post operative diet in oral and maxillofacial patients

nutrition in OMFS patients

1. Dietary considerations in post op OMFS patients Under the guidance of: Dr. Irshad Ahmad Misger Head of department Dept Of Oral & maxillofacial surgery. Presented by: Dr Rashfiya Nazir PG ist yr Dept Of Oral & Maxillofacial surgery.

2. Contents Introduction Normal diet Nutritional requirements Nutrients Nutritional assessment Feeding modalities

3. Nutrition plays a major role in the post op recovery and healing Nutritional support is intended to supply all the essential inorganic &organic nutritional elements necessary to maintain optimal body composition as well as positive nitrogen balance Improper diet in OMFS pt`s lead to malnutrition increases the post op morbidity and mortality rate

4. Balanced diet Contains an adequate amount of all the nutrients required by the body to grow,remain healthy & be disease free. In addition a healthy balanced diet provides the necessary energy requirement ,protects against vitamin,mineral & other nutritional deficiencies & builds up immunity.

5. 7 Essential components of a balanced diet 1. Carbohydrates ; (50-60% of diet) provides energy whole grains like oats whole wheat, dahlia,rice legumes,vegetables millets like ragi,bajra,barley 2. Proteins ; (10-35% of diet) :builds muscle & develops skin & hair legumes & beans ,soyabean poultry chicken seafood fish , crab,prawn,lobester eggs lean meat-lamb ,beef nuts & seeds

6. 3. Fats (20-35% of diet):maintain body temperature & help absorb fat soluble vitamins ADE&K nuts seeds olive oil fatty fish-salmon ,sardines 4. Vitamins( 13 essential vitamins mainly A,C,B&D) fruits vegetables poultry seeds nuts

7. 5. Minerals (help release energy from the food & promote the growth of organs) eg. Fe,Ca,K,I,Na fish meat beans,cereals nuts & seeds 6. Fibre(helps in digestion & helps in lowering your cholesterol levels & controlling sugar levels) oats,dahlia beans, whole grains nuts & seeds 7. Water(should take at least 8 glasses of water as it hydrates body & used in body functions) women =2.7l/day men=3.7L/day

8. carbohydrates Proteins fats Phsiologic fuel value 4 4 9

9. Person Calorie requirements Sedentary children: 2–8 years 1,000–1,400 Active children: 2–8 years 1,000–2,000 Females: 9–13 years 1,400–2,200 Males: 9–13 years 1,600–2,600 Active females: 14–30 years 2,400 Sedentary females: 14–30 years 1,800–2,000 Active males: 14–30 years 2,800–3,200 Sedentary males: 14–30 years 2,000–2,600 Active people: 30 years and over 2,000–3,000 Sedentary people: 30 years and over 1,600–2,400 Current  guidelinesTrusted Source  list the following calorie intakes for males and females of different ages: Depends on the age,physical activity,BMR

10. Nutritional requirements Surgery inc’s nutritional requirements Initial nutritional needs in a person with…… jaw # > osteotomy for cosmetic reason patient with resection for malignat neoplasm of mandible >enucleation of a benign odontogenic cyst

11. Metabolic response to stress Stress ( surgery,trauma,sepsis ) catabolic respose (hypothalamus and mediated via SNS) glucogon , catecholamines & corticosteroids ( gluco & mineralo ) glycogenolysis, inhibit insulin relase dec insulin sensitivity, Na & water promote lipolysis catabolism of skel proteins retention & K exc inc lipolysis freefaty acids &ketosis hypermetabolic response to stress( inc BMR,HR,RR,temp )

12. SUBSTRATE DEPLETION AND REQUIREMENTS PROTEIN REQUIREMENTS In an uninjured healthy patient, daily protein losses 20 to 30 g/day[approx.] In a critically ill patient in a hypermetabolic state, the protein losses are greater. The net losses can be 1% of the total body protein each day. Therefore, daily protein supplementation should be 1.5 to 2.0 g/kg of ideal body weight. There have been no studies showing that there is benefit to the patient beyond 2 g/kg, no matter the degree of injury and insensible protein losses. Normal 70 kg man 70 kg man with severe injury 0.8gm/kg 2gm/kg Energy requirements; normal healthy patient =30-35 kcal/kg injured patient = 40-45kcal/kg

13. Evaluation & correction of malnutrition Time consuming, yet its correct recognition & application can reduce post op complications Some believe that early enteral feeding in trauma patients results in decreased morbidity and complications. Others conclude that nutritional support is currently 1.Overused 2.improperly used 3.and has failed to show an improvement in clinical outcome.

