SurgicalNutrition

(EnteralandParenteralNutritionTherapy)

1

Learningobjectives5TounderstandtheindicationsandcomplicationsofENandPNandhowtopreventorcounteractcomplicationsofthem1Tolearntheinfluenceonbodyenergymetabolisminsimplestarvation/stressstarvation(trauma/septicpatients)2Tolearntheprinciplesandpracticeofnutritionalscreeningandassessment3Toknowthedifferenttypesofcommerciallyformulas

4TobefamiliarwithbasicconceptsandmethodsofENandPN2

Surgicalnutrition≈clinicalnutritiontherapy

(EnteralandParenteralNutritionTherapy)

Clinicalnutritionshouldbepartofanintegratedprotocolofmanagementinmanysevereoracuteillness.Indifferentclinicalillnessorthedifferentcourseofdiseases,therearedifferentcompositionofnutritionaladmixturesandformulasforPNandEN.3SeveremalnutritionPeroperativenutritionCriticallyillandsepticpatients(COPD)TraumaInflammatoryboweldisease(CD/UC)LiverdiseaseRenaldiseasePulmonaryandcardiacdiseaseGIfistulasShortbowelsyndrome(extensivegutresection)AcuteandchronicpancreatitisSurgicalnutrition≈clinicalnutritiontherapyThenutritiontherapycanbeappliedinthefollowingdisease:4Malnutritionisaacuteorsubacuteorchronicstateofdisorderednutritioninwhichacombinationofvaryingdegreesofoverorundernutritionandinflammatoryactivityhaveledtoincreasednutrientconsumptionandachangeinbodycompositionanddiminishedfunction.

Malnutrition(1)5

Malnutrition(1)

Inclinicalpracticehowever,foodsupplyisnottheonlyfactorcausingmalnutrition.Increasednutrientconsumptionrateduetoacceleratedcatabolismisalsoanimportantfactorintraumaandinflammatorydiseases.Duringthecatabolicphaseofsevereillness,thenegativeenergyandnitrogenbalancecan’tbereversedbynutritiononly,evenitisgiveninlargeamounts.Onlywheninflammationgiveswaytoconvalescence,losttissuecanberestored.6Malnutrition(3)Recently,anInternationalConsensusGuidelineCommitteeagreeduponanetiology-baseddiagnosisofadultstarvationanddisease-relatedmalnutritioninclinicalpractice.Starvation-relatedmalnutrition:chronicstarvationwithoutinflammatory(e.g.anorexianervosa)Chronicdisease-relatedmalnutrition:chronicandmildtomoderatedegreeofinflammation(e.g.cancer/rheumatoidarthritis/sarcopeniaobesity)Acuteorinjury-relatedmalnutrition:acuteandofseveredegreeofinflammatory(severeinfection/burns/trauma/closedheadinjury)7

Proteinmetabolismduringcriticalillness

Thedegreeofproteincatabolisminsepsisislarge,reachinglossesofnitrogenofupto20-40g/d≈protein:125-250g/d≈leantissue600-1200g/d(attheusualconversionfigureof30:1forleantissuetonitrogen).

Whenproteincatabolismcontinuesatthisrateandthesepatientsdonotreceivenutritionsupport,muscletissueandothertissue(organs)willbelostrapidly,Finally,leadingtoMOF(MODS).8Thefattyacidsthatarereleasedfromadiposetissueareonlypartlyoxidatedintheliverandperipheraltissuelikemusclesandmyocardiumandpartlyre-esterifiedtotriglycerides.Thiscanleadtofattyinfiltrationoftheliverandmuscletissue,especiallywhenhighdosesofglucose(aboveoxidationlimit4-5mg.kg-1.min-1)inanadultpatient.Lipidmetabolismduringcriticalillness9※Injuryandsepsisinitiatesastrongincreaseinendogenousglucoseproduction(upto15%abovecontrollevel)Formationofnewglucosebytheliver(gluconeogenesis)fromlactate,glycerolandaminoacidisincreased.Endogenousglucoseproductionisrelatedtocriticallyillnessandcannotbefullysuppressedbyexogenousglucoseorbyinsulin.Incriticalconditionsgluconeogenesisisanobligatoryprocess,initiatedbystresshormonesandcytokines（corticosterioid/adrenaline/glucagon/TNF/IL-1/IL-6）Carbohydratesmetabolism

