isc workshop - surgical nutrition and fluid and electrolytes - 2010

8/12/2019 ISC Workshop - Surgical Nutrition and Fluid and Electrolytes - 2010

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Surgical Nutrition


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Nutrition requirement

Caloric requirement

Protein requirement

Vitamins and Minerals


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Caloric requirement

Patients total caloric requirement =

BEE x AF x IF

BEE = basal energy expenditure

AF = activity factorIF = injury factor


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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)]

FemaleBEE (kcal/day) = 655.1 + [9.56 x weight

(kg)] + [1.85 x height (cm)] [4.68 x

age (yrs)]


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Activity Factor (AF)

Activity Factor

Confined to bed 1.2

Ambulatory 1.3


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Injury Factor (IF)

Injury Factor

Non-stressed on ventilator 1.0-1.2Congestive heart failure 1.1-1.2

Minor surgery 1.1-1.2

Fever, per 1oC 1.13

Skeletal trauma 1.15-1.35

Mild to moderate infection 1.2-1.4

Major abdominal / thoracic surgery 1.3-1.5

Multiple trauma 1.35-1.55

Closed head injury 1.4-1.6

Stressed ventilator dependent 1.4-1.6

Liver failure, cancer 1.5

Sepsis 1.5-1.8


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Example

What is the caloric requirement of a 35y.o. man, weighing 70 kg and measuring

1.8 m in height, who has sufferedmultiple injury in a RTA and is nowconfined to bed? (Note: the man washealthy previous and he does not have a

fever nor is he septic at the moment)

Answer: 3401 to 3904 kcal/day


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Malnutrition

DefinitionMalnutrition in pre-opand post-op patients

Effects of malnutritionNutritional assessment


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Definition of Malnutrition

1 . Gross underweight (weight forheight < 80% of standard) ; or

2. Recent weight loss of 10% ormore of pre-morbid body weight.


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Pre-operative malnutrition

StarvationPoverty

DysphagiaVomiting

Self-neglect e.g. elderly, alcoholics

Failure of digestionPancreatic/biliary disease

Duodenal/jejunal disease


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Post-operative malnutrition

resting metabolic expenditure

stress hormones adrenaline, glucagonglycolysis

cortisol, glucagongluconeogenesis

growth hormone, glucagon, noradrenalinelipolysis

Diabetes of injury

-ve nitrogen balance

protein breakdown + protein synthesisrate


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Hypercatabolic State

E.g severe sepsis, severe trauma, severemajor viscera disturbances, burns

Muscle wasting

Protein catabolism (myofibrillar proteins,retin and myosin) &Protein synthesis

Prolonged visceral protein depletionmulti-

organ failure Principal mediators: TNF, IL-1,

glucocorticoids

Sepsis: Fat oxidation, hepatic glucose

production despite hyperglycemia


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Effects of malnutrition

Poor wound healing Delayed callusformation

Disordered coagulation

enzyme synthesis

Impaired oxidative metabolism of drugsby liver

Immunity (risk of infection) tolerance to radiotherapy and

chemotherapy

Severe mental apathy and physical

exhaustion


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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)

Blood indices Serum albumin (1500/mm3)

Candida skin test (-ve=cell-mediatedimmunity)

Nitrogen balance studies


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Parenteral Nutrition

Peripheral and CentralIndications

Contraindications

PreparationAdministration

Monitoring

Complications


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Parenteral nutrition

Intravenous (peripheral/central)

Partial/total

< 4-5% of all hospital admissions(B&L)

serious, non-infectious

complications

septic complications


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Peripheral ParenteralNutrition

Peripheral vein nutrition

- Low dextrose concentration

- Fat emulsion reduces irritating effect of

a.a. on vein wallUse if

GI tract expected to be functional in 7-10days

Low calorie and protein needs

Osmolarity is a limiting factor

Complication

Thromophlebitis


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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


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Indications

Principles

Inability to absorb

nutrients via GI tract Complete bowel rest

Nutrient needs notmet by enteral

feedings within 7-10days

Severe malnutrition/

catabolism

Absolute indication:

Enterocutaneousfistulae

Relative indications:

Moderate/severemalnutrition

Acute pancreatitis

Abdominal sepsis

Prolonged ileus

Major trauma/burns

Severe IBD


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Home parenteral nutrition

Chronic intestinal failure

Short bowel syndromeCrohn's disease

Mesenteric vascular disease

Volvulus

Extensive bowel resection

Multiple high output fistulas

Motility disorders (usually pseudo obstructionsyndromes and systemic sclerosis)

Sequelae of radiation damage (radiation enteritis)


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Preparation before TPN

Weigh the patient

Calculate fluid needs for next 24

hours Calculate energy and nitrogen intake

on a body wt basis


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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 ofcatabolism)

Fat in form of long-chain or medium-chain triglyceride, at most 1g/kg/day.


