Post Operative Nutrition Basic

8/8/2019 Post Operative Nutrition Basic

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Metabolic responses to starvation

After 12 hrs Starvation

Plasma Insulin Levels drop Glucagon Rises

Hepatic glycogenolysis

Muscle glycogenolysis


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After 24 hrs

Hepatic gluconeogenesis from proteins,

muscles

75 gram protein/day to 300 g of protein per

day may be lost


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Longer fasting

Fat stores mobilized

- glycerol and fatty acids

- ketogenesis 2-3 wks brain adapts to use ketones instead of

glucose

This reduces muscle breakdown

ATP-dependent pathways are suppressed


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Indications for nutritional intervention

Compromise in

Physiology

Immunity

Wound healing

Malnutrition

Infections**

Malignancy


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Indices

Clinical History

Body Composition Analysis

Anthropometry

Respiratory function Triceps thickness, Mid-arm circumference

Biomarkers:

- Pre-albumin

TBP

Nitrogen balance

End-of-bed-ogram


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Nitrogen Balance

measuring 24-hour losses

24-hour urine collection

nitrogen loss is compared with nitrogen

intake, and nitrogen balance is thus obtained.

Nitrogen balance = Intake - Loss (urine 90%,

stool 5%, others 5%)


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Measurements of Immunologic

Function Delayed cutaneous hypersensitivity (anergy)

most commonly tested by delayed reaction to skin

antigens

trauma or infection, anergy to injected cutaneous

recall antigens is associated with high mortality andmorbidity

Neutrophil function


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Glucose

Glucose is the preferred carbohydrate sourcein traditional TPN

Infused glucose has nitrogen-sparing effect:

1. hepatic gluconeogenesis is suppressed.

2. glucose itself is an energy substrate, so fewer

amino acids need be oxidized for energy


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maximum suppression of gluconeogenesis isachieved @infusion rates of4 mg/kg/min

(400 g/day for a 70-kg man)

@infusions rates higher than 9 mg/kg/min

glucose is degraded by nonoxidative pathways,leading to net synthesis of lipid.


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Toxicity of Hyperglycemia and

Excessive Calorie Administration Excess carbohydrate is converted to fat in the liver

-de novo lipogenesis

increase in Vco2

-impaired ventilatory function

Immunosuppression

increased frequency of nosocomial infections.


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Hyperglycaemia

Impairs

chemotaxis

Adherence

Phagocytosis

bactericidal function

* immunosuppression*


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Hypocaloric feeding

diabetic patient with difficult-to-control

blood sugar

massively volume overloaded patient in renal

failure

patient with poor oxygenation who is being

maintained on high ventilatory support


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reasonable protein goal - 1.5 g/kg/day

total calories - 1000kcal/day

limit excessive volume administration

obese patients- have large fat stores


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IMUNONUTRITION

Glutamine free amino acid in the extra and

intracellular compartments

nitrogen transport

acid base homeostasis

fuel for rapidly dividing cells such as

enterocytes, lymphocytes and fibroblasts

antioxidant defence mechanisms by

influencing glutathione synthesis

severe stress or nutritional depletion the

demand < body's capacity to synthesise it.


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Bioelectrical Impedance

Accumulation of lean body mass is theprincipal objective of nutritional support

Bioelectrical Impedance

Exchange of Labeled Ions- Na , K

Neutron Activation Analysis

Computed Tomography

Indirect Calorimetry (RQ)


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creatinine-height index

triceps skinfold thickness

Mid arm circumference ideal body weight (IBW) -before and after


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Carbohydrate:

Gets used in 24hrs

Protein:

Daily 60gm is used,

75 to 300 gm/day in post op

Fat

Daily use 150g

Higher in long starvation


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Cachexia of Cancer

reduced food intake altered metabolic rate

endocrine abnormalities

anticancer treatments cytokines - TNF, IL-1, IL-6, and IFN-

deranged central nervous system satiety

mechanisms Proteolysis-inducing factor (PIF).


