Transcript Surgical Nutrition

Surgical Nutrition
B.E.Mostafa, MD
Professor of ENT-HNS
ASU
Malnutrition
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In 30-50% of Head and Neck Patients
Causes:
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The tumor itself may present a barrier to deglutition
Tumor metabolism remains constant despite changes in
nutritional status. Consequently, starvation responses
such as lipolysis are not used by tumor cells, and glucose
is continuously derived from protein catabolism.
Cancer cachexia may be induced by catabolic factors
secreted by tumor cells.
Finally, tumor treatment may induce anorexia through
discomfort, obstruction, and loss of taste.
Types of PEM
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Marasmus:
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Fat and muscle catabolism make up for
deficient intake without depression of
serum albumin level
Kwashiorkor:
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Visceral protein depletion
Consequences
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Poor wound healing
Immune suppression
Poor response to therapy
Poor survival
Scope
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Nutrition
Metabolic
Setting
Malnutrition
Organ
failure
Basis
Starvation
Stress
Focus
Protein
synthesis
Weight gain
Restore
organ
function
Stop
catabolism
Fuel
Glucose
Mixed
Nutritional support
Simple starvation
Metabolic support:
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Hypermetabolism and
multiple organ failure
Activation of
neuroendocrine pathways
Evaluation
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Clinical
Anthropometric
Biochemical
Immunological
Anthropometric measures:
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Body weight:
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> 10% Usual body weight loss in 6 mos
Ideal body weight
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BMI
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Mild malnutrition
= 80 to 90% IBW
Moderate malnutrition = 70 to 79% IBW
Severe malnutrition
= < 69% IBW
Underweight:
Adequate weight:
Overweight:
Obese:
Triceps skin fold
Mid arm circumference
BMI < 18.5
BMI = 18.5 to 24.9
BMI = 25 to 29.9
BMI > 30
Biochemical
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Albumin:
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= > 3.5 g/dL
= 2.7 to 3.5 g/dL
= 2.1 to 2.6 g/dL
= < 2.1 g/dL
Transferrin:
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Adequate
Mild
Moderate
Severe
Adequate
Mild
Moderate
Severe
= 200 to 400 mg/dL
= 180 to 200 mg/dL
= 160 to 180 mg/dL
= < 160 mg/dL
Pre-albumin:
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Adequate
Mild
Moderate
Severe
= 18 to 42 mg/dL
= 13 to 17 mg/dL
= 8 to 12 mg/dL
= ≤ 7 mg/dL
Immunocompetence
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Total lymphocyte count:
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Adequate
Mild
Moderate
Severe
= > 1,800 mm3
= 1,500 to 1,800 mm3
= 900 to 1,500 mm3
= < 900 mm3
Cutaneous hypersensitivity:
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Non reactive = 0
1
< 5mm induration
2
> 5mm induration
Requirements
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Energy requirements
Nutrient requirements
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Glucose requirements
Fat requirements
Protein requirements
Electrolytes
Vitamins,minerals and trace elements
Energy requirements
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Adult daily calorie requirements 30 to 35 kcal/kg
Add 10 kcal/kg to compensate for surgical stress.
The Harris-Benedict equation estimate basal energy
expenditure (BEE)
For men:
66.47 + [13.75 × wt (kg)] + [5.0 × ht (cm)] – [6.76 × age (y)]
For women
665.10 + [9.56 × wt (kg)] +[1.85 × ht (cm)] – [4.68 × age (y)]
The BEE is multiplied by a stress and activity factor totaling
1.3 to 1.5
Nutritional requirements
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Protein requirements are estimated at
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1.0 g/kg/day.
1.2 g/kg/day.
1.5 g/kg/day
up to 2.0 g/kg/day.
Glucose:
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Normal
Mildly stressed
Mild to moderate
Reconstruction
20-25 nonprotein Kcal/Kg/day
Fat:
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< 30 % of non protein calories
Route of Administration
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This is determined by:
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Oral supplements
Enteral feeding:
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Patient's condition
Access available
Skill and preferences of surgeon
NGT/NIT
Gastrostomy
Jejunostomy
Total parenteral nutrition TPN
Combined
Enteral feeding
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Normal functioning GIT
Prevents intestinal mucosal atrophy
Supports gut associated immunological shield
Cheaper with less complications than TPN
May be supplemented with IV solutions
Equipment
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Enteral feeding set with bag
Formula
Graduated cylinder
Irrigation container
60 cc syringe with catheter adaptor
NGT
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Local decongestant and anaesthetic
Introduce a 16 or 18 Fr tube [silastic .]
