body composition, injury, and wound healing in surgery surgical nutrition training module level 1...
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Body composition, injury, and wound healing in surgery
Surgical Nutrition Training ModuleLevel 1
Philippine Society of General SurgeonsCommittee on Surgical Training
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Objectives
• To discuss the body composition and its key components
• To discuss body composition changes in injury particularly in surgery
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BASICS AND NORMAL BODY COMPOSITION
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The cell and its organelles
Major:• Cell membrane• Cytoplasm• Mitochondria• Nucleus• Endoplasmic
reticulum• Golgi apparatus
Illustrations from Guyton’s Textbook of Physiology
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Nutrients, structure, function
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Human body = 100 trillion cells
• Nervous system• Musculoskeletal system• Cardiovascular system• Respiratory system• Gastrointestinal system• Genitourinary system• Reproductive system• Endocrine system• Hemopoietic systemENERGY
radicals
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Body composition, all ages
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Muscle and fat mass, all ages
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BODY COMPOSITION IN HEALTH AND DISEASE
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Body compartments in health and disease
WATER (60%)
FAT (25%)
PROTEIN (14%)
WATER (72%)
FAT (15%)
PROTEIN (12%)
WATER (70%)
FAT (23%)
PROTEIN (6%)
CARBO + OTHER (1%)
NORMAL STARVATION CRITICAL CARE
WATER (55%)
FAT (30%)
PROTEIN (14%)
OBESE
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Energy utilization
POST-PRANDIAL Glucose
POST-PRANDIAL: within 24 hours Glycogen
Glycogen
FASTING: within 24 to 72 hours
Gluconeogenesis
Fatty acid: lipolysis(minimal)
Lipogenesis
FASTING: beyond 5 days Fatty acid: lipolysis(full blast)
Note: Cardiac and skeletal muscle (slow) are mainly dependent on fatty acid for energy source
(preserving protein)
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No food intake: glucose utilization
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Surgery, wound healing, and nutritional status
SURGERY
INFLAMMATION
↑WBC + ↑ENERGY
↑CELL MULTIPLICATION + ↑NUTRIENT NEEDS
WOUND HEALING
NORMAL POOR ± COMPLICATIONS
No Malnutrition Malnutrition
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• Catecholamines• Glucagon• Thyroid hormones• Cortisol
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Loss of lean body mass = ↑mortality
Loss of Total LBM
Complications Associated Mortality
10% Decreased immunityIncreased infections
10%
20% Decrease in healing, increaseIn weakness, infection
30%
30% Too weak to sit, pressure ulcers,Pneumonia, lack of healing
50%
40% Death, usually from pneumonia 100%
Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9.
LBM=Lean Body Mass
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BODY COMPOSITION ANALYSIS
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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
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Nutritional Assessment
and Risk Level Form
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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.
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SURGICAL DECISION MAKING BASED ON BODY COMPOSITION ANALYSIS
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malnutritionScheduled• esophageal resection• gastrectomy• pancreaticoduodenectomy
Enteral nutrition for 10-14 days
oral immunonutrition for 6-7 days
Early oral feeding within 7 days
yes no
within 4 days
yes
“Fast Track”
no
Parenteral hypocaloric
Adequate calorie intake within 14 days
Enteral access (NCJ)
yes no
enteral nutrition immunonutrition for 6-7 days
Oral intake of energy requirements
yes no
combined enteral / parenteral
no slight, moderate severe
SURGERY
PRE-OPERATIVE PHASE
POST-OP
EARLY DAY 1 - 14
LATE DAY 14
Oral intake of energy requirements
yesnosupplemental enteral diet
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WOUND HEALING ISSUES
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Inflammation: part of wound healing
• Cell proliferation• ↑ nutrient and
energy requirements
• Adequacy of response is dependent on the nutrient supply / reserves
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Wound healing
Angiogenesis
Stages of wound healing and repair
Reference: Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003.
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Basement membrane:1.Cell support2.Exchange 3.Transport4.Development5.Repair6.Defense7.Integrity of structure and environment
Intercellular environment1.Tissue support/shape2.Exchange3.Growth4.Repair5.Defense6.Movement
Wound healing: molecular environment
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Wound healing
Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003.
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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
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Energy calculations are good enough
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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
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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
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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
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Carbohydrate and fat ratios
Stoner et al
McFie et al
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Do lipids matter?
LCT = mostly ω6FA (arachdionic acid) content = proinflammatory
MCT = reduces ω6FA (arachidonic acid) content + direct utilization in the liver
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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
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Energy requirements and antioxidants
Glutathione reductase
Glutathione peroxidase
Glutathione peroxidase
Superoxide dismutase
• 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.
Oxygen radicalsO•2
Hydrogen peroxideH2O2
ONOO-
ZnCu
2H2O
ONO- + H2O
Glutathione reductase
Se
2GSH
2GSH
GSSG
GSSG
Vitamin C
Vitamin C
Catalase
2H2O
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Antioxidants
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.
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.
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Body composition, intake and outcome
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CONCLUSION
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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