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 Wretlind 安全的脂肪乳剂 1937 年 Robert Elman1930 氨基酸+葡萄糖

1968 年 Stanley Dudrick 中央静脉插管

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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 • internal jugular approach • external jugular approach Superior Vena Cava

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 •peritonitis •soft tissue trauma •fracture •fever (per oC rise) - 30% + 15% + 15% + 20% + 13% •Moderate infection + 20% •Severe infection •<20% BSA Burns •>40% BSA Burns + 40% + 50%

•20-40% BSA Burns + 80% + 100%

Caloric requirements
Activity Factor
Bed-bound Ambulant Active
+ 20% + 30% + 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 • Moderate stress • Severe stress 1.0 to 1.2 g / kg / day 1.3 to 1.75 g / kg / day 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+ K+ Mg++ Ca++ PO421 to 2 mmol/kg/d (or 60-120 meq/d) 0.5 to 1 mmol/kg/d (or 30 - 60 meq/d) 0.35 to 0.45 meq/kg/d (or 10 to 20 meq /d) 0.2 to 0.3 meq/kg/d (or 10 to 15 meq/d) 20 to 30 mmol/d

Trace Elements
Total requirements not well established Commercial preparations exist to provide RDA
• • • • Zn Cr Cu Mn 2-4 mg/day 10-15 ug/day 0.3 to 0.5 mg/day 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 • Renal Panel # 1 • Ca++, Mg++, PO42• • • • Liver Function Test Iron Panel Lipid Panel Nitrogen Balance
• weekly, unless indicated • daily until stable, then 2x/wk • daily until stable, then 2x/wk • weekly • weekly • 1-2x/wk • weekly

Nutritional Balance
Nutritional Balance = N input - N output
1gN N input N output = 6.25 g protein = (protein in g  6.25) = 24h urinary urea nitrogen + nonurinary 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 air embolism arterial injury bleeding • • • • brachial plexus injury catheter malplacement catheter embolism 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 K 3.0 mmol/l Rest of electrolytes normal Total Bilirubin 4 mmol/l Albumin 35 mg/l ALP and GGT normal