Nutrition

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Nutrition

• . . . and the surgical patient

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Nutrition

• ENERGY SOURCES
• Carbohydrates
• Fats
• Proteins

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Nutrition

• Carbohydrates
• Limited strorage capacity, needed for CNS
  (glucose) function
• Yields 3.4 kcal/gm
• Pitfall too much lipogenesis and increased CO2
  production

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Nutrition

• Fats
• Major endogenous fuel source in healthy adults
• Yields 9 kcal/gm
• Pitfall too littleessential fatty acid
  (linoleic acid) deficiencydermatitis and
  increased risk of infections

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Nutrition

• Proteins
• Needed to maintain anabolic state (match
  catabolism)
• Yields 4 kcal/gm
• Pitfall must adjust in patients with renal and
  hepatic failure

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Nutrition
Fats
Non-protein ? Calories
Carbohydrates
Protein ? Calories
Proteins
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Nutrition

• Requirements

• HEALTHLY 70 kg MALE
• Caloric intake35 kcal/kg/day (max2500/day)
• Protein intake0.8-1gm/kg/day (max150gm/day)
• Fluid intake30 ml/kg/day

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Nutrition

• Requirements

? SURGICAL PATIENT ?
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Nutrition

• Special considerations
• Stress
• Injury or disease
• Surgery
• Prehospital/presurgical nutrition

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Nutrition

• The surgical patient . . . .
• Extraordinary stressors (hypovolemia, bacteremia,
  medications)
• Wound healing
• Anabolic state, appropriate vitamins (A, C, Zinc)
• Poor nutritionpoor outcomes
• For every gm deficit of untreated hypoalbuminemia
  there is 30 increase in mortality

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Nutrition
HEALTHLY 70 kg MALE Caloric intake 35
kcal/kg/day (max2500/day) Protein
intake 0.8-1gm/kg/day (max150gm/day) Fluid
intake 30 ml/kg/day
SURGERY PATIENT Caloric intake Mild stres,
inpatient 20-25 kcal/kg/day Moderate stress,
ICU patient 25-30kcal/kg/day Severe stress, burn
patient 30-40 kcal/kg/day Protein
intake 1-1.8gm/kg/day Fluid intake INDIVIDUALIZE
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Nutrition
Non-protein ? Calories
30
70
Protein ? Calories
Proteins
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Nutrition

• Measures of success
• Serum markers
• Retinol binding protein, prealbumin, transferrin,
  albumin

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Nutrition

• Measures of success
• Nitrogen balance
• Protein 16 nitrogen
• Protein intake (gm)/6.25 - (UUN 4) balance in
  grams
• Metabolic cart (indirect calorimetry)
• ICU patient, measure of exchange of O2 and CO2
• Respiratory quotient 1

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Nutrition

• What route to feed?
• GUT, GUT, GUT

• When to feed?
• EARLY, EARLY, EARLY

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Diet Advancement

• Traditional Method
• Start clear liquids when signs of bowel function
  returns
• Rationale
• Clear liquid diets supply fluid and electrolytes
  that require minimal digestion and little
  stimulation of the GI tract
• Clear liquids are intended for short-term use due
  to inadequacy

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Diet Advancement

• Recent Evidence
• Liquid diets and slow diet progression may not be
  warranted!!
• Clinical study
• Early post-operative feeding with regular diets
  vs. traditional methods demonstrated no
  difference in post-operative complications
• Emesis, distention, NGT reinsertion, and Length
  of stay

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Pitfalls

• For liquid diets, patients must have adequate
  swallowing functions
• Even patients with mild dysphagia often require
  thickened liquids.
• Must be specific in writing liquid diet orders
  for patients with dysphagia

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Patients who cannot eat . . . ?

• Two types of nutritional support
• Enteral
• Parenteral

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Indications for Enteral Nutrition

• Malnourished patient expected to be unable to eat
  adequately for gt 5-7 days
• Adequately nourished patient expected to be
  unable to eat gt 7-9 days
• Following severe trauma or burns

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Enteral Access Devices

• Nasogastric/nasoenteric (temporary)
• Gastrostomy (long-term)
• Percutaneous endoscopic gastrostomy (PEG)
• Open gastrostomy
• Jejunostomy
• Percutaneous endoscopic jejunostomy (PEJ)
• Open jejunostomy
• Transgastric Jejunostomy
• Percutaneous endoscopic gastro-jejunostomy (G-J)
• Open gastro-jejunostomy

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Feeding Tube Selection

• Can the patient be fed into the stomach, or is
  small bowel access required?
• How long will the patient need tube feedings?

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Gastric vs. Small Bowel Access

• If the stomach empties, use it.
• Indications to consider small bowel access
• Gastroparesis/gastric ileus
• Abdominal surgery
• Significant gastroesophageal reflux
• Pancreatitis
• Aspiration
• Proximal enteric fistula or obstruction

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Enteral Nutrition Case Study

• 78-year-old woman admitted with new CVA
• Significant aspiration detected on bedside
  swallow evaluation, confirmed on modified barium
  swallow study
• Speech language pathologist recommended strict
  NPO with alternate means of nutrition

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What is parenteral nutrition?

