REVISION COURSE OF THE WACS IN PHC SEPT 2007)

DEPARTMENT OF SURGERY, UNIVERSITY OF PORT HARCOURT TEACHING HOSPITAL

ENTERAL AND PARENTERAL NUTRITION IN SURGICAL PRACTICE(INTEGRATED

DR P.N.WICHENDU.FWACS

 A THOROUGH UNDERSTANDING OF NUTRITIONAL THERAPY IS VERY IMPORTANT TO THE SURGEON:

30 5O% OF HOSPITALISED PTS AFFECTED EITHER BEFORE/RESULT OF DX. MALNUTRITION PRODUCES :

INTRODUCTION

RESULT IN

A REDUCTION IN LEAN MUSCLE MASS , ALTERATIONS IN RESPIRATORY MECHANICS, IMPAIRED IMMUNE RESPONSES AND INTESTINAL ATROPHY.

NEED TO KNOW AND PREVENT THESE.

DIMINISHED WOUND HEALING, PREDISPOSITION TO INFECTION AND INCREASED POST-OPERATIVE MORBIDITY AND MORTALITY.

 SURGICAL PATIENTS
MAY HAVE ALTERED INTAKE AND ABSORPTION OF NUTRIENTS, AS WELL AS THEIR UTILISAT ION AND STORAGE BY THE BODY .THUS THEY MAY NEED NUTRITIONAL INTERVENTION MUCH SOONER THAN NORMAL HEALTHY INDIVIDUALS.

PREOPERATIVE NUTRITIONAL REPLETION HAS BEEN SHOWN TO SIGNIFICANTLY REDUCE PERIOPERATIVE MORBIDITY AND MORTALITY.

CAUSES OF INADEQUATE NUTRITION

POOR INTAKE:
POVERTY ALCOHOLISM ANOREXIA:

GIT OBSTRUCTION:

NERVOSA HYPEREMESIS CANCER SEPSIS LIVER DX

BENIGN STRICTURE. NEOPLASM. COLONIC MALIGNANCY

INADEQUATE ABSORPTON. MOTILITY DISORDERS

PSEUDO-OBSTRUCTION
MAJOR GASTRIC RESECTIONS SHORT BOWEL SYNDROME EXCESSIVE LOSSES: GIT FISTULA MALABSORPTIONS STATES INFLAMMATORY BOWEL DX

PROTEIN LOSING ENTEROPATHY

EXCESSIVE DEMAND: HYPERCATABOLIC STATES: BURNS SEPSIS TRAUMA SURGICAL STRESS

NUTRITIONAL ASSESSMENT PROCESS OF IDENTIFYING PATIENTS WHO ARE EITHER MALNOURISHED OR AT THE RISK OF DOING SO. INVOLVES:
HISTORY. PHYSICAL EXAMINATION. LABORATORY TESTS.

 HISTORY(FACTORS
PREDISPOSING TO MALNUTRITION).

ALCOHOLISM AIDS ABSORPTION DISORDERS PAST SURGICAL HX. HX OF RECENT WT LOSS. INFLAMMATORY BOWEL DX. MALIGNANCY. DETAILED DIETARY HX. INTESTINAL OBST.
GASTRECTOMY ILEAL RESECTION

PROLONGED STARVATION. PSYCHIATRIC DISORDERS ANOREXIA NERVOSA RECENT MAJOR SURGERY, TRAUMA, OR BURNS. SEVERE CARDIOPULMONARY DISEASE.

PHYSICAL EXAMINATION
OVERALL APPEARANCE: OBVIOUSLY
MALNOURISHED?. SKIN HAIR EYES/SIGHT MOUTH: CHEILOSIS, GLOSSITIS. MUCOSAL ATROPHY,DENTITION. HEART: CHAMBER ENLARGEMENT, MURMURS-HAEMIC. ABDOMEN: LIVER ,ABD. MASS, STOMAS, FISTULA. RECTUM: STOOL COLOUR, PERINEAL FISTULA NEUROLOGIC: NEUROPATHIES EXTREMITIES: MUSCLE SIZE AND STRENGTH, PEDAL OEDEMA.