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Procedures

Full aseptic conditions

Gold standard: Subclavian vein (Broviacor Hickman catheter)

Alternative: Internal jugular vein

Subclavian vein cutdown technique

Silicone catheter

least irritative to the veinless thrombogenic

probably less susceptible to infection.

CXR to confirm location of tip


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Administration

Administered into the catheter via agiving set: separately in individual bottlesor mixed in a bag (3 in 1 TPN bag)

Start by giving 50% of calculatedrequirement 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.

M it i


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Monitoring

Daily

Body weight

Fluid balanceCBC, urea, electrolytes

Blood glucose

Urine and plasma osmolality

Electrolyte and Nitrogen analysisof urine and GI losses

Acid base status

Thrice weekly Serum Ca2+, Mg2+, PO43-

Plasma proteins

LFT, Clotting studies

10 days Serum B12, folate, Fe, lactate,

triglycerides


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Complications

Metabolic

Hyperglycemia

Hypoglycemia(sudden discontinuance)

Excess Fat:fatty liver, Saturation of RE system

Vitamin and mineral deficienciesmetabolic bone disease, hypophosphatemia

Liver dysfunctionAST, ALT, Bilirubin, ALP; usually transitory

Adverse reactions to lipid emulsions


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Complications

Problems of insertion

Pneumothorax

HaemothoraxArterial puncture

Brachial plexus injury

Mediastinal hematomaThoracic duct injury

Problems of care

Catheter-related

sepsis(S.aureus,Candida sp, Klebsiellapneumoniae

Airembolism

ThrombosisThromboembolism


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Preventions

CXR to confirm location of tip after insertion

TPN line should not be used for any otherpurpose

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


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Routes of administration

By mouth

cervicoesophagostomy


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IndicationsBymouth

Functioning GI tract; should always beattempted

By NGtube

Patient unable to eat for approx. 7-30 days

Inserted to stomach

Functioning G.I. tract, but is unable to meettotal nutritional requirements through oral

feeding (e.g. esophageal stricture)Inserted to duodenum

If gastrostomy is contraindicated

Gastro-

stomy

Passage of fine-bore NG tube is not possible

or when more than 4 weeks of enteralfeeding is anticipated

Jejun-ostomy

If gastrostomy is contraindicated


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Formulas CHO: corn syrup solids, hydrolyzed cornstarch,

maltdextrins, other glucose polymers (+/- fibre,fructose and fluctooligosaccharides) 30-90%

Lipids: corn and soybean oil, canola andsafflower oil (provide LCT); MCT for patientswith malabsorption disorders (no EFA) - 1-55%

Protein: caseinates and soy protein isolates,enzymatically hydrolyzed casein or whey, freeaa, bcaa 4-32%

Water: caloric density (1kcal/ml 85%;

2kcal/ml 70%) Micronutrients

Fibre: soy polysaccharide, hemicellulose,lignans, guar gum, oat fibre, pectin (improvesstool consistency - debatable)

Ad i i t ti


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AdministrationIndications Advantages Disadvantages

Bolus Noncritically ill

patient

Home TF

Rehabilitation

patient

Easy to administer

Inexpensive

Short administration

time (usually 15

minutes)

Highest risk of

aspiration, N/V,

abdominal pain anddistention, and diarrhea

Inter-

mittent

Noncritically ill

patient

Home TF

Rehabilitation

patient

Flexibility in feeding

schedule

Inexpensive

Feeding over shorter

time allows patient more

free time

Higher risk of

aspiration, N/V,abdominal pain and

distention, and diarrhea

May require formula

with more calories and

proteinContin-

uous

Initiation of tube

feedings

Critically ill patient

Small bowel feeding

Intolerance ofintermittent or bolus

Pump assisted

Minimizes risk of high

gastric residuals and

aspiration

Minimizes risk of

metabolic abnormalities

Restricts ambulation

Infused over 24

hours/day

Increased cost (need

pump)


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In the past tube feedings that werehyperosmolar were diluted strength - currentrecommendations are to leave the formula full

strength and begin at a lower volume untiltolerance is determined.

Full strength if isotonic - DO NOT DILUTEISOTONIC FORMULAS!

