Transcript 35-Nutritional_support.ppt

Nutritional support in
surgical patients
Outline of
the lecture
• Definition of nutritional support
• The Role of Nutrients in the Body
• Body's endogenous reserve of major
nutrients
• Classification of Malnutrition and it’s
effect in the body
• Nutritional Assessment
Definition
•Nutrients
is the constituents of food necessary to
sustain normal function of the body
•Nutritional support
The provision of nutrients orally,
enterally or parenterally with
therapeutic intent.
The Role of
Nutrients in the
Body
•
•
•
•
•
•
•
•
ESSENTIAL NUTRIENTS:
carbohydrates, protein, and fats:
supplying energy and raw materials for metabolism.
Missing just one of these Essential Nutrients puts the
body into a state of being malnourished.
ESSENTIAL AMINO ACIDS:
required to make proteins they cannot be created by the
body
ESSENTIAL FATTY ACIDS:
Lipids that cannot be created by the body required to
make some of the phospholipids.
• VITAMINS:
• organic molecules that
serve as co-enzymes or
parts of co-enzymes and
therefore have catalytic
functions
• required in small amounts
• Water-soluble:
• B complex, Vitamin C
excreted with the urine
• mild overdoses are
harmless
• fat-soluble: E,D,A,K
• should be monitored
more closely
• MINERALS:
• Calcium: bone, nerves
and muscles
• Phosphorus: bone, ATP
and nucleic acids
• Iron: cellular respiration
and hemoglobin
• Iodine: thyroxine
• Sodium, potassium, and
chlorine are important in
nerve function
• Magnesium, manganese,
zinc, and cobalt are
cofactors built into the
structure of certain
enzymes
Body's endogenous reserve of major
nutrients
including adipose and somatic muscle tissue
CLASSIFICATION OF MALNUTRITION
MARASMUS
-depletion in the somatic compartment
KWASHIORKOR
-depletion in the visceral compartment
MARASMUS-KWASHIORKOR MIX
-depletion in both compartments
Malnutrition
•
1.
2.
•
Preoperative
Starvation
failure of proper digestion
Postoperative
Starvation
which may be secondary to:
• Poverty and inability to obtain food
• Dysphagia
• Vomiting
• Self neglect, e.g alcoholics and the
elderly
• Conserve energy by decrease in
metabolism Initial loss of glycogen
(24 hr), body fat, then skeletal
protein
• Death is due to weakness of
diaphragm, pneumonia or other
infection; timing depends on size of
fat stores
Failure of
digestion
• Pancreatic or biliary disease, e.g.
carcinoma, stone
• Duodenal or jejunal disease, e.g.
fistula, blind loop syndrome
• Postoperative
malnutrition
• Usually result of the stress of surgery and
is a transient nature
• However, it may be as severe with such
major operations as
• esophagectomy and paralytic ileus
What happens during acute stress?
• Catabolism of body protein (viscera and
skeletal) in order to support gluconeogenesis.
• Hormones: glucagons, catecholamine,
glucocorticoids … promote fluid retention
• Cytokine response: fever, inflammation,
increase metabolism.
• Skeletal protein is depleted
Hypercatabolic states
•
An increase in metabolic rate and protein
catabolism of >25% e.g.
1. Sever sepsis
2. Sever trauma as in burns
3. Sever inflammation as in pancreatitis
• Body fat used more gradually
• Death is due to weakness of diaphragm,
pneumonia or other infection.
Manifestations
General
• Physical and mental exhaustion
• Infection, due to immunosuppression
• Intolerance to radio- and chemo-therapy
Metabolic:
• Lowered rates of enzyme synthesis
• Impaired oxidative metabolism of drugs by
the liver
Healing problems:
• Wound dehiscence
• Leakage from bowel anastomoses
• Delayed callus formation
• Disordered coagulation
Nutritional
Assessment
How do we detect malnutrition?
• History
• Physical examination
• Laboratory investigations
History
• Dietary history
• Change in appetite
• Significant weight loss within last 3 months
15% loss of body weight
• Compare with ideal weight
• Beware the patient with ascites / edema
Physical
examination
• Evidence of muscle wasting
• Depletion of subcutaneous fat
• Features of Vitamin deficiency
(Glossitis in vit B12 def , hypertrophic gum :
scurvy in vit C def, follicular keratosis in vit A
def , pellagra in niacin def)
• Echymosis and easy bruising
• Easy to detect > 15% loss weight
Physical
examination
• Weight for Height comparison
• Body Mass Index
– Wt (kg) / Ht (M)2.
– NORMAL BETWEEN 18.5 – 24.5
Physical
examination
Anthropometry
– triceps skin fold (TSF) by caliper (minimum :
13 mm in female, 10 mm in male)
–
mid arm circumference (MAC).
– mid arm muscle circumference (MAMC)
– (feeding is indicated if less than 23 cm in F and 25
cm in M)
{MAMC = MAC cm – (TSF mm × 0.314)}
Lab
Investigations
• Albumin < 30 mg/dl
• Pre-albumin < 12 mg/dl
• Transferring < 150 mmol/l
• Total lymphocyte count < 1800 /mm3
• Tests reflecting specific nutritional
deficits
– e.g. prothrombin time
• Candida skin test
• Nitrogen balance studies
• urinary creatinine and 3—methylhistidine
excretion
• total body K and N
• 14C--leucine incorporation
• Fecal fat test
• Schilling test
• Hydrogen breath test
• D-xylose
Assessing Nutritional
Status:
The SGA
A. History
• Weight change
<5% = “small”
5–10% = “potentially
significant”
>10% = “definitely
significant”
• Change in dietary intake
• Gastrointestinal symptoms
(nausea, vomiting, diarrhea,
anorexia)
• Functional capacity
• Disease and its relation to
nutritional requirements
B. Physical
•
•
•
•
•
Loss of subcutaneous fat
Muscle wasting
Ankle edema
Sacral edema
Ascites
C. SGA Rating
subjective global assessment
• A = Well nourished
• B = Moderately malnourished
• C = Severely malnourished
Thank you
•
•
•
•
•
•
•
•
•
•
•
•
•
•
NOTES
ESSENTIAL NUTRIENTS
%57Carbohydrates (sugar, sweets, bread, cakes )
%30Fats (dairy products, oil )
%13Protein (eggs, milk, meat, poultry, fish )
Body's endogenous reserve of major nutrients
The Carbohydrates provide energy for 24 hr max
Brain , RBC and kidney relay on Carbohydrates for
supplying the energy
After 24 hr the body protein undergo gluconeogenesis to
supply energy for the three vital organs
Nutritional Assessment
The must important (practical) steps
History : 10% weight loss in 3-6 months
BMI
Albumin and HGB
The Doctor said you may ask to
calculate the total calories in
MCQs
• Calories per gram of:
Water = (0 Cal)
Protein = (4 Cal)
Dietary fiber = (3 Cal)
Fat = (9 Cal)
Alcohol = (7 Cal)
Carbohydrates = (4 Cal