 F.B.C: T.L.C. E/U/CR. LFT:

LABORATORY TESTS

AST, ALT, ALK. PHOS, BILIRUBIN, ALBUMIN, PREALBUMIN, RETINOL BINDING PROTEIN, PROTHROMBIN.

MISCELLANEOUS:
BUN, TGS,, FFA, KETONES,URIC ACID, TRANSFERIN , TRACE
ELEMENTS

USES:

SERUM ALB: < 3.5mg/dl =INCREASE PERIOPERATIVE

MORBIDITY AND MORTALITY. LONG T1/2 =20 DAYS.NOT FOR ASSESSING RESPONSE. TRANSFERIN: T1/2= 8 -10 DAYS. PREALBUMIN: T1/2 =2 -3 DAYS. RETINOL BINDING PROTEIN: T1/2 =12 HRS

IMMUNE FUNCTION: ASSESSED BY

HYPERSENSITIVITY TESTING AS WELL AS BY TOTAL LYMPHOCYTE COUNTB & T CELL FUNCTION TLC : CORRELATES WELL COUNT MAY BE ALTERED BY OTHER THINGS e.g infection, chemotherapy etc.

ANTHROPOMETRIC MEASUREMENTS:
SCIENCE OF ASSESSING BODY SIZE , WT, AND PROPORTIONS. BED SIDE MEASUREMENTS: HT AND WT

BMI = WT (kg)
HT2 (cm). BMI CAN BE USED TO ASSESS MALNUTRITION AND OVER NUTRITION. NORMAL= 18.5 -24.9

OVER WT =25 29.9

OBESITY = > 30 -40 MORBID OBESITY=
> 40

IDEAL BODY WT: USE OF TABLES DUAL ENERGY X-RAY ABSORPTIOMETRY (DEXA).

USED TO ASSESS VARIOUS BODY COMPARTMENTS- FAT, LEAN MUSCLE, MINERAL . MID HUMERAL CIRCUMFERENCE (MHC) SOMATIC PROTEIN RESERVE. MID HUMERAL MUSCLE CIRCUMFERENCE ACCOUNT FOR SUBCUTANEOUS TISSUE. THE RESULTS ARE COMPARED WITH NORMAL VALUES FOR THE PATIENTS AGE AND GENDER. TRICEPS SKIN FOLD THICKNESS.. ESTIMATES FAT RESERVE

NUTRITIONAL INDICES
PROVIDES A MEANS OF RISK STRATIFICATION AND OBJECTIVE COMPARISON AMONG PATIENTS. HELPS U TO DETERMINE WHEN TO INTERVENE AND TO ASSESS PROGRESS BEING MADE

NUTRITIONAL INDICES

SUBJECTIVE GLOBAL ASSESSMENT ONLY REPRODUCIBLE CLINICAL METHOD. HX AND P.E 5 FEATURES IN HX:
WT LOSS PAST 6 MONTHS DIETARY INTAKE GI SYMPTOMS FUNCTIONAL STATUS OR ENERGY LEVEL METABOLIC DEMANDS

4 FEATURES IN P.E:

LOSS OF SUBCUT. FAT, OEDEMA, ASCITIS AND MUSCLE WASTING.

STAGING OF MALNUTRITION

DETERMINING ENERGY REQUIREMENTS

1.

BASAL ENERGY EXPENDITURE(BEE) USING MODIFIED HARRIS-BENEDICT EQUATION. 2. TOTAL ENERGY EXPENDITURE(TEE):
1. REPRESENTS THE CALORIC NEEDS OF THE BODY UNDER CERTAIN PATHOPHYSIOLOGICAL STRESSES. 2. TEE = BEE + A DISEASE SPECIFIC STRESS FACTOR. 3. TEE SHOULD THEN BE USED TO DETERMINE NUTRITIONAL SUPPLEMENTATION NEEDS.

