Nutrition

Dogma of Nutrition in Surgery

• NPO at midnight for all surgical procedures

• NPO until bowel function resumes
• Clear Full Liquid Soft Diet Regular Diet
• Nutrition stresses surgical anastomosis
• TPN early in malnourished patients
Prior Research
• Malnourished patients have worse outcomes
• Healthy individuals, when starved long enough, will develop adverse
clinical events
• 80% of surgeons agree that nutrition decreases complications and
LOS, but only 20% implement any interventions
Assessment of Nutritional
Status
• Weight loss is a significant indicator
• More than 10% unintentional loss in 6 month period.
• 5% loss in 1 month.
• Anorexia, persistent nausea, vomiting, diarrhea, malaise.
• Loss of subcutaneous fat, muscle wasting, edema, ascites.
Evaluation of Body Composition
• Ideal body weight (IBW)
• Men 106lb+ 6lb for each inch over 5 feet
• Women 100lb + 5lb for each inch over 5 ft.
• IBW depends on patient age, body habitus.
• Other measurements include triceps skin fold, arm circumference.
Body Composition

• BMI characterizes degree of obesity.

• = weight(kg)/total body surface area.
• BMI over 40 or over 35 with co-morbid conditions are considered
candidates for surgical treatment (bariatric surgery)
• Severe obesity is associated with significant increase in morbidity and
mortality.
Laboratory Markers
• Serum proteins
• Albumin half life 20 days
• Transferrin half life 8.5 days
• Prealbumin half life 1.3 days
• Severe hypoalbuminemia <2 poor outcomes
Energy Expenditure
• Can be measured by the respiratory quotient.
• RQ= CO2 production(VCO2)/O2 consumption (VO2).
• Indirect calorimetry allows for gas analysis and calculation of RQ.
RQ
• RQ of 1.0 predominant glucose utilization.
• RQ of 0.7 and 0.8 consistent with fat and protein utilization.
• RQ higher than 1.0 suggests over feeding and lipogenesis.
Nutritional Requirements
• Total energy requirements.
• Total protein requirements.
• The relative distribution of calories between carbohydrates, fats, and
protein.
Energy Requirements
• Harris-Benedict equation estimates BEE at rest.
• Men 66 + (13.7x weight) + (5x height) –(6.8 x age).
• Women 65 + (9.6 x weight) + (1.7 x height) – (4.7 x age)
• Most require 25-35 kcal/kg/day.
• Stress increases these values.
Stress
• Low stress 1.2 x BEE
• Moderate stress 1.2-1.3 x BEE
• Severe stress 1.3-1.5 x BEE
• Major burn injury 1.5-2.0 x BEE
• Requirements are increased by fever, infection, activity, burns, head
injury, trauma, renal failure, surgery.
• Decreased by sedation, paralysis, B blocker
Stress Factors
• Starvation 0.8
• Postoperative 1-1.05
• Cancer 1.1-1.45
• Peritonitis 1.05-1.25
• Sepsis 1.25-1.55
• Multiple Trauma 1.25-1.55
• Burn 1.5-1.7
Carbohydrate (30-60% of Total)
• Each gram releases 4 kcal.
• Also important in membranes as glycoproteins, glycolipids, carbon
backbone of essential amino acids.
• CHO are stored as glycogen in liver (40%), muscle (60%), cardiac
muscle.
• Stores depleted in 48hrs (starve), 24 hrs (stress).
Protein
• Essential components of all living cells, involved in virtually all bodily
functions.
• Total protein in a healthy male is 15-18% of body weight.
• 2.5% of total body protein is broken down and re-synthesized every
24hrs.
• Protein yields 4 kcal per gram.
Protein Requirements
• Most healthy individuals require 0.8-1.0 g protein/kg/day.
• Mild stress 1-1.2 g/kg/day.
• Moderate stress 1.3-1.5 g/kg/day.
• Severe stress 1.5-2.5 g/kg/day.
• Renal failure (more)
• Hepatic encephalopathy (less)
Nitrogen Balance
• A crude measurement of protein consumption.
• Difference between net nitrogen intake and excretion.
• Positive balance indicates more protein ingested than excreted.
• Negative balance is catabolism.
• Protein excretion in urine= nitrogen x 6.25g.
Lipids
• provide 25-40% of total calories.
• Fatty acids a major source of fuel for heart, liver, skeletal muscle.
• Liver oxidation of fatty acids yields ketones which are used by the
heart, brain, muscle during starvation.
• During the fed state, insulin stimulates lipogenesis and fat storage,
inhibits lipolysis in adipocytes.
Vitamins
• Deficiencies can occur in severely malnourished patients, chronic
nutritional support.
• Impaired wound healing can be a direct result of deficiencies in
Vitamin A, C, and zinc.
Deficiencies
• Vitamin A- Wound healing
• Vitamin D- Rickets, osteomalacia
• Vitamin E- Anemia, ataxia, nystagmus, edema, myopathy.
• Vitamin C- Wound healing
• Thiamine- Encephalopathy
• vit B6 - neuropathy
Stress
• The same events as starvation.
• Much more accentuated tissue protein breakdown in order to:
– Supply increased demands of energy
– Supply building blocks for acute phase reactant proteins by the
liver.
• This accentuated protein breakdown is stimulated by
– Increased steroid production
– Cytokines associated with acute stress response
Stress
• Nitrogen loss:
– 5-8 gm/d normally
– 2-4 gm/d after several days of unstressed starvation
– 30-50 gm/d under severe stress (multiple trauma, sepsis,burns)
Critical Illness
• Metabolic rate is increased
• While patients are in negative nitrogen balance, protein synthesis is
active centrally
• Fat not as available as energetic substrate
– Cortisol and catecholamines block lipolysis and oxidation of
fatty acids to ketone bodies
Protein Synthesis in Critical Illness
Reprioritization
• Albumin
• Retinol binding protein
• Transferrin

