Ahmed Mayet Associate Professor King Saud University NUTRITION

Ahmed Mayet Associate Professor King Saud University NUTRITION SUPPORT Done by : 428 surgery team 1

Nutrition Nutrition—provides with all basic nutrients and energy required for maintaining or restoring all vital body functions from carbohydrate, fat and protein 428 surgery team 2

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Malnutrition Malnutrition—come from extended inadequate intake of nutrient or severe illness burden on the body composition and function —affect all systems of the body 428 surgery team 4

Types of malnutrition Kwashiorkor: (kwa-shior-kor) is protein malnutrition Marasmus: (ma-ras-mus) is protein-calorie malnutrition “overall malnutrition” 428 surgery team 5

Kwashiorkor Protein malnutrition - caused by inadequate protein intake in the presence of fair to good calories intake in combination with the stress response Common causes - chronic diarrhea, chronic kidney disease”b/c there will be leaking out of protein”, infection, trauma , burns, hemorrhage, liver cirrhosis “b/c the liver can not synthesis any protein so, we have a –ve protein ” and critical illness. 428 surgery team 6

Clinical Manifestations Marked hypoalbuminemia Anemia Edema and ascites Muscle atrophy Delayed wound healing Impaired immune function 428 surgery team 7

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Marasmus The patient with severe protein-calorie malnutrition characterized by calories deficiency Common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa and starvation 428 surgery team 9

Clinical Manifestations Weight loss Reduced basal metabolism Depletion skeletal muscle and adipose (fat) stores Decrease tissue turgor Bradycardia Hypothermia 428 surgery team 10

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Risk factors for malnutrition Medical causes Psychological and social causes 428 surgery team 12

Medical causes (Risk factors for malnutrition) Recent surgery or trauma Sepsis Chronic illness Gastrointestinal disorders Anorexia, other eating disorders Dysphagia Recurrent nausea, vomiting, or diarrhea Pancreatitis Inflammatory bowel disease Gastrointestinal fistulas 428 surgery team 13

Psychosocial causes Alcoholism, drug addiction Poverty, isolation Disability Anorexia nervosa Fashion or limited diet 1 g Alcohol = 7 kcal 428 surgery team 14

Consequences of Malnutrition places patients at a greatly increased risk for morbidity and mortality Longer recovery period from illnesses Impaired host defenses Impaired wound healing Impaired GI tract function 428 surgery team 15

Cont: Muscle atrophy “in renal diseases and liver cirrhosis” Impaired cardiac function Impaired respiratory function Reduced renal function mental dysfunction Delayed bone callus formation Atrophic skin 428 surgery team 16

International, multicentre study to implement nutritional risk screening and evaluate clinical outcome “Not at risk” = good nutrition status “At risk” = poor nutrition status Results: Of the 5051 study patients, 32. 6% were defined as ‘atrisk’ At-risk’ patients had more complications, higher mortality and longer lengths of stay than ‘not at-risk’ patients. Sorensen J et al Clinical. Nutrition(2008)27, 340 349 428 surgery team 17

Metabolic Rate Patients with major burn, their metabolic rate is very high so, they consume a lot of calorie and u have to replace these calories or u will end up having a malnutrition. . Same thing with sepsis and trauma patients. Normal range Long CL, et al. JPEN 1979; 3: 452 -6 428 surgery team 18

Protein Catabolism Also here patients with major burn, trauma or sepsis their protein catabolism or consumption rate is very high, and u have to give extra amount of protein or otherwise the body will catabolize his self and people will end up with malnutrition Normal range Long CL. Contemp Surg 1980; 16: 29 -42 428 surgery team 19

Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein 428 surgery team 20

Standard monogram for Height and Weight in adult-male Height Small Frame Medium Frame Large Frame 4'10" 102 -111 109 -121 118 -131 4'11" 103 -113 111 -123 120 -134 5'0" 104 -115 113 -126 122 -137 5'1" 106 -118 115 -129 125 -140 5'2" 108 -121 118 -132 128 -143 5'3" 111 -124 121 -135 131 -147 5'4" 114 -127 124 -138 134 -151 5'5" 117 -130 127 -141 137 -155 5'6" 120 -133 130 -144 140 -159 5'7" 123 -136 133 -147 143 -163 5'8" 126 -139 136 -150 146 -167 5'9" 129 -142 139 -153 149 -170 5'10" 132 -145 142 -156 152 -173 5'11" 135 -148 145 -159 155 -176 6'0" 138 -151 148 -162 428 surgery team 158 -179 21

We took a person who is 5. 9’’ and his weight is 50 kg: First we have to convert into lbs, then we take the ideal weight regarding his height from the previous chart. . Then, (ideal weight” 129” – his weight” 110”) = 19 lbs 19 / (ideal weight” 129” )= (malnutrition percentage) Percent weight loss 50 kg x 2. 2 = 110 lbs Small frame 129 lbs – 110 lbs = 19 lbs 19/129 x 100 = 15% 3 -5% == mild malnutrition 5 -9%== moderate malnutrition >10 % == severe malnutrition Medium frame 139 lbs – 110 lbs = 29 lbs 29/139 x 100 = 20% 428 surgery team 22

Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein 428 surgery team 23

Average Body Mass Index (BMI) for Adult Classification Underweight Normal Overweight BMI (kg/m 2) <18. 5 -24. 9 25. 0 -29. 9 Obesity Class Obesity Moderate obesity Extreme obesity 30. 0 -34. 9 35. 0 -39. 9 >40. 0 I II III Our patient BMI = 16. 3 kg/m 2 428 surgery team 24

Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein 428 surgery team 25

Fat Assessment of body fat Triceps skinfold thickness (TSF) Waist-hip circumference ratio Waist circumference Limb fat area Compare the patient TSF to standard monogram 428 surgery team 26

Laboratory and other tests Weight BMI Fat storage Somatic and visceral protein 428 surgery team 27

Protein (Somatic Protein) Assessment of the fat-free muscle mass (Somatic Protein) Mid-upper-arm circumference (MAC) Mid-upper-arm muscle circumference Mid-upper-arm muscle area Compare the patient MAC to standard monogram 428 surgery team 28

Cont; Protein (visceral protein) In visceral protein we look for albumin Assessment of visceral protein depletion Serum albumin <3. 5 g/d. L Serum transferrin <200 mg/d. L Serum cholesterol <160 mg/d. L Serum prealbumin <15 mg/m. L Creatinine Height Index (CHI) <75% Our patient has albumin of 2. 2 g/dl 428 surgery team 29

Vitamins deficiency Vitamin Bs (B 1, B 2, B 6, B 9, B 12, ) Vitamin C Vitamin A Vitamin D Vitamin K 428 surgery team 30

Trace Minerals deficiency Zinc Copper Chromium Manganese Selenium Iron 428 surgery team 31

ESTIMATING ENERGY/CALORIE 428 surgery team 32

BEE Basal Metabolic Rate (BMR) or Basal Energy Expenditure (BEE) accounts for the largest portion of total daily energy requirements 428 surgery team 33

Total Energy Expenditure TEE (kcal/day) = BEE x stress/activity factor 428 surgery team 34

BEE The Harris-Benedict equation is a mathematical formula used to calculate BEE 428 surgery team 35

Harris–Benedict Equations Energy calculation Male BEE = 66 + (13. 7 x actual wt in kg) + (5 x ht in cm) – (6. 8 x age in y) Female BEE = 655 + (9. 6 x actual wt in kg) + (1. 7 x ht in cm) – (4. 7 x age in y) 428 surgery team 36

A correlation factor that estimates the extent of hyper-metabolism 1. 15 for bedridden patients 1. 10 for patients on ventilator support 1. 25 for normal patients The stress factors are: 1. 3 for low stress 1. 5 for moderate stress 2. 0 for severe stress 1. 9 -2. 1 for burn 428 surgery team 37

Calculation Our patient Wt = 50 kg Age = 45 yrs Height = 5 feet 9 inches (175 cm) BEE = 66 + (13. 7 x actual wt in kg) + (5 x ht in cm) – (6. 8 x age in y) =66 + (13. 7 x 50 kg) + (5 x 175 cm) – (6. 8 x 45) =66 + ( 685) + (875) – (306) = 1320 kcal TEE = 1320 x 1. 25 (normal activity) = 1650 kcal 428 surgery team 38

CALORIE SOURCES 428 surgery team 39

Calories 60 to 80% of the caloric requirement should be provided as glucose, the remainder 20% to 40% as fat To include protein calories in the provision of energy is controversial 428 surgery team 40

FLUID REQUIREMENTS 428 surgery team 41

Fluid The average adult requires approximately 3545 ml/kg/d NRC* recommends 1 to 2 ml of water for each kcal of energy expenditure Fluid replacement either: Weight distributed *NRC= National research council 1 -2 ml/kcal expended 428 surgery team 42

Fluid 1 st 10 kilogram 100 cc/kg 2 nd 10 kilogram 50 cc/kg Rest of the weight 20 to 30 cc/kg Example: Our patient 1 st 10 kg x 100 cc = 1000 cc 2 nd 10 kg x 50 cc = 500 cc Rest 30 kg x 30 cc = 900 cc total = 2400 cc 428 surgery team 43

PROTEIN NEEDS 428 surgery team 44

Protein The average adult requires about 1 to 1. 2 gm/kg 0 r average of 70 -80 grams of protein per day 428 surgery team 45

Protein Stress or activity level Initial protein requirement (g/kg/day) Baseline 1. 4 g/kg/day Little stress 1. 6 g/kg/day Mild stress 1. 8 g/kg/day Moderate stress 2. 0 g/kg/day Severe stress 2. 2 g/kg/day 428 surgery team 46

ROUTES OF NUTRITION SUPPORT 428 surgery team 47

The nutritional needs of patients are met through either parenteral or enteral delivery route 428 surgery team 48

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ENTERAL NUTRITION 428 surgery team 50

