Surgical Nutrition

北京协 和医院肠外 肠内营养科： 用药样品一

览
Nutritional Support may supplement normal
feeding, or completely replace normal feeding
into the gastrointestinal tract
什么是肠外营养 (PN) ？
1963 实验室研究

Oral food
8 weeks

全静脉 营养
8 weeks

引自 Dudrick
Wilmore
什么是肠外营养 (PN) ？
1964 临床研究
先天性
腹壁缺 损
全静脉 营养
2 years
After birth

引自 Wilmore
Dudrick
肠外营养发展的里程碑

脂肪乳系统 葡萄糖系统

氨基酸系统

1961 年 1968 年
Wretlind Stanley Dudrick
安全的脂肪乳剂 中央静脉插管

1937 年
Robert Elman1930 40 50 60 70 80
氨基酸＋葡萄糖
Benefits of Nutritional Support

• Preservation of nutritional
status
• Prevention of complications of
protein malnutrition
∀ ↓ Post-operative complications
Who requires nutritional support?

• Patients already with malnutrition -

surgery/trauma/sepsis

• Patients at risk of malnutrition

Patients at risk of malnutrition

Depleted reserves
Cannot eat for > 5 days
Impaired bowel function
Critical Illness
Need for prolonged bowel rest
How do we detect malnutrition?
Nutritional Assessment

History
Physical examination
Anthropometric measurements
Laboratory investigations
 Nutritional Assessment
History
• Dietary history
• Significant weight loss within last 6 months
• > 15% loss of body weight
• compare with ideal weight
• Beware the patient with ascites/ edema
Nutritional Assessment
Physical Examination

• Evidence of muscle wasting

• Depletion of subcutaneous fat
• Peripheral edema, ascites
• Features of Vitamin deficiency
• eg nail and mucosal changes
• Ecchymosis and easy bruising
• Easy to detect >15% loss
 Nutritional Assessment
Anthropometry
• Weight for Height comparison
• Body Mass Index (<19, or >10% decrease)
• Triceps-skinfold
• Mid arm muscle circumference
• Bioelectric impedance
• Hand grip dynamometry
• Urinary creatinine / height index
 Nutritional Assessment
Lab investigations
• albumin < 30 mg/dl
• pre-albumin <12 mg/dl
• transferrin < 150 mmol/l
• total lymphocyte count < 1800 / mm3
• tests reflecting specific nutritional deficits
• eg Prothrombintime
• Skin anergy testing
Types of Nutritional Support

Enteral Nutrition
Parenteral Nutrition
Enteral Feeding is best

More physiologic
Less complications
Gut mucosa preserved
No bacterial translocation
Cheaper
Enteral Feeding is indicated

When nutritional suport is needed

Functioning gut present
No contra-indications
no ileus, no recent anastomosis, no
fistula
 Types of feeding tubes

Tubes inserted down the upper GIT, following normal anatomy

Naso-gastric tubes
Oro-gastric tubes
Naso-duodenal tubes
Naso-jejunal tubes
 Types of feeding tubes
Tubes that require an invasive procedure for insertion

Gastrostomy tubes
• Percutaneous Endoscopic Gastrostomy (PEG)
• Open Gastrostomy

Jejunostomy tubes
 What can we give in tube
feeding?
Blenderised feeds

Commercially prepared feeds

• Polymeric
• eg Isocal, Ensure, Jevity
• Monomeric / elemental
• eg Vivonex
Complications of enteral feeding
12% overall complication rate

Gastrointestinal complications
Mechanical complications
Metabolic complications
Infectious complications
Complications of enteral feeding
Gastrointestinal

Distension
Nausea and vomiting
Diarrhoea
Constipation
Intestinal ischaemia
Complications of enteral feeding

Infectious

Aspiration Pneumonia
Bacterial contamination
Complications of enteral feeding
Mechanical

Malposition of feeding tube

Sinusitis
Ulcerations / erosions
Blockage of tubes
Parenteral Nutrition
1904 Paul Friedrich

• Friedrich 把脂肪、糖和电解质通过皮
下输入进行肠外营养 , 但是这种方法实
在是太疼了！
无菌 配液室
实验研 究
层流配液
室
 卡比娃娃（蔡惟） ——
生命奇迹，已载入吉尼斯世界记
录
图为 1994 年周绮思母女与英脱利匹特的发明者、三次荣获诺贝尔提名的惠特林教
授合影
Parenteral Nutrition
Allows greater caloric intake

BUT

Is more expensive
Has more complications
Needs more technical expertise
 Who will benefit from
parenteral nutrition?
Patients with/who
• Abnormal Gut function
• Cannot consume adequate amounts of nutrients by
enteral feeding
• Are anticipated to not be able to eat orally by 5 days
• Prognosis warrants aggressive nutritional support
 Two main forms of
parenteral nutrition
• Peripheral Parenteral Nutrition
• Central (Total) Parenteral Nutrition