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Marked muscle wasting in advanced cancer.

increased rate of ATP-dependent proteolysis with

increased levels of mRNA for ubiquitin and subunits

of the proteolysis-inducing factor (PIF)activates the

ubiquitin-proteasome pathway in muscle

treatment with eicosapentaenoic acid (EPA), blocks

formation of 15-hydroxyeicosatetraenoic acid by PIFin muscle cells, inhibits weight loss even in those

with advanced disease


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Indications for Nutrition Support

1. The patient's premorbid state (healthy or otherwise)

2. Poor nutritional status (current oral intake meeting 7 days' inanition)


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5. An anticipated duration of artificial nutrition

(particularly total parenteral nutrition [TPN]) of

longer than 7 days

6. The degree of the anticipated insult, surgical or

otherwise

7. A serum albumin value less than 3.0 g/dL

measured in the absence of an inflammatory state

8. A transferrin level of less than 200 mg/dL

9. Anergy to injected antigens


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Additional variables

Infections- upto 60%

Thyrotoxicosis

Metabolic disorders

Short bowel

Cancer patient

Burns 110% Multi-organ failure

Obstuctive pathology like Ca- Esophagus,

Distal Stomach


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BMR variations

Patient condition

No post op complications,Fistula without infection

Mild peritonitis, long bonefracture, mild-mod injury

Severe injury, ICU infection,MOF

40- 100% Burns

BMR

Normal

25% above

50% above normal

100% above normal


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Nutrition

Calories- 25-35kcal/kg body wt

Proteins- 1.5 g/kg0.8 to 2 or 2.5g/kg body wt

1g nitrogen (6.25g protein) /150kcal/day


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Vitamins, Trace elements

short-bowel syndrome

extensive ileal resection

pancreatic insufficiency


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Entero-hepatic Circulation

Minerals-zinc, copper, manganese, selenium

Vitamins -cobalamin, folate

Fat-soluble vitamins A, D, E, and K


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DAILY DOSAGE

Vitamins: Water soluble

Thiamine 25 mg

Riboflavin 25 mg

Niacin 200 mg

Pantothenic acid 50 mg

Pyridoxine 50 mg

Folic acid 2.5 mg

Vitamin B12 5 mg


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Fat soluble Vitamins

A- 5000 g

D-

400 g

E 100 g

K 10 mg


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Trace Elements

Zinc 10-20 mg

Copper 0.5-2.0 mg

Chromium 20 g Selenium 70-150 g

Manganese 2-2.5 mg

Iron 25 mg


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Initiation ofNutrition Support

Poor nutritional status (oral intake 10%)

Anticipated duration of artificial nutrition

longer than 7 days

Nonfunctioning gastrointestinal tract

Serum albumin


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Enhanced recovery of patients after

surgery (ERAS)

avoidance of long periods of pre-operative fasting;

re-establishment of oral feeding as early as possibleafter surgery;

integration of nutrition into the overall managementof the patient;

metabolic control, e.g. of blood glucose; electrolytes

reduction of factors which exacerbate stress-related

catabolism or impair gastrointestinal function; early mobilisation


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EN advantages

Prevents intestinal mucosal atrophy

Supports gut associated immunological shield

principal defense against an enteral osmoticload

Cheaper than TPN and has fewer

complications


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Routes for Administration of

Enteral Feeding

Nasogastric tube

Dobhoff tube feeding tubes with indwelling removable

metal stylet

rigid plastic overtube


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Gastrostomy

Stamm gastrostomy- a small laparotomy incision, LUQ

PEG-

Necrosis of the gastric wall

Erythema, Induration

leak due to pull

granulation tissue with intermittent bleeding

continuous drainage.

Percutaneous techniques-

Adhesions, colon perforation, open revision


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Jejunostomy

open jejunostomy

percutaneous -G-J tube

percutaneous - fluoroscopic or CT guidance

continuous fashion feeding

watching for signs of intolerancehypo-osmolar or at most iso-osmolar solutions

Risk ofpneumatosis, necrosis, perforation, and

death


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Gastric feeding

Mortality

Propped up position

hypo-osmolar feeds first

Then, increase osmolality & then volume

? Gastric residual volume

Avoid hyperosmolar feeding:

Pneumatosis bowel necrosis

Perforation mortality


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Parenteral Feeding

>900 mOsm/L

CVL

peripheralTPN (dextrose < 5%) Costly

? Benefit over enteral nutrition

? Complications

Feed tailored??


