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For 4th year medical student
Surgical Nutrition For 4th year medical student
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Surgical nutrition Starvation Response to injury
Nutritional assessment Nutritional requirement and planning Formula and route Monitoring
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Nutrition Storages Obligate glycolytic cells
Carbohydrate: glycogen (liver and muscles) Protein: muscles, enzyme Fat Obligate glycolytic cells neurons leukocytes erythrocytes renal medullae
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Starvation Short-term fasting (<5 days) Principal sources of fuel
Muscle protein and body fat fat being the most abundant source of energy Glycogen storages in liver : muscle 75 to 100 : 200 to 250 g Muscle-deficiency in glucose-6-phosphatase Hepatic glycogen stores ; rapidly and preferentially depleted, which results in a fall of serum glucose concentration within hours (<16 hours)
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Short-term fasting
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Starvation Prolonged starvation Decrease systemic proteolysis
Adaptation by vital organs (e.g., myocardium, brain, renal cortex, and skeletal muscle) Using ketone bodies as their principal fuel source compensated starvation
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Prolonged starvation
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Response to injury Neuroendocrine and immunologic responses Ebb phase
sympathetic activation and catecholamine release -> increase in energy expenditure Ebb phase Flow phase Catabolic phase: hypermetabolism, negative nitrogen balance Anabolic phase: positive nitrogen balance, increase weight Recovery phase
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Response to injury
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Estimation of Energy Requirements
Nutritional assessment Pertinent information: Age, sex BMI presence of weight loss: 5% in 1 month, 10% in 6 months chronic illnesses dietary habits Physical examination: assess loss of muscle and adipose tissues organ dysfunction changes in skin, hair, or neuromuscular function
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Estimation of Energy Requirements
Nutritional assessment Anthropometric data triceps or subscapular skin fold thickness mid-arm muscle circumference Biochemical determinations creatinine excretion albumin level (half-life days) prealbumin level total lymphocyte count transferrin level
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Estimation of Energy Requirements
BMI = weight (kg) / hight2 (metre) BMI weight status < 18.5 Underweight 20-25 Normal Overweight >30 Obese >40 Very obese Total lymphocyte count = WBC x %lymphocyte
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Estimation of Energy Requirements
A fundamental goal of nutritional support to meet the energy requirements for essential metabolic processes and tissue repair Caloric requirement indirect calorimetry (oxygen consumption and carbondioxide production) serum markers (e.g., prealbumin level) urinary nitrogen excretion Failure to provide adequate nonprotein energy sources will lead to consumption of lean tissue stores.
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Estimation of Energy Requirements
Basal energy expenditure (BEE) BEE (men) = (W) (H) – 6.76 (A) kcal/d BEE (women) = (W) (H) – 4.68 (A) kcal/d W = weight in kilograms H = height in centimeters A = age in years BEE = kcal x Wt.
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Estimation of Energy Requirements
Total energy expenditure (TEE) TEE=(BEE x AF x SF) + FF+GF Activity factors Bed ridden Respirator support Limited activity on bed 1.2 Normal activity 1.3
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Estimation of Energy Requirements
Stress factors Major surgery 1.2 Peritonitis, multiple trauma Major sepsis 1.3 Cancer Severe thermal burn Fever factors Plus13%ofBEE/1C(>37.0C) Growth factors Moderate degree previous malnutrition add 5% of BEE Severe degree previous malnutrition add 10-15% of BEE 3500 excessive kcal/wk (500 kcal/day) 1 lb weight gain
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Estimation of Energy Requirements
Adjustment of carbohydrate: protein: fat ratio Carbohydrate % 4 kcal/gm, dextrose = 3.4 kcal/gm Protein % 4 kcal/gm Fat % 9 kcal/gm Adequate carbohydrate intake Insulin secretion Inhibit proteolysis Glucose 150 gm/day->protein-sparing effect
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Estimation of Energy Requirements
