Transcript Surgical Nutrition

외과적 영양 (外科的 營養)
Surgical Nutrition
인제대학교 부산백병원
일반외과 · 장기이식센터
이병욱
Department of General Surgery &
Organ Transplantation Center,
Inje University, Pusan Paik Hospital
Byong Wook Lee, M.D.
[email protected]
[email protected]
Inflammatory Response
POTraC 2000
Metabolic Response to Injury
POTraC 2000
Metabolic Response to Fasting
- Glucose homeostasis
POTraC 2000
Metabolic Response to Fasting
60g
120g
POTraC 2000
Gluconeogenesis from 3 carbon presursors
- Cori (lactate) and Alanine Cycle (pyruvate)
POTraC 2000
Gluconeogenesis from 3 Carbon precursors
- glutamine, pyruvate
POTraC 2000
Metabolic Response to Starvation
POTraC 2000
Fat metabolism during Starvation
POTraC 2000
Metabolism after Injury
•
Sustained activities of
macroendocrine hormones
• Immune cell activation
POTraC 2000
Metabolism after Injury
- Energy Balance
• Increase in energy balance
directly with severity of injury
• Increased activity of SNS
• energy required for ion pump
action to maintain normal
transmembrane concentration
overcoming increased cell
membrane sodium
permeability
POTraC 2000
Metabolism after Injury
– Substrate Metabolism
POTraC 2000
Interorgan Flux of Nutrients after Injury
POTraC 2000
Metabolism after Injury
- Lipid Metabolism 1
• Free fatty acid; predominant energy source afer injury
• Increased lipolysis by catecholamine, and other stress hormones
and reduction in insulin level
• Continuation of net lipolysis during flow phase; oxidation for
cardiac and skeletal muscle energy source
• Fatty acid induced inhibition of glcolysis in moderate injury;
not in severe injury, hemorrhage, or sepsis (persistent glycolysis
and net proteolysis)
 Lipoprotein lipase in endothelium
 Cytokine
POTraC 2000
Metabolism after Injury
- Lipid Metabolism 2
• High concentration of intracellular fatty acids and elevated
concentration of glucagon
 inhibition of fatty acid synthesis
 simulate transport of acyl CoA into mitochondria for oxidation and
ketogenesis in liver
• Keotgenesis
 variable and inversely correlated with severity of injury
 Decreased after major injury, severe shock and sepsis
 Suppressed by increases in levels of insulin and other energy
substrates
 Suppressed by increased uptake and oxidation of free fatty acids
 Suppressed by an associated counter regulatory hormone response
POTraC 2000
Metabolism after Injury
– Carbohydrate Metabolism
• A state of relative insulin resistance
• Net gluconeogenic response due to active control of glucagon with
permissive requirement for cortisol + Proinflammatory mediators
• Reduced glucose oxidation; mediator induced reduction of skeletal
muscle pyruvate dehydrogenase activity  shunting of 3-carbon
skeleton to liver
• Increased hepatic gluconeogenesis  Hyperglycemia
 energy source of nervous system, wound, RBC, WBC
• Wound;
 increase in glucose uptake associated with an increased in activity
of phosphoructokinase
 dereased insulin sensitivity and failed glucose uptake and
glycogenolysis in response to insulin
POTraC 2000
Metabolism after Injury
– Protein Metabolism
• Net proteolysis
• Skeletal muscle depletion with relative preservation
of visceral tissue
• Extracellular hormonal millieu, proinflammatory
cytokines
• Ubiquitin-dependent proteolytic pathway
upregulated by intracellular oxidative intermediates
and antioxidants
• Greater release of glutamine and alanine than
normal concentration of muscle
• Glutamine; major energy source for lymphoytes,
fibroblasts, and GI tract
POTraC 2000
Ubiquitin-ATP dependent Proteolysis
POTraC 2000
Severity of Injury and Proteolysis
POTraC 2000
Nutrition in the Surgical Patients
• Obligatory increases in energy expenditure and
nitrogen excretion
• Post-injury metabolic environment precluding
efficient oxidation of fat and ketone production
 continued erosion of protein pools
 critical organ failure
POTraC 2000
Nutritional Supprot of the Surgical Patient
- Protein
• Requirement