14. ASSESSMENT TOOLS FOR DIAGNOSIS OF NUTRITIONAL FAILURE CLINICAL ASSESSMENT Most of the methods available are too difficult to use . Most produce results no better than a well-considered clinical judgment based on history and physical examination. Ideal body weight BMI Anthropometric measurements Energy expenditure indirect calorimetry Harris Benedict equation Ireton Jones equation LABORATORY ASSESSMENT Nitrogen balance Sreum albumin

15. Ideal Body Weight A medical history and review of systems revealing nausea, anorexia, diarrhea, or weight loss is suggestive of nutritional abnormality. Change in body weight, intentional or unintentional, is important. Normal ideal body weight (IBW) for patients can be calculated by the formulas : • Healthy males: 106 lb for initial 5 feet, plus 6 lb for every inch over 5 feet, plus 10% if over 50 years old. • Healthy females: 100 lb for initial 5 feet, plus 5 lb for every inch over 5 feet, plus 10% if older than 50 years. A decreasing ratio of actual to normal weight reflects increasing malnutrition. >80% to 90% mild malnutrition, 70% to 85% moderate malnutrition, and <75% severe malnutrition.

16. Body mass index BMI= Body weight in kg /height in m A BMI of 26 to 27 moderate health risk BMI of 30 increases the risk of death. The average American woman has a BMI of 26; fashion models typically have BMIs of 18. Conversely, a BMI < 18.5 has been proposed as an indication to screen for malnutrition; a BMI < 15 is also associated with increased mortality. Normal BMI=18.5---24.9

17. Anthropometric Measurements Anthropometric means the study of human body measurements on a comparative basis. When applied to nutrition, anthropometric measurements estimate stores of subcutaneous fat and lean skeletal muscle mass, which are assumed to reflect protein and caloric intake. Triceps skin fold, and midarm muscle circumference are some of the measurements used for nutritional estimates. MAMC measurements < 5 th percentile =evidence of depletion Triceps skin folds > 85 th percentile =obesity

18. Triceps skinfold thickness(mm) Midarm circumference(cm) men women interpretation 12.5 16.5 adequate 6 8 borderline 2.5 3 severe men women interpretation 25.5 23 adequate 20 18.5 borderline 15 14 depletion 10 9 severe

19. Caloric requirements - Energy expenditure Harris Benedict Equation   W = BW in kg, A = age in yrs, H = ht in cm. BMR for Male: 66 + (13.7 X W) + (5XH) - (6.8 X A)= kcal/day BMR for Female: 65 + (9.6 X W) + (1.9XH) - (4.7 X A). Multiply X activity level / stress level :   Well nourished and unstressed = 1.  Confined to bed or minor surgery = 1.2.   Out of bed =  1.3.   Mild starvation = 0.85-1.  Bone trauma = 1.35.  Major sepsis = 1.6.  Severe burn = 2.1.   20

20. Ireton-Jones 1997 Equations Ventilator-Dependent Patients: EEE = 1784 – 11(A) + 5(W) + 244(G) + 239(T) = 804(B) Spontaneously-Breathing Patients: EEE = 629 – 11(A) + 25(W) – 609(O) Where: A = age in years W = weight (kg) O = presence of obesity >30% above IBW (0 = absent, 1 = present) G = gender (female = 0, male = 1) T = diagnosis of trauma (absent = 0, present = 1) B = diagnosis of burn (absent = 0, present = 1) EEE = estimated energy expenditure

21. Labortary assessment Test Mild def. Moderate Severe Serum albumin g/dl < 3.5 – 3.2 < 3.2 – 2.8 <2.8 Transferrin mg/dl <200 - 180 <180 – 160 < 160

22. Principles of adequate nutrition Sufficient carbohydrate to prevent protein catabolism and to maintain a positive nitrogen balance Sufficient protein to provide the building blocks of repair Adequate vitamins to permit normal metabolic events,wound healing & coaagulation

23. Post operative recommendations for specific conditions A) tooth extn B )resection of a cyst or benign tumor C) resection of malignant lesions D) bone grafting E) jaw immobilization F) diabetic patients G) patients operated under GA