Protein requirement Normal condition Protein gm/kg/d Stress Increase protein requirement (up to 2 gm/kg/d) Non-protein calorie : nitrogen ratio (kcal : gram Nitrogen) :1 :1 1 gm Nitrogen = 6.25 gm protein
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Estimation of Energy Requirements
Polyunsaturated fatty acids Long chainfatty acids (long chain triglycerides : LCT) Hydrolyzed by bile salt and pancreatic lipase Monoglyceride and free fatty acid Medium-chain fatty acids (medium chain triglycerides : MCT) Directly absorbed by enterocyte For fat mulabsorption (intestinal mucosa damage, bile salt deficiency), obstructive jaundice
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Estimation of Energy Requirements
Nitrogen balance = nitrogen intake-nitrogen loss = Total protein intake (grams)/ (UUN + 4 grams) UUN = grams of nitrogen excreted in the urine over a 24 hour 4 = 4 grams of nitrogen lost each day as “insensible losses” via the skin and gastrointestinal tract
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Formula and route Enteral nutrition Advantages easily administered
well tolerated promotion of gut mucosal growth and development maintain the barrier function of the gastrointestinal tract supporting the body’s mucosal immune system better nutrient use fewer metabolic disturbances such as hyperglycemia, cholestasis, and fatty infiltration of the liver less expensive fewer infectious complications
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Formula and route Enteral nutrition Contraindication Bowel obstruction
Intractable N/V Severe short gut Upper GI tract or high output fistula Severe acute pancreatitis
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Formula and route Parenteral nutrition Peripheral parenteral nutrition
Limit osmolarity 12.5% glucose Short term Total parenteral nutrition Central vein
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Monitoring Initial monitoring Daily: BW and intake-output
Blood sugar, urine sugar, electrolyte Daily: BW and intake-output Weekly: Blood sugar, BUN, Cr, Electrolyte, Live function test, Trace element, Urine urea nitrogen
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Complication Refeeding syndrome
Chronic malnutrition, prolong fasting -Decrease insulin -Increase glucagon and cortisol -Glycogenolysis -Gluconeogenesis -Protein catabolism -Depletion of electrolytes, protein, fat, mineral and vitamins Refeeding Insulin secretion Protein and glycogen synthesis Increase glucose, Mg, PO, K uptake -Hypophosphatemia -Hypokalemia -Hypomagnesaemia -Thiamine deficiency -Sodium and water retention
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Complication High risk patient Severe malnutrition
Glucose base formula Electrolyte abnormality
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Complication Prevention Correct electrolyte abnormality Slow feeding
Avoid over feeding
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Question 64 year-old male, CA mid esophagus with cachexia and aspiration pneumonia Nutritional risk status Severe malnutrition with systemic infection Nutritional assessment Healthy BW 70kg, current BW 56 kg, Height 156 cm, moderate dehydration, moderate loss of muscle mass, physical signs of essential fatty acid deficiency, anular stomatitis Hct 35%, N 88%, L11% Eo1% BUN 20 mg/dl, Cr1.5 mg/dl Na 132 mEq/L, K 2.8 mEq/L, Cl 102 mEq/L, CO2 28 mEq/L Albumin 3.4 mg/dl, globulin 4.0 mg/dl Urine spec , urine ketone +
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Question Planning for primary disease Nutritional planning
Radiation Nutritional planning Route: GI function? Esophageal stent +/-NG tube Nutritional requirement Total energy requirement: 30x70= 2100 kcal/d Protein requirement: 1.5 x70= 105 g/d, 105/6.25=16.8 g N2 420 kcal/d Non Protein calories = =1680 kcal NPC:N = 1680/16.8 = 100:1 Carbohydrate 50%
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Question Nutritional requirement Carbohydrate: 50% Fat Water Potassium
2100/2= 1050 kcal/d Fat 2100-( )= 630 kcal Water 1ml/kcal/d = 2,100 ml Holliday -Sagar Potassium Every 1 mEq/L ↓K below 3.5 mEq/L = total body potassium deficit of mEq =0.7, 70 mEq Elixir KCl 15 ml= 20 mEq, 52.5 ml Every 1 mEq/L ↓K below 3.5 mEq/L = total body potassium deficit of mEq K3-3.5 : แก้ 1-2 mEq/kg, K2.5-3 แก้ 2-3mEq/kg
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Question Formula and route Monitoring
Generic feeding formula, step feeding Goal: 5-7 days Add water: 1 kcal/ml Add multivitamins syr. Monitoring Calories count: goal? NG feeding BW OD Electrolyte, BUN, Cr, BS, PO, Mg Nitrogen balance, prealbumin Current condition: change caloric requirement
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Thank you
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