Nutrition Support

1
Nutrition Support

• NI Regional Programme
• for
• Specialist General Surgical Registrars

2
What is Undernutrition ?

• Calorie malnutrition (marasmus)
• Protein malnutrition (kwashiorkor)
• Calorie and protein malnutrition
• (marasmic kwashiorkor)
• Weight Loss
• BMI
• Nutrition assessment

3
Causes of malnutrition

• Reduced food intake
• (anorexia, fasting, pain on swallowing, handicap)
• Malabsorption
• (impaired digestion, impaired absorption or
  excess losses from the gut)
• Modified metabolism
• (trauma, burns, sepsis, surgery)

4
Frequency of malnutrition in GI surgical patients

• Hospital population 40
• McWhirter Pennington BMJ 1994
• Patients undergoing GI surgery
• mild 50
• moderate 30
• Meguid et al Am J Surg 1990

5
Does UndernutritionMatter?
6
Impact of Malnutrition on Survival after GI
surgery

• Peptic ulcer surgery
• Weight loss gt20
• 8x increase in post-operative mortality
• Studley et al JAMA 1936

7
Impact of Malnutrition on Complications of GI
surgery

• GI Surgery
• pre-op severely malnourished
• 6x increase in significant complications
• Detsky et al JPEN 1987

8
Malnutrition and Outcome of major surgery

• M and M
• 2X minor complications
• 3X major complications
• 3X mortality
• longer hospital stay
• increased cost

• Delayed wound healing
• Impaired immune resistance
• Weak muscles
• Apathy
• Depression
• Loss of morale

9

• I live on good soup not on fine words
• Moliere
• Les femmes savantes

10
Prevention of Malnutrition

• Avoid unnecessary fasting
• Improve hospital food
• Reduce surgical stress
• minimal access approach
• optimal pain relief
• Provide support to those at high risk

11
Does Nutrition Support Work ?
12
Nutrition Support and Outcome

• Reduces post-op weight loss
• Improves muscle function
• Reduces post-op complications
• Reduces length of hospital stay
• Complications associated with NS

vs
13
Who should receive Nutrition Support?
14
Indications for Artificial NS

• Severe anorexia
• Moderate or severe malnutrition but unable to eat
  sufficient orally
• Pre-op patient with wt loss gt10 BW
• Unable to eat or swallow
• Oral diet not anticipated for gt 10 days
• Intestinal failure

BSG Guidelines 1996
15
How should NutritionSupport be given?
16

• Enteral Nutrition is superior to PN
• with respect to
• Maintenance of intestinal structure and function
• Outcome (infectious complications)
• Complications associated with NS
• Cost

17

• If the gut works,
• Use It!
• Anderson
• and Steinberg 1986

18
Contraindications to EN

• Intestinal obstruction
• High output intestinal fistula
• Intractable vomiting
• Intractable diarrhoea
• Severe malabsorption
• Ischaemic intestine

19
How should EnteralNutrition be
administered?
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Sip Feeds

• increased intake between meals
• partial oesophageal obstruction
• elemental if intestinal inflammation

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Tubes

• Indications
• Inability to swallow
• Lack of palatability of liquid feeds
• Volume of feed

• Methods
• Nasoenteric
• Percutaneous
• Gastrostomy
• Jejunostomy

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Fine Bore Nasoenteral Tube

• Comfortable
• Allow feed to be given
• independent of appetite independent of
  swallowing without muscular effort continuously
  

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Jejunostomy

• If concurrent surgery
• and
• patient is malnourished
• or likely to become malnourished
• upper GI anastomoses
• relaparotomy
• trauma

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PEG Tubes

• Techniques
• Pull through
• Push technique
• Direct stab
• Indications
• Neuro disorders
• Prolonged feeding

• Contraindications
• Coagulopathy
• Peritonitis
• Ileus
• Anorexia Nervosa

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Route Enteral Nutrition

• Up to 4 weeks
• Pernasal fine bore
• tubes
• Naso-gastric or
• naso -jejunal

• More than 3-4 weeks
• Percutaneous
• gastrostomy
• Surgical gastrostomy
• Surgical jejunostomy

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What type of enteralfeed?
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Enteral Nutrition - Composition

• Polymeric
• Pre-digested
• Disease-specific
• Organ-specific

• normal or near-normal GI fn
• elemental or semi-elemental
• nutrient malabsorption
• resp, renal or hepatic failure
• nutrient enriched

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How do you assess tolerance?
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How do you assess tolerance?

• Abdominal distension
• Nausea or vomiting
• Diarrhoea
• Abdominal discomfort
• Residual volume

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Complications of Enteral Nutrition

• Gastrointestinal
• Tube-related
• Metabolic

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EN- GI Complications

• Diarrhoea
• Reflux
• Vomiting
• Abdominal distension

• hyperosmolarity
• lactose deficiency
• too cold
• bacterial contamination
• hypoalbuminaemia
• drugs

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EN- Tube-related Complications

• Malposition
• Accidental removal
• Tube obstruction
• Skin ulceration or necrosis
• Tube breakage
• IV infusion of enteral diet

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EN - Metabolic Complications

• Electrolyte
• Glucose
• Vitamin and trace element deficiency
• Tube feeding Syndrome ??