24. Tooth extraction: simple extraction: multiple extractions or extraction of an impacted tooth: more blood loss, a longer healing time & greater nutritional requirements. soft diet for several days,increased amounts of protein,calories ,& ascorbic acid needed.Good oral hygiene by brushing and rinsing after eating Resection of a cyst or a benign tumor : involves minimal blood loss unless there is extensive soft tissue or bone involvement liquid diet for 2 or 3 days,a commercial dietary supplement or a blended diet diet advanced from liquid to soft consistency in 2 to 7 days depending on the size of wound Resection of a malignant lesions : cancer inluences the nutritional status of an individual by increasing energy requirements while at the same time causing anorexia & dysgeusia resulting in weight loss& severe malnutrtion Liquid or blended diet ,commercial supplement,vit A & C, Zn

25. Bone grafting nutritional requirements are increased after bone grafting. protein,calories,ascorbic acid,vit A,D & Ca ----needed for bone & soft tissue regeneration Jaw immobiliztion a major handicap ,interfering with eating,chewing,drinking & maintaining good oral hygiene. full liquid foods,a commercial liq supplement,or a blended dietmay be taken by drinking from a cup or sucking through a straw eating will take longer & become monotonus after a few days. Diabetic patients to prevent hypoglycemia or hyperglycemia simple procedures e.g , tooth extraction or cyst removal --------not require changes in diet or insulin routine but when patient is required to omit a meal for surgery, insulin dosage & type are adjusted & carbohydrate is supplied as i /v glucose regular insulin every 6 hrs before,during & after surgery. glucose given i /v to supply 50 gms of carbs every 6 hrs during surgery If patient still unable to ingest food (500ml of 10% glucose) Those receiving oral hypoglycemic agents ----similar regimen of insulin & i /v glucose during surgery

26. NPO duration is likely the critical factor in determining fluid status. Physical findings of hypovolemia may include changes in lowering of blood pressure,narrowing of pulse pressure & inc in heart rate. Calculating patient fluid requirements requires an assessment of preoperative deficits, intraoperative maintenance requirements, and replacement of surgical bloodloss , third spacing, and insensible losses. For office-based dental and oral surgery, fluid deficits can be calculated using the classical 4 : 2 : 1 rule for maintenance rate and deficit. The total volume is the maintenance rate per hour. The deficit due to fasting is the maintenance rate multiplied by the number of hours the patient has fasted. Surgical blood loss is replaced in a 3 : 1 ratio of crystalloid to blood loss, and a 1 : 1 ratio if colloid is administered Measurement of urine output can serve as a valuable indicator of volume status and perfusion of vital organs.Urine output at a rate of 0.5–1.0 mL/kg/h is acceptable

27. DIET: Diet consists of smooth, easily swallowed food. The preparation of a nutritiously blended diet which will help you heal and maintain your weight and energy.

28. Blender Information: Consistency of Food Guidelines for Blending Foods Blending Fruit Blending Vegetables Blending Meat

29. Consistency of Food: During the first few weeks of your recovery period your diet will consist of fluids and thin blenderized foods. The addition of finely chopped foods into your diet varies with the type of surgery performed.

30. Guidelines for Blending Foods: For this diet, food should be blended with enough liquid to produce a thin, easily-swallowed meal. When the jaws are wired together tightly, it may be necessary to strain the blended food. To add flavor and interest to blended foods, it may be seasoned with flavoring agents.

31. Blending Fruit: Chopped fruit blending with 15-30 ml (1-2 tbs.) unsweetened fruit juice, ice cream or pudding. Use lemon juice or orange juice with fresh peaches or bananas to keep them from turning brown. Note: Certain fruit, such as cherries and pineapple, cannot be pureed well.

32. Blending Vegetables: Use 125 ml (1/2 cup) well-chopped cooked or canned vegetables blended with 30-45 ml (2 or 3 tbs.) cream sauce or vegetable cooking water. Note: Cabbage and celery cannot be blended well

33. Blending Meat: Use 125 ml (1/2 cup) tender cooked cubed meat, fish, or poultry (not fried) blended with 45-60 ml (3 or 4 tbs.) gravy or cream soup, or vegetable cooking water or vegetable juice. Note: 1 serving of meat, fish or poultry is 90-125 ml (6-8 tbs.) pureed

