Transcript Body composition, injury, and wound healing in surgery

Body composition, injury, and
wound healing in surgery
Surgical Nutrition Training Module
Level 1
Philippine Society of General Surgeons
Committee on Surgical Training
Objectives
• To discuss the body composition and its key
components
• To discuss body composition changes in injury
particularly in surgery
BASICS AND NORMAL BODY
COMPOSITION
The cell and its organelles
Major:
• Cell membrane
• Cytoplasm
• Mitochondria
• Nucleus
• Endoplasmic
reticulum
• Golgi apparatus
Illustrations from Guyton’s
Textbook of Physiology
Nutrients, structure, function
Human body = 100 trillion cells
ENERGY
radicals
•
•
•
•
•
•
•
•
•
Nervous system
Musculoskeletal system
Cardiovascular system
Respiratory system
Gastrointestinal system
Genitourinary system
Reproductive system
Endocrine system
Hemopoietic system
Body composition, all ages
Muscle and fat mass, all ages
BODY COMPOSITION IN HEALTH
AND DISEASE
Body compartments in health and
disease
CARBO +
OTHER (1%)
PROTEIN (14%)
FAT (25%)
WATER (60%)
NORMAL
PROTEIN (14%)
PROTEIN (12%)
PROTEIN (6%)
FAT (15%)
FAT (23%)
WATER (72%)
WATER (70%)
STARVATION
CRITICAL CARE
FAT (30%)
WATER (55%)
OBESE
Energy utilization
Lipogenesis
POST-PRANDIAL
Glucose
Glycogen
POST-PRANDIAL: within 24 hours
Glycogen
Gluconeogenesis
FASTING: within 24 to 72 hours
Fatty acid: lipolysis
(minimal)
FASTING: beyond 5 days
Fatty acid: lipolysis
(full blast)
(preserving protein)
Note: Cardiac and skeletal muscle (slow) are mainly dependent on fatty
acid for energy source
No food intake: glucose utilization
Surgery, wound healing, and
nutritional status
SURGERY
INFLAMMATION
↑WBC + ↑ENERGY
↑CELL MULTIPLICATION + ↑NUTRIENT NEEDS
WOUND HEALING
No Malnutrition
NORMAL
POOR ± COMPLICATIONS
Malnutrition
•
•
•
•
Catecholamines
Glucagon
Thyroid hormones
Cortisol
Loss of lean body mass = ↑mortality
Loss of
Complications
Total LBM
10%
Decreased immunity
Increased infections
20%
Decrease in healing, increase
In weakness, infection
30%
Too weak to sit, pressure ulcers,
Pneumonia, lack of healing
40%
Death, usually from pneumonia
Associated
Mortality
10%
30%
50%
100%
LBM=Lean Body Mass
Demling RH. Nutrition, anabolism, and the wound healing process: an
overview. Eplasty 2009;9:e9.
BODY COMPOSITION ANALYSIS
The surgical nutrition process
All admitted patients are nutritionally screened
All nutritionally at risk patients are assessed
All high risk patients are given nutrition care plans
Monitoring of the nutrition process is done
Nutrition care plan modification / Discharge
Nutritional
Assessment
and Risk Level
Form
Complication(s) prediction
Predicting post-operative complications based on surgical nutritional risk level using the SNRAF in colon cancer
patients - a Chinese General Hospital & Medical Center experience. Ocampo R B, Kadatuan Y, Torillo MR,
Camarse CM, Malilay RB, Cheu G, Llido LO, Gilbuena AA. Yr 2007.
SURGICAL DECISION MAKING BASED
ON BODY COMPOSITION ANALYSIS
PRE-OPERATIVE PHASE
severe
Scheduled
• esophageal resection
• gastrectomy
• pancreaticoduodenectomy
Enteral nutrition
for 10-14 days
oral immunonutrition
for 6-7 days
malnutrition
no
slight, moderate
SURGERY
Early oral feeding within 7 days
POST-OP
EARLY DAY 1 - 14
no
yes
Enteral access (NCJ)
within 4 days
enteral nutrition
Oral intake of energy requirements
no
yes
immunonutrition for 6-7 days
yes
“Fast Track”
no
Parenteral hypocaloric
combined enteral / parenteral
Adequate calorie intake within 14 days
LATE DAY 14
yes
no
Oral intake of energy requirements
supplemental enteral diet
no
yes
WOUND HEALING ISSUES
Inflammation: part of wound healing
• Cell proliferation
• ↑ nutrient and
energy
requirements
• Adequacy of
response is
dependent on
the nutrient
supply /
reserves
Wound healing
Stages of wound healing and
repair
Angiogenesis
Reference: Robbins Basic Pathology 7th edition.