Tube feeding is progressed until assessednutrition 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


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Complications

Metabolic

Gastrointestinal

Mechanical


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Metabolic complications

Hyponatremia

Hypernatremia

Hypokalemia

Hyperkalemia

Hyperglycemia

Prerenal azotemia

Hypophosphatemia

Hypomagnesemia

Hypermagnesemia

Hypocalcemia

Hypercalcemia

Hypozincemia

Essential Fatty AcidDeficiency

Excessive CO2production


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GI complications

Constipation

Diarrhea

High gastric residuals Nausea / vomiting

Abdominal cramps

Bloating


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Mechanical complications

Aspiration

Clogged tube

Tube discomfort / nasal necrosis

Tube dislodgement


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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


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Different ways of writing

23.4% NaCl = 4mmol Na/ml

15% KCl = 2mmol K/ml

1/5 solution 0.18% NaCl, 4.3% dextrose

1/3 solution

0.3% NaCl, 3.3% dextrose

solution

0.45% NaCl, 2.5% dextrose


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Scenario 1

60kg male with newly diagnosed Caoesophagus

Plan for operation in 5 days time Cannot tolerate solid food, barely

tolerate liquid food

Whats your IVF order?


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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


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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?


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Scenario 3

50kg woman with 20% total bodysurface area burn


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IVF / special circumstances

GI loss

Diarrhoea, vomiting, poor intake,

malignancy Cardiac

Over load? Pulmonary congestion

Physiology Age? Post op stress? Drugs?

Temperature? Body size?

References


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References

R.C.G. Russell , N.S. Williams , C.J.K. Bulstrode Bailey & Love's ShortPractice of Surgery 22ndEdition 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 PrescribingInformation(http://www.vh.org/adult/provider/surgery/totalparenteralnutrition/)

Department of Health, UK: Specialised Services National DefinitionSet(http://www.doh.gov.uk/specialisedservicesdefinitions/12parenteral.htm)

Surgical Tutor, UK (http://www.surgical-tutor.org.uk/default-home.htm?core/ITU/nutrition.htm)

Prof. S.T. Fan Lecture notes Feed him up before surgery: Surgicalnutrition: 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.
http://www.merck.com/pubs/mmanual/section1/chapter1/1c.htmhttp://www.vh.org/adult/provider/surgery/totalparenteralnutrition/http://www.doh.gov.uk/specialisedservicesdefinitions/12parenteral.htmhttp://www.doh.gov.uk/specialisedservicesdefinitions/12parenteral.htmhttp://www.surgical-tutor.org.uk/default-home.htm?core/ITU/nutrition.htmhttp://www.surgical-tutor.org.uk/default-home.htm?core/ITU/nutrition.htmhttp://www.espen.org/education/documents/Khair-2-010902-web.dochttp://www.emedicine.com/radio/topic798.htmhttp://www.rxkinetics.com/tpntutorial/2_1.htmlhttp://www2.ncn.com/~bln/Album/NUR108/NUR108_TubeFeeding.htmhttp://www2.ncn.com/~bln/Album/NUR108/NUR108_TubeFeeding.htmhttp://www.rxkinetics.com/tpntutorial/2_1.htmlhttp://www.emedicine.com/radio/topic798.htmhttp://www.espen.org/education/documents/Khair-2-010902-web.dochttp://www.espen.org/education/documents/Khair-2-010902-web.dochttp://www.espen.org/education/documents/Khair-2-010902-web.dochttp://www.espen.org/education/documents/Khair-2-010902-web.dochttp://www.espen.org/education/documents/Khair-2-010902-web.dochttp://www.espen.org/education/documents/Khair-2-010902-web.dochttp://www.espen.org/education/documents/Khair-2-010902-web.dochttp://www.surgical-tutor.org.uk/default-home.htm?core/ITU/nutrition.htmhttp://www.surgical-tutor.org.uk/default-home.htm?core/ITU/nutrition.htmhttp://www.surgical-tutor.org.uk/default-home.htm?core/ITU/nutrition.htmhttp://www.surgical-tutor.org.uk/default-home.htm?core/ITU/nutrition.htmhttp://www.surgical-tutor.org.uk/default-home.htm?core/ITU/nutrition.htmhttp://www.doh.gov.uk/specialisedservicesdefinitions/12parenteral.htmhttp://www.doh.gov.uk/specialisedservicesdefinitions/12parenteral.htmhttp://www.vh.org/adult/provider/surgery/totalparenteralnutrition/http://www.merck.com/pubs/mmanual/section1/chapter1/1c.htm


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isc workshop - surgical nutrition and fluid and electrolytes - 2010

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