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

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

3. 3

4. 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 4 428 surgery team

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

6. 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. 6 428 surgery team

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

8. 8

9. Marasmus  The patient with severe 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 protein-calorie 9 428 surgery team

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

11. 11 428 surgery team

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

13. Medical causes (Risk factors for malnutrition) RRecent surgery or trauma SSepsis CChronic illness GGastrointestinal disorders AAnorexia, other eating disorders DDysphagia RRecurrent nausea, vomiting, or diarrhea PPancreatitis IInflammatory bowel disease GGastrointestinal fistulas 13 428 surgery team

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

15. Consequences of Malnutrition  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 15 428 surgery team

16. 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 16 428 surgery team

17. Results: Of the 5051 study patients, 32.6% were defined as ‘at- risk’ At-risk’ patients had more complications, higher mortality and longer lengths of stay than ‘not at-risk’ patients. International, multicentre study to implement nutritional risk screening and evaluate clinical outcome Sorensen J et al ClinicalNutrition(2008)27,340 349 “Not at risk” = good nutrition status “At risk” = poor nutrition status 17 428 surgery team

18. Metabolic Rate Long CL, et al. JPEN 1979;3:452-6 Normal range 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. 18 428 surgery team

19. Protein Catabolism Long CL. Contemp Surg 1980;16:29-42 Normal range 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 19 428 surgery team

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

21. Height Small Frame Medium Frame Large Frame 4'10"102-111109-121118-131 4'11"103-113111-123120-134 5'0"104-115113-126122-137 5'1"106-118115-129125-140 5'2"108-121118-132128-143 5'3"111-124121-135131-147 5'4"114-127124-138134-151 5'5"117-130127-141137-155 5'6"120-133130-144140-159 5'7"123-136133-147143-163 5'8"126-139136-150146-167 5'9"129-142139-153149-170 5'10"132-145142-156152-173 5'11"135-148145-159155-176 6'0"138-151148-162158-179 Standard monogram for Height and Weight in adult-male 21 428 surgery team

22. Percent weight loss 129 lbs – 110 lbs = 19 lbs 19/129 x 100 = 15% 139 lbs – 110 lbs = 29 lbs 29/139 x 100 = 20% Small frame Medium frame 50kg x 2.2 = 110 lbs 3-5% == mild malnutrition 5-9%== moderate malnutrition >10 % == severe malnutrition 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) 22 428 surgery team

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

24. ClassificationBMI (kg/m 2 )Obesity Class Underweight<18.5 Normal18.5-24.9 Overweight25.0-29.9 Obesity30.0-34.9I Moderate obesity35.0-39.9II Extreme obesity>40.0III Average Body Mass Index (BMI) for Adult Our patient BMI = 16.3 kg/m2 24 428 surgery team

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

26. 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 26 428 surgery team

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

28. 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 28 428 surgery team

29. Protein (visceral protein) Assessment of visceral protein depletion  Serum albumin <3.5 g/dL  Serum transferrin <200 mg/dL  Serum cholesterol <160 mg/dL  Serum prealbumin <15 mg/mL  Creatinine Height Index (CHI) <75% Cont; Our patient has albumin of 2.2 g/dl In visceral protein we look for albumin 29 428 surgery team

30. Vitamins deficiency  Vitamin Bs (B1,B2, B6, B 9, B12, )  Vitamin C  Vitamin A  Vitamin D  Vitamin K 30 428 surgery team

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

32. 32 428 surgery team

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

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

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

36. Harris–Benedict Equations  Energy calculation Male  BEE = 66 + (13.7 x actual wt in kg) + (5x 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) 36 428 surgery team

37. 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 37 428 surgery team

38. 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) + (5x 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 38 428 surgery team

39. 39 428 surgery team

40. 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 40 428 surgery team

41. 41 428 surgery team

42. Fluid  The average adult requires approximately 35- 45 ml/kg/d  NRC* recommends 1 to 2 ml of water for each kcal of energy expenditure *NRC= National research council Fluid replacement either: Weight distributed1-2ml/kcal expended 42 428 surgery team

43. 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 100cc = 1000 cc 2 nd 10 kg x 50cc = 500cc Rest 30 kg x 30cc = 900cc total = 2400 cc 43 428 surgery team

44. 44 428 surgery team

45. Protein  The average adult requires about 1 to 1.2 gm/kg 0r average of 70-80 grams of protein per day 45 428 surgery team

46. 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 46 428 surgery team

47. 47 428 surgery team

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

49. 49 428 surgery team

50. 50 428 surgery team

51. 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 51 428 surgery team

52. Potential benefits of EN over PN  Nutrients are metabolized and utilized more effectively via the enteral than parenteral route  Gut and liver process EN before their release into systemic circulation  Gut and liver help maintain the homeostasis of the AA pool and skeletal muscle tissue 52 428 surgery team

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

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

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

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

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

58. 58 428 surgery team

59. Intact food Predigested food 59 428 surgery team

60.  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 ever start feeding a malnurished patient with full calorie >> start gradually.. 60 428 surgery team

61. TF = tube feeding 61 428 surgery team

62. 62 428 surgery team

63. Purpose  To maintain positive nitrogen balance through the intravenous administration of required nutrient such as glucose, IL, AA, electrolytes, vitamins, minerals and trace elements  Patients who didn’t eat for 4-5 days u have to feed them PN first.. 63 428 surgery team

64. 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- 64 428 surgery team

65. 65 428 surgery team

66. 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”. 66 428 surgery team

67. Special Indications (can not eat) 67 428 surgery team

68. 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) 68 428 surgery team

69. 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 69 428 surgery team

70. 70 428 surgery team

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

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

73. Not to be memorized 73 428 surgery team

74. 74 428 surgery team

75. Diabetic  DM is not contraindication to TPN  Use sliding-scale insulin to avoid hyperglycemia 75 428 surgery team

76. 76 428 surgery team

77. Central PN (TPN)  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 77 428 surgery team

78.  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. 78 428 surgery team

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

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

81. 81 428 surgery team

82. 82 428 surgery team

83. 83 428 surgery team

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

85. 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 85 428 surgery team

86. 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 86 428 surgery team

87. 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 87 428 surgery team

88. 88 428 surgery team

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

90. 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 90 428 surgery team

91. 91 428 surgery team