duringcriticalillness10

Metabolicresponseto

simplestarvationandcriticalillness

Glucose/protein/Lipid-metabolism

simplestarvation

Stressreaction(Criticalillness)Protein

Proteolysis

ProteosynthesisAminoacidoxidationGlucose

Gluconeogenesis

Glycolysis_GlucoseoxidationGlucosecyclingLipidLipolysisinfattissue

LipidoxidationKetogenesisFattyacids-triglyceridecycling11

NutritionalAssessmentNutritionalassessmentshouldincludethefollowingprinciples:MeasurementofnutrientbalanceMeasurementofbodycompositionMeasurementofinflammatoryactivityMeasurementoforganortissuefunction

Nutritionalassessmentisamoredetailedandtimeconsumingprocess,carriedoutbystaffexperiencedinclinicalnutrition,e.g.dietitians,nutritionnurses,ordoctorswithaspecialistinterest.Appropriateinterventionplanandcontinuousmonitoringshouldbedevised.12Weightloss/appetite/dietaryintake/gastrointestinalsymptoms/fever/nutrientlossesinexcreta/medicalanddrughistoryshouldallbeassessedAccurateanddetailedinformationonfoodintakeisacriticalmeasureforassessingnutritionalstates.DiseasestatusandinflammatoryactivityDiseasestatusandinflammatoryactivitycanbeassessedbymedicalhistory/clinicalexamination/bedsidemeasurementstemperature/pulserate/bloodpressure/moreimportantincludinglaboratorytests(C-reactiveprotein/serumalbumin/fullbloodcount/hemoglobin)

NutritionalBalance13Measurementsofskeletalmusclefunctionarevaluablesincetheyaresensitivebothtochangesinmusclemassandtonutrientintake.Improvementsinmusclestrengthoccur

within2-3daysofbeginningnutritionalsupport.Converselymusclestrengthbeginstodeterioratewithinafewdaysoftotalstarvation.Thesimplestmeasurementuseshandgrip,whichcorrelatesverywellwithclinicaloutcomeinpatients.

FunctionalAssessment14

Nutritionalstatus

assessmentandmonitoring

Nutritionalstatusassessment：Anthropometry

Bodyweight--themostfrequentlyusedparameterinclinicalpractice

ShorttermweightchangesreflectfluidbalanceLongtermweightchangesmayreflectnetchangesinrealtissuemass(Bodycompositionchanges:fatfreemass(FFM)andfatmass(FM))

ForgeneralpatientsForpatientsofdifficulttostand15

Nutritionalstatus

assessmentandmonitoring

Last3-6monthsmildmalnutritionseveremalnutritionweightlosss<5%>10-15%Eveniftherehasbeenweightlossforoverayear,thismaynotreflectmalnutritioniftherehasbeenrecentweightregain.Ontheotherhand,ifweightlossiscontinuing,thereasonsshouldbeexplored.16Bodymassindex(BMI)=Weight(kg)/Heightsquare(m2)

Nutritionalstatus

assessmentandmonitoring

BMI(kg/m2)Assessment>30Obese(malnutrition)25-30Overweight(malnutrition)20-25Normalweight18.5-20Possibleundernutrition<18.5Undernutrition17Midarmcircumference(MAC)MACismeasuredusingatapeatthemidpointbetweentheacromionandolecranonprocess.Lowlevelscorrelatewellwithmortality,morbidityandbenificialresponsetonutritionalsupport.Ineldlypeople,MAChasbeenshowntobeabetterpredictorofmortalitythanBMI.NormallevelMAC≥22cm

Nutritionalstatus

assessmentandmonitoring

MAC18

LaboratoryTestsSerumalbumin

----isagoodpredictorofsurgicalrisk

----notreflectsmalnutrition

-----half-lifeofitabout19dSerumalbuminismainlyaffectedbydistributionanddilution,duetoincreasedalbuminescaperatefromthecirculationassociatedwiththecytokineresponsetoinjuryandduetodilutioninanincreasedextravascularvolume.Theshorterhalf-lifeproteins:pre-albumin(12h)

Pre-albuminismoresensitivereflectionofrecentfoodintakeandagoodmeasurefornutritionalstate.19

EnteralNutrition

——ENConcept

EnteralNutrition(EN)isasafe,effectiveandgenerallywell-toleratedmeansofadministeringnutritionaltherapytopatientswithafunctioninggastrointestinaltract.Summary

Inabroadsense—Providenutrientstothegastrointestinaltractthroughthemouthortubefeeding.