Enteral The gastrointestinal tract is always the preferred route of support (Physiologic) “If the gut works, use it” EN is safer, more cost effective, and more physiologic that PN 428 surgery team 51

EN (Immunologic) Gut integrity is maintained by enteral feeding and prevent the bacterial translocation from the gut and minimize risk of gut related sepsis 428 surgery team 53

Safety ”complications” Catheter sepsis Pneumothorax Catheter embolism Arterial laceration 428 surgery team 54

Cost (EN) Cost of EN formula is less than PN Less labor intensive 428 surgery team 55

Contraindications v. imp. Gastrointestinal obstruction Severe acute pancreatitis High-output proximal fistulas Intractable nausea and vomiting or osmotic diarrhea 428 surgery team 56

Enteral nutrition (EN) Long-term nutrition: “like in esophagus cancer” Gastrostomy Jejunostomy Short-term nutrition: Nasogastric feeding Nasoduodenal feeding Nasojejunal feeding 428 surgery team 57

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Intact food Predigested food 428 surgery team 59

We can’t use polymeric food in patient with naso doudenal or nasojejunal b/c there will be no breaking down of the food by stomach, but we need a predigested”monomeric” food for them. . U never start feeding a malnurished patient with full calorie >> start gradually. . 428 surgery team 60

TF = tube feeding 428 surgery team 61

TOTAL PARENTRAL NUTRITION 428 surgery team 62

PN Goal Provide patients with adequate calories and protein to prevent malnutrition and associated complication PN therapy must provide: Protein in the form of amino acids Carbohydrates in the form of glucose Fat as a lipid emulsion Electrolytes, vitamin, trace elements, min- 428 surgery team 64

PATIENT SELECTION 428 surgery team 65

General Indications Requiring NPO > 5 - 7 days Unable to meet all daily requirements through oral or enteral feedings Severe gut dysfunction or inability to tolerate enteral feedings. Can not eat ”intestinal restriction”, will not eat ”nausea & vomitting”, should not eat ”pancreatitis”. 428 surgery team 66

Special Indications (can not eat) 428 surgery team 67

Cont: When enteral feeding can’t be established After major surgery Pt with hyperemesis gravidarum Pt with small bowel obstruction Pt with enterocutaneous fistulas (high and low) 428 surgery team 68

Cont: Hyper-metabolic states: Burns, sepsis, trauma, long bone fractures Adjunct to chemotherapy Nutritional deprivation Multiple organ failure: Renal, hepatic, respiratory, cardiac failure Neuro-trauma Immaturity 428 surgery team 69

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Fat Emulsion Concentrated source of calories Source of essential fatty acids (EFAs) Substitute for carbohydrate in diabetic & fluid restricted patients 428 surgery team 71

Fat (Intralipid) contraindications: Hyperlipdemia Acute pancreatitis Previous history of fat embolism Severe liver disease Allergies to egg, soybean oil or safflower oil 428 surgery team 72

Not to be memorized 428 surgery team 73

ADMINISTRATION 428 surgery team 76

Central PN (TPN) is a concentrated formula and it can delivered large quantity of calories via subclavian or jugular vein only Peripheral PN provides limited calories 428 surgery team 77

There are two types of enteral nutrition: 1. Central: through subclavian vein or jugular vein for pt who needs a lot of calories. 2. Peripheral: through peripheral veins for pt who needs limited calories because of the osmolarity. 428 surgery team 78

Parenteral Nutrition Central Nutrition Peripheral nutrition Subclavian line Peripheral line Long period Short period < 14 days Hyperosmolar solution Low osmolality Full requirement < 900 m. Osm/L Min. requirement Large volume Thrombophlebitis Minimum volume Expensive More side effect 428 surgery team 79

Note PPN can infuse through central line but central TPN can NOT infuse through the peripheral line 428 surgery team 80

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COMPLICATIONS OF TPN 428 surgery team 83

Complications Associated with PN Mechanical complication Septic complication Metabolic complication 428 surgery team 84

Mechanical Complication Improper placement of catheter may cause pneumothorax, vascular injury with hemothorax, brachial plexus injury or cardiac arrhythmia Venous thrombosis after central venous access 428 surgery team 85

Infectious Complications PN imposes a chronic breech in the body's barrier system The mortality rate from catheter sepsis as high as 15% Inserting the venous catheter Compounding the solution Care-giver hanging the bag Changing the site dressing 428 surgery team 86

Metabolic Complications Early complication -early in the process of feeding and may be anticipated Late complication - caused by not supplying an adequate amount of required nutrients or cause adverse effect by solution composition 428 surgery team 87

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Iron is not included in TPN solution and it can cause iron deficiency anemia Add 100 mg of iron 3 x weekly to PN solution or give separately 428 surgery team 89

Vitamin K TPN solution does not contain vitamin K and it can predispose patient to deficiency Vitamin K 10 mg should be given weekly IV or IM if patient is on long-term TPN 428 surgery team 90

THANK YOU 428 surgery team 91