34. Meal/snack Pureed/blended diet Soft diet Breakfast Pureed banana, fruit smoothies, cereal softened in milk, pureed cooked egg, oatmeal Soft diced fruit without skin or peel, scrambled eggs, omelets , cereal softened in milk Mid morning snack Vanilla or flavored yoghurt Rice pudding Lunch Any pureed or strained soup, pureed chicken salad, pureed beans, pureed fruit Vegetable barley soup, chicken salad or egg salad, well cooked vegetables Mid afternoon snack Ensure plus Boost plus Dinner Pureed or strained soup, pureed meat or fish, mashed potatoes, pureed vegetables with olive oil or butter, apple sauce Soup, baked fish(boneless)with sauce, ground beef, chicken diced, pasta,macroni,cheese , soft potatoes, well cooked vegetables with olive oil or butter, fruits

35. Oral Feeding Stimulates normal action of the gastrointestinal tract Can usually resume once regular bowel sounds return Progresses from clear to full liquids, then to a soft or regular diet Mosby items and derived items © 2006 by Mosby, Inc. Slide 36

36. Tube Feeding Flow rate approx.=10ml/min Faster rate causes GI cramping & diarrhea For intermittent feedings----50 ml formula +50 ml water given every 2 hrs -----decreases the possibility of intolerance Gradually increased tolerance ---200-350ml/feeding Mosby items and derived items © 2006 by Mosby, Inc. Slide 37

37. Alternate Routes for Enteral Tube Feeding Esophagostomy Percutaneous endoscopic gastrostomy (PEG) Percutaneous endoscopic jejunostomy (PEJ) Mosby items and derived items © 2006 by Mosby, Inc. Slide 40

38. Tube-Feeding Formula Generally prescribed by the physician Important to regulate amount and rate of administration Diarrhea is most common complication Wide variety of commercial formulas available Mosby items and derived items © 2006 by Mosby, Inc. Slide 41

39. Currently available enteral feeding formulas TYPE OF FORMULA FEATURES Polymeric formula (whole protein) Blenderized Long term feeding, glucose intolerance, bowel regulation Standard 100 kcal, 4 g proteinll00 ml Concentrated 1.5-2 kcal/ml; for high calorie requirement/volume restriction High-fat feed May help in weaning difficult patients away from a ventilator Medium chain Fat malabsorption / maldigestion , chyle leak , triglyceride- triglycerides rich diet High protein Increased nitrogen requirement Low proteinl / low mineral Renal impairment Low sodium Patients with ascites /hypertension Fibre added For long term feeding, prevents gut bacterial translocation Elemental formula Peptides Protein-losing enteropathy (radiation enteritis), coeliac sprue Free amino acids Short bowel sydromes , severe malabsorpti ve states.

40. TUBE FEEDING Tube feeding may be administered by three basic methods .   1. CONTINUOUS DRIP . Using an infusion pump to ensure a constant rate over a 24 hour period.  2. BOLUS FEEDINGS . Giving a large volume of formulate at time intervals ex. 400ml/ 30 min every 6 hours   3. TIMED FEEDINGS . Administered. a drip between set time intervals usually during day time, when the pt is alert .  

41. COMPLICATIONS

42. PARENTERAL NUTRITION; Indications;

43. Parenteral Feeding Routes Peripheral parenteral nutrition (PPN): uses less concentrated solutions through small peripheral veins when feeding is necessary for a brief period (10 days) Total parenteral nutrition (TPN): used when energy and nutrient requirement is large or to supply full nutritional support for long periods of time through large central vein Mosby items and derived items © 2006 by Mosby, Inc. Slide 48

44. Modes of administration 49

45. Peripheral Parenteral Nutrition Mosby items and derived items © 2006 by Mosby, Inc. Slide 50

46. Catheter Placement for TPN Slide 51

47. GENERAL :

48. Example of Basic TPN Formula Components Mosby items and derived items © 2006 by Mosby, Inc. Slide 53

49. Administration of TPN Formula Mosby items and derived items © 2006 by Mosby, Inc. Slide 54

50. Conclusions; Nutritional support plays an integral role in the healing & recovery of the trauma patient. Poor nutrition plays an important role in development of post op complications & may inc patient morbidity The surgeon should look upon the diet as an adjuvant,similar to analgesics & antibiotics ,so to make patient more comfortable & of speeding recovery. Henceforth,a basic knowledge of nutrition is essential for the treating surgeon

51. References: Oral & maxillofacial surgery laskin volume 2 Oral & maxillofacial surgery fonsica volume 1 Intraoperative fluids and fluid management for ambulatory dental sedation and general anesthesia by Mana Saraghi,DMD Balanced diet – definition,importance,benefits & diet chart by Ritika Samaddar in dietetics

52. THANK YOU