Download MBBS Surgery Presentations 43 Nutrition In Surgery Lecture Notes

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What is Nutritional Support

"The provision of nutrients orally, enterally, or

parenterally with therapeutic intent.

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This includes provision of total enteral or

parenteral nutrition support,and provision of

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therapeutic nutrients to maintain and /or

restore optimal nutrition,status and health."
Who Should Get Nutritional

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Support?

Patients who:
v Cannot meet nutrient requirements

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v Have documented inadequate oral intake

v Have unpredictable return of GI function

v Need a prolonged period of NPO/bowel rest

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Evaluation of Nutritional Status

v Weight loss >10%

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v Wt.for Ht <90%

v Serum markers

? Albumin level <35g/L

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? Transferrin <2g/L

v Total lymphocyte count <1200-1500x109 /L

v Triceps fold thickness < 10mm (men),

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<13mm(women)
Assessment

v Signs of specific nutritional deficiencies

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v Skin rash

v Pallor

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v Cheilosis

v Glossitis

v Gingival lesions, hepatomegaly, neuropathy

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v Dementia

Recommended Daily Requirement

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Nutrient

Per Kg body Wt

Water(ml)

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35

CHO(gm)

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2.0

Fat(gm)

3.0

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Protein(gm)

0.7

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Nitrogen(gm)

0.1

Na (mmol)

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1-1.5

K (mmol)

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1.0

Vit B(mg)

0.5

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Vit C(mg)

1.0
Energy Requirements

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v Harris-Benedict equation estimates BER at rest

v Men 66 + (13.7x weight) + (5x height) ?(6.8 x age)

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v Women 65 + (9.6 x weight) + (1.7 x height) ? (4.7 x age)

v Most require 25-35 kcal/kg/day

v Stress increases these values

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Stress

v Low stress 1.2 x BER

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v Moderate stress 1.2-1.3 x BER

v Severe stress 1.3-1.5 x BER

v Major burn injury 1.5-2.0 x BER

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v Requirements are increased by fever, infection,

activity, burns, head injury, trauma, renal failure,

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surgery.

v Decreased by sedation, paralysis, B blocker
Stress Factor

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Total Energy Requirements=
Basal energy requirement x Stress factor x

Activity factor

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Activity factor for ambulatory patients=1.25
Indications

v Nutrition support

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v As primary therapy for a disease

v As an adjunct to primary therapy

v To treat malnutrition

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v To avoid development of malnutrition from low

energy & nutrient intake or increased needs

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Enteral Nutrition

? Use of formulae as oral supplements or

meal replacements when oral intake is

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inadequate or contraindicated

? Delivery of nutrients via a tube into the GI

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tract
Benefits of Enteral Nutrition

v Maintains gut mucosal physiology

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v Preserves gut barrier function

v Promotes peristalsis

v May modulate immune response

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v Inexpensive compared with parenteral nutrition

Appropriate Candidates for Tube

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Feeding

v Functional GI tract

v Oral intake is inadequate

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v To restore nutritional status

v To maintain nutritional status
Conditions that often Require

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Enteral Nutrition

v Impaired Nutrient Digestion

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v ? Inability to Consume Adequate Oral Nutrition

v ? Impaired Digestion, Absorption, Metabolism

v ? Severe Wasting or Growth Retardation

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A good determinant of safe tolerance of EN is a
GI output of less than 600 ml/24 hr (e.g,effluent
from a nasogastric tube, stoma, fistula or rectal
tube)

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Complications of Enteral Nutrition

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v Access Problems

v Administration Problems

v Gastrointestinal

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v Metabolic

v Psychologic

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Relative contraindications to

enteral feeding

v Mesenteric ischemia

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v Bowel obstruction

v Sepsis

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v Pancreatitis

v Fistula

v SBS

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Parenteral Nutrition

TPN- indicated when GI tract is unavailable or

nonfunctional.

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v Small bowel resection

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v Bowel obstruction (small or large)

v Large output fistula

? below enteral feeding site

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Via Central catheter due to hyperosmolarity of

the solutions

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TPN Orders

v Calculate VOLUME requirements/24h

v Determine PROTEIN requirements g/kg/d

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v Calculate daily CALORIES kcal/kg/d

v Determine % to be given as protein, CHO, fats
TPN Orders

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v Add ELECTROLYTES, TRACE ELEMENTS

v Co-administer Lipids to prevent fatty acid

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deficiency

v Lipids give more calories in less volume

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A 10% lipid sol. 1.1kcal/ml, 20% is 2.0 kcal/ml

TPN associated complications

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v Catheter related

v Metabolic

vHyperglycemia

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vHyperosmolarity

v Hepatic dysfunction

v Cholecystitis

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To Conclude...

v Enteral feeding must be the first choice always for

nutritional supplementation

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v Parenteral nutrition an important tool, but has a lot

of inherited problems.

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v Only used when enteral feeding cannot be done.

v Overfeeding is very harmful for patients and must

be avoided and looked for.

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