surgical nutrition for ms part 1 peradeniya march 2007

7/29/2019 Surgical Nutrition for MS Part 1 Peradeniya March 2007

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Enteral and Parenteral Nutritionin the Critically Ill patient

MS Part 1 Peradeniya 2007


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Medical Ethics

Obligations of a moral nature which govern

medical practice.

1. Autonomy the right for self determination

2. Avoiding harm (non-maleficence) together with the

aim of providing benefit (beneficence)3. Justice fair and equitable provision of available

medical resources


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Nutrition

Ethics

In most societies food is a symbol of caring

and comfort Provision of food and water to the sick is most

fundamental of all human relationships

It is Unethical and Immoral not to provide

nutritional support for a patient with more

than one week of inadequate intake

The current legal and clinical view


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Metabolic response to trauma (Surgery)

Mediators

Cytokines Paracrine hormones

TNF- Hypermetabolism,

hyperglycaemia, fever, lacticacidosis, shock

Activates hypothalamic-pituitary-adrenal axis

Interleukins

IL-1 Potent H-P-A axisinducer

IL-6 Acute phase response

Neuroendocrine Activated sympathetic

response

Activated hypothalamic-

pituitary hormones

Insulin and glucagon

levels are increased

GH increased

ADH , Renin ,

Aldosterone


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We do have an energy reserve

Protein sparing strategies

Pre-op care Treat sepsis

Avoid starvation

Mobilisation burns fat, spares protein

Nutritional support


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Nutritional Therapy

Patient focused nutritional therapy

is the only way to treat or prevent malnutrition Goal of therapy

is to improve or prevent malnutrition when they

are unable meet the nutritional demands

Minimize wasting Lean body mass

Starvation 2% muscle mass loss per day


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Nutritional Assessment

Why?

Accurately define nutritional status of patient

Define clinically relevant malnutrition Monitor the response to treatment

Research


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Nutritional assessment

How?

Single index

Serum albumin

Limited use long half life, recover with illness not just nutrition

Anthropometry

Skin fold thickness, body wt

Multiple parameters

Prognostic nutritional index (Mullen et al 1979) Serum albumin, transferrin, triceps skin fold, delayed skin

hypersensitivity

Medical history and physical examination


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MalnutritionUnder nutrition, over nutrition, unbalanced intake

Why? Inadequate food intake

e.g. anorexia, dysphagia, vomiting

Malabsorption

Inability to metabolize certain nutrients e.g. renal disease, liver disease, inborn errors of

metabolism Increased requirements

Any one or combination of above


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MalnutritionUnder nutrition, over nutrition, unbalanced intake

Leads to

Immune incompetence

Impaired barrier function, non specific function, specific immunity

Poor wound healing

Impaired vital organ function

Reduced muscle function, lung function, cardiac function, GIT

function

Increased post operative complications

Prolonged hospital stay

Increased mortality


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Weight loss

0-10% Safe zone

10-15% Entering danger zone: Consider artificial nutrition of major

treatment planned

20-25% Danger zone: Nutritional support compulsory if treatment to be

continued

30-35% Risk of death due to cachexia: Immediate nutrition therapy


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Aim of nutritional therapy

Give sufficient energy

25-35 kcal/kg/day Mostly as carbohydrate and not fat

Give sufficient nitrogen

1g/kg/day


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How to give nutritional therapy

correctly

Identify patients at risk

Calculate requirement of specific nutrients Select appropriate route of administration

Monitor intake daily

Monitor effects using objective parameters Watch for adverse reactions or complications

Modify the regimen if necessary


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Goals of nutrition therapy

Improve mental and physical function

Minimize deleterious effects of catabolism Prevent death from starvation

Restore normal body tissue

Accelerate rehabilitation Reduce hospital stay

Improve quality of life


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Routes

Parenteral

Peripheral Central

Enteral

Oral Naso gastric

Naso jejunal

Gastrostomy

Jejunostomy


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When the gut works

Use it


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Range of Enteral formulae

Oral supplements

Usually lactose free, liquid, palatable

Enteral

Polymeric: standard or fibre

Provide 1 kcal/ml or 1.5 kcal/ml

Pre-digested

Semi elemental or elemental Disease specific

Liver, renal or pulmonary failure

Specialized formulae


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Specialized formulae : Rationale

Pulmonary disease Reduce CO2 production

High fat, low CHO

Liver disease Prevent encephalopathy

Low fat, high CHO, more branched chain AA

Renal disease To minimize renal load

Low mineral, high calorie, moderate protein


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Indications for parenteral nutrition