Both differ in • composition of feed

• primary caloric source
• potential complications
• method of administration
肠外营 养支 持途径 的建 立
•静脉 切开插 管
•胸前 隧道 Por t
•经外 周中央 静脉 插管
（ PI CC ）
 Peripheral Parenteral Nutrition

Given through peripheral vein

• short term use
• mildly stressed patients
• low caloric requirements
• needs large amounts of fluid
• contraindications to central TPN
What to do before starting
TPN

Nutritional Assessment
Venous access evaluation
Baseline weight
Baseline lab investigations
 Venous Access for TPN
Need venous access to a “large” central line
with fast flow to avoid thrombophlebitis
• Long peripheral line
• subclavian approach
Superior Vena Cava
• internal jugular approach
• external jugular approach
Baseline Lab Investigations
• Full blood count
• Coagulation screen
• Screening Panel # 1
• Ca++, Mg++, PO42-
• Lipid Panel # 1
• Other tests when indicated
 Steps to ordering TPN
Determine Total Fluid Volume

Determine Non-N Caloric needs Decide how much fat &

carbohydrate to give

Determine Protein requirements

Determine Electrolyte and Trace

element requirements

Determine need for additives

 Steps to ordering TPN
Determine Total Fluid Volume

Determine Caloric needs Decide how much fat &

carbohydrate to give

Determine Protein requirements

Determine Electrolyte and Trace

element requirements

Determine need for additives

 How much volume to give?
• Cater for maintenance & on going losses
• Normal maintenance requirements
• By body weight
• alternatively, 30 to 50 ml/kg/day
• Add on going losses based on I/O chart
• Consider insensible fluid losses also
• eg add 10% for every oC rise in temperature
 Steps to ordering TPN
Determine Total Fluid Volume

Determine Caloric needs Decide how much fat &

carbohydrate to give

Determine Protein requirements

Determine Electrolyte and Trace

element requirements

Determine need for additives

 Caloric requirements
Based on Total Energy Expenditure

• Can be estimated using predictive equations

TEE = REE + Stress Factor + Activity Factor

• Can be measured using metabolic cart

 Caloric requirements
Stress Factor
•Malnutrition - 30% •Moderate infection + 20%
•peritonitis + 15% •Severe infection + 40%
•soft tissue trauma + 15% •<20% BSA Burns + 50%
•fracture + 20% •20-40% BSA Burns + 80%
•fever (per oC rise) + 13% •>40% BSA Burns + 100%
Caloric requirements
Activity Factor

Bed-bound + 20%

Ambulant + 30%

Active + 50%
Caloric requirements
REE Predictive equations
Harris-Benedict Equation
Males: REE = 66 + (13.7W) + (5H) - 6.8A
Females: REE= 655 + (9.6W) + 1.8H - 4.7A

Schofield Equation

25 to 30 kcal/kg/day
 How much CHO & Fats?
• “Too much of a good thing causes
problems”
• Not more than 4 mg / kg / min Dextrose
(less than 6 g / kg / day)
Rosmarin et al, Nutr Clin Pract 1996,11:151-6
• Not more than 0.7 mg / kg / min Lipid
(less than 1 g / kg / day)
Moore & Cerra, 1991
 How much CHO & Fats?
• Fats usually form 25 to 30% of calories
• Not more than 40 to 50%
• Increase usually in severe stress
• Aim for serum TG levels < 350 mg/dl or 3.95
mmol / l

• CHO usually form 70-75 % of calories

 Steps to ordering TPN
Determine Total Fluid Volume

Determine Caloric needs Decide how much fat &

carbohydrate to give

Determine Protein requirements

Determine Electrolyte and Trace

element requirements

Determine need for additives

 How much protein to give?
• Based on calorie : nitrogen ratio

• Based on degree of stress & body weight

• Based on Nitrogen Balance

 Calorie : Nitrogen Ratio

Normal ratio is
150 cal : 1g Nitrogen

Critically ill patients

85 to 100 cal : 1 g Nitrogen in
 Based on Stress & BW
• Non-stress patients 0.8 g / kg / day

• Mild stress 1.0 to 1.2 g / kg / day

• Moderate stress 1.3 to 1.75 g / kg / day

• Severe stress 2 to 2.5 g / kg / day

Based on Nitrogen Balance

Aim for positive balance of

1.5 to 2g / kg / day
 Steps to ordering TPN
Determine Total Fluid Volume

Determine Protein requirements

Determine Non-N Caloric needs Decide how much fat &

carbohydrate to give

Determine Electrolyte and Trace

element requirements

Determine need for additives

 Electrolyte Requirements
Cater for maintenance + replacement needs

Na+ 1 to 2 mmol/kg/d (or 60-120 meq/d)