Inanarrowsense—Providenutrientstothegastrointestinaltractthroughtubefeeding.

MostcomplicationsofENortheerrorsinitsapplicationshouldbeavoided.20

EnteralNutrition——ENIndicationsofEN

Ifgutworks,useit.his/hernutritionalneeds,enteralfeedingcanbeconsidered.DisorderofswallowingandchewingDisturbanceofconsicousnessorcomaShortBowelSyndromeHighmetabolicstateAcutepancreatitisChronicinflammationofintestinalCorrectiveandpreventivemalnutritionbeforeandafteroperationBenefitsofEN

1ENleadstofewerclinicalcomplicationsthanPN2ENcostsfivetimeslessthanPN

21ContraindicationstoENENshouldalwaysbethefirstoptionTheremaybecontraindications,theseinclude

Absenceofintestinalfunction-----failure/severeinflammation/postoperative/stasis

Completeintestinalobstruction

Highlossintestinalfistulae

Thedigestivetractactivebleeding

Shock

EnteralNutrition——EN22

CommoncommercialformulasofENEnsureSpecialformulas(disease-specific)areavailablefordiabetes/renaldisease/liverdiseasePeptisorb(SP)

polymericformulas(apowderform)arenutritionallycompleteandcomprisemostlyintactnutrients23oligomericfoemulas--dipeptidesenhanceintestinalabsorptionofnitrogen

ComplicationsofEnteralNutritionToknowthemaintypesofcomplicationsassociatedwithtube-feeding.topreventcomplicationsofenteralnutrition.24

ComplicationsofEnteralNutritionGastrointestinalMechanicalMetabolismGastrointestinalcomplications:diarrhoea/nausea/vomitingDiarrhoea:

Definitionliquidorsoftstoolmass>250g/d;

astoolfrequency≧3to5timesperdayThemostcommoncomplicationinENOccurringwithinawiderange(2%-6%)Diarrhoeapersist,thefollowingoptionsshouldbeconsideredSwitchtocontinuousadministrationifpreviouslyintermittentDecreasethedeliveryrateChangetoENformula:anoligomericormonomericIf,despitetheabovemeasures,theproblemspersist,parenteralnutritionshouldbeconsidered.

25ComplicationsofEnteralNutrition

Gastrointestinalcomplications:diarrhoea/nausea/vomiting

NauseaandvomitingApproximately20%ofpatientsDelayedgastricemptyingisthemostcommoncauseofnauseaorvomitingTheassessmentofpatientsonENwithnauseaorvomitingshouldinclude-----theexclusionintestinalobstruction-----thepatient'sprescriptionsregardingnauseainducingdrags-----delayedgastricemptyingisconsideredareductionindeliveryrate

usingprokineticdrugs

GastrointestinalMechanicalMetabolism26

ComplicationsofEnteralNutrition

Mechanicalcomplications---Aspiration/Tuberelatedcomplications/TubecloggingAspiration

pulmonaryaspirationofEN(extremelyseriousandmaybealife-threateningcomplication),withanincidenceof1%-4%,themajorityofthesepatientsaspirateatleastonceduringtheearlycourseofEN,andthosewhoaspiratefrequentlyhaveasignificantlyhighriskofdevelopingpneumonia.GastrointestinalMechanicalMetabolism27

ComplicationsofEnteralNutrition

Mechanicalcomplications---Aspiration/Tuberelatedcomplications/TubecloggingRiskfactorsforaspirationinclude:decreasedlevelofconsciousnessgastrointestinalrefluxsupinepositionuseoflarge-bonefeedingtubeslargegastricresidues(>200ml)Topreventaspiration,thefollowingshouldbeconsidered:

measuregastricreflux,adjustthedeliveryratepreferenceforasemi-recumbentposition(30-45o)preferencefornasojejunalinsteadofnasogastrictubefeedingGastrointestinalMechanicalMetabolism28Topreventaspiration,thefollowingshouldbeconsidered:measuregastricreflux,adjustthedeliveryratepreferenceforasemi-recumbentposition(30-45o)preferencefornasojejunalinsteadofnasogastrictubefeeding

ComplicationsofEnteralNutrition

RaisethebedMeasruethegastricresidualvolueAdjustmentofdeliveryrate29Mechanicalcomplications---

Aspiration/