LEC:3 ) 4 ( ‫العدد‬

2012/10/23 ‫االربعاء‬ ‫جراحة‬ ‫مدثر‬.‫د‬

Nutrition and fluid therapy
FJMC (A&E( ,HS(A&E(

LEARNING OBJECTIVES

The causes and consequences of malnutrition in the surgical patient

Fluid and electrolyte requirements in the pre and postoperative patient

The nutritional requirements of surgical patients

The different methods of providing nutritional support and their

complications

Reference

chapter 19, Nutrition and Fluid therapy, Bailey&Love`s Short practice of

surgery, 27th editionCRC Press ,Taylor & Francis Group, 2018.

Metabolic response to starvation

●●Low plasma insulin

●●High plasma glucagon

●●Hepatic glycogenolysis

●●Protein catabolism

●●Hepatic gluconeogenesis

●●Lipolysis: mobilisation of fat stores (increased fat oxidation)– )

overall decrease in protein and carbohydrate oxidation)

●●Adaptive ketogenesis

●●Reduction in resting energy expenditure (from approximately 03-52

kcal/kg per day to 15–20 kcal/kg per day

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Metabolic response to trauma and sepsis

●●Increased counter-regulatory hormones: adrenaline,

noradrenaline, cortisol, glucagon and growth hormone

●●Increased energy requirements (up to 40 kcal/kg per day)

●●Increased nitrogen requirements

●●Insulin resistance and glucose intolerance

●●Preferential oxidation of lipids

●●Increased gluconeogenesis and protein catabolism

●●Loss of adaptive ketogenesis

●●Fluid retention with associated hypoalbuminaemia

NUTRITIONAL ASSESSMENT

Laboratory techniques -- serum albumin

Man Kind measures Body Mass Index
Body weight and anthropometry , BMI

( A BMI of less than 18.5 indicates nutritional impairment and a BMI

below 15 is associated with significant hospital mortality.)

Anthropometric techniques incorporating measurements of skinfold

thicknesses and mid-arm circumference permit estimations of body fat
and muscle mass

Clinical:

Malnutrition Universal Screening Tool (MUST), which is a five step

screening tool to identify adults who are malnourished or at risk of under
nutrition

FLUID AND ELECTROLYTES

Maintenance fluid requirements are calculated approximately from an
estimation of insensible and obligatory losses.

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Various formulae are available for calculating fluid replacement based
on a patient’s weight or surface area .

For example, 30–40 ml kg–1 gives an estimate of daily requirements.

FLUID AND ELECTROLYTES

The following are the approximate daily requirements of some

electrolytes in adults:

•sodium: 50–90 mM day–1;

•potassium: 50 mM day–1;

•calcium: 5 mM day–1;

•magnesium: 1 mM day–1

IV solutions contain

dextrose or electrolytes or other material mixed in various proportions

with water

Can electrolyte-free water can be administered by IV?

NOO! it rapidly enters red blood cells and causes them to rupture

Crystalloid solutions

Aqueous solutions of salts, minerals or any other water soluble

substances. Saline, which is an aqueous solution of sodium chloride, is a
crystalloid. Since they contain small molecules, they can be passed
through all the cell membranes and go into cells e.g. normal saline

Types of IV Solutions according to osmolarity

Colloids:

A homogeneous mixture, The particles in colloidal solutions are of

intermediate size compared to particles in crystalloids so they remain in
intravascular compartment e.g. hetastarch

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FLUID AND ELECTROLYTES

In addition to maintenance requirements, ‘replacement’ fluids

are required to correct pre-existing deficiencies and ‘supplemental’ fluids

are required to compensate for anticipated additional

intestinal or other losses .

FLUID AND ELECTROLYTES

The nature and volumes of replacement fluids are determined by:

•A careful assessment of the patient including pulse, blood pressure and

central venous pressure, if available. Clinical examination to assess
hydration status (peripheries, skin turgor, urine output and specific
gravity of urine), urine and serum electrolytes and haematocrit.

FLUID AND ELECTROLYTES

•Estimation of losses already incurred and their nature: forexample,

vomiting, ileus, diarrhoea, excessive sweating or fluid losses from burns
or other serious inflammatory conditions.

•Estimation of supplemental fluids likely to be required in view of

anticipated future losses from drains, fistulae, nasogastric tubes or
abnormal urine or faecal losses.

FLUID AND ELECTROLYTES

•When an estimate of the volumes required has been made, the

appropriate replacement fluid can be determined from a consideration of
the electrolyte composition of gastrointestinal
secretions. Most intestinal losses are adequately replaced with normal
saline containing supplemental potassium

NUTRITIONAL REQUIREMENTS
In the majority of hospitalised patients in whom energy demands from
activity are minimal, total energy
requirements are approximately 1300–1800 kcal/day.

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The obligatory glucose requirement to meet the needs of the central
nervous system and certain haematopoietic cells,
which is equivalent to about 2 g/kg per day.

There is no evidence to suggest that any particular ratio of glucose to fat

is optimal as long as under all conditions the basal requirements for
glucose (100–200 g/ day) and essential fatty acids (100–200 g/week) are
met.

NUTRITIONAL REQUIREMENTS

The basic requirement for nitrogen in patients without pre-existing

malnutrition and without metabolic stress is 0.10–0.15 g/kg per day. In
hypermetabolic patients, the nitrogen requirements increase to 0.20–0.25
g/kg per day.

The water-soluble vitamins B and C act as coenzymes in collagen

formation and wound healing. Supplemental vitamin B12 is often
indicated in patients who have undergone intestinal resection or gastric
surgery.

Absorption of the fat-soluble vitamins A, D, E and K is reduced in

steatorrhoea and the absence of bile.

ARTIFICIAL NUTRITIONAL SUPPORT

Any patient who has sustained 5–7 days of inadequate intake or who is
anticipated to have no intake for this period should be considered for
nutritional support.

Enteral nutrition
The term ‘enteral feeding’ means delivery of nutrients into the
gastrointestinal tract.

Complications of enteral nutrition

-1Tube-related
Malposition
Displacement
Blockage
Breakage/leakage

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Local complications (e.g. erosion of skin/mucosa)

-5Gastrointestinal
Diarrhoea
Bloating, nausea, vomiting
Abdominal cramps
Aspiration
Constipation

-0Metabolic/biochemical
Electrolyte disorders
Vitamin, mineral, trace element deficiencies
Drug interactions

■4Infective
Exogenous (handling contamination)
Endogenous (patient)

Parenteral nutrition
Taqdeem
Total parenteral nutrition (TPN) is defined as the provision of all
nutritional requirements by means of the intravenous route and without
the use of the gastrointestinal tract.

Parenteral nutrition is indicated when energy and protein needs cannot be

met by the enteral administration

Complications of parenteral nutrition

■Related to nutrient deficiency

Hypoglycaemia/hypocalcaemia/
hypophosphataemia/hypomagnesaemia (refeeding
syndrome)
Chronic deficiency syndromes (essential fatty acids,
zinc, mineral and trace elements)

■Related to overfeeding
Excess glucose :

Excess fat :

Excess amino acids:

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■Related to sepsis
Catheter-related sepsis
Tendency
Possible increased predisposition to systemic sepsis

■Related to line

1--On insertion: pneumothorax, damage to adjacent

artery, air embolism, thoracic duct damage,
cardiac perforation or tamponade, pleural effusion,
compression of the heart by an accumulation of fluid in the pericardial sac
hydromediastinum
2--Long-term use: occlusion, venous thrombosis