K+ 0.5 to 1 mmol/kg/d (or 30 - 60 meq/d)
Mg++ 0.35 to 0.45 meq/kg/d (or 10 to 20 meq /d)
Ca++ 0.2 to 0.3 meq/kg/d (or 10 to 15 meq/d)
PO42- 20 to 30 mmol/d
 Trace Elements

Total requirements not well established

Commercial preparations exist to provide RDA
• Zn 2-4 mg/day
• Cr 10-15 ug/day
• Cu 0.3 to 0.5 mg/day
• Mn 0.4 to 0.8 mg/day
 Steps to ordering TPN
Determine Total Fluid Volume

Determine Protein requirements

Determine Non-N Caloric needs Decide how much fat &

carbohydrate to give

Determine Electrolyte and Trace

element requirements

Determine need for additives

 Other Additives
• Vitamins
• Give 2-3x that recommended for oral intake
• us give 1 ampoule MultiVit per bag of TPN
• MultiVit does not include Vit K
• can give 1 mg/day or 5-10 mg/wk
 Other Additives
• Medications
• Insulin
• can give initial SI based on sliding scale according
to hypocount q6h (keep <11 mmol/l)
• once stable, give 2/3 total requirements in TPN & review daily

• alternate regimes
– 0.1 u per g dextrose in TPN
– 10 u per litre TPN initial dose

• Other medications
 TPN Monitoring

Clinical Review
Lab investigations

Adjust TPN order accordingly

 Clinical Review
• clinical examination
• vital signs
• fluid balance
• catheter care
• sepsis review
• blood sugar profile
• Body weight
 Lab investigations
• Full Blood Count • weekly, unless indicated
• Renal Panel # 1 • daily until stable, then 2x/wk
• Ca++, Mg++, PO42- • daily until stable, then 2x/wk
• Liver Function Test • weekly
• Iron Panel • weekly
• Lipid Panel • 1-2x/wk
• Nitrogen Balance • weekly
 Nutritional Balance
Nutritional Balance = N input - N output

1gN = 6.25 g protein

N input = (protein in g  6.25)
N output = 24h urinary urea nitrogen + non-
urinary N losses
(estimated normal non-urinary Nitrogen losses
about 3-4g/d)
Complications related to TPN

• Mechanical Complications
• Metabolic Complications
• Infectious Complications
 Mechanical Complications
Related to vascular access technique

• pneumothorax • brachial plexus injury

• air embolism • catheter malplacement
• arterial injury • catheter embolism
• bleeding • thoracic duct injury
Mechanical Complications
Related to catheter in situ

Venous thrombosis
catheter occlusion
Metabolic Complications
Abnormalities related to excessive or
inadequate administration

hyper / hypoglycaemia
electrolyte abnormalities
acid-base disorders
hyperlipidaemia
Metabolic Complications
Hepatic complications

Biochemical abnormalities
Cholestatic jaundice
• too much calories (carbohydrate intake)
• too much fat
Acalculous cholecystitis
Infectious Complications
• Insertion site contamination
• Catheter contamination
• improper insertion technique
• use of catheter for non-feeding
purposes
• contaminated TPN solution
• contaminated tubing
• Secondary contamination
• septicaemia
 Stopping TPN
• Stop TPN when enteral feeding can restart
• Wean slowly to avoid hypoglycaemia
• Monitor hypocounts during wean
• Give IV Dextrose 10% solution at previous
infusion rate for at least 4 to 6h
• Alternatively, wean TPN while introducing
enteral feeding and stop when enteral intake
meets TEE
 Case Study 1

A 48 year old man was admitted after a road

traffic accident in which he suffered multiple
fractures to his lower limbs and head injuries.
He is scheduled for an operation to fix his
fractures tomorrow. How would you feed this
man?
 Case Study 2

54 year old man was admitted into the

hospital for treatment after a stroke. He has
problems with swallowing and tends to choke
whenever he is given fluids to drink. How
would you feed him?
 Case
Study 3
A 20 year old (65kg) man is admitted
with blunt abdominal trauma. At
surgery a liver laceration is repaired

What are his nutritional requirements

How should nutritional therapy be

delivered
 Case Study 4
• A 50 year old man (60)kg had a bowel
resection. On the 8th POD he developed
a enterocutaneous fistula and was septic.
His urine N loss was 14 g/dl.

What are his nutritional problems

How can nutritional therapy help in his

recovery ?
 Case Study 5

Mdm X is a 54 year old Chinese lady who

underwent a laparotomy for volvulus of the
small bowel. At operation, resection of the
gangrenous bowel was carried out. Only 20
cm of midgut remained. How do you propose
to feed her?
 Case Study 5 (continued)
Mdm X weighed 50 kg before operation.
She is well hydrated with good urine
output
Her lab investigation results included the
following:
Na 140 mmol/l Total Bilirubin 4 mmol/l
K 3.0 mmol/l Albumin 35 mg/l
Rest of electrolytes normal ALP and GGT normal