Either proximal to GEJ or into duedenum
Tube should be 30-35 cms from external nares
Check tube placement by x-ray or auscultation
Change nostril 10-14 days to prevent necrosis
Tube feeding
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Bolus feeding:
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4-6 times/day
Intermittent feeding
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250-500 mL
400 mL by slow drip ½-1 hour 4-6 times/day
Continuous infusion
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Feeding pump
125 mL/hour for 16-24 hours
Important points
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Elevate head of bed 30-45°
Check tube patency
Start with 100 mL D5W and wait for 1 hour
Increase by 50 to 100 mL / 8h or daily as tolerated
Assess gastric residue every 4 hours
Flush the feeding tube to clear formula
Dilute medications with 30 cc water and administer a
few minutes apart if patient is polymedicated
The final feed no later than11:00 pm
Complications
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Tube clogging
Diarrhoea
Nausea and vomiting
Formula-drug interactions
Refeeding syndrome
Aspiration
Columellar necrosis
Tube clogging
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Inject 5 mL of warm water and clamp for 5 minutes
Inject a bolus (20 to 30 cc) of air
Follow with 30 to 50 mL of warm water
Flush with:
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324 mg sodium bicarbonate tablet
One pancrelipase(Cotazym or Viokase) capsule
5 mL of sterile water.
Clamp it for 5 minutes. Flush the tube with water until clear.
The tube should be replaced
Diarrhoea
3 or more  500 cc / 24 hours
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An inappropriate rate of formula infusion,
Impaired functional capacity of the GIT
Hypoalbuminemia
Concurrent use of antibiotics and other medications
Altered bacterial flora
Enteral formula contamination.
Within 48 hours after feedings :
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Change to sterile water 50 cc / h/ 12 hours, then resume formula
feeding at 50 cc per hour and advance per protocol.
After 48 hours:
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Antidiarrhoeal medications 3-4 times
Re-evaluate formula and infection
Nausea / Vomiting
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Continuous feeding:
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Interval feeding:
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Stop feeding for 1 hour. Resume feeding
at the last tolerated rate for the next 12
hours and then increase.
Stop feeding and hold until next
scheduled feeding
Administer antacid ± H2 blocker
Intolerance
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Continuous feedings:
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If residual is greater than 2 hours of present rate, hold the
feeding and recheck in 1 hour. Resume feeding when
amount is less than 2 hours of present rate, otherwise
continue to check hourly.
When the desired volume of feeding is achieved,
discontinue checking residual unless feeding intolerance
occurs.
Interval feedings:
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If more than 100 cc of the previous feeding is aspirated,
hold the feeding and recheck in 1 hour. If aspirate remains
more than 100 cc, hold feeding until next scheduled time.
When residuals are less than 100 cc for 24 hours,
discontinue checking residual unless intolerance occurs.
Formula drug interaction
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Diminished bioavailablity of:
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Quinolones, tetracyclines, azithromycin
antivirals
Increased absorption of antifungals
Vitamin B, iron and Ca syrup clog
tubes
Administer drugs separately
Flush after each dose
Refeeding syndrome
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Serious metabolic disturbance that may occur with the
initiation of aggressive nutrition support in patient with
severely depleted nutrition stores.
Significant compartmental shifts in phosphorus,
magnesium, and potassium and sodium retention with
expansion of the extracellular space.
Hypophosphatemia is the most serious single consequence
in refeeding syndrome.
Cardiopulmonary failure and death may occur within days
In patients at risk for refeeding syndrome, normal levels of
phosphorus, potassium, and magnesium should be
monitored constantly
Aspiration
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Avoid transgressing GEJ
Keep patient semi sitting during feeding
Avoid feeding while asleep
Slow instillation of fluid
Check tube location before each feed and after
changing sides
Add H2 blockers/PPI
Feeding formulas
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Custom processed formulas
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Commercially available
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Combination
Commercially available formulas:
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Polymeric formulas
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Protein
12 to 20%
Carbohydrates,
40 to 60%;
Fats
30 to 40%.
