Nutritional assessment in surgical patients.pptx

Nutrition has paramount importance both preoperatively in preparation for surgery and postoperatively for recovery from major operations. Wound healing will be fasten if patient is nutritionally ok.

1. Nutritional assessment and support in surgical patients Seyfe B. GSR II March 2018

2. Surgical metabolism and responses to starvation. Perioperative factors for malnutrition. Why assessment? Methods of assessment. Who should get nutritional support? Methods of support. Nutrition in some specific conditions. Discussion Points

3. Surgical metabolism and responses to starvation

4. Nutrition SURGERY PATIENT Caloric intake Mild stress, inpatient: 25-30 kcal/kg Moderate stress, ICU patient: 30-35 Severe stress, burn patient: 40-50 Protein intake 1-2 gm/kg/day Fluid intake INDIVIDUALIZED HEALTHY 70 kg MALE Caloric intake 25-30 kcal/kg/day Protein intake 0.8-1gm/kg/day (max=150gm/day) Fluid intake 30 ml/kg/day

5. Energy Expenditure Equations Harris-Benedict Equation Multiplication by a stress factor in surgical pts. 1.1 and 1.2 for minor and major elective surgery; 1.35 and 1.6, for skeletal trauma and head injury; 1.1, 1.5, and 1.8, for mild, moderate, and severe infection.

6. Carbohydrates There is an obligatory glucose requirement ( 200gm/kg/day ) to meet the needs of CNS and hematopoietic cells Yields 4kcal/g for glucose Primary goal for maintenance glucose administration in surgical patients serves to minimize muscle wasting Fats Major endogenous fuel source in healthy adults Yields 9 kcal/gm If too little=essential fatty acid ( linoleic & linolenic acid acid ) deficiency-dermatitis and increased risk of infections Basal requierement essential fatty acids (100–200 g week–1)

7. Cont.. Protein Needed to maintain anabolic state (match catabolism) Yields: 4 kcal/gm substrates for gluconeogenesis and for the synthesis of acute phase proteins The basic requirement for nitrogen in patients without pre-existing malnutrition and without metabolic stress is 0.10–0.15 g/ kg/day 7

8. Moses Jesus

9. Guinness Book of Records Andreas Mihavecz is an Austrian from Bregenz who holds the record of surviving the longest without any food or liquids-----18 days study from 1973 in which a 27 years old male has fasted for 382 days under the supervision of researchers from a Scotland University. This is the longest fast ever been recorded.

10. Metabolic responses to starvation Liver glycogenolysis (16hrs)  muscle glycogenolysis (24-48 hrs)  lipolysis from GI, omentum , heart (7days)  peripheral protein: skeletal and intestinal (??)  structural and elemental proteins (heart, kidneys) (14-21 days).

11. Metabolism after Injury

12. Ebb and Flow Phases Phase Duration Role Physiological Hormones Ebb 24 - 48 hrs Conserve - blood volume & energy reserves - Repair ↓ BMR, ↓ temp, ↓ CO, hypovolaemia , lactic acidosis Catecholamines , Cortisol, aldosterone Flow Catabolic 3 – 10 days Mobilisation of energy stores – Recovery & Repair ↑ BMR, ↑ Temp, ↑ O2 consump , ↑ CO Cytokines + ↑ Insulin, Glucagon, Cortisol, Catechol but insulin resistance Anabolic 10 – 60 days Replacement of lost tissue + ve Nitrogen balance Growth hormone, IGF 16

13. Why assessment? Undernutrition in a hospital setup may reach up to 50% Effects of malnutrition

14. Clinical Sequelae of Impaired Nutrition Numerous studies have clearly shown an increased incidence of nosocomial infection, longer hospital stay, and increased mortality in patients with significant unintentional weight loss (>10%) before their acute illness Even in an individual with initially normal nutritional status , after 7 to 10 days of inanition, the body's ability to heal wounds and to support normal immune function begins to be impaired . 18

15. Consequences of malnutrition Impaired immune responses (diminished complement and immunoglobulin production, poor cellular immunity, and impairment of leukocyte action, including chemotaxis , phagocytosis , and oxidative burst) Reduced muscle strength (contribute to reduced ventilatory performance and prolonged ventilator dependence ) Impaired thermoregulation Impaired psycho-social function 19

16. Consequences of malnutrition--cont 5. Impaired wound healing surgical wound dehiscence, anastomotic breakdowns, development of postsurgical fistulae, failure of fistulae to close, increased risk of wound infection and un-united fractures. 20

17. A 45 year old female patient is admitted for elective esophagectomy after she was diagnosed to have esophageal ca. What factors contribute to malnutrition in this patient?

