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Nutrition in Surgery
Name: Nurzawani Binti ShamsudinMatric No: 0918424
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OUTLINE OF THE SEMINAR
• Definition • Causes of inadequate intake• Nutritional status, assessment, &
support
Introduction
• Introduction • Indications• Composition• Complications
Enteral nutrition
•Introduction •Indications•Composition•Complications
Parenteral nutrition
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INTRODUCTION
1. Definition of nutrition & malnutrition
2. Causes of malnutrition
3. Objectives of nutritional support
4. Assessment of nutritional status
5. Estimating energy requirement
6. Estimating nutritional requirement.
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NUTRITION
DefinitionThe taking in and metabolism of nutrients (food and other nourishing material) by an organism so that life is maintained and growth can take place.
Dorland’s Pocket Medical Dictionary
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MALNUTRITION
Definition
A disorder of nutrition or a wasting condition resulting from energy and protein deficiency, sometimes with vitamin and trace element deficiency as well.
Dorland’s Pocket Medical Dictionary
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MalnutritionCauses
◦Reduced food intake anorexia fasting pain on swallowing, physical or mental
impairment
◦Malabsorption impaired digestion or
absorption excess loss from gut
◦Altered metabolism trauma burns sepsis surgery cancer cachexia
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IMPORTANCE OF NUTRITION IN SURGERY
1. Surgical procedures (and subsequent fasting) after admission can cause these patients to go into severe malnutrition quickly, often before the treating team realizes it.
2. There is evidence that patient with severe protein depletion have greater incidence of postoperative complication such pneumonia, wound infection, & prolonged hospital stay.
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Disease/surgery
Neuroendocrine stress responsePro-inflammatory cytokine response
Metabolic change or/and reduced food intake
Protein and energy loss
Slow recovery, poor wound healing, and Increased infection
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CAUSES OF INADEQUATE INTAKE
Not appetiz
ing food
weak and
anorexic
patientincreased
metabolic
demand
GI obstruc
tion
Cumulative
effects of
repeated
periods of
fasting
Intestinal
failure
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OBJECTIVE OF NUTRITIONAL SUPPORT
•Provide nutrition support consistent with patient’s medical condition
•Prevent/ treat macronutrient and micronutrient deficiency
•Provide doses of nutrient compatible with existing metabolism
•Avoid/ manage complications related to the technique of nutrient delivery.
•Improve patient’s outcome such as those related to morbidity
•To prevent and minimize the effect of catabolism
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ASSESSMENT OF NUTRITIONAL STATUS
Nutritional assessment
Depleted reserves
Muscle wasting, loss
of subcutaneous fat, albumin < 30 g/L, weight loss 10-15%.
Poor current intake
Anorexia/vomiting, poor intake on food
chart
NUTRITIONAL
SUPPORT
Likely clinical courseIf not going to eat within
next 5 days, if already
malnourish and at risk of further major complication
such as abscess/fistul
a
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ASSESSMENT OF NUTRITIONAL STATUS
1. History
2. Diet assessment.
3. Physical Examination.
4. Investigation
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ASSESSING PATIENT FOR MALNUTRITION1. Clinical assessment: Lack of nutritional intake for 5 days or more. Clinical appearance – does the patient
looked malnourished? Unintentional weight loss for more than
10% from usual body weight for previous 6 months. More than 20% is likely to represent severe malnutrition.
BMI less than 18.5. History of poor nutrient intake: anorexia,
nausea, vomiting, early satiety and food preference.
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• Clinical nutritional history based on understanding of the etiologies and pathophysiology of malnutrition.