• Parenteral Nutrition
• AKA
• total parenteral nutrition
• TPN
• hyperalimentation
• Liquid mixture of nutrients given via the blood
  through a catheter in a vein
• Mixture contains all the protein, carbohydrates,
  fats, vitamins, minerals, and other nutrients
  needed to maintain nutrition balance

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Indications for Parenteral Nutrition

• Malnourished patient expected to be unable to eat
  gt 5-7 days AND enteral nutrition is
  contraindicated
• Patient failed enteral nutrition trial with
  appropriate tube placement (post-pyloric)
• Severe GI dysfunction is present
• Paralytic ileus, mesenteric ischemia, small bowel
  obstruction, enteric fistula distal to enteral
  access sites

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TPN vs. PPN

• TPN
• High glucose concentration (15-25 final
  dextrose concentration)
• Provides a hyperosmolar formulation (1300-1800
  mOsm/L)
• Must be delivered into a large-diameter vein
  through central line
• Peripheral parenteral nutrition (PPN)
• Similar nutrient components as TPN, but lower
  concentration (5-10 final dextrose
  concentration)
• Osmolarity lt 900 mOsm/L (maximum tolerated by a
  peripheral vein)
• Because of lower concentration, large fluid
  volumes are needed to provide a comparable
  calorie and protein dose as TPN

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Parenteral Access Devices

• Peripheral venous access
• Catheter placed percutaneously into a peripheral
  vessel
• Central venous access (catheter tip in SVC)
• Percutaneous jugular, femoral, or subclavian
  catheter
• Implanted ports (surgically placed)
• PICC (peripherally inserted central catheter)

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Complications of Parenteral Feeds

• Hepatic steatosis
• May occur within 1-2 weeks after starting TPN
• May be associated with fatty liver infiltration
• Usually is benign, transient, and reversible in
  patients on short-term TPNtypically resolves in
  10-15 days
• Limiting fat content and cycle feeds over 12
  hours to control steatosis in patients on
  long-term TPN

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Parenteral Nutrition Case Study

• 55-year-old male admitted with small bowel
  obstruction
• History of complicated cholecystecomy 1 month
  ago. Since then patient has had poor appetite
  and 20-pound weight loss
• Patient has been NPO for 3 days since admit
• Right subclavian central line was placed and plan
  noted to start TPN since patient is expected to
  be NPO for at least 1-2 weeks

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Nutrition

• What route to feed?

VS
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Nutrition

• What route to feed?

TPN
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Benefits of Enteral Nutrition(Over Parenteral
Nutrition)

• Cost
• Tube feeding cost 10-20 per day
• TPN costs up to 1000 or more per day!
• Maintains integrity of the gut
• Tube feeding preserves intestinal function it is
  more physiologic
• TPN may be associated with gut atrophy
• Less infection
• Enteral feedingvery small risk of infection and
  may prevent bacterial translocation across the
  gut wall
• TPNhigh risk/incidence of infection and sepsis

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Refeeding Syndrome

• The metabolic and physiologic consequences of
  depletion, repletion, compartmental shifts, and
  interrelationships of phosphorus, potassium, and
  magnesium
• Severe drop in serum electrolyte levels resulting
  from intracellular electrolyte movement when
  energy is provided after a period of starvation
  (usually gt 7-10 days)
• Sequelae may include
• EKG changes, hypotension, arrhythmia, cardiac
  arrest
• Weakness, paralysis
• Respiratory depression
• Ketoacidosis / metabolic acidosis

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Refeeding Syndrome

• Prevention and Therapy
• Correct electrolyte abnormalities before starting
  nutrition support
• Continue to monitor serum electrolytes after
  nutrition support begins and replete aggressively
• Initiate nutrition support at low
  rate/concentration ( 50 of estimated needs)
  and advance to goal slowly in patients who are at
  high risk

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Over and Under Feeding

• Risks associated with over-feeding
• Hyperglycemia
• Hepatic dysfunction from fatty infiltration
• Respiratory acidosis from increased CO2
  production
• Difficulty weaning from the ventilator
• Risks associated with under-feeding
• Depressed ventilatory drive
• Decreased respiratory muscle function
• Impaired immune function
• Increased infection

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Food for Thought (that is . . . nutrition for
your brain)

• Life is not measured by the number of breaths we
  take, but by the moments that take our breath
  away.  

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• References
• American Society for Parenteral and Enteral
  Nutrition. The Science and Practice of Nutrition
  Support. 2001.
• Han-Geurts, I.J, Jeekel,J.,Tilanus H.W,
  Brouwer,K.J., Randomized clinical trial of
  patient-controlled versus fixed regimen feeding
  after elective abdominal surgery. British Journal
  of Surgery. 2001, Dec88(12)1578-82
• Jeffery K.M., Harkins B., Cresci, G.A.,
  Marindale, R.G., The clear liquid diet is no
  longer a necessity in the routine postoperative
  management of surgical patients. American Journal
  of Surgery.1996 Mar 62(3)167-70
• Reissman.P., Teoh, T.A., Cohen S.M., Weiss, E.G.,
  Nogueras, J.J., Wexner, S.D. Is early oral
  feeding safe after elective colorectal surgery? A
  prospective randomized trial. Annals of Surgery.
  1995 July222(1)73-7.
• Ross, R. Micronutrient recommendations for wound
  healing. Support Line. 2004(4) 4.