Nutritional Support in Surgical Patients
Dr. Ahmed khan
Definition
Nutritional support is an adjuvant therapy used to support the surgical patients until they can sustain themselves with adequate spontaneous nutrition by mouth.
Severely malnourished patient with wasting of fat and muscle
Consequence of malnutrition in the surgical Patient
- Reduced Gut Barrier Function
- Poor wound healing and collagen maturation
- Poor immune function
- Reduced muscle strength β
- Respiratory muscle
- Atelectasis and
- pneumonia.
- Psychological β Apathy and depression
Indications Of Nutritional support
In general, should be considered in any patient who is unable to take or resume an adequate dietary intake for more than 5 days.
-
Patient who cannot eat, e.g.
- Esophageal/gastric outlet obstruction.
- Head and neck surgery or injury.
- Stroke or other neurological problem.
-
Patient who cannot eat enough, i.e.,
- hypermetabolic states.
- Severe burns
- Major trauma
- Sepsis.
-
Patient who wonβt eat
- Patient with anorexia due to malignant disease.
- Depression, eating disorders.
-
Patient who should not eat
- Inflammatory bowel disease
- GI fistulae
- Bowel obstruction
- Prolonged paralytic ileus
- Radiation enteritis
- Intestinal failure.
The principles of nutritional Support
Pre-operative nutrition: is indicated in severely malnourished patients (weight loss is >20%).
Postoperative Nutritional Support -
TPN (Total parenteral nutrition) is established:
- within 5β7 days for a depleted patient, and
- within 7β10 days for a normal patient.
Early Enteral Feeding - nutrition: is prefered to avoid bacterial translocation.
Fluid requirements
-
100 ml/ kg/day β first 10 kg body wt.
-
50 ml / kg /day- for next 10 kg
-
20 ml / kg /day- for each additional kg (Example: 70 Kg : 1000+500+1000=2500ml=2.5L)
-
1 ml of water / cal. / day
-
Adjust in patients:
- who cannot tolerate large volume
- additional fluid loss
- febrile or septic
Nutritional Requirements:
- Water β 35 ml/kg/day
- Energy β 30 kcal/kg/day
- Na+β1 to 1.5 mmol/kg/day
- K+ β 1 mmol/kg/day
- Fat β 1-1.5-2 gm/kg/day
- Carbohydrate β 2-8g/kg/day
- Protein β 1.5-2g/kg/day
- Vitamins β Variable daily allowance.
- Minerals β Zinc, magnesium, phosphate, selenium
- Nitrogen β 0.15 β 0.2 gm/kg/day (6.25 gm protein = 1gm Nitrogen)
Parameters to Assess Nutritional Status:
-
History: Presence of weight loss and dietary history (significant Wt. loss 15-20%)
-
Physical examination includes testing of muscle power, peripheral edema, angular stomatitis, glossitis.
- Muscle power is assessed by handgrip strength and respiratory muscle function.
-
Body weightβ Unintentional weight loss of greater than 10 percent of a patientβs weight in the preceding 6 months is a good prognostic indicator of poor clinical outcome.
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Body Mass Index (BMI)
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Anthropometric measurements ( human body measurements) TSF & MAC
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Biochemical Assessment (albumin-transferrin-retinal binding protein- prealbumin) and
-
immunological assessment (Lymphocyte count)
Clinical assessment based on history and physical examination better than laboratory measurements in identifying malnourished patients.
Simple Starvation vs. Post-Surgery
| Feature | Simple Starvation | Post-Surgery | |
|---|---|---|---|
| Energy expenditure | β | β | |
| Nitrogen loss | β | β | |
| Glucose use by brain | β* | ||
| Use of fat for fuel | β | β | |
| Lipolysis | β | β |
- RBC, WBC, renal medulla, neurons, muscles & intestinal mucosa supply maintained
Question
When a severely malnourished patient starts receiving TPN, his laboratory tests show a rapid drop in potassium, magnesium, and phosphorus levels. The findings indicate which of the following conditions
A. Fluid shock B. Hypervolemia C. Hypovolemia D. Refeeding syndrome
ILOs
At the end of this presentation students will be able to describe:
- The pathophysiology & importance of nutritional support
- Aims of nutritional support measures
- Indications & complications of different forms of nutritional support.
BOOK REFERENCE
PRINCIPLES AND PRACTICE OF SURGERY 6th edition: PAGE NO: 38-44