Ratio of nonprotein calories to nitrogen is 150 to 1
Polymeric formulas contain whole proteins isolated from
casein, whey, lactalbumin, and egg white.
The source of carbohydrate is usually glucose
polymerspolymers from starch and its hydrolysates.
Formulas are l;actose-free
The fats are from vegetable sources.
Essential vitamins and minerals
Monomeric formulas:
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Require less digestion , rarely used
Sustagen®
Calories / mL
1
Carbohydrate
Non protein Calories
Sucrose,corn syrup
140 g/L
Soy protein isolate
61 g/L
Soy oil
23 g/L
79:1
Na/K mEq/L
40/53
Vitamins for 100% RDA
1080 mL
Protein
Fat
Custom prepared formula
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Breakfast
1 cup Citrus juice
2 tsps sugar
3 glasses:
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½ cup strained refined cereal
[Cerelac]
1 cooked egg
1 ½ cup milk
¼ corn syrup
1 tablespoon vegetable oil
½ cup water
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Lunch & Dinner
1 cup juice
2 tspns sugar
3 glasses:
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1 cup strained meat
½ cup strained vegetable
2 cups warm milk
2 tbsp vegetable oil
Custom prepared formula
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Provides 2800 Kcal
Should be warmed, blended and strained
Given at body temperature
The glass should be stirred to mix components
Keep only 24 hrs in refrigerator
Some coffee may be added to stimulate appetite
In case of lactose intolerance lactose-free milk may
be used
A commercially formula may be added to provide
extra nutrients
Remember
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Adequate free water
Formula at room temperature
Encourage activity
Oral feeding allowed if possible.
Supplement with minerals and vitamins
Indications of TPN
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Absolute indications
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Enterocutaneous fistulae
Relative indications
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Moderate or severe malnutrition
Acute pancreatitis
Abdominal sepsis
Prolonged ileus
Major trauma and burns
Severe inflammatory bowel disease
Parenteral nutrition
The intravascular administration of carbohydrates,
protein, fat, vitamins, and minerals.
 Total parenteral nutrition
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Nutrient administration into the superior vena cava,
Peripheral partial nutrition
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Supplements enteral feeding
Through a peripheral vein
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10% glucose solution,
Amino acids
Fat emulsion
Typical content / 2.5 L soln
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Hyperosmolar, low pH and irritant to vessel walls
14g nitrogen as
L amino acids
250g
25 % glucose 5mg/Kg/Min
500 ml
20% lipid emulsion
Electrolytes:
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100 mmol
100 mmol
150 mmol
15 mmol
13 mmol
30 mmol
0.4 mmol
Na+
K+
ClMg2+
Ca2+
PO42Zn2+
Vitamins / Trace elements / Insulin
Preparations
10% AA solutions
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Aminosteril
Panamine
Aminoleban
Haes-sterile
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Intralipid
20% lipid emulsion
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Hydroxyethyl starch
Complications
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Problems of insertion
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Failure to cannulate
Pneumothorax
Haemothorax
Arterial puncture
Brachial plexus injury
Mediastinal haematoma
Thoracic duct injury
Problems of care
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Line and systemic sepsis
Air embolus
Thrombosis / thrombophlebitis
Catheter breakage
Metabolic complications
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Hypo / hyper glycaemia
Excess CO2 production
Hyperlipedimia
Abnormal liver functions
Cholestasis
Hypo / hypervolaemia
Disturbances in Na, K , Mg PO4 ,Ca
Acid/base disturbances
Care of TPN lines
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Strict asepsis in care
Do not use for sampling
Do not use for drug administration
Check for signs of sepsis
Monitoring of TPN
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Clinical evaluation twice daily
Urine sugar or glucocheck / 6 hrs
Daily
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Twice weekly
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Weight
Fluid chart
Electrolytes,
BUN,
Weekly
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Blood count,
Liver functions
Final Aim
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Restore body weight
Improve anthropometric parameters
Improve biochemical parameters
Improve immunological parameters
Prevent organ failure and catabolism