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EN - Metabolic Complications

• Electrolyte
• Glucose
• Vitamin and trace element deficiency
• Tube feeding Syndrome
• Hypertonic dehydration
• Elevated Na, Cl, ammonia
• Inadequate volume replacement

35
When should Parenteral Nutrition be
administered?
36
Indications for PN

• Malnourished
• or
• likely to become malnourished
• and
• GI tract
• not functional or not accessible

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Specific Indications for PN

• Short Bowel
• Intestinal fistulae
• Prolonged ileus
• IBD

• Pancreatitis
• Sepsis
• Burns
• Multiple Trauma

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Contraindications to PN

• Enteral intake exceeds calculated requirements
• Quality of life not sufficient to outweigh burden
  or risks
• First do no harm
• Hippocrates

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ParenteralNutrition - What composition ?
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Parenteral Nutrition - Composition

• Calories
• Nitrogen
• Fluid
• Trace elements
• Vitamins

• Dextrose 70
• Fat 30
• L-amino acids
• Additrace
• MV 1-12

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Parenteral Nutrition
What Route ?
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Parenteral Nutrition - Route

• Peripheral
• Short-term (1-4 /52)
• marginally depleted
• thrombophlebitis
• large fluid volumes
• lack of balance

• Central
• Longer term
• high requirements for fluids, or calories
  nitrogen
• internal jugular
• subclavian
• cut-down

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How muchParenteralNutrition ?
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How many Calories ?

• 1. Determine BMR (table)
• 2. Adjust for stress factor (nomogram)
• 3. Adjust for activity
• 4. Adjust for energy stores
• W N Schofield 1985

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Determine BMR

• Male Female
• 15-18 17.6 x W 656 13.3 x W 690
• 18-30 15.0 x W 690 14.8 x W 485
• 30-60 11.4 x W 870 8.1 x W 842
• gt 60 11.7 x W 585 9.0 x W 656
• W weight in kg
• Schofield Equation

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How many Calories ?Determine Stress
60
50
Burns 25-90
40
Severe sepsis Multiple trauma
30

Burns 10-25 Multiple s
persistent fever gt2C
20
persistent fever gt1C

10
Burns 10 single IBD, postop

0
Partial starvation
-10
-20
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Activity Factor

• Bedbound immobile 10
• Bedbound mobile
• or sitting 15-20
• Mobile on ward 25

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Energy stores

• Increase energy stores
• add 400-1000 kcals/day
• or
• Decrease energy stores

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How much nitrogen ?

• Nitrogen (g/kg/day)
• Normal 0.17
• Hypermetabolic
• 5-25 0.20
• 25-50 0.25
• gt50 0.30
• Depleted 0.30

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Nutrition Support - Amount

• Nitrogen Calories
• gN/kg/day kcal/kg/day
• 0.17 28.6
• 0.26 34.3
• 0.34 34.2 - 42.9

• Illness severity
• Reduced intake
• Mod injury/sepsis
• Severe injury/sepsis

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What about Complications?

• I am dying with the
• help of too many
• physicians
• Alexander the Great

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PN- Complications

• Related to Catheter
• Catheter Occlusion Catheter damage
• Catheter-related Sepsis Catheter Extrusion
• Air Embolism
• Venous Thrombosis
• Endocarditis

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PN - Complications

• Related to Nutrition Solution
• Acute and Chronic deficiencies ??
• Nutrient Excesses
• Hepatic dysfunction
• Metabolic bone disease
• Refeeding Syndrome

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PN - Metabolic Complications

• Acute Deficiencies
• Glucose Rebound (abrupt cessation)
• Phosphate Alcoholic or Malnourished
• Mg
• Ca

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PN - Metabolic Complications

• Chronic Deficiencies
• Essential Fatty Acid
• Zinc
• Trace elements
• Vitamins

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PN - Metabolic Complications

• Nutrient Excesses
• Glucose Fat
• Hyperglycaemia Triglyceride excess
• Dehydration
• Excess CO2

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PN - Metabolic Complications

• Hepatic Dysfunction
• excess fat cyclical better
• excess glucose balanced calorie source
• cholestasis
• related to illness

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PN - Metabolic Complications

• Refeeding Syndrome
• Sudden glucose load low phosphate
• insulin release low K
• uptake of glucose low Mg
• phos

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So What Do You Really Need to Know?
60
Pragmatic approach to NS

• Nutritional support used in those unable to
  tolerate oral diet for
• gt7-10 days (well-nourished)
• gt5-7 days (malnourished)
• Enteral nutrition safer than parenteral
• If post-operative delay predictable then enteral
  feeding tube inserted at operation

61
Pyramid of Nutritional Support
Oral intake insufficient
Gut failure
PN/E
Eating insufficient
Tube Feeding
Oral Nutritional Supplements
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Bluffers Guide to PN prescription

• Fluids 30ml/kg/day
• Calories 30kcals/kg/day
• Fat 30 Total
• Nitrogen Calories/150 (g/day)
• Na 1 mmol/kg/day (1-1.5)
• K 1 mmol/kg/day (0.75-1)
• Cl 1 mmol/kg/day

Per 1000cal Ca 2.5 Mg 4 P 10
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• Do not shoot the pianist
• He is doing his best
• Oscar Wilde