18. Perioperative factors for malnutrition . Preoperative Impaired intake : anorexia, dysphagia , sedation, coma, poverty, NPO hours, poor food service in hospitals, missing meals for investigations, Impaired digestion and absorption: malabsorption Altered metabolic nutrient requirements ; and Sepsis, surgery, burn, malignancy, chronic infections Excess nutrient losses : vomiting, diarrhea, 3 rd space losses, bowel preparation, high output stoma Underlying malnutrition

19. Intra op Bleeding Extent of resection Type of surgery : e.g. stoma Post op Period of NPO Complications : SSI, leak, relap ,…. Stomas Effects of RX: chemoRx , Radiation, nausea, vomiting

20. Methods of assessment. A - nthropometric B - iochemical C - linical D - ietary E - conomic ?

21. Anthropometric Body weight: reflects fluid balance and nutritional status Significant weight loss over a broader period of time (weeks to months) is a powerful predictor of mortality, particularly if the loss is rapid or unplanned . Involuntary loss >10%-15% of usual body weight within 6 mo or >5% within 1 mo Ideal body wt. Lean body mass: nonadipose tissue mass, exclusive of any added mass from acute shifts in water content E,g in malnourished obese pts

22. BMI : is a statistical index that uses height and weight to provide an estimate of body fat in males and females of all ages . BMI > 30 or <18 are associated with increased postoperative complications Skinfold Thickness Estimates subcutaneous fat stores to estimate total body fat Compared with percentile standards from multiple body sites or collected over time Triceps, biceps, subs capular , and supra iliac using calipers are most commonly used TSF < 10mm (male) & < 13mm (female) indicates malnutrition . Disadvantages: total body fluid overload

23. Body Circumferences and Areas Estimates skeletal muscle mass ( somatic protein stores and body fat stores) Mid upper arm circumference ( MUAC) Indicates acute adult malnutrition <18.5cm – moderate malnutrition <16 cm - severe malnutrition Mid arm muscle circumference (MAMC) : determined from the MUAC and triceps skin fold (TSF) MAMC = MAC – (3.14 X TSF) G ood indication of lean body mass < 23cm (male) & < 22cm (female) indicates malnutrition. 27

24. DEXA: dual-energy X-ray absorptiometry Whole body scan with 2 x-rays of different intensity Computer programs estimate Bone mineral density Lean body mass Fat mass “Best estimate” for body composition of clinically available methods 28

25. Biochemical Serum Albumin level accounts for more than 50% of the total protein in serum the major contributor to colloid osmotic pressure Albumin requires significant energy stores for synthesis, is inhibited by inflammation, and has a long half-life of approximately 20 days. In patients undergoing elective surgery, preoperative albumin levels have been found to be a better prognostic indicator of morbidity and mortality than anthropometric measurements . Preoperative albumin levels less than 3 g/ dL are independently associated with an increased risk of developing serious complications within 30 days of surgery, including sepsis, acute renal failure, coma, failure to wean from ventilation, cardiac arrest, pneumonia, and wound infection.

26. There is a linear increase in complications in patients undergoing elective GI surgery as preoperative albumin decreases from normal to levels below 2.0 g/ dL / dL . Complications increase in patients undergoing gastrectomy or pancreatic surgery when preoperative albumin levels drop below 3.25 g/ dL / dL . Patients undergoing elective colectomy have little increase risk unless preoperative albumin levels drop below 2.5 g/ dL Patients undergoing esophagectomy appear at risk if albumin drops below 3.75

27. The value of serum protein level as an indicator of nutritional status is limited in the acute phase following injury, inflammation, infection, and surgical stress. Fluid shifts and increased capillary permeability  protein leakage from the intravascular compartment  hemodilution and false hypoprotein - emia . In critical and acute care settings, short-term changes in albumin levels should not be interpreted as being indicative of nutritional progress.

