Surgical Nutrition

Outline of presentation
Nutritional requirements Malnutrition Parenteral nutrition Enteral nutrition Fluid & electrolytes

Nutrition requirement
Caloric requirement Protein requirement Vitamins and Minerals

Caloric requirement
Patients total caloric requirement = BEE x AF x IF
BEE = basal energy expenditure AF = activity factor IF = injury factor

Basal Energy Expenditure

Harris-Benedict method

Male BEE (kcal/day)= 66.47 + [13.75 x weight (kg)] + 5.0 x height (cm)] [6.76 x age (yrs)]
Female BEE (kcal/day) = 655.1 + [9.56 x weight (kg)] + [1.85 x height (cm)] [4.68 x age (yrs)]

Activity Factor (AF)

Activity Factor Confined to bed 1.2

Ambulatory

1.3

Injury Factor (IF)

Injury Factor Non-stressed on ventilator 1.0-1.2

Congestive heart failure

Minor surgery Fever, per 1 C Skeletal trauma Mild to moderate infection Major abdominal / thoracic surgery Multiple trauma
o

1.1-1.2
1.1-1.2 1.13 1.15-1.35 1.2-1.4 1.3-1.5 1.35-1.55

Closed head injury

Stressed ventilator dependent Liver failure, cancer Sepsis

1.4-1.6
1.4-1.6 1.5 1.5-1.8

Example

What is the caloric requirement of a 35 y.o. man, weighing 70 kg and measuring 1.8 m in height, who has suffered multiple injury in a RTA and is now confined to bed? (Note: the man was healthy previous and he does not have a fever nor is he septic at the moment)
Answer: 3401 to 3904 kcal/day

Shorter method for estimating daily caloric requirements

Level of Activity or Severity of Illness Weight Goal Lose weight Maintain wt Gain weight Low Moderate High 25 kcal/kg 30 kcal/kg 35 kcal/kg 15 kcal/kg 20 kcal/kg 20 kcal/kg 25 kcal/kg 25 kcal/kg 30 kcal/kg

+ 13 % increase in kcal/day for each oC of fever above 37oC Severity of illness Additional caloric requirement

Mild Moderate Severe

+ 10 % + 25 % + 50-100 %

Protein Requirement
RDA: 0.8 g/kg/day Mild stress: 1-1.2 g/kg/day Moderate stress: 1.5-1.75 g/kg/day High stress: 1.5-2.0 g/kg/day Renal Failure: 0.7-1.5 Hepatic Disease: 0.6 1.5

Vitamins
Vit Requirement in surgical patients Functions
Coenzymes in collagen formation and wound healing
Hematogenesis

Special considerations

60-80 mg/day

B12 500 ug/wk

A K 5000 IU/wk 5-10 mg/wk

IMI

Inflammatory response Hematostasis (coagulation)

IMI / infusion

Minerals

Sodium Potassium Iron Calcium Magnesium Zinc Copper Chromium

Manganese Cobalt Molybdenum Vanadium

Malnutrition
Definition
Malnutrition

in pre-op and post-op patients Effects of malnutrition Nutritional assessment

Definition of Malnutrition
1 . Gross underweight (weight for height < 80% of standard) ; or 2. Recent weight loss of 10% or more of pre-morbid body weight.

Pre-operative malnutrition

Starvation
Poverty Dysphagia Vomiting Self-neglect e.g. elderly, alcoholics

Failure of digestion
Pancreatic/biliary disease Duodenal/jejunal disease

Post-operative malnutrition

resting metabolic expenditure stress hormones

adrenaline, glucagon glycolysis cortisol, glucagon gluconeogenesis growth hormone, glucagon, noradrenaline lipolysis

Diabetes of injury -ve nitrogen balance protein breakdown + protein synthesis rate

Hypercatabolic State

E.g severe sepsis, severe trauma, severe major viscera disturbances, burns Muscle wasting Protein catabolism (myofibrillar proteins, retin and myosin) & Protein synthesis Prolonged visceral protein depletionmultiorgan failure Principal mediators: TNF, IL-1, glucocorticoids Sepsis: Fat oxidation, hepatic glucose production despite hyperglycemia