• History of poor nutrient intake • Anorexia • Nausea• Vomiting• Early satiety• Food preference
• Loss of body weight (see table)• Weight loss of more than 10-15% during the
past 6 months
EVALUATION OF MALNUTRITION (HISTORY)
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Percentage of weight loss and impression
% weight loss Impression5 Normal 10 -15 Risk15 – 20 Malnutrition20 – 30 Severe malnutrition30 - 40 Incompatible
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Social & economic condition that may lead to poverty & malnutrition◦ Inadequate income◦ Homeless◦ Drug abuse◦ Chronic alcoholism
Gastrointestinal symptoms◦ Dysphagia◦ Recurrent vomiting◦ Chronic diarrhea◦ Food intolerance
Other chronic medical illnesses◦ Disseminated cancer◦ COPD◦ Chronic inflammatory disease
EVALUATION OF MALNUTRITION (HISTORY)
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EVALUATION OF MALNUTRITION (PHYSICAL EXAMINATION)Findings Interpretation
General appearance Weight loss
Decreased temporal & proximal extremity muscle mass
Decreased “pinch test”
Malnutrition < 90% of ideal weight
Decreased skeletal protein
Decreased body fat stores
Skin, nails, hairEasily plucked hair
Spooning of nails
Protein
Iron
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Findings InterpretationSkin, nails, hairEasy bruising, perifollicular hemorrhage
“Flaky paint” of the lower extremity
Coarse skin, papular keratitis “goose bumps”
Peripheral edema
Vitamin C
Zink
Vitamin A
Protein
EyesConjunctival pallor
Bitot spot
Opthalmoplegia
Anemia (non-specific)
Vitamin A
Thiamine
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Papular keratitis
Bitot spot
Perifollicular hemorrhage
Nasolabial seborrhea
Flaky paint of lower limb
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PHYSICAL EXAMINATION ANTHROPOMETRY
Definition
• The science dealing with measurement of the size, weight and proportions of human body
• It can assess level of energy reserves by estimate amount of subcutaneous adipose stores.
• However it cannot identify specific nutrient deficiency
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Anthropometric assessment: Triceps skin fold thickness (mm)
Mid arm circumference (cm) :
Mid-upper circumference (cm) – (π x triceps skin fold thickness) (cm)
% standard men women interpretation
100 12.5 16.5 Adequate
50 6 8 Borderline
20 2.5 3 Severe
% standard men women interpretation
100 25.5 23 Adequate
80 20 18.5 Borderline
60 15 14 Depletion
40 10 9 Severe
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Body Mass Index
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EVALUATION OF MALNUTRITION (LABORATORY INVESTIGATION)
To detect subclinical nutritional deficiencies in patients
• Nitrogen Balance• Serum Albumin• Creatinine excretion • Immunological Function
assessment
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Nitrogen balance
◦ Nitrogen balance provides an index of protein gain or loss:
6.25 protein gained is equivalent to 1 g nitrogen
◦ Can be assessed by measuring the difference between nitrogen consumed (mouth, enteral tube or IV) and nitrogen excreted in the urine, feces and other intestinal sources.
◦ In most cases, total urine nitrogen can be calculated by dividing 24-h urinary urea nitrogen by 0.85 & assuming approximately 2g/d for nitrogen losses in feces & sweat.
Blood indices:
Nitrogen Intake – loss [90% urine, stool 5%, integument 5%]
or[Protein intake (g)/6.25] – urinary urea (g) – 2(for stool & skin) – 2(non-urea nitrogen)
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Serum Albumin
◦ Serum albumin level falls during the acute stress of surgery, sepsis or other acute inflammatory illness because of increased circulating extravascular volume
TNF-α mediated inhibition of albumin synthesis
◦ The measurement of serum proteins, in particular albumin, is often used as an index of malnutrition (<35g/L)
◦ Sensitive but non-specific.
◦ The half-life of albumin is 14 to 18 days.
◦ Prealbumin (half-life, 3 to 5 days) or transferrin (<200 mg/dL; half-life, 7 days), have been proposed as more sensitive indicators of rapid changes in nutritional status.
Blood indices
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Creatinine Excretion
◦ Creatinine is a metabolic product of skeletal muscle creatine.
◦ It is produced constantly in an amount directly proportional to skeletal muscle mass.
◦ With steady state a day-to-day renal function, each gram of creatinine in the 24-h urine collection represents 18.5g of fat free skeletal muscle.
◦ Measurement of creatinine in 24-h urine collection can be used as a relative measure of this body compartment.
Blood indices
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Immunological assessment
◦ Delayed cutaneous hypersensitivity or anergy, most commonly tested by delayed reaction to skin recall antigens, was widely used in early studies of nutritional assessment and is a manifestation of cell-mediated immunity
◦ Total Lymphocyte count is often <1000 /μL in PCM and may accompany anergy to common skin test antigens.
