1. Note

2. Lecture 10c
21 March 2011
Surgery and Burns

3. 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

4. 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 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

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

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

7. 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

8. Burns
- regardless of routes of administration
-Protein g /kg body weight/day
25 % protein, 50 % carbohydrate, 25 % fat
-Kcal- additional 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)

10. Table 29-2, p. 903

11. Table 29-3, p. 904

12. 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

13. 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

14. 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

15. 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

16. 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)

17. 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

18. 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

19. 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

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

22. 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

23. -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)