– Average normal requirement; 0.8 g/Kg/d
– Essential amino acids
– On parenteral nutrition, 200-250 nitrogen/Kg/d
POTraC 2000
Nutritional Support of the Surgical Patient
– Calories
• Caloric Sources
– Amino acids 15% (BCAA 6-7%)
– Fat 70-75%
– Carbohydraes 10-15%
• Calorie-Nitrogen Ratio
– Normal ratio for protein synthesis; 100-150:1
– Changes in different disease states;
100:1 for sepsis, 400:1 for uremia
POTraC 2000
Nutritional Support of the Surgical Patient
– Energy Requirement
• BEE
=66.5 + 13.7 x weight (Kg) + 5.0 x
height (cm) – 6.8 x age (yr.) [male]
= 655.1 + 9.56 x wt + 1.85 x ht –
4.68 x age [female]
POTraC 2000
Nutritional Support of the Surgical Patient
- Carbohydrates
• Supplement calories without elevating glucose concentration
• Lipid supplementation; replacing glucose as energy source
• lipid not efficient in severe sepsis
POTraC 2000
Nutritional Support of the Surgical Patient
- Fat
• Caroric source
• Source of essential fatty acids providing precursors of PG’s
– Modifying inflammatory and immunologic response
• 25% of nonprotein calories as fat; optimal for hepatic protein
synthesis
• Fat overload syndrome
< 2 g/Kg/d for adults
< 4 g/Kg/d for infants
POTraC 2000
Nutritional Assessment
• Estimate changes in body nutritional composition to
predict risk for surgery
• Evaluation of nutritional system; measurement of
functional lean body mass (muscular, respiratory, cardiac,
hepatic, renal, immunologic and host defense function)
• Prognostic Nutritional Index (PNI)
– = 158- 16.6 alb – 0.78 TSF – 0.20 TFN – 5.8 DH
POTraC 2000
Bases of PNI
POTraC 2000
Malnourished Patients at Risk
• Recent weight loss > 10% body weight and/or
body weight 80-85% ideal body weight
• Serum albumin in a stable, hydrated patient < 3.0
g/dl
• Anergy to injected skin recall antigens
• True transferrin < 200 mg/dl
• History of functional impairment
• Significant deficits in hand dynamometry or
muscle response to nerve stimulation
POTraC 2000
Indication for Nutritional Support
•
•
•
•
•
•
•
•
Premorbid state
Nuritional status
Age
Duration of starvation
Degree of anticipated insult
Likelihood of resuming normal intake soon
Weight loss of 15%
Serum albumin level < 3.0 g/d
POTraC 2000
Route of Administration- Enteral route
•
•
•
•
•
•
More physiologic
Costs less
Protects and improves hepatic function
Mimics normal ingress of nutrients to liver
Maintains gut mucosal integrity
early gut feedings resulting in lower mortality and septic
complication rates in posttraumatic situation
– Prevention of bacteria and/or their products from
translocating the gut mucosa
releasig catecholamines and other counter regulatory
stimuli,  preventing hypercatabolism
– Increased substrate supply to the liver
 improved hepatic acute phase protein synthesis
POTraC 2000
Enterocyte-specific Nutritional Substrates
- Glutamine
• Conditionally essential amino acid
• 40% of available glutamine taken up by gut from general
circulation
• Addition of 2% glutamine to parenteral nutrition maintains
jejunal or ileal mucosal thickness, protein content and DNA
• Prevention or healing of chemotherapeutic or radiation toxicity
• Regrowth after massive small bowel resection
POTraC 2000
Enterocyte-specific Nutrients
– Short Chain Fatty Acids
• Acetoacetate (10%), propionic acid (50%), butyrate (80%)
• Produced by fermentation of soluble pectin by colonic
bacteria
• Disruption of colonic mucosa in deficient state
• BHBA
– wall thickening and increased protein content of ileum
and colon
– 70% of energy supply to colonic mucosa
– Stimulation of ketogenesis, increased ATP generation,
lipolysis, absorption of sodium and potassium
POTraC 2000
Principles of Eneral Feeding
•
•
•
•
•
Stmach;principal defense against an enteral osmotic load
Duodenum; calcium,iron and other metal absorption
Small bowel: principal area for nutreint absorption
Terminal ileum; enterohepaic circulation
Bile and pancreatic juice; fat and protein absorption
