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Nutrition in Surgical Patients

Ronald Merrell, MD Chairman of Surgery Virginia Commonwealth University

What?
• • • • • Carbohydrate Lipid Protein Trace elements Vitamins

Who? • Malnourished (>10% lean body mass) • Incapable of eating (>10 days) .

poor healing and higher mortality • Malnutrition is exacerbated by physiological stress .Why? • Risks of malnutrition including infection.

When? • • • • Preoperative? Early? Late? ---after initial resuscitation following injury or surgery .

How? • • • • Parenteral Enteral Total Partial .

Parenteral . hormones Biology of substrates Enteral vs. inflammation.Issues • • • • Metabolic response to injury Cytokines.

25:233. a thready pulse and cold clammy extremities…” The Ebb Phase Cuthbertson.“Ashen faces. J. Med.1932 . Quart.

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The Ebb Phase • • • • Hypometabolic Hypothermic Hypoinsulinemic Hypoperfusion • • • • Hypercortisolism Hyperglucagonemia Hyperglycemia Hypercatecholemia .

1942 .cardiac output increases and the surgical team relaxes…” The Flow Phase Cuthbertson.“The patient warms up. Lancet 1:233.

The Flow Phase • Hypermetabolic • Hyperthermic • Catabolic • • • • Hyperinsulinism Hypercortisolism Hyperglucagonemia High cardiac output .

DH • Nitrogen balance . prealbumin. transferrin • Immune competence: lymphocytes.Nutritional Assessment • • • • Body weight Body mass index creatinine height index Serum proteins:albumin.

Caloric Requirement • • • • Formula Indirect calorimetry PRN for nitrogen balance Approximation .

Nutritional Requirements • • • • • 25 cal/kg/day carbohydrate ~70% Lipid 15-30% Protein 1. Not for calories Additional 50% to 100% for stress as in ICU patients .5-2.0g/kg/day.

Nutritional Goals • • • • • Nitrogen balance Preserve or restore visceral protein Reduce morbidity Reduce mortality Reduce hospital stay .

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Early Enteral Feeding: a metaanalysis • Eight prospective randomized trials with trauma and high risk surgical patients(118 enteral. 112 parenteral) • Septic complications:enteral 18%. Ann. Surg. 216:172.1992 . parenteral 35% • Moore.

Parenteral requirements • Dilution in right heart return because of hyperosmolarity…….Central Venous Line • Delivery of simple carbohydrate (20%glucose) • Lipid emulsion • Amino acids .

Enteral Requirements • Delivery into the GI tract by tube with minimum risk of aspiration or patient effort • Delivery of nutrients with minimal need for digestion • Control of rate to prevent osmotic diarrhea .

Advantages of enteral nutrition • • • • Easier GI bacterial translocation Cheaper Fewer specific complications .

Nutrients with specific putative contributions • • • • • Branch chain amino acids Glutamine Arginine Nucleotides Omega-3 fatty acids .

1995 . 23:436. fewer infections • Bower Critical Care Medicine. fish oil • Shorter stay.Immune Enhancing Diet • Arginine. nucleotide.

Poorly administered Hyperglycemia No nucleotides No arginine No taurine Excessive fats .• • • • • • Parenteral Nutrition Immunosuppressive IF...

Overfeeding with parenteral diets • Carbohydrate: hyperglycemia. fatty liver • Lipids: hypertriglyceridemia. hypercarbia. infection • Protein: azotemia . hypoxia.

Conclusions • Nutrition is a powerful determinate of patient outcome • The proper provision of nutrition is a component of basic patient care • Nutrition is a precise and potentially very hazardous form of intervention .