Nutritional support in Nutritional support in surgical patientssurgical patients

Outline of the lecture

• Definition of nutritional supportDefinition of nutritional support • The Role of Nutrients in the BodyThe Role of Nutrients in the Body• Body's endogenous reserve of Body's endogenous reserve of

major nutrientsmajor nutrients• Classification of Malnutrition and Classification of Malnutrition and

it’s effect in the body it’s effect in the body • Nutritional AssessmentNutritional Assessment

Definition

• NutrientsNutrients

is the constituents of food is the constituents of food necessary to sustain normal necessary to sustain normal function of the bodyfunction of the body

• Nutritional supportNutritional support

The provision of nutrients orally, The provision of nutrients orally, enterally or parenterally with enterally or parenterally with therapeutic intent.therapeutic intent.

The Role of Nutrients in the Body

• ESSENTIAL NUTRIENTS:ESSENTIAL NUTRIENTS:• carbohydrates, protein, and fats:carbohydrates, protein, and fats:• supplying energy and raw materials for metabolism.supplying energy and raw materials for metabolism.• Missing just one of these Essential Nutrients puts the Missing just one of these Essential Nutrients puts the

body into a state of being malnourishedbody into a state of being malnourished..• ESSENTIAL AMINO ACIDS:ESSENTIAL AMINO ACIDS:• required to make proteins they cannot be created by the required to make proteins they cannot be created by the

bodybody• ESSENTIAL FATTY ACIDS:ESSENTIAL FATTY ACIDS:• Lipids that cannot be created by the body required to Lipids that cannot be created by the body required to

make some of the phospholipids. make some of the phospholipids.

• VITAMINSVITAMINS::• organic molecules that organic molecules that

serve as co-enzymes or serve as co-enzymes or parts of co-enzymes and parts of co-enzymes and therefore have catalytic therefore have catalytic functionsfunctions

• required in small amountsrequired in small amounts• Water-soluble:Water-soluble:• B complex, Vitamin CB complex, Vitamin C

excreted with the urineexcreted with the urine• mild overdoses are mild overdoses are

harmlessharmless• fat-soluble:fat-soluble: E,D,A,KE,D,A,K• should be monitored should be monitored

more closelymore closely

• MINERALSMINERALS::• Calcium:Calcium: bone, nerves bone, nerves

and musclesand muscles• Phosphorus:Phosphorus: bone, ATP bone, ATP

and nucleic acidsand nucleic acids • Iron:Iron: cellular respiration cellular respiration

and hemoglobinand hemoglobin • Iodine:Iodine: thyroxinethyroxine • Sodium, potassium, Sodium, potassium,

and chlorineand chlorine are are important in nerve important in nerve functionfunction

• Magnesium, Magnesium, manganese, zinc, and manganese, zinc, and cobaltcobalt are cofactors built are cofactors built into the structure of into the structure of certain enzymescertain enzymes

Body's endogenous reserve of major Body's endogenous reserve of major

nutrientsnutrients including adipose and somatic muscle tissueincluding adipose and somatic muscle tissue

CLASSIFICATION OF CLASSIFICATION OF MALNUTRITIONMALNUTRITION

MARASMUSMARASMUS

--depletion in the somatic compartmentdepletion in the somatic compartment

KWASHIORKORKWASHIORKOR

--depletion in the visceral compartmentdepletion in the visceral compartment

MARASMUS-KWASHIORKOR MIXMARASMUS-KWASHIORKOR MIX

--depletion in both compartmentsdepletion in both compartments

MalnutritionMalnutrition

• PreoperativePreoperative

1.1. StarvationStarvation

2.2. failure of proper digestionfailure of proper digestion• PostoperativePostoperative

StarvationStarvation

which may be secondary to:which may be secondary to:• Poverty and inability to obtain foodPoverty and inability to obtain food

• DysphagiaDysphagia

• VomitingVomiting

• Self neglect, e.g alcoholics and the Self neglect, e.g alcoholics and the elderlyelderly

• Conserve energy by decrease in Conserve energy by decrease in metabolism Initial loss of metabolism Initial loss of glycogen (24 hr), body fat, then glycogen (24 hr), body fat, then skeletal proteinskeletal protein