◦ However, not all malnourished patients are at risk and the defect is immunologic, not nutritional.
Blood indices
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Adverse effect of protein or calories depletion
Impaired wound healing and higher rate of wound breakdown.
Impaired immune function and the ability to against infection.
Skeletal muscle mass is lost, reducing muscular strength and general physical activity as well as causing fatigue.
Thoracic muscle mass depletion depresses respiratory efficiency and increase risk of pneumonia.
Albumin becomes depleted leading to generalized edema.
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Adverse effect cont.
Small bowel mucosa atrophy reduces its ability to absorb nutrient and may lead to bacterial translocation into bloodstream because loss of mucosal integrity.
Impaired mental function leads to apathy, depression and low morale.
Post operative complication rates are higher. Prolonged recovery times and longer hospital stay.
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ASSESSMENT OF NUTRITIONAL REQUIREMENT
Energy and protein requirement vary depending on weight, body composition, clinical status, mobility and dietary intake.
Few patients require more than 2500 kcal/day. Additional calories are unlikely to be used effectively and may constitute a metabolic stress.
Refeeding the chronically starved patient must be cautious because of the dangers of hypokalemia and hypophosphatem.ia
uncomplicated Complicated/stressed
Energy (kcal/kg/day)
25 30 – 35
Protein (g/kg/day) 1.0 1.3 – 1.5
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REFERENCESGarden’s Principles & Practice of
Surgery, 5th edition.Burkitt’s Essential Surgery, 4th
edition.Medical Nutrition Therapy
Guidelines for nutrition support in critically ill adult by Ministry of Health, Malaysia
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Metabolic Response to StarvationAfter 12 hours of not feeding
Plasma insulin level falls Glucagon rises Hepatic glycogen is gradually converted into
glucose With prolong starvation, muscle glycogen is
broken down and converted into lactate which is taken to the liver and converted to glucose
After 24 hours Hepatic gluconeogenesis from amino acids
precursors start with loss of about 75g of skeletal muslce protein per day.
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Metabolisms in starvation and stressed state
MuscleProtein
75g
Fat storesTryglicerides
Amino acid
Glycerol
Fatty acid
LiverGlycogen
75ggluconeogenesis
Oxidation
Fatty acid
Glucose180g
brain
RBCWBC
NeuronsKidneymuscle
Lactate +pyruvate
Ketone HeartKidneysmuscle
Fig :Metabolism during fasting (<5 days)
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MuscleProtein250g
Fat storesTryglicerides
Amino acid
Glycerol
Fatty acid
KIDNEYgluconeogenesis
Gluconeogenesis
LIVERoxidation
Fatty acid
Glucose360g
Wound
RBCWBCNerveMuscleKidney
Lactate+pyruvate
Ketone
HeartKidneyMuscle Fig: Fuel utilization following trauma
In Acute injury, significant alteration in substrate utilization. There is enhanced
nitrogen loss indicative of protein catabolism.
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ENERGY REQUIREMENToBEE (men) = 66.47 + 13.75 (weight) + 5.0 (height) – 6.76 (age) x (activity factor) x (injury factor) kcal/dayoBEE (women) = 655.1 + 9.56 (weight) + 1.85 (height) – 4.68 (age) x (activity factor) x (injury factor) kcal/day
BEE = Basal Energy Expenditure = quantity of energy required to satisfy the requirements of the body at rest
oEquation adjusted for type of surgical stress
oSuitable for estimating energy requirement in >80% of patients
oProvision of 30kcal/kg/day will adequately meet energy requirement ( reduce risk of overfeeding)
oActivity factor伉 confined to bed :1.2伉 out of bed :1.3
oInjury Factor伉 minor operation :1.20 伉 skeletal trauma :1.35伉 Major sepsis :1.60伉 severe thermal burn :1.5
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•Estimation of energy and protein requirement:
Uncomplicated Complicated
Energy 30 34 – 40(kcal/kg/day)Protein 1.0 1.3 – 2(g/kg/day)
•24-hour urinary urea excretion• Common method for assessing protein
requirement