28. Prealbumin ( transthyretin ) Function → Transports thyroxine and retinol-binding protein Normal value: 18-40 mg/dl short half-life ~2 days Advantages Most useful parameter for detecting short-term effects of nutritional changes Reflective of nutritional changes within 3 days of altered nutrient intake Disadvantages Rapidly declines in response to acute stress or illness 33

29. Transferrin Function → Binds and transports ferric iron to the liver for storage Smaller body pool size (100 mg/kg ) shorter half-life ~ 8.5 days Advantages Reflective of acute protein deficiency Prognostic indicator of mortality & morbidity Disadvantages Affected by comorbid states → critical illness, hydration status, and iron stores(increased in iron deficiency ) 34

30. C-reactive protein Positive acute phase respondent Increases early in acute stress as much as 1000-fold Decrease correlates with end of acute phase and beginning of anabolic phase where nutritional repletion is possible Immunologic markers… Delayed cutaneous hypersensitivity (skin test) Evaluates cellular immunity Antigen injected under skin → No response may indicate malnutrition No longer used as an assessment of nutritional status due high incidence of scarring at the injection site. Total lymphocyte count (TLC) Not specific to nutritional status , not used for assessment of hospitalized pts

31. Clinical History Focused assessment of risk of malabsorption or inadequate dietary intake Dietary → anorexia, food intolerance, drug/alcohol abuse ,recent wt loss, Social → income, living situation Surgical/Medical → surgical procedures, chronic diseases Alimentary → Abdominal pain, nausea, vomiting Changes in bowel pattern Difficulty of swallowing Early satiety Indigestion or heartburn Pain in swallowing

32. PHYSICAL EXAM General appearance → wasted, Loss of subcutaneous tissue , obesity Head and neck exam : Hair loss, bitemporal wasting, conjunctival pallor, xerosis , glossitis , angular cheilosis or stomatitis , Skin/mucus membranes → decubitus ulcers, poor skin turgor , dermatitis, ecchymoses , petechiae , pallor, pressure ulcers, signs of wound infection Musculoskeletal → muscle atrophy, Edema Neurologic → Evidence of peripheral neuropathy, reflexes, tetany , mental status ataxia, night blindness, encephalopathy

33. Dietary Detailed dietary History / Usual intake of food, type, amount 24 hr recall of actual intake Food frequency questionnaire Weighted or measured food intake Economic Socioeconomic status Cultural practices, food habits Food prices…….

34. nutritional support

35. Who should get nutritional support?

36. Methods of support. Enteral Nutrition : delivery of nutrients into the gastrointestinal tract Advantages Trophic effect on intestinal mucosa Low cost Avoids risks of IV routes Disuse of GI leads to decreased IgA and cytokine production ,bacterial overgrowth and altered mucosal defenses 44% reduction in infectious complication in critically ill patients More physiological (liver not bypassed) Lesser cardiac work Safer and more efficient Better tolerated by the patient More economical

37. In critically ill patients, early enteral nutrition is associated with Better small-intestinal carbohydrate absorption, Shorter duration of mechanical ventilation, and Shorter time in the intensive care Often well tolerated even in severe illnesses

38. Delivering enteral nutrition Oral Feeding For a conscious patient with an intact appetite and swallowing function Nasogastric , naso -duodenal, and nasojejunal tubes are used in patients who are expected to require support for a short time (<4 weeks). open or percutaneous gastrostomy and jejunostomy , usually for patients who are expected to require long-term EN (>4 weeks).

39. Nasoenteric Tubes. Nasogastric feeding should be reserved for those with intact mentation and protective laryngeal reflexes to minimize risks of aspiration Nasojejunal feedings are associated with fewer pulmonary complications including risk of pneumonia, but access past the pylorus requires greater effort to accomplish.

40. Enteral formulas Standard formulas are sterile, nutritionally complete, and intended for patients with a normal GI tract who cannot ingest adequate nutrients and calories by regular oral diets. Specialty formulations may be more efficiently absorbed in patients with short gut syndrome, severe trauma, burn injury, and chronic malabsorptive diarrhea. Modular formulas consist of a singular macronutrient as a source of calories (e.g., fiber, protein) and are generally used by mixing with standard or specialty formulas Immune-enhancing formulas consist of nutritional components enriched with arginine , glutamine, nucleotides, and omega-3 fatty acids.

