition therapy is indicated and there is a contraindication for enteral nutrition, such as in intestinal obstruction.

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