Note

Lecture 10c 21 March 2011 Surgery and Burns  

Surgery   -well nourished prior to surgery -surgical patients are often malnourished due to anorexia, nausea, vomiting, burns, fever, malabsorption, and blood loss -surgical prep- range of actions high calorie protein diet enteral parenteral

Surgery -NPO for a least 8 hours prior to general anesthesia due to risk of aspiration   -oral intake is resumed after bowel sounds return- usually 24-48 hours after surgery -clear liquids to full liquids to soft or regular diet as tolerated post-op -usually a high protein high calorie diet is appropriate

Burns   -hypermetabolism involved- why? -solution to hypermetabolism? -large quantities of nutrients leech through burn area -fluid and electrolyte imbalances are a problem

Burns -anorexia, pain, emotional trauma, weight loss and immune incompetence, malnutrition are issues -nutritionally how are these overcome?   -48-72 hours after burn- maintain fluid and electrolyte balance and minimise loss of lean body and total weight

Burns -after fluid and electrolytes and by hour 72 (if bowel sounds)- oral intake begins   -if no bowel sounds by hour 96 then PPN or TPN

Burns - regardless of routes of administration   -Protein 1.5-3.0 g /kg body weight/day 25 % protein, 50 % carbohydrate, 25 % fat -Kcal- additional 40-60 kcal/kg body weight/day -high fluid intake –including more potassium, zinc and vitamin C (wound healing) and vitamins B1, B2 and B3 (in proportion to increased energy intake)

Table 29-2, p. 903

Table 29-3, p. 904

Cancer Dietary factors - cancer initiators - these dietary components start cancer   -additives and pesticides are of particular but not exclusive concern here -stomach cancer particularly high in parts of world where pickled or salt cured foods that produce carcinogenic nitrosamines are consumed

Cancer Dietary factors -alcohol associated with high incidence of some cancers, especially of the mouth, esophagus and liver in all persons and breast cancer in females -beer and scotch may contain nitrosamines -wine and brandy may contain urethane -urethane and nitrosamines are carcinogens -moderation is the key here

Dietary factors –cancer promoters   Dietary factors –cancer promoters -cancer promoters accelerate the rate of progression of cancer once it has started   - eg excess dietary fats -linoleic acid- has been suggested to promote -omega 3s have been suggested to prevent or delay cancer development

  Dietary factors-antipromoters   Fruits and veggies as per Canada’s food guide -fibre speeds up gi transit time thus reducing carcinogen exposure -colon cancer is controversial re:fruits and veggies as per Canada’s food guide -fruits and vegetables containing antioxidants that scavenge free radicals –such free radicals contribute to cancer -various phytochemicals activate enzymes that can destroy carcinogens

Once cancer starts   -do nutritional assessment and respond accordingly -early intervention prepares body for stresses that lay ahead -enteral (tube) or parenteral feeding does not change outcome except in bone marrow transplants- (GI tract severely compromised in pre-op prep)

In bone marrow transplants -once GI tract function returns -oral feeding returns along with TPN wherever possible     -TPN is tapered off as oral intake improves post-op  - if oral intake is inadequate post-op then permanent TPN required -early oral feedings often start with lactose free, low-residue, low fat liquids to maximise absorption and minimise nausea, vomiting and fat malabsorption

In bone marrow transplants   -for about 3 months post-op most fruits and veggies, undercooked meats, poultry, eggs and ground meats excluded to reduce risk of food-borne infections   -fibre and lactose and fat are gradually returned to diet as individual tolerances allow -immunosuppressants often lead to negative calcium and nitrogen balances so provide high kcal, high protein, high calcium diet- may also require calcium and vitamin D supplements -persons with diarrhea will need high potassium foods

Nutritional implications can further deteriorate patient’s health   Aids       Weight loss, diarrhea, seborrhea, eczema, fever, sweating-nutritional implications?     Nutritional implications can further deteriorate patient’s health     Drugs can exacerbate nutritional difficulties (table)     Kcal requirement is increased compared to non-infected persons in good health Protein requirements 1-2 g/kg bw/day due to lean body mass loss and other protein losses

AIDS Fat – medium chain triglycerides (6-12 carbon fatty acids) for additional calories -lipase and bile not required for mct- therefore easier absorption

AIDS Vitamins and Minerals -requirements not known but poor intake and altered nutrient absorption are a problem recommendation-fat soluble vitamins taken at RDA and water soluble vitamins be taken at 3 X RDA -trace element and antioxidant supplements may also be prescribed -avoid large doses of iron and zinc since they can impair immune function

-liquid commercial preparations -antidiarrheals shortly before meals     AIDS Feedings -small, numerous meals -liquid commercial preparations -antidiarrheals shortly before meals -high soluble fibre foods like oatmeal, cooked carrots, bananas, peeled apples and apple sauce may help slow transit time (diarrhea reduced perhaps)