• Immunologic functions of the gut
• largest immunoogic organ in the body; GALT, secretory Ig’s
• Secretion of mucin
• Gut mucosal barrier function
POTraC 2000
Practical Enteral Feeding
•
•
•
•
•
Goals of Nutritional Support
 Use the gut if possible
 Administer at least 20% of caloric and protein requirement by gut
Smalllest possible nasgastric tube, tip at the duodenum
Constant infusion except at bed time, head up 30
For gastric feeding, first osmolality and then volume,
reversed for jejunal feeding
Complications
 Malposition and/or aspiration
 Diarrhea, dehydration, hyperglycemia and ions
 Pneumaosis intestinalis with perforation
 Hyperosmolar nonketotic coma
 perforation
POTraC 2000
Parenteral Nutrition
- Peripheral Hyperalimentation
• Without protocol
• Lipid system;
10-20% of caloric need as fat emulsion
+ 5% dextrose and amino acids
• Hypocaloric amino acids and 5% dextrose or
glycerol solution
 Dextrose free amino acids by allowing
utilization of endogenous fat secondary to
low plasma insulin level
 Minimize nitrogen breakdown for limited
periods of time
POTraC 2000
Parenteral Nutrition
- Central Approach
•
•
•
•
•
Silastic or Teflon-coated catheters
Percutaneous or open
Temporal or permanent
Enforced protocol for TPN
Nutritional requirements
– 250 mg nitrogen/Kg/d
– 35 Kcal/Kg/d
– 20-25% of nonprotein calories as fat
– Adequate vitamin and trace minerals
POTraC 2000
Parenteral Nutrition
- Indications
• Primary Therapy
– Efficacy shown
 GI-cutaneous fistula
 Renal failure
 Short bowel syndrome
 Acute burns
 Hepatic Failures
– Efficacy not shown
 Crohn’s disease
 Anorexia nervosa
POTraC 2000
•
Supportive therapy
– Efficacy shown
 Acute radiation enteritis
 Acute chemotherapy
toxicity
 Prolonged ileus
 Weight loss preliminary to
major surgery
– Efficacy not shown
 Before cardiac surgery
 Prolonged respiratory
support
 Large wound losses
Complications of Parenteral Nutrition
- Technical
• Placement complications
– Pneumothorax
– Arterial lacerations
– Hemothorax
– Mediastinal hematoma
– Nerve injury
• Late complications
– Erosion of catheter
– Subclavian thrombosis
– Septic thrombosis
–
–
–
–
–
Sympathetic effusion
Thoracic duct injury
Air embolism
Hydrothorax
Catheter embolism
POTraC 2000
Complications of Parenteral Nutrition
- Metabolic Complications
• Plasma electrolyte abnormalities
• Trace mineral deficiency
– zinc, copper, chromium, selenium
• Essential fatty acid deficiency
• Disorders of glucose metabolism
– Hypoglycemia
– Hyperglycemia
– Diabetic patient; hyperosmolar nonketotic coma
– Liver function derangements
POTraC 2000
Parenteral Nutrition Order Form
POTraC 2000
Complications of Parenteral Nutrition
– Septic Complications
•
Catheter Infection
1. Absence of proocol
2. Degree of colonization of the pericatheter skin; > 103
3. G(+) organism from remote site seeding the fibrin
sleeve along catheter; vs G(-) organism
4. Candida from the gut
•
Management of patient with suspected catheter sepsis
POTraC 2000
Prevention of Catheter Complications
• Catheter Placement
• Nutritional Support teams and Protocols
POTraC 2000
Nutritional Protocol
POTraC 2000
Parenteral Nutrition for Pediatric Patients
•
•
•
•
More rapid growth
High proportion of viscera with little fat or muscle
Incompletely developed enzyme system
Liable to heat loss
•
Nutritional Requirements in Pediatric Patients
Protein
(g/Kg/d)
Calories
Fat
0-6 mo
6-12 mo
School age
Adolescent
C/N
2.5-3.0
2.0-2.5
1.75
1.2
150:1
Newborn or
premature
Infant
(~ 10Kg)
10-20 Kg
> 20 Kg
120
100
100 + 50
100 + 50 + 20
? 35% of calories (up to 3.5 g/Kg/d)
POTraC 2000
Home Hyperalimentation
• Silastic catheters with long
subcutaneous tunnel
• Mean catheter life; 7 years
• Overnight PN
• Septic complications
POTraC 2000
Nutritional Pharmacology
• Nutritional support to change either the milieu
or the pathophysiology of a disease process to
affect outcome
 Arginine




Glutamine
Nucleotides
Omega 3-fatty acids
Ketone bodies
POTraC 2000