Effects of malnutrition

Poor wound healing Delayed callus formation Disordered coagulation enzyme synthesis Impaired oxidative metabolism of drugs by liver Immunity (risk of infection) tolerance to radiotherapy and chemotherapy Severe mental apathy and physical exhaustion

Nutritional assessment

Clinical Assessment

Body weight & BMI (BMI 20,21,23 20.5, 22,23.5)

Anthropometric assessment

Upper arm circumference (23cm;25cm) Triceps skinfold thickness (13mm;10mm)

Serum albumin (<35g/L) Lymphocyte count (>1500/mm3)

Blood indices

Candida skin test (-ve=cell-mediated immunity) Nitrogen balance studies

Parenteral Nutrition
Peripheral and Central Indications Contraindications Preparation Administration Monitoring Complications

Parenteral nutrition
Intravenous (peripheral/central) Partial/total < 4-5% of all hospital admissions (B&L) serious, non-infectious complications septic complications

Peripheral Parenteral Nutrition

Peripheral vein nutrition - Low dextrose concentration - Fat emulsion reduces irritating effect of a.a. on vein wall Use if GI tract expected to be functional in 7-10 days Low calorie and protein needs Osmolarity is a limiting factor Complication Thromophlebitis

Total Parenteral Nutrition

Requires central venous access Use to meet nutrient needs for longer than 7-10 days Full nutritional support High dextrose concentration severe fluid restrictions poor peripheral access

Indications
Principles Inability to absorb nutrients via GI tract Complete bowel rest Nutrient needs not met by enteral feedings within 7-10 days Severe malnutrition/ catabolism
Absolute indication: Enterocutaneous fistulae Relative indications: Moderate/severe malnutrition Acute pancreatitis Abdominal sepsis Prolonged ileus Major trauma/burns Severe IBD

TPN Contraindications
Functional and usable GI tract < 5 days of treatment anticipated

Home parenteral nutrition

Chronic intestinal failure Short bowel syndrome

Crohn's disease Mesenteric vascular disease Volvulus Extensive bowel resection Multiple high output fistulas Motility disorders (usually pseudo obstruction syndromes and systemic sclerosis) Sequelae of radiation damage (radiation enteritis)

Preparation before TPN

Weigh the patient Calculate fluid needs for next 24 hours Calculate energy and nitrogen intake on a body wt basis

TPN Basic requirements

Water (30-40 mL/kg/day) Energy (30kcal/kg/day) Carbohydrate in form of glucose Protein in form of amino acid 300 mg N/kg/day,(depend on degree of catabolism) Fat in form of long-chain or mediumchain triglyceride, at most 1g/kg/day.

Procedures

Full aseptic conditions Gold standard: Subclavian vein (Broviac or Hickman catheter) Alternative: Internal jugular vein Subclavian vein cutdown technique Silicone catheter
least irritative to the vein less thrombogenic probably less susceptible to infection.

CXR to confirm location of tip

Administration
Administered into the catheter via a giving set: separately in individual bottles or mixed in a bag (3 in 1 TPN bag) Start by giving 50% of calculated requirement slowly Increase to desired daily intake over days Regulated by infusion pump Amino acids infused simultaneously with carbohydrate and/or fat to spare a.a. for protein synthesis or anabolism.

Monitoring
Body weight Fluid balance CBC, urea, electrolytes Blood glucose Urine and plasma osmolality Electrolyte and Nitrogen analysis of urine and GI losses Acid base status Serum Ca2+, Mg2+, PO43Plasma proteins LFT, Clotting studies Serum B12, folate, Fe, lactate, triglycerides

Daily

Thrice weekly

10 days

Complications
Metabolic Hyperglycemia Hypoglycemia (sudden discontinuance) Excess Fat: fatty liver, Saturation of RE system Vitamin and mineral deficiencies

metabolic bone disease, hypophosphatemia

Liver dysfunction
AST, ALT, Bilirubin, ALP; usually transitory

Adverse reactions to lipid emulsions

Complications
Problems of insertion Pneumothorax Haemothorax Arterial puncture Brachial plexus injury Mediastinal hematoma Thoracic duct injury

