Nutritional management in surgical patients
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This document discusses nutritional management in surgical patients. It outlines the fundamental goals of nutritional support which are to meet energy requirements, maintain core body temperature, and allow for tissue repair. Early recovery after surgery protocols aim to avoid long pre-operative fasting, establish early oral feeding, integrate nutrition into overall patient care, and encourage early mobilization. Patients who require nutritional support include those who are already malnourished, at risk of malnutrition, unable to eat due to medical reasons, unable to eat enough due to conditions like burns or trauma, or unwilling to eat due to psychological reasons. Both enteral and parenteral nutrition routes are discussed, with enteral generally being preferred when possible due to improved outcomes. Guidelines for fluid, protein,
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Nutritional management in surgical patients
- 2. By Dr Pirah Korai Pg, SU-2 CMC LARKANA Nutritional management in surgical patients
- 3. OUTLINES Introduction Fundamental goals of nutritional support ERAS Criteria Who require nutritional support? Post operative complications Criteria of malnutrition Daily fluid maintenance requirement Routes of administration of nutrition ASPEN Guidelines Enteral v/s parenteral Principles of TPN Standard regime and energy requirement
- 8. Fundamental goals of Nutritional support: To meet the energy requirement for metabolic processes To maintain a normal core body temperature For tissue repair
- 9. ERAS Criteria Avoidance of long periods of pre-operative fasting; Re-establishment of oral feeding as early as possible after surgery; Integration of nutrition into the overall management of the patient; Reduction of factors which exacerbate stress- related catabolism or impair gastrointestinal function; Metabolic control, e.g. of blood glucose; Early mobilisation
- 10. WHO REQUIRE NUTRITIONAL SUPPORT?
- 11. 11 A) Patients already with malnutrition B) Patients at risk of malnutrition WHO CANT EAT: ESOPHAGEAL/GASTRIC OUTLET OBSTRUCTION, HEAD & NECK INJURY/SURGERY, SHOCK WHO CANT EAT ENOUGH: SEVERE BURNS, MAJOR TRAUMA , SEPSIS WHO WONT EAT: ANOREXIA, DEPRESSION & EATING DISORDERS WHO SHOULD NOT EAT: BOWEL OBSTRUCTION/LEAKAGE, GI FISTULAS, SEVERE PANCREATITIS, IBD, RADIATION ENTERITIS, PROLONGED ILEUS
- 12. 12 POST-OP COMPLICATIONS • Impaired defenses – decreased immunity – decreased phagocytosis – decreased chemotaxis • Increased post-op infections • Impaired wound healing • Longer recovery period • Prolonged hospital stay
- 13. 13 IMPAIRED NUTRITION 40% 60% 40% of hospitalized patients have an impaired nutritional status
- 14. 14 33% 67% 33% of all gastrointestinal surgery patients are malnourished IMPAIRED NUTRITION
- 15. Criteria of Malnutrition • O/H: Wt loss >10-15% within 6months • BMI: <18.5 kg/m2 • Subjective global assessment: Grade C • S-Albumin: <30g/L (with no evidence of hepatic or renal dysfunction)
- 16. 1/3rd to 1/4th part of fluid to be provided by Normal saline while rest through 5% Dextrose Daily maintenance requirement:
- 17. Routesof ADMINISTRATIONOF NutritionS --- Enteral ---Parenteral ---Combined
- 18. 18 ASPEN NUTRITION SUPPORT ALGORITHM Functional GIT Yes No Enteral nutrition Parenteral nutrition Short term Long term/fluid restriction PPN Central PN GI Function returns No GI Function Standard Nutrients Speciality Formulas Normal Compromised Adequate progress to oral feeding Adequate progress to more complex diet and oral feedings as tolerated Inadequate PN supplementation Nutrient tolerance Progress to total enteral feedings Yes Nutrition Assessment
- 20. 20
- 21. 21 Principles of TPN • Used only when indicated • All devices must be managed by staff trained in aseptic • Cyclical feeds better than continuous infusion (Infusion over 10-18 hrs) • Adequate adjustments in standard solutions as & when required • Stop TPN when not needed • Never discontinue at once ( Ramp down) (Rate of infusion reduce to one half for 2 hrs, then half again for 2 hrs & then discontinue) • Careful monitoring & watch for complications
- 23. 23 Parenteral nutrition standard regimens • Energy 30 kcal/kg/day (as energy and fat) • Amino acids 1.5g/kg/day • Electrolytes basal amounts • Vitamins and trace elements basal amounts Above are maintenance requirements. Additional fluid and electrolytes may be required
- 24. Basic Energy Requirements: -Esimated total caloric need of the patient : 25- 35kcal/kg/day ( so, 1800-2100 kcal/day for a 70-kg man) -Generally 30% of calories should be via lipid (fat) and the rest by glucose (carbohydrates) -1.5 L of 20% dextrose contains 300g of Glucose and will provide 1200kcal 0.5 L of 20% Lipid emulsion contains 100g of lipids and will provide 900kcal. -Thus , a combination will provide 2100kcal in 2L of fluids
- 25. Protein Requirement: -Estimated daily requirement : 1-2g/kg/day ( so, 70g/day for a 70kg man) -0.5 L of amino acid solution can thus complete the usual nutritional requirement within daily fluid allowance.
- 26. 26 Enteral vs Parenteral Parenteral ‘guaranteed’ intake ‘never’ rejected can be used with short gut or absent gut function Less nutritionally effective than EN Hyperglycaemia Electrolyte imbalance Hyperlipidemia Constant supervision Needs long term CVC Sterility and infection considerations Costly Enteral Requires functional gut can cause solute overload Vomiting, Diarrhea Can cause perforation(rarely) Can be used to continue oral meds More effective – on-line to portal system Encourages gut motility Normalises gut flora Electrolyte imbalance unusual Less supervision Less infection Cheap(er)
- 27. SUMMARY