• Acute phase proteins

• Immune proteins
Nutritional Supplementation
• Benefits high risk patients such as severely malnourished, critically ill,
burns, severe trauma.
• Delayed oral intake 7-10 days.
• Enteral route is indicated in all patients with an intact, functioning GI
tract.
• Prevents intestinal atrophy, gut immune function, inhibition of stress
induced increase in intestinal permeability.
Nutritional Supplementation
• Oro-enteric, naso-enteric, gastrostomy, jejunostomy.
• Small bore NG tubes can be use for short period of time.
• Gastrostomy and jejunostomy for long term.
• Complications in placement, organ injury, aspiration, malfunction,
leaks, sinusitis, erosion..
Over Feeding
• Detected if respiratory quotient (RQ) is above 1 (determined by the
metabolic cart). That means that there is lipogenesis.
• Has adverse effects
– Respiratory failure due to excess CO2 production during
lipogenesis.
– Hepatic failure due to excess fatty liver infiltration and cholestasis.
• Overfeeding has to be completely avoided as it is harmful to the
patient.
Parenteral Feeds
• TPN- indicated when GI tract is unavailable or nonfunctional.
• Via Central catheter due to hyperosmolarity of the solutions.
• Complications related to catheters frequent.
• Severe metabolic complications can occur.
• Hyperglycemia, hypoNa, hypoK, hypoMg, hypoP,.
TPN Orders
• Calculate VOLUME requirements/24h.
• Determine PROTIEN requirements g/kg/d.
• Calculate daily CALORIES kcal/kg/d.
• Determine % to be given as protein, CHO, fats.
• Add ELECTROLYTES, TRACE ELEMENTS.
• Co-administer Lipids to prevent fatty acid deficiency.
• Lipids give more calories in less volume…
• A 10% lipid sol. 1.1kcal/ml, 20% is 2.0 kcal/ml.