Kumar, Cotran, Robbins editors. 2003.
Wound healing: molecular environment
Basement membrane:
1. Cell support
2. Exchange
3. Transport
4. Development
5. Repair
6. Defense
7. Integrity of structure and
environment
Intercellular environment
1. Tissue support/shape
2. Exchange
3. Growth
4. Repair
5. Defense
6. Movement
Wound healing
Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003.
Wound healing requirements
• Increased requirements
– Energy and protein
– Electrolytes, vitamins, trace elements
– Oxygen and water
• Addition of:
– conditional essential amino acids (glutamine)
– Trace elements (selenium in burns)
– Antioxidants
• Continuous supply of the requirements
Energy calculations are good enough
ESPEN Guidelines 2009: Surgery
• Calorie Requirement(s):
– The commonly used formula of 25 kcal/kg ideal
body weight furnishes an approximate estimate of
daily energy expenditure and requirements.
– Under conditions of severe stress requirements
may approach 30 kcal/kg ideal body weight
– (Grade B)
ESPEN: European Society of Parenteral and Enteral Nutrition
Protein synthesis
• Requirements:
– ↑Insulin levels induced by adequate glucose
intake
– ↑plasma amino acid levels
– Adequate essential amino acid levels
– Adequate non-protein calories from carbohydrate
and fat
ESPEN Guidelines 2009: Surgery
• Protein Requirement(s)
– In illness/stressed conditions a daily nitrogen
delivery equivalent to a protein intake of 1.5 g/kg
ideal body weight (or approximately 20% of total
energy requirements) is generally effective to limit
nitrogen losses. The Protein:Fat:Glucose caloric
ratio should approximate to 20:30:50% (Grade C)
ESPEN: European Society of Parenteral and Enteral Nutrition
Carbohydrate and fat ratios
Stoner et al
McFie et al
Do lipids matter?
 LCT = mostly ω6FA (arachdionic
acid) content = proinflammatory
 MCT = reduces ω6FA (arachidonic
acid) content + direct utilization in
the liver
ESPEN Guidelines 2009: Surgery
• Nitrogen sparing; non-protein calories
– Optimal nitrogen sparing has been shown to be
achieved when all components of the parenteral
nutrition mix are administered simultaneously
over 24 hours (Grade A)
ESPEN: European Society of Parenteral and Enteral Nutrition
Energy requirements and antioxidants
2H2O
Vitamin C
Catalase
Hydrogen peroxide
H2O2
Superoxide
dismutase
Zn
Glutathione
peroxidase
Cu
Glutathione
peroxidase
ONOO-
GSSG
Se
ONO- + H2O
GSSG
2GSH
•
Glutathione
reductase
2H2O
Oxygen radicals
O•2
•
2GSH
Vitamin C
Glutathione
reductase
Munoz C. Trace elements and immunity: Nutrition, immune functions and health; Euroconferences,
Paris; June 9-10, 2005;
Robbins Basic Pathology 7th edition 2003. Kumar, Cotran, Robbins editors.
Antioxidants
1. α-tocopherol
1,000 IU (20 mL) q
8h per naso- or
orogastric tube
2. ascorbic acid
1,000 mg given IV
in 100 mL D5W q
8h for the shorter
of the duration of
admission to the
ICU or 28 days.
Nathens AB, Neff MJ, Jurkovich GJ, Klotz P, Farver K, Ruzinski JT, Radella F, Garcia I, Maier
RV. Randomized, prospective trial of antioxidant supplementation in critically ill surgical
patients. Ann Surg. 2002; 236(6): 814-22.
Body composition, intake and outcome
CONCLUSION
Body composition
• Body composition changes occur in surgery
• Quality of body composition determines
outcome in surgery
• Analysis of body composition and correction
of deficiencies through nutrition improves
outcomes in surgery