41. Whole-protein formulations are appropriate for most patients. Peptide-based or free amino acid formulations : may be considered for patients with a severely compromised GI tract or severe protein-fat malabsorp tion Although most formulations are hyperosmolar at full strength , dilution by 25% to 50% to make isotonic and hypotonic formulas is initially preferred to minimize the possibility of diarrhea from excess osmotic load and to facilitate absorption

42. What can we use in our setup??? Mumbai formula Contents 1 Lt. milk 4 Large eggs 2 Bananas 50g sugar 1333.5kcal Prt 4.09% fat 3.7% Crbs 10.27% 52

43. Plumpy’Nut ®

44. Complications of Enteral feeding Mechanical Nausea and vomiting, epistaxis, sinusitis, nasal necrosis, Aspiration leading to pneumonia T ube malpositioning , dislodgment R apid administration of hyperosmolar solutions diarrhea, dehydration, electrolyte imbalance, hyperglycemia, and loss of K + , Mg , and other ions through diarrhea Perforation ,stricture 54

45. Ileus and Enteral Feeding Intolerance Ileus may reflect an underlying deterioration ; monitoring gastric residual volumes serves as an indicator of intercurrent conditions such as sepsis A full sepsis workup should be considered in any critically ill or injured patient with a sudden increase in gastric residuals greater than 200 mL. Postinjury ileus does not affect the small bowel as profoundly as it affects the stomach. Feeding using a nasoduodenal tube passed through the pylorus or a nasojejunal tube advanced past the ligament of Treitz can be initiated as soon as possible, preferably within 6 hours after injury.

46. Monitoring

47. Parenteral Nutrition PN involves IV infusion of nutrients in an elemental form, bypassing the usual processes of digestion. Indications Contraindications to EN are present Enteral feeding is poorly tolerated Limitation of GI tract function

48. When long-term delivery of hyperosmolar regimens is required, TPN is facilitated through a dedicated central line A peripheral line can be used to provide lower osmolar solutions during shorter periods of time.

49. Complications Technique associated complications Sepsis secondary to contamination of the central venous catheter CLA-BSI Sudden development of glucose intolerance 80% staphylococcus,15%fungal, 5% gram- ve bacteria Dx ; clinical + blood culture + catheter tip culture Pneumothorax , hemothorax Damage to vessels(SCA , Thoracic duct injury) Air embolism, and thrombosis

50. Intestinal atrophy

51. 3. Overfeeding complications increased oxygen consumption, increased carbon dioxide production and prolonged need for ventilatory support, fatty liver, suppression of leukocyte function, hyperglycemia, and increased risk of infection

52. . 4. Metabolic complications Hypoglycemia or Hyperglycemia Hypertriglyceridemia (acceptable concentrations <400 mg/dl) Essential fatty acid deficiency Azotemia Metabolic bone disease (osteoporosis in 41% of those on long- term home Pn ) Elevated liver function parameters (increased transaminase , bilirubin , ALP levels)

53. Immunonutrition Specific nutrients, including arginine , omega-3 polyunsaturated fatty acids, glutamine, and nucleotides , have been shown to modulate the host response in animal and clinical experiments, with potential improvements in immune function. immune-enhancing enteral formulas Their use has been recommended from 7 days before to 7 days after surgery in the following patients Patients undergoing major neck surgery for cancer (e.g., lar - yngectomy , pharyngectomy Severely malnourished patients (serum albumin level <2.8 g/ dL ) or patients undergoing major oncologic GI surgery (e.g., esophagus, stomach, pancreas, duodenum, hepatobiliary tree) Patients with severe trauma to two or more body systems (e.g., abdomen, chest, head, spinal cord, extremities) and an injury severity score of 18 or greater or an abdominal trauma index of 20 or greater, which generally includes grade 3 pancreatoduo - denal , grade 4 colonic, and grade 4 hepatic or gastric injuries Patients with mild sepsis (Acute Physiology and Chronic Health Evaluation II score <15; possibly harmful and not recommended for patients with severe sepsis) Patients with acute respiratory distress syndrome

54. Post op resumption of feeding Early (24 to 48 hours) institution of EN after major surgery minimizes the risk of undernutrition and can abate the hyper -metabolic response seen after surgery Initiation of enteral nutrition should occur immediately after adequate resuscitation , most readily determined by adequate urine output. The presence of bowel sounds and the passage of flatus or stool are not absolute prerequisites for initiation of enteral nutrition, but in the setting of gastroparesis , feedings should be administered distal to the pylorus.