INDIRECT CALORIMETRY
MOST ACCURATE METHOD OF MEASURING DAILY CALORIC REQUIREMENT.
USING A METABOLIC CART IS CUMBERSOME AND EXPENSIVE. USING THE WEIR FORMULA. VCO2 , V02 , URINE NITROGEN. R.E.E (Kcal/min) = ( 3.9*VO2)+(1.1*VCO20- (2.2*URINE NITROGEN)

BASAL METABOLIC RATE:

ENERGY REQUIRED TO CARRY OUT BASAL METABOLIC PROCESSES. 50%=WORK OF ION PUMPING. 30%= WORK OF PROTEIN TURNOVER. 20%=. RECYCLING OF AMINO ACIDS,GLUCOSE,LACTATE,PYRUVATE.

TOTAL ENERGY EXPENDITURE:THE SUM OF ENERGY

CONSUMED IN BASAL PROCESSES, PHYSICAL ACTIVITY ,THE SPECIFIC DYNAMIC ACTION OF PROTEIN(DIET INDUCED THERMOGENESIS),AND REQUIREMENTS RESULTING FROM INJURY, SEPSIS, OR BURNS.

ENERGY ABOVE BASAL NEEDS IS ABOUT 10% FOR ELECTIVE

OP, 10 -30% FOR TRAUMA, 50-80% FOR SEPSIS, AND 100- 200% FOR BURNS.

 15% BASAL ENERGY REQ 4Kcal/g CALORIE-NITROGEN RATIO:

PROTEIN REQUIREMENT

THE NUMBER OF NON PROTEIN CALORIES GIVEN SHOULD BE A RATIO OF NITROGEN INTAKE. approx. 100-150kcal: 1g of NITROGEN
THIS RATIO MAXIMISES CHO AND PROTEIN ASSIMILATION AND MINIMISES METABOLIC COMPLICATIONS

1000 -2000 kcal :13g of Nitrogen. 1g of N =6.25g of protein DAILY PROTEIN NEED OF A NORMAL ADULT = O.8g/kg. MALNOURISHED, NO STRESS.

POSTOPERATIVEL, NO ORGAN FAILURE.

1.2-1.5g/kg/day.

1-2g/kg/day

SEVERELY CATABOLIC , NO ORGAN FAILURE. 1.5-2g/kg/day THESE ARE GUIDES THEYSHOULD ADJUSTED TO OPTIMISE NITROGEN BALANCE WHILE MAINTAINING THE BUN AT LESS THAN 100mg/dl and the BUN TO CREATININE RATIO AT <40. NITROGEN BALANCE: NITROGEN OUTPUT= NITRGEN XXCRET IN URINE AND FAECES + LOSSES FROM ANY OTHER SOURCEFISTULA etc FAECAL=1g NON UREA URINE NITROGEN =2-3g (OUT PUT=UUN * 24 URINE VOL.) + 3 NITROGEN BALANCE= INTAKE OUTPUT =(PROTEIN INTAKE/6.25) (UUN * VOL) + 3

 LIPID:

CHO:

35% BASAL ENERGY REQ 9 Kcal/g USUALLY FOR CALORIES AS FAT EMULSION LINOLEIC, LINOLENIC,ARACHIDONIC ARE ESSENTIAL.

WATER ELECTROLYTES..NA,K,CL, MAGNESIUM, SULPHATES,PHOSPH, CAL. VITAMINS TRACE ELEMENTS

50% BASAL ENERGY REQUIREMENT 4Kcal/g GLUCOSE SUPPLIES MOST OF THE FUEL IN NUTRITIONAL THERAPY ESP. TPN.

DAILY REQUIREMENTS

INDICATIONS FOR ENTERAL NUTRITION

GENERALLY : INTACT GIT UNABLE TO EAT OR UNWILLING TO EAT IN OTHER TO MEET 2/3 TO OF THEIR DLY NEEDS. MALNOURISHED INDIVIDUALS WITH INTACT GIT. PARTIALLY FUNCTIONING GIT SHORT BOWEL SYN, ENTEROCUTANEOUS FISTULA

 ENTERALLY:

DELIVERY OF NUTRIENTS
ORAL ROUTE..NATURAL ROUTE TUBE FEEDING:
PREPYLORIC ACCESS VIA NG TUBES;NOT FOR: DELAYED GASTRIC EMPTYING GOO HX OF REPEATED ASPIRATION. NO GAG REFLEX. NOTE FINE BORE NG TUBES 1mm. Better tolerance POST PYLORIC ACCESS: NASODUODENAL OR NASOJEJUNAL TUBES PREFERED TO NGT IN THE FACE OF THE ABOVE PROBLEMS. DOUBLE LUMEN TUBES OROGASTRIC: NASAL OBSTRUCTION,SEVERE FACIAL FRACTURES.R/O SKULL BASE #

CONFIRM TUBE PLACEMENT RADIOLOGICALLY.

