Transcript Body composition, injury, and wound healing in surgery
Body composition, injury, and wound healing in surgery
Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training
Objectives
• • To discuss the body composition and its key components To discuss body composition changes in injury particularly in surgery
BASICS AND NORMAL BODY COMPOSITION
The cell and its organelles
• • • • • • Major: Cell membrane Cytoplasm Mitochondria Nucleus Endoplasmic reticulum Golgi apparatus Illustrations from Guyton’s Textbook of Physiology
Nutrients, structure, function
Human body = 100 trillion cells
ENERGY
• • • • • • • • • Nervous system Musculoskeletal system Cardiovascular system Respiratory system Gastrointestinal system Genitourinary system Reproductive system Endocrine system Hemopoietic system
radicals
Body composition, all ages
Muscle and fat mass, all ages
BODY COMPOSITION IN HEALTH AND DISEASE
Body compartments in health and disease
CARBO + OTHER (1%) PROTEIN (6%) PROTEIN (14%) PROTEIN (14%) PROTEIN (12%) FAT (15%) FAT (23%) FAT (25%) FAT (30%) WATER (60%) WATER (55%) WATER (72%) WATER (70%) NORMAL OBESE STARVATION CRITICAL CARE
POST-PRANDIAL
Energy utilization
Lipogenesis Glucose Glycogen POST-PRANDIAL: within 24 hours Glycogen Gluconeogenesis FASTING: within 24 to 72 hours Fatty acid: lipolysis (minimal) FASTING: beyond 5 days Fatty acid: lipolysis (full blast) (preserving protein)
Note: Cardiac and skeletal muscle (slow) are mainly dependent on fatty acid for energy source
No food intake: glucose utilization
Surgery, wound healing, and nutritional status
SURGERY INFLAMMATION
No Malnutrition
↑WBC + ↑ENERGY ↑CELL MULTIPLICATION + ↑NUTRIENT NEEDS WOUND HEALING
Malnutrition
NORMAL POOR ± COMPLICATIONS
• • • •
Catecholamines Glucagon Thyroid hormones Cortisol
Loss of lean body mass = ↑mortality
Loss of Total LBM
10% 20% 30%
Complications
Decreased immunity Increased infections Decrease in healing, increase In weakness, infection Too weak to sit, pressure ulcers, Pneumonia, lack of healing 40% Death, usually from pneumonia LBM=Lean Body Mass
Associated Mortality
10% 30% 50% 100% Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9.
BODY COMPOSITION ANALYSIS
The surgical nutrition process
All admitted patients are nutritionally screened All nutritionally at risk patients are assessed All high risk patients are given nutrition care plans Monitoring of the nutrition process is done Nutrition care plan modification / Discharge
Nutritional Assessment and Risk Level Form
Complication(s) prediction
Predicting post-operative complications based on surgical nutritional risk level using the SNRAF in colon cancer patients - a Chinese General Hospital & Medical Center experience. Ocampo R B, Kadatuan Y, Torillo MR, Camarse CM, Malilay RB, Cheu G, Llido LO, Gilbuena AA. Yr 2007.
SURGICAL DECISION MAKING BASED ON BODY COMPOSITION ANALYSIS
PRE-OPERATIVE PHASE no malnutrition slight, moderate
severe • • •
Scheduled esophageal resection gastrectomy pancreaticoduodenectomy Enteral nutrition for 10-14 days oral immunonutrition for 6-7 days POST-OP EARLY DAY 1 - 14 SURGERY Early oral feeding within 7 days yes no within 4 days yes no Enteral access (NCJ) enteral nutrition immunonutrition for 6-7 days Oral intake of energy requirements yes no “Fast Track” Parenteral hypocaloric Adequate calorie intake within 14 days combined enteral / parenteral Oral intake of energy requirements LATE DAY 14 yes no supplemental enteral diet no yes
WOUND HEALING ISSUES
Inflammation: part of wound healing • • • Cell proliferation ↑ nutrient and energy requirements Adequacy of response is dependent on the nutrient supply / reserves
Wound healing Stages of wound healing and repair Angiogenesis Reference: Robbins Basic Pathology 7 th Kumar, Cotran, Robbins editors. 2003.
edition.
Wound healing: molecular environment
Basement membrane: 1. Cell support 2. Exchange 3. Transport 4. Development 5. Repair 6. Defense 7. Integrity of structure and environment Intercellular environment 1. Tissue support/shape 2. Exchange 3. Growth 4. Repair 5. Defense 6. Movement
Wound healing
Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003.
Wound healing requirements
• • • Increased requirements – Energy and protein – Electrolytes, vitamins, trace elements – Oxygen and water Addition of: – conditional essential amino acids (glutamine) – Trace elements (selenium in burns) – Antioxidants Continuous supply of the requirements
Energy calculations are good enough
ESPEN Guidelines 2009: Surgery
• Calorie Requirement(s): – The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements.
– Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weight – (Grade B) ESPEN: European Society of Parenteral and Enteral Nutrition
Protein synthesis
• Requirements: – ↑Insulin levels induced by adequate glucose intake – ↑plasma amino acid levels – Adequate essential amino acid levels – Adequate non-protein calories from carbohydrate and fat
ESPEN Guidelines 2009: Surgery
• Protein Requirement(s) – In illness/stressed conditions a daily nitrogen delivery equivalent to a protein intake of 1.5 g/kg ideal body weight (or approximately 20% of total energy requirements) is generally effective to limit nitrogen losses. The Protein:Fat:Glucose caloric ratio should approximate to 20:30:50% (Grade C) ESPEN: European Society of Parenteral and Enteral Nutrition
Carbohydrate and fat ratios
Stoner et al McFie et al
Do lipids matter?
LCT = mostly ω6FA (arachdionic acid) content = proinflammatory MCT = reduces ω6FA (arachidonic acid) content + direct utilization in the liver
ESPEN Guidelines 2009: Surgery
• Nitrogen sparing; non-protein calories – Optimal nitrogen sparing has been shown to be achieved when all components of the parenteral nutrition mix are administered simultaneously over 24 hours (Grade A) ESPEN: European Society of Parenteral and Enteral Nutrition
Energy requirements and antioxidants
2H 2 O
Vitamin C
Superoxide dismutase Cu Zn Catalase Hydrogen peroxide H 2 O 2 Glutathione peroxidase 2GSH GSSG Glutathione reductase 2H 2 O Oxygen radicals O• 2 Glutathione peroxidase Se ONO + H 2 O
• •
ONOO GSSG
Vitamin C
2GSH Glutathione reductase
Munoz C. Trace elements and immunity: Nutrition, immune functions and health; Euroconferences, Paris; June 9-10, 2005; Robbins Basic Pathology 7 th edition 2003. Kumar, Cotran, Robbins editors.
Antioxidants
1. α-tocopherol
1,000 IU (20 mL) q 8h per naso- or orogastric tube
2. ascorbic acid
1,000 mg given IV in 100 mL D 5 W q 8h for the shorter of the duration of admission to the ICU or 28 days.
Nathens AB, Neff MJ, Jurkovich GJ, Klotz P, Farver K, Ruzinski JT, Radella F, Garcia I, Maier RV. Randomized, prospective trial of antioxidant supplementation in critically ill surgical patients. Ann Surg. 2002; 236(6): 814-22.
Body composition, intake and outcome
CONCLUSION
Body composition
• • • Body composition changes occur in surgery Quality of body composition determines outcome in surgery Analysis of body composition and correction of deficiencies through nutrition improves outcomes in surgery