• Death is due to weakness of Death is due to weakness of

diaphragm, pneumonia or other diaphragm, pneumonia or other

infection; timing depends on size infection; timing depends on size

of fat storesof fat stores

Failure of digestionFailure of digestion

• Pancreatic or biliary diseasePancreatic or biliary disease, e.g. , e.g. carcinoma, stonecarcinoma, stone

• Duodenal or jejunal diseaseDuodenal or jejunal disease, e.g. , e.g. fistula, blind loop syndromefistula, blind loop syndrome

• Postoperative malnutrition

• Usually result of the stress of surgery Usually result of the stress of surgery and is a transient natureand is a transient nature

• However, it may be as severe with However, it may be as severe with such major operations assuch major operations as

• esophagectomy and paralytic ileusesophagectomy and paralytic ileus

What happens during acute stress?What happens during acute stress?

• Catabolism of body protein (viscera and Catabolism of body protein (viscera and

skeletal) in order to support skeletal) in order to support

gluconeogenesis.gluconeogenesis.

• Hormones: glucagons, catecholamine, Hormones: glucagons, catecholamine,

glucocorticoids … promote fluid retentionglucocorticoids … promote fluid retention

• Cytokine response: fever, inflammation, Cytokine response: fever, inflammation,

increase metabolism.increase metabolism.

• Skeletal protein is depletedSkeletal protein is depleted

Hypercatabolic statesHypercatabolic states

• An increase in metabolic rate and An increase in metabolic rate and protein catabolism of >25% e.g.protein catabolism of >25% e.g.

1.1. Sever sepsisSever sepsis

2.2. Sever trauma as in burns Sever trauma as in burns

3.3. Sever inflammation as in Sever inflammation as in pancreatitispancreatitis

• Body fat used more graduallyBody fat used more gradually• Death is due to weakness of Death is due to weakness of

diaphragm, pneumonia or other diaphragm, pneumonia or other infection.infection.

ManifestationsManifestations

General• Physical and mental exhaustionPhysical and mental exhaustion• Infection, due to immunosuppressionInfection, due to immunosuppression• Intolerance to radio- and chemo-Intolerance to radio- and chemo-

therapytherapyMetabolic:• Lowered rates of enzyme synthesis• Impaired oxidative metabolism of

drugs by the liver

Healing problems:Healing problems:• Wound dehiscenceWound dehiscence• Leakage from bowel anastomosesLeakage from bowel anastomoses• Delayed callus formationDelayed callus formation• Disordered coagulationDisordered coagulation

Nutritional AssessmentNutritional Assessment

How do we detect malnutrition?How do we detect malnutrition?

• HistoryHistory

• Physical examinationPhysical examination

• Laboratory investigationsLaboratory investigations

HistoryHistory

• Dietary historyDietary history

• Change in appetiteChange in appetite

• Significant weight loss within last 3 Significant weight loss within last 3

monthsmonths

15% loss of body weight15% loss of body weight

• Compare with ideal weightCompare with ideal weight

• Beware the patient with ascites / Beware the patient with ascites /

edemaedema

Physical examinationPhysical examination

• Evidence of muscle wastingEvidence of muscle wasting

• Depletion of subcutaneous fatDepletion of subcutaneous fat

• Features of Vitamin deficiencyFeatures of Vitamin deficiency

(Glossitis in vit B12 def , hypertrophic (Glossitis in vit B12 def , hypertrophic

gum : scurvy in vit C def, follicular gum : scurvy in vit C def, follicular

keratosis in vit A def , pellagra in niacin keratosis in vit A def , pellagra in niacin

def)def)

• Echymosis and easy bruisingEchymosis and easy bruising

• Easy to detect > 15% loss weightEasy to detect > 15% loss weight

Physical examinationPhysical examination

• Weight for Height comparisonWeight for Height comparison

• Body Mass IndexBody Mass Index

– Wt (kg) / Ht (M)2.Wt (kg) / Ht (M)2.