PHARYNGOSTOMY. CERVICAL OESOPHAGOSTOMY. TUBE ENTEROSTOMIES: GASTROSTOMY: STAMM

JANEWAY..PERMANENT..GASTRIC TUBE
PEG. HAS ITS OWN SPECIFIC CONTRAINDICATIONS OESOPHAGEAL OBTS. ASCITIS SEPSIS BLEEDING TENDENCY PERITONEAL DIALYSIS JEJUNOSTOMY: WITZEL(SEROMUSCULAR TUNNEL) NEEDLE

KEDAR- SENN TECHNIQUE

WITZEL JEJUNOSTOMY

30 cm

LARGE BORE NEEDLE

ENTERAL FORMULAS: 1. POLYMERIC COMMERCIAL FORMULAS:

1. BLENDERIZED DIET.
2. NUTRITIONALLY COMPLETE COMMERCIAL PREPARATIONS. 1. ENSURE (HYPEROSMOLAR), OSMOLITE ,JEVITY (ISOTONIC). 2. CHEMICALLY DEFINED FORMULAS: 1. COMMONLY CALLED ELEMENTAL DIETS 2. PRE-DIGESTED AND READILY ABSORBABLE 3. A.A +TG+ SIMPLE SUGARS.

4. EXPENSIVE, UNPALATABLE
5. BLOATING, DIARRHOEA, CRAMPING. 6. VIVONEX, NEUTRAMEL 3. MODULAR FORMULATIONS: 1. SPECIAL FORMULAR FOR SPECIFIC CLINICAL CONDITIONS RENAL, HEPATIC , PULMONARY,IMMUNE DEFICIENCY. 2. EXAMPLES: PROMOD, MICROLIPID

ADVANTAGES OF ENTERAL FEEDING: PHYSIOLOGIC AND METABOLIC: ALLOWS ADMN OF COMPLEX NUTRIENT LIVER IS NOT BYPASSED STIMULUS FOR SYNTHESIS OF PROTEIN BENEFICIAL EFFECTS ON GUT MUCOSA: IMMUNOLOGICAL
TROPHIC STIMULATON, ABSORPTIVE STRUCTRE MAINTENANCE

STIMULATES FEEDING DEPENDENT NEUROENDOCRINE ACTIVITY.SECRETORY IGA NORMAL PH AND FLORA SAFETY COST

INITIATING FEEDING
10-50ml/hr ., INCREMENTS OF 1020ml/hr EVERY 8hrs. MONITORING:
SIGNS OF AB FULLNESS. GASTRIC RESIDUAL VOL.
>200ml STOP CHECK PROMOTILITY DRUGS:METOCLOPRAMIDE

PARENTERAL NUTRITION
HISTORICAL ASPECTS
1938 :ROBERT ELLMAN:
1ST SUCCESSFUL ATTEMPT USING PROTEIN HYDROLYSATES. ADMINSTERED FAT AND PROTEIN I.V TO SUPPORT AN INFANT WITH INTRACTABLE DIARRHOEA.

1944: HELRICK AND ABELSON:

1960: DUDRICK:

FIRST REALISED TPN.

