Note

Lecture 10c 18 March 2013 Surgery and Burns

Surgery

-patient should be well nourished prior to surgery-this gives better recovery -however, surgical patients are often malnourished due to anorexia, nausea, vomiting, burns, fever, malabsorption, and blood loss -surgical prep- range of actions include: -high calorie protein diet -enteral feeding -parenteral feeding

Surgery

-nothing by mouth (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 -start with clear liquids to full liquids to soft or regular diet as tolerated post-op -usually a high protein high calorie diet is appropriate-this helps with healing

Burns

-hypermetabolism involved- why?

-solution to hypermetabolism?

-large quantities of nutrients leech through burn area -therefore fluid and electrolyte imbalances are a problem

Burns

-result in anorexia, pain, emotional trauma, weight loss and immune incompetence, malnutrition -nutritionally how are these overcome?

Burns

-after fluid and electrolytes are addressed 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 20-25 % protein, 50 % carbohydrate, 25 % fat -Kcal- additional 40-60 kcal/kg body weight/day -high fluid intake –including more potassium, zinc and vitamins A and C (zinc, vitamins A and C for wound healing) and vitamins B 1 , B 2 and B 3 intake) (in proportion to increased energy

Table 29-1, p. 870

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(post menopausal) in females -beer and scotch may contain nitrosamines -wine and brandy may contain urethane -urethane and nitrosamines are carcinogens -moderation is the key to prevention here

Dietary factors –cancer promoters and inhibitors

-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 -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 dietary intervention prepares body for stresses that lay ahead

AIDS

Weight loss, diarrhea, seborrhea, eczema, fever, sweating-nutritional implications?

Nutritional implications can further deteriorate patient’s health e.g. further immune response compromise 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

Drugs can exacerbate nutritional difficulties (table)

AIDS Fat

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

AIDS Vitamins and Minerals

recommendation-close to DRI-otherwise adverse interactions with antiretroviral drugs

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)