55. There is no evidence to support withholding enteric feedings for patients after bowel resection or for those with low-output enterocutaneous fistulas of <500 mL /d. In fact, a recent systematic review of studies of early enteral feeding (within 24 hours of gastrointestinal surgery) showed no effect on anastomotic leak and a reduction in mortality .

56. EN is frequently delayed unnecessarily because of concerns of exacerbating postoperative ileus or damaging fresh GI anasto - mosis , although repeated studies and expert panels have con - cluded that such practices are misguided. Full feeds should not be delivered in the setting of marked hemodynamic instability or high-dose vasopressor requirements because of risk of inducing or exacerbating nonobstructive mesenteric ischemia. Complete EN can be delivered safely to patients on low-to-moderate doses of vasopressors with stable or decreasing vasopressor requirements

57. Nutrition in Acute pancreatitis In patients with acute pancreatitis, initial volume resuscitation and pain control should be followed by early postpyloric enteral feeding starting within 24 hours of admission. This approach has been shown to reduce complications, length of stay, and mortality. It is no longer acceptable to “rest the pancreas” by avoiding enteral nutrition Enteral nutrition should be commenced after initial fluid resuscitation and within the first 24 hours of admission. It can be introduced through a nasogastric tube and increased in step-wise fashion over 2 to 3 days. The tube can be advanced to the jejunum, by endoscopy or fluoroscopy, if there is evidence of feeding intolerance.

58. Nutrition in burn patients Elevated metabolic rate increased nutritional requirements Nutritional support should be initiated as early as possible to supply vastly elevated caloric and protein demands.

59. Nutrition in Pts with enterocutaneous fistulas Factors for selection of route of feeding origin of fistula, length of healthy bowel available for absorption, and fistula output. Enteral : If there is sufficient functioning bowel for adequate nutrients absorption and no intraabdominal sepsis and manageable fistula output, If the nutritional requirement could not be achieved enterally or the fistula output is high, the parenteral feeding should be used

60. FFP --- a choice for treatment of hypoalbuminemia ?? Literatures In limited setup like ours?? 535 mg/dl glucose, 172 mEq /L sodium, 73 mEq /L chloride, 3.5 mEq /L potassium, 15 mEq /L bicarbonate, and 5.5 g/dl protein with 60% albumin

61. References Sabiston textbook of surgery 20 th ed. Schwartz’s principles of surgery 10 th ed. Bailey and loves short practice of surgery, 25 th ed Uptodate 21.2 Guinness world records 1997 Gibbs J, Cull W, Henderson W, et al: Preoperative serum albumin level as a predictor of operative mortality and morbidity: Results from the National VA Surgical Risk Study. Arch Surg 134:36–42, 1999 Jie B, Jiang ZM, Nolan MT, et al: Impact of preoperative nutritional support on clinical outcome in abdominal surgi -cal patients at nutritional risk. Nutrition 28:1022–1027, 2012. Alverdy JC, Aoys E, Moss GS: Total parenteral nutrition promotes bacterial translocation from the gut . Surgery 104:185–190, 1988.

62. Boelens PG, Heesakkers FF, Luyer MD, et al: Reduction of postoperative ileus by early enteral nutrition in patients undergoing major rectal surgery: Prospective, randomized, controlled trial. Ann Surg 259:649–655, 2014. Barlow R, Price P, Reid TD, et al: Prospective multicentre randomised controlled trial of early enteral nutrition for patients undergoing major upper gastrointestinal surgical resection . Clin Nutr 30:560–566, 2011. Osland E, Yunus RM, Khan S, et al: Early versus traditional postoperative feeding in patients undergoing resectional gas- trointestinal surgery : A meta-analysis. JPEN J Parenter Enteral Nutr 35:473–487, 2011.