PARENTERAL NUTRITION:
PERIPHERAL PN CENTRAL PN TOTAL PN

SUPPLEMENTAL
HOME HOSPITAL PARENTERAL HYPERALIMENTATION: THIS IS I.V DELIVERY OF NUTRIENTS TO A MALNOURISHED PATIENT IN A STATE OF HYPERMETABOLISM IN AMNTS AS HIGH AS 2.5* THE BASAL NEED OF A HEALTHY INDIVIDUAL OF THE SAME BODY SIZE AND SURFACE AREA TO ACHIEVE A LEVEL OF NUTRITION 40-50% ABOVE NITROGEN EQUILIBRIUM AND CONVERT THE PT INTO AN ANABOLIC STATE(+N BAL)

INDICATION FOR PN: 1. DIMINISHED INTAKE 1. GIT BLOCKED ANATOMICALLY 1. STRICTURE, MALIGNANCIES, 2. ACHALAZIA, INTESTINAL OBST

3. GOO
2. GIT FUNCTIONALLY BLOCKED 1. ILEUS:PERITONITIS,EXOMPHALOS,GASTROCHISIS 2. POST-0P: GIT, MAXILLOFACIAL, OESOPHAGEAL 3. GI IRRADIATION, CYTOTOXIC CHEMOTHERAPY. 4. ANOREXIA NERVOSA 5. HYPEREMESIS GRAVIDARUM 2. DIMINISHED ABSORPTION FROM THE INTESTINE 1. SHORT BOWEL SYNDROME, FISTULA OF GI, MALABSORPTON STATES 2. GI INFLAMMATION

3. INCREASED REQUIREMENT: BURNS, SEVERE TRAUMA, SEVERE SEPSIS,TETANUS 4. PREOPERATIVELY NUTRITIONAL REPLETION 5. AS A PRIMARY THERAPEUTIC MANOEVRE: 1. ATN 2. HEPATIC FAILURE 3. RESP FAILURE.

PPN:
SAFER SUPPLEMENTAL NUTRITION FOR < 14 DAYS FORMULATIONS: GLUCOSE 5-10% AA---2-5% FAT10-30%

OSMOLARITY:600-1000mosm/kg
DELIVERED IN A VEIN WITH A FLOW 10-50ml/min

CENTRAL PN:
TOTAL USUALLY RARELY SUPPLEMENTAL ACCESS: SUBCLAVIAN INT. JUGULAR FEMORAL RARELY TEFLON OR SILASTIC COATED CATHETERS BROVIAC OR HICKMAN TYPE.

COMPONENTS: FLUID 3L: 3 LITRE BAG DELIVERY SYSTEM AMINO ACID 45% ESSENTIAL 20% BRANCHED CHAIN LEUCINE,ISOLEUCIN,VALINE 12% AROMATIC PHENYLALA,TYR,TRYPTOPHAN OTHERS CALORIES GLUCOSE 50%-70%,FAT 20-30% ELECTROLYTES TRACE ELEMENTS VITAMINS MISCELLANEOUS-HEPARIN, INSULIN etc.

ADMINISTRATION:

GRADUAL 1000Kcal/DAY, INCREASE BY 500ml/day UNTIL GOAL IS ACHIEVED.

MONITORING:
DAILY. WT FLUID BALANCE

FBC
E/U/C GLUCOSE ACIDBASE STATUS THRICE WKLY: CAL, MG, PHOSPHATE PLASMA PROTEINS

LFT
COAGULATION SCREEN FORTHNIGHT-2WK B12, FOLATE, IRON, LACTATE, TG, TRACE ELEMENTS.

TPN THERAPY ORDERS

COMPLICATIONS:
ENTERAL AND PARENTERL

 NUTRITIONAL SUPPORT AVAILABLE > 2DECADES. PROVEN TO BE OF VALUE IN SURGERY STILL IN ITS INFANCY ADVANCES IN NUTRITION & NUTRITIONAL PHARMACOLOGY WILL CONTRIBUTE TO IMPROVEMENT IN DX OUTCOME THAT HAVE TODAY SIGNIFICANT MORTALITY. NEED TO IMPROVE SAFETY,REDUCE COST AND MAKE IT EASIER TO ADMINISTER. SOME ADVANCES IN DX TREATMENT TO BYE PASS NUTRITIONAL THERAPY AND FIND PERMANENT CURE FOR THE VARIOUS CAUSES OF INTESTINAL FAILURE HAVE YIELDED GOOD RESULTSMALL BOWEL TRANSPLANTATION.

CONCLUSION

THANK YOU