SURGICAL NUTRITION Peyton Lloyd Lawrence

SURGICAL NUTRITION










Peyton Lloyd Lawrence

ASSESSMENT

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PRINCIPLE IS IDENTIFYING MALNUTRITION THEN,CLASSIFYING TYPE AND STRATIFYING SEVERITY, WITH THE VIEW TO DEVICE AN APPROPRIATE SUPPORT STRATEGY

CLINICAL


HISTORY
- Weight and dietary changes over time

- Catabolic factors (comorbidity, Rx, recent stress, GI disease, Anorexia nervosa or bulimia)

- Anabolic factors (insulin / GH use, eating disorder, family hx or genetic mutation- leptin and melancortin-r)

PHYSICAL EXAM
- General- wasting + mucocutaneous lesions

- Specific: abdomen, cardiopulmonary



Townsend, Courtney M. Jr, Beauchamp, Daniel R; Evers, Mark B and Mattox, Kenneth L 2010. Sabiston Textbook of Surgery. 19th ed. Canada: Elsevier

ANTHROPOMETRY




1. WEIGHT MEASURES- % wgt loss,
BMI, IBW


2. SKIN FOLD THICKNESS - MAC, TSF

BODY COMPOSITION ASSAY

- Dual Xray ABsorptiometry
compares differential tissue xray
absorption to standardised norms


- gives relative values for lean mass,
fat and bone

Townsend, Courtney M. Jr, Beauchamp, Daniel R; Evers, Mark B and Mattox, Kenneth L 2010. Sabiston Textbook of Surgery. 19th ed. Canada: Elsevier

BLOOD

- serum proteins (Alb, Transferrin,
Prealbumin, RBP)
- TLC (%lymph / WBC)
- CBC , U&E


NITROGEN BALANCE = N(g) intake minus 24hr UN

CALORIMETRY


1. Energy expenditure equations
BMR - HARRIS BENEDICT,
Stressed state = CURRERI- GALVESTON e.g.Burns pts)


2. Resting energy Expenditure = (RQ from ventilator)


3. DIRECT-using calorimeter


Townsend, Courtney M. Jr, Beauchamp, Daniel R; Evers, Mark B and Mattox, Kenneth L 2010. Sabiston Textbook of Surgery. 19th ed. Canada: Elsevier

OBESITY PARADOX

OBESITY PARADOX

TRADITIONAL THOUGHTS

Obesity associated with:
- increased Anaesthetic and Surgical complications e.g. Thromboembolic phenom; Wound sepsis and cardiovascular events

weight loss confers benefits of decreased incidence of metabolic syndrome and bertter perioperative outcome

Sjöström, L., Lindroos, A.K., Peltonen, M., et al. (2004) Lifestyle, diabetes, and cardiovascular risk factors
10 years aft er bariatric surgery. New England Journal of Medicine , 351 , 2683–93.

ref [3], [4] [19]

ref [3], [4] [19]

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paradox is not well understood but thought that obese states confer more physiological reserves fortimes of hypermetabolic demand

Survival

Survival

Conclusion

Appproach to nutrition in the perioperative is evolving as
our understanding of Claude Bernard's internal milieu (homeostasis) grows.

The results seen in fast track surgery and the observations of the Obesity Paradox substantiate the views that "a little extra physiological reserves" confers a mortality advantage!

References

1. Townsend, Courtney M. Jr, Beauchamp, Daniel R; Evers, Mark B and Mattox, Kenneth L 2010. Sabiston Textbook of Surgery. 19th ed. Canada: Elsevier

2. Sjöström, L., Lindroos, A.K., Peltonen, M., et al. (2004) Lifestyle, diabetes, and cardiovascular risk factors
10 years aft er bariatric surgery. New England Journal of Medicine , 351 , 2683–93.

3. Fonarow GC, Srikanthan P, Costanzo MR, Cintron GB, Lopatin
M. ADHERE Scientific Advisory Committee and Investigators.
An obesity paradox in acute heart failure: analysis of body mass index and inhospital mortality for 108,927 patients in the Acute Decompensated Heart Failure National Registry. Am Heart J. 2007;153:74–81.

4. Uretsky S, Messerli FH, Bangalore S, Champion A, Cooper-DeHoff
RM, ZhouQ, et al. Obesity paradox in patients with hypertension and
coronary artery disease. Am J Med. 2007;120:863–70.

5. Doehner W, Erdmann E, Cairns R, Clark AL, Dormandy JA,
Ferrannini E, Anker SD. Inverse relation of body weight and
weight change with mortality and morbidity in patients with type
2 diabetes and cardiovascular co-morbidity: an analysis of the
PROactive study population. Int J Cardiol. 2011. doi:10.1016/j.
ijcard.2011.09.039.

SUPPORT STRATEGIES

SUPPORT STRATEGIES
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principle- supply caloric requirement to preserve lean mass, promote goodimmunologic function and wound healing WHILST AVOIDING OVERFEEDING

ROUTE (EN vs PN)

Enteral preferred - more physiologic:-

- prevents mucosal atrophy = prevents
bacterial translocation
- propagates Portal circulation and hepatic function

*Blind/ Endoscopic (<4/52) or Surgical (>4/52)


Parenteral- only if EN is contraindicated or
insufficient to handle requirements.

COMMENCEMENT TIME (early vs delayed)


Early usually preferred

Optimise to anabolic state before surgery

Preop weight loss 0f 10-20% intentional for obese pts

Early postop - fast track surgery

Early enteral even in Pancreatitis


Townsend, Courtney M. Jr, Beauchamp, Daniel R; Evers, Mark B and Mattox, Kenneth L 2010. Sabiston Textbook of Surgery. 19th ed. Canada: Elsevier

QUALITY


-EN
- Gastric+ Duodenal - bolus non elemental feed, Slow
- Jejunal - elemental- (no brush border enteropeptidases to monomers)

- Dx specific e.g. Glucerna - DM; Nepro- CKD; Vivonex - Burns

- Immune enhancing - Oxepro; Crucial

PN

- 2 in 1, 3 in 1 mixes or single (varying concentrations)


- immune enhancing - incr glutamine; arginine

- antinflammatory - omega 3 (eicospantaeoate)
instead of omega 6 (linoleiate) based


Townsend, Courtney M. Jr, Beauchamp, Daniel R; Evers, Mark B and Mattox, Kenneth L 2010. Sabiston Textbook of Surgery. 19th ed. Canada: Elsevier

QUANTITY


objectively - depends on total caloric requirement determined by assessment (BMR, REE, direct)

rough estimates - maintenance = 25-30kca/kg/dy
weight gain- 30-40kcal/kg/day

principle for TPN mixing - minus protein contribution from
total caloric requirement and make up the rest with DW and Lipid

usually in a 20:50:30 ratio (pro:carb:fat)