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Indications

Gastrointestinal cutaneous fistulas

Renal failure (ATN)

Short-bowel syndrome Acute burns

Hepatic failure

?Crohn's disease, Anorexia nervosa ?


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Supportive Benefit

Acute radiation enteritis

Acute chemotherapy toxicity

Prolonged ileus

Weight loss preliminary to major surgery

? Prolonged ventilatory support


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TNA

Total nutrient admixture- 3 in 1

1. Limits the number of central venous

catheter violations and chance for

contamination 2. Produces a hyperosmolar environment in

the TNA solution that protects against

bacterial growth 3. Allows continuous infusion, thereby

ensuring lipid administration at a safe rate

(


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common stock solutions

70% dextrose, 10% to 20% amino acids, and

20% lipid

1 L of solution in the absence of fat, the

maximal achievable concentrations are

7% amino acids (70 g/L) and 21% dextrose (210 g/L).

Volume can be reduced with lipid

emulsification


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PARAMETER DAY 1 DAY 2 DAY 3

Volume

(mL/24 hr)

1000 1000-1500 1500-2000

Calories

(% of goal)

50% 75%, may add fat 100%

Dextrose

(g/24 hr)

100-150 150-200 200-350

Amino acids

(% of total)

50%-100% 100% 100%, check BUN

Fat No Perhaps Often (3%-5%,30-50 g/24 hr)

Insulin Give separately Add 50% to TPN Add 50% to TPN


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Mandatory Monitoring During

Intravenous Nutrition

Clinical:

Vitals

Daily fluid balance

body weight

Evidence of infection-

catheter infectionthrombophlebitis

CVP


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Laboratory:

Baseline & OD

- Electrolytes, BUN, creatinine, Ca, Mg,PO4

Glucose Q6H

Weekly- liver function, coagulation

BASELINE:

LFT, COAGULATION, ELECTROLYTES


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BMR

Male BMR = 66 + (13.7wt in kg) + (5ht in

cm) - (6.8age in yr)

Female BMR = 65.5 + (9.6wt in kg) + (1.7ht

in cm) - (4.7age in yr)


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25 to 35 kcal/kg/day

patient is underweight ABW

patient is obese (ABW is >120%

of IBW)add 25% of the difference between ABW and

IBW to the IBW as the feeding weight.

If no reliable weight is available, use IBW

alone.

IBW [Ht-152

..]*0.91+50


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TPN Formulation

STANDARD

Non-STAND

ARD

(P

rescription)


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Hickmans Cath

Hickman, Broviac, Groshong


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Port A Cath


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Complications- CVL

Catheter Sepsis- Fungemia, S. epidermidis

Catheter Thrombosis

Pneumothorax

vascular injuries (arterial or venous lacerations, delayedarteriovenous fistulas)

brachial plexus injury

chronic pain

thoracic duct injury

air embolism

Erosion of the catheter into the bronchus/ right atrium


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Hepatic dysfunction

Hyperbilirubinemia

Hepatic steatosis, cholestasis

cirrhosis and death in infants

Metabolic Bone Disease

decreased bone mineral density

increased urinary calcium or phosphate excretion

decreased PTH levels

vitamin D deficiency


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Pancreatitis

severe hypertriglyceridemia

glucose intolerance

particularly if sepsis


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Is preoperative metabolic preparation

ofthe elective patient using carbohydrate

treatment useful?

Reduces insulin tolerance

Reduces PONV

But no diff b/w CHO drink and placebo


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Is postoperative interruption of oral

nutritional intake necessary after

surgery?

Inadequate oral intake for more than 14 days

Anticipated -unable to eat for 710 days

intestinal obstructions or ileus

severe shock

intestinal ischemia


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Trends

-3 fatty acids

neutralizing antibodies to TNF

glucocorticoid receptor antagonist RU-486

glucagon-like peptide-2 (GLP-2)

Insulin-like Growth Factors

Growth Hormone

? testosterone


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Documents

Post Operative Nutrition Basic