Problems of care Catheter-related sepsis (S.aureus,

Candida sp, Klebsiella pneumoniae

Air embolism Thrombosis Thromboembolism

Preventions

CXR to confirm location of tip after insertion TPN line should not be used for any other purpose External tubing changed q24h Swab site of catheter insertion on alt. days Special occlusive dressings changed q48h with full aseptic and sterile precautions Septic work-up if developed unexplained fever, hypotension, vomiting, diarrhoea, confusion or seizures

Enteral Nutrition
Route of administration Indications Contraindications Formulas Complications

Routes of administration

By mouth

cervicoesophagostomy

Indications
By mouth By NG tube Functioning GI tract; should always be attempted Patient unable to eat for approx. 7-30 days Inserted to stomach Functioning G.I. tract, but is unable to meet total nutritional requirements through oral feeding (e.g. esophageal stricture) Inserted to duodenum If gastrostomy is contraindicated Passage of fine-bore NG tube is not possible or when more than 4 weeks of enteral feeding is anticipated If gastrostomy is contraindicated

Gastrostomy Jejunostomy

Contraindications
By mouth

Inadequate PO intake Decreased mental state Dysphagia, esophageal obstruction Intractable vomiting Intestinal obstruction Upper GI tract hemorrhage Severe, intractable diarrhea Severe, acute pancreatitis Expected need less than 5-10 days + contraidication for gastrostomy Gastric disease Impaired gastric emptying Significant GE reflux Loss of gag reflex + contraindication for jejunostomy Uncorrective coagulopathy Absence of safe access route

By NG tube

gastrostomy

jejunostomy

Formulas

CHO: corn syrup solids, hydrolyzed cornstarch, maltdextrins, other glucose polymers (+/- fibre, fructose and fluctooligosaccharides) 30-90% Lipids: corn and soybean oil, canola and safflower oil (provide LCT); MCT for patients with malabsorption disorders (no EFA) - 1-55% Protein: caseinates and soy protein isolates, enzymatically hydrolyzed casein or whey, free aa, bcaa 4-32% Water: caloric density (1kcal/ml 85%; 2kcal/ml 70%) Micronutrients Fibre: soy polysaccharide, hemicellulose, lignans, guar gum, oat fibre, pectin (improves stool consistency - debatable)

Administration
Indications
Bolus
Noncritically

Advantages
ill
Easy

Disadvantages
Highest risk of aspiration, N/V, abdominal pain and distention, and diarrhea

patient Home TF Rehabilitation patient Intermittent

Noncritically

to administer Inexpensive Short administration time (usually 15 minutes)

Flexibility

ill

patient Home TF Rehabilitation patient

risk of schedule aspiration, N/V, abdominal pain and Inexpensive distention, and diarrhea Feeding over shorter time allows patient more May require formula with more calories and free time protein
Pump Restricts

in feeding

Higher

Continuous

Initiation

assisted feedings Minimizes risk of high Critically ill patient gastric residuals and Small bowel feeding aspiration Minimizes risk of Intolerance of metabolic abnormalities intermittent or bolus

of tube

ambulation Infused over 24 hours/day Increased cost (need pump)

In the past tube feedings that were hyperosmolar were diluted strength - current recommendations are to leave the formula full strength and begin at a lower volume until tolerance is determined. Full strength if isotonic - DO NOT DILUTE ISOTONIC FORMULAS! Tube feeding is progressed until assessed nutrition goal reached If TF is diluted, do not advance concentration and rate at the same time Sanitation

bag should hang no longer than 1 shift ( 8 hours) bag should be changed every 24 hours * formula is administered at room temperature

Complications
Metabolic Gastrointestinal Mechanical

Metabolic complications

Hyponatremia Hypernatremia Hypokalemia Hyperkalemia Hyperglycemia Prerenal azotemia Hypophosphatemia

Hypomagnesemia Hypermagnesemia Hypocalcemia Hypercalcemia Hypozincemia Essential Fatty Acid Deficiency Excessive CO2 production

