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Nutrition

1. Surgical Nutrition Team frossman

2. Indications a. Preoperative nutritional depletion. b. Postoperative complications: Sepsis, ileus, fistula. c. Intestinal fistula: High type wherein output is more than 500 ml/day. It may be duodenal, biliary, pancreatic, intestinal. d. Pancreatitis, malabsorption, ulcerative colitis, pyloric stenosis. e. Anorexia nervosa and intractable vomiting.

3. f. Trauma —multiple fractures, fasciomaxillary injuries, head and neck injuries. g. Burns. h. Malignant disease. i. Renal and liver failure. j. Massive bowel resection causing short bowel syndrome.

4. Principles of Nutrition •Caloric requirement: Neonatal 100 kcal/kg/day. Adult 40 kcal/kg/day. Adult with catabolism 60 kcal/kg/day. •It is given as: Carbohydrates 50%. Fat 30-40%. Protein 10-15%. • Caloric values: Carbohydrate 4 kcal/g. Protein 4 kcal/g. Fat 9 kcal/g

5. Assessment Body weight Mid-arm circumference Triceps skin fold thickness *Serum albumin

6. Methods of Feeding 1) Enteral 2) Parenteral

7. 1) Enteral Gastrointestinal tract is the best route to provide nutrition. Enteral feeding can be delivered by bolus, by gravity or using mechanical pump. 1. By mouth 2. By nasogastric tube 3. By enterostomy 4.Gastrostomy 5.Jejunostomy.

8. Nasogastric Suitability Short term-functional Gl tract Insertion method and confirmation Blind at bedside; fluoroscopy guided Advantages Easy to insert, replace; can monitor gastric pH and residual volume, capable of bolus feeding Complications Misplacement complications, sinusitis, epistaxis, nasal necrosis, esophageal strictures, erosive esophagitis

9. Nasoduodenal, nasojejunal Suitability Short term-functional Gl tract but poor gastnc emptying. reflux, aspiration risk; begin feed only when volume resuscitated and hemodynamically stable Information and confirmation Blind at bedside; fluoroscopy guided, endoscopy guided Advantages Reduced aspiration risk. some tubes enable decompression of stomach while feeding into jejunum Disadvantages Easily clogged or displaced, aspiration risk, misplacement complications, displacement and reflux into stomach, sinusitis, epistaxis, nasal necrosis; requires continuous infusion; cannot check gastric residuals except with specialized gastric port

10. Gastrostomy Suitability Long term- good gastric emptying; avoid if significant reflux or aspiration problem Insertion method and confirmation Surgical, percutaneous, endoscopic, radiologic Advantages Bolus feeding: large-bore tube less likely to block Disadvantages Procedure risks include bleeding, perforation, aspiration risk, dislodgment with peritoneal contamination, wound site infection, granulation

11. Jejunostomy Suitability Long term-functional Gl tract but poor gastric emptying. reflux, aspiration risk, gastroparesis or gastric dysfunction Information and confirmation Surgical, percutaneous, endoscopic, radiologic Advantages Theoretical reduced aspiration risk Disadvantages Bleeding, infection, perforation, migration, aspiration, dislodgment and leakage into peritoneal cavity, occlusion, pneumatosis, intestinal ischemia or infarction, bowel obstruction; difficult to replace, cannot check residuals; requires continuous infusion

12. Advantages of Enteral Nutrition • Enteral nutrition preserves mucosal protein, digestive enzymes, IgA secretion; prevents mucosal atrophy and bacterial translocation. • It is more physiological as nutrients pass through liver, the first filter to process and store. • It has got less serious complications. It is cost-effective. • It supplies glutamine and short chained fatty acids to gut.

13. 2) TOTAL PARENTERAL NUTRITION (TPN) All nutritional requirements are given only through intravenous route, not through gastrointestinal tract. It can also be a peripheral (Peripheral parenteral nutrition/PPN) through a peripherally inserted central venous catheter (PICC) or through a formal peripheral venous line.

14. Indications •Failure or contraindication for any enteral nutrition for 7-10 days •High output abdominal fistulas, duodenal, biliary, pancreatic fistulas •Major abdominal surgeries of liver, pancreas, biliary, colonic •Septicaemia •Multiple trauma •Short bowel syndrome Severe pancreatitis, bowel ischaemia, peritonitis, ileus •Massive GI bleeding, unstable haemodynamically •High risk of aspiration •Hyperemesis gravidarum •Multiorgan failure, head injury, severe burns

15. Assessment Fluid requirement is assessed by—1500 ml for 20 kg weight + 20 ml/kg for additional weight. • Energy needed is calculated by calculating resting energy expenditure (REE). By simple calculation: REE in kcal/day = 25 x weight in kg. Harris Benedict equation: REE in men = 66 + (13.7 x weight (in kg) + (5 x ht in cm) - (6.7 x age in years). In women = 655+ (9.6 x weight) + (1.8 x ht) - (4.7 x age).

16. Components 1. Carbohydrates: Dextrose (1 gram dextrose 3.4 kcal) Rate of administration of dextrose is 5 mg/kg/min. It supplies calories, stimulates insulin release and glucose oxidation, prevents muscle protein breakdown, has got nitrogen sparing ability. Problems of carbohydrate/dextrose are—low calorie value compared to fat, requires large fluid volume to infuse, hyperglycaemia, causes more COz production, because of high osmolality it causes thrombophlebitis in 10% or above concentration.

17. 2. Fat > Fat gives high calorie (1 gram—9 kcal). > It contains soyabean/sunflower oil with egg yolk phospholipids (emulsifying factor), glycerin (isotonic). > It is available as 10%, 20%, 30% emulsions. > Problems of lipids in PN are-hypertriglyceridaemia, sepsis, fat embolism, fat overload, hepatic dysfunction, pancreatitis, delayed gastric emptying. > Lipid emulsion is a good culture media for bacteria and fungi; so care should be taken to prevent sepsis. > Triglyceride level should be monitored weekly; if more than 400 mg%, infusion is discontinued.

18. 3) Protein > Calorie value of amino acid is 4 kcal/gram. > Daily protein need is 0.8-1.5 gram/kg. > Protein supplement should be less in patients with CRF and hepatic encephalopathy. > Protein need is more in burns, trauma, enteropathy, sepsis. Protein supplement should not exceed 1.7 gram/kg/day; if so will cause raised urea production. > Uses of amino acids in PN-in protein anabolism; prevents scatabolism. > Proper monitoring by doing BUN or ammonia level is essential during amino acid therapy.