Temporary or permanent intestinal failuremajor trauma, abdominal surgery,pancreatitis,inflammatory bowel disease

Inadequate oral intake for one week or more

Severely malnourished unable to meet his or

her requirements enteraly


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Sites of central venous access for parenteral nutrition


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Parenteral Nutrition supplies

Energy

Amino acids Electrolytes

Vitamins

Water Trace elements


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Parenteral nutritionstandard regimens

Amino acids 1.5g/kg/day

Energy 30 kcal/kg/day (CHO + fat) Electrolytes basal amounts

Vitamins and trace elements basal amounts

Above are maintenance requirements. Additional fluid

and electrolytes may be required


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Adult parenteral nutrition

on a single slide

3000 ml water

3000 Cals (12,800 Kj) 100 Grams L-amino acids

100 mmol Sodium

100 mmol Potassium Phosphate and Magnesium

Vitamins and trace elements


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Parenteral Nutrition

1. Catheter-related complications Pneumothorax

Air embolism

Catheter embolisation

Venous thrombosis

Catheter occlusion

Improper tip location Phlebitis

Catheter-related sepsis


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Parenteral nutrition

2. Gastrointestinal complications Liver dysfunction

Hepatic steatosis Intra hepatic cholestasis

Gastrointestinal atrophy

Translocation of bacteria

Gastric hyperacidity


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Parenteral Nutrition

3. Metabolic and Electrolyte Complications Hyperchloraemic metabolic acidosis

Due to high Chloride intake

Electrolyte disturbances Hypokalemia, Hypernatraemia

Rebound Hypoglycemia TPN should be weaned not abruptly stopped

Refeeding syndrome when TPN given after a period of starvation

increased insulin lead to severe hypophosphatemia,hypokalemia, hypomagnesaemia

Deficiencies

Trace elements, vitamins (thiamine, folic acid, vitamin K)


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Enteral Nutrition?


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Early enteral nutrition

in the acutely ill

Reduces septic and non septic complications

Improve outcome of the critically ill and injuredpatient

Small bowel function and the ability to absorb

nutrients remains intact despite critical illness ,even in the presence of gastro paresis and

absent bowel sounds

Consider trans-pyloric feeding even in this state


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How does early enteral nutrition help?(Crit Care Med 2001; 29: 2264-70)

Improves nitrogen balance

wound healing host immune function

Augment cellular antioxidant mechanisms

Decrease hyper metabolic response to tissue injury

Preserve intestinal mucosal integrity maintain mucosal immunity

prevent increase in mucosal permeability

decrease bacterial translocation)


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Nutrition in specific diseases

Acute renal failure With CRRT no need to

restrict volume

Normal nutritional supportappropriate

Liver disease Use lipids in caution

Restrict proteins 0.5g/kg/day

Risk of hypoglycemia Inhibitory neurotransmitters

Branched chain AA ifdeficient may contribute toencephalopathy

Respiratory failure Oxidation of fat produce less

CO2 than CHO

Acute pancreatitis Enteral feeding useful

jejunal feeds lessstimulation


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Adjunctive nutrition Glutamine

An oxidative fuel

Nucleotide precursor for enterocytesand immune cells

Large amounts released by muscle incatabolic states

Branched chain amino acids Benefit no evidence yet

Omega-3 fatty acids Less cytokine production

Anti-inflammatory

ARDS - ?benefit

Arginine Precursor of nitric oxide

Enhanced cell mediated immunity

Nucleotides DNA, RNA precursors

If deficient immunity affected

Immuno-nutrition Enriched diets with Omega 3 +

Arginine + nucleotides and Glutamine


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Enteral vs ParenteralParenteralguaranteed intake

never rejected

can be used with short gut or absent gutfunction

Less nutritionally effective than EN

Hyperglycaemia

Electrolyte imbalance

HyperlipidemiaConstant supervision

Needs long term CVC

Sterility and infection considerations

Costly

Enteralcan be capricious

can be vomited

Requires functional gutDiarrhoea

Can be used to continue oral meds

More effective on-line to portal system

Encourages gut motility

Normalises gut flora

Electrolyte imbalance unusualLess supervision

Less infection

Cheap(er)


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Wherever possible resort toEnteral feeding

Use parenteral nutrition to

supplement above and only if

essential for total nutritional

support


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Summary

Nutrition is essential not an option

Move towards enteral feeding

Control sepsis

Early mobilisation

Remember the vitamins

surgical nutrition for ms part 1 peradeniya march 2007

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