GI complications
Constipation Diarrhea High gastric residuals Nausea / vomiting Abdominal cramps Bloating

Mechanical complications
Aspiration Clogged tube Tube discomfort / nasal necrosis Tube dislodgement

Fluids & electrolytes

Adults: 40ml/kg/day Paedi: 100/kg/day (first 10kg), 50ml/kg/day (second 10kg), 20ml/kg/day
5% dextrose = 5g dextrose in 100ml Dextrose is added to water to provide isotonicity, not for nutritional value Normal saline (NS) = 0.9% saline 0.9% saline = 0.9g NaCl in 100ml 150mmol NaCl in 1L

Different ways of writing

23.4% NaCl = 4mmol Na/ml 15% KCl = 2mmol K/ml 1/5 solution

0.18% NaCl, 4.3% dextrose 0.3% NaCl, 3.3% dextrose 0.45% NaCl, 2.5% dextrose

1/3 solution

solution

Scenario 1
60kg male with newly diagnosed Ca oesophagus Plan for operation in 5 days time Cannot tolerate solid food, barely tolerate liquid food

Whats your IVF order?

IVF - volume
40ml/kg/day Na 2mmol/kg/day K 1mmol/kg/day

60kg: 2500ml fluid with 120mmol NaCl and 60mmol K

IVF - electrolyes

3D2S/day + 10mmol KCl/pint

3D: three pints of 5% dextrose 5% dextrose = 5g dextrose in 100ml Dextrose is added to water to provide isotonicity, not for nutritional value

Normal saline (NS) = 0.9% saline 0.9% saline = 0.9g NaCl in 100ml 150mmol NaCl in 1L

Scenario 2
3kg 6 weeks old baby boy Presented with projectile non-bile stained vomiting for 2 weeks Emergency admitted for suspected pyloric stenosis Whats your IVF order?

IVF - volume

infant 120ml/kg/day Na: 3 5 mmol/kg/day K: 2 4 mmol/kg/day 3kg 360ml, 4% dextrose, 0.18% NaCl, 0.15% KCl
1/5 solution + 10mmol KCL 360ml/day (as maintainence) Replace chloride if <100 (according to bld results) (additional)

E.g. NS 10 to 20ml/kg Q1H

Scenario 3

50kg woman with 20% total body surface area burn

Parkland formula

4ml/kg/TBSA ringer lactate

First half volume in initial 8 hrs, second half in the remaining 16hrs

Then add the normal maintainence IVF

IVF / special circumstances

GI loss

Diarrhoea, vomiting, poor intake, malignancy Over load? Pulmonary congestion Age? Post op stress? Drugs? Temperature? Body size?

Cardiac

Physiology

References

R.C.G. Russell , N.S. Williams , C.J.K. Bulstrode Bailey & Love's Short Practice of Surgery 22nd Edition Ch.5 Nutritional support and rehabilitation Merck Manual, Sec.1, Ch.1, Nutrition:general considerations (http://www.merck.com/pubs/mmanual/section1/chapter1/1c.htm) Adel S. Al-Jurf, M.D., Karen Dillon, R.N., B.S.N. et al. Total Parenteral Nutrition: Policies, Procedures, and Prescribing Information (http://www.vh.org/adult/provider/surgery/totalparenteralnutrition/) Department of Health, UK: Specialised Services National Definition Set(http://www.doh.gov.uk/specialisedservicesdefinitions/12parenteral.ht m) Surgical Tutor, UK (http://www.surgical-tutor.org.uk/defaulthome.htm?core/ITU/nutrition.htm) Prof. S.T. Fan Lecture notes Feed him up before surgery: Surgical nutrition: enteral and parenteral feeding http://www.espen.org/education/documents/Khair-2-010902-web.doc http://www.emedicine.com/radio/topic798.htm http://www.rxkinetics.com/tpntutorial/2_1.html http://www2.ncn.com/~bln/Album/NUR108/NUR108_TubeFeeding.htm M. Marian, C. Thomsom, M. Esser, J. Warneke. Surgery Nutrition Handbook.

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