– NORMAL BETWEEN 18.5 – 24.5NORMAL BETWEEN 18.5 – 24.5

Physical examinationPhysical examination

AnthropometryAnthropometry

– triceps skin fold (TSF) by caliper triceps skin fold (TSF) by caliper

(minimum : (minimum :

13 mm in female, 10 mm in male)13 mm in female, 10 mm in male)

– mid arm circumference (MAC). mid arm circumference (MAC).

– mid arm muscle circumference (MAMC) mid arm muscle circumference (MAMC)

– (feeding is indicated if less than 23 cm in F (feeding is indicated if less than 23 cm in F

and 25 cm in M)and 25 cm in M)

{MAMC = MAC cm – (TSF mm × 0.314)}{MAMC = MAC cm – (TSF mm × 0.314)}

Lab InvestigationsLab Investigations

• Albumin < 30 mg/dlAlbumin < 30 mg/dl

• Pre-albumin < 12 mg/dlPre-albumin < 12 mg/dl

• Transferring < 150 mmol/lTransferring < 150 mmol/l

• Total lymphocyte count < 1800 Total lymphocyte count < 1800

/mm3 /mm3

• Tests reflecting specific nutritional Tests reflecting specific nutritional

deficitsdeficits

– e.g. prothrombin timee.g. prothrombin time

• Candida skin testCandida skin test• Nitrogen balance studiesNitrogen balance studies• urinary creatinine and 3—urinary creatinine and 3—

methylhistidine excretionmethylhistidine excretion• total body K and Ntotal body K and N• 14C--leucine incorporation14C--leucine incorporation• Fecal fat testFecal fat test• Schilling test Schilling test • Hydrogen breath testHydrogen breath test• D-xyloseD-xylose

Assessing Nutritional Status:The SGA

A. History• Weight change Weight change

<5% = “small”<5% = “small”5–10% = “potentially 5–10% = “potentially significant” significant” >10% = “definitely >10% = “definitely significant”significant”

• Change in dietary intakeChange in dietary intake• Gastrointestinal Gastrointestinal

symptomssymptoms(nausea, vomiting, (nausea, vomiting, diarrhea, anorexia)diarrhea, anorexia)

• Functional capacityFunctional capacity• Disease and its relation Disease and its relation

to nutritional to nutritional requirementsrequirements

B. Physical• Loss of subcutaneous fatLoss of subcutaneous fat• Muscle wastingMuscle wasting• Ankle edemaAnkle edema• Sacral edemaSacral edema• AscitesAscites

C. SGA Ratingsubjective global assessment

• A = Well nourishedA = Well nourished• B = Moderately B = Moderately

malnourishedmalnourished• C = Severely C = Severely

malnourishedmalnourished

Thank youThank you

• NOTESNOTES• ESSENTIAL NUTRIENTSESSENTIAL NUTRIENTS• 57% 57% Carbohydrates (sugar, sweets, bread, cakesCarbohydrates (sugar, sweets, bread, cakes) ) • 30% 30% Fats (dairy products, oilFats (dairy products, oil) ) • 13% 13% Protein (eggs, milk, meat, poultry, fishProtein (eggs, milk, meat, poultry, fish) ) • Body's endogenous reserve of major nutrientsBody's endogenous reserve of major nutrients• The Carbohydrates provide energy for 24 hr maxThe Carbohydrates provide energy for 24 hr max• Brain , RBC and kidney relay on Carbohydrates for Brain , RBC and kidney relay on Carbohydrates for

supplying the energysupplying the energy• After 24 hr the body protein undergo After 24 hr the body protein undergo

gluconeogenesis to supply energy for the three vital gluconeogenesis to supply energy for the three vital organsorgans

• Nutritional AssessmentNutritional Assessment• The must important (practical) stepsThe must important (practical) steps• History : 10% weight loss in 3-6 monthsHistory : 10% weight loss in 3-6 months• BMIBMI• Albumin and HGB Albumin and HGB

The Doctor said you may ask to calculate the total calories in

MCQs• Calories per gram of:

Water = (0 Cal)Protein = (4 Cal)Dietary fiber = (3 Cal)Fat = (9 Cal)Alcohol = (7 Cal)Carbohydrates = (4 Cal