Surgical nutrition

* Malnutrition causes:
o Delayed wound healing
o Reduced ventilatory capacity
o Reduced immunity and increased risk of infection
* Does improving nutritional status influence outcome?
* Currently the topic of intensive investigation
Nutritional assessment
* Clinical assessment
o eight loss
o !"# $mild malnutrition
o %"# $ severe malnutrition
o &ody mass inde'
* (nthropometric assessment
o )riceps skin fold thickness
o Mid arm circumference
o *and grip strength
* &lood indices
o Reduced serum al+umin, preal+umin or transferrin
o -ymphocyte count
* ./nd0of0+edogram1
* No inde' of nutritional assessment shown to +e superior to clinical assessment
Methods of nutritional support
* 2se gastrointestinal tract if availa+le
* 3rolonged post0operative starvation is pro+a+ly not re4uired
* /arly enteral nutrition reduced post0operative mor+idity
/nteral feeding
* 3revents intestinal mucosal atrophy
* Supports gut associated immunological shield
* (ttenuates hypermeta+olic response to in5ury and surgery
* Cheaper than )3N and has fewer complications
* 3olymeric li4uid diet
o Short peptides, medium chain triglycerides and polysaccharides
o 6itamins and trace elements
* /lemental diet
o -0amino acids, simple sugars
o /'pensive and unpalata+le
o *igh osmolarity can cause diarrhoea
* /nteral feed can +e taken orally or +y N7)
* Nasoenteral tu+e 0 usually fine +ore
* -ong term feeding can +e +y:
o Surgical gastrostomy, 5e5unostomy
o 3ercutaneous endoscopic gastrostomy
o Needle catheter 5e5unostomy
* Rate of infusion 8 often started at low rate and increased
* Strength of initial feed 8 often diluted and strength gradually increased
* Complications of enteral feeding
o Malposition and +lockage of tu+e
o 7astrooesophageal reflu'
o 9eed intolerance
3arenteral nutrition
* :ntestinal failure $ .( reduction in functioning gut mass +elow the minimal necessary for ade4uate
digestion and a+sorption of nutrients1
* 2seful concept for assessing need for )3N
* Can +e given +y either a peripheral or central line
:ndications for total parenteral nutrition
* (+solute indications
o /nterocutaneous fistulae
* Relative indications
o Moderate or severe malnutrition
o (cute pancreatitis
o (+dominal sepsis
o 3rolonged ileus
o Ma5or trauma and +urns
o Severe inflammatory +owel disease
3eripheral parenteral nutrition
* *yperosmotic solution
* Significant pro+lem with throm+ophle+itis
* Need to change cannulas every ;<0 <= hours
* No evidence to support it as a clinically important therapy
* Composition 0 !;g nitrogen, ;""" Calories
Central parenteral nutrition
* *yperosmolar, low p* and irritant to vessel walls
* )ypical feed contains the following in ;>?-
* !<g nitrogen as - amino acids
* ;?"g glucose
* ?"" ml ;"# lipid emulsion
* !"" mmol Na@
* !"" mmol A@
* !?" mmol Cl0
* !? mmol Mg;@
* !% mmol Ca;@
* %" mmol 3B<;0
* ">< mmol Cn;@
* ater and fat solu+le vitamins
* )race elements
Complications of su+clavian and 5ugular central venous lines
!"# of central lines develop significant complications
* 3ro+lems of insertion
o 9ailure to cannulate
o 3neumothora'
o *aemothora'
o (rterial puncture
o &rachial ple'us in5ury
o Mediastinal haematoma
o )horacic duct in5ury
* 3ro+lems of care
o -ine and systemic sepsis
o (ir em+olus
o )hrom+osis
o Catheter +reakage
Monitoring of parenteral nutrition
* 9eeding lines should only +e used for that purpose
* Drugs and +lood products should +e given via separate peripheral line
* ?# patients on )3N develop meta+olic derangement
* Nutrition should +e monitored:
o Clinically 8 eight
o &iochemically twice weekly
o 9&C, 2@/s, -9)s,
o Mg;@, Ca;@, 3B<;0, Cn;@
o Nitrogen +alance
* &lood cultures on any sign of sepsis
Meta+olic complications of parenteral nutrition
* *yponatraemia
* *ypokalaemia
* *yperchloraemia
* )race element and folate deficiency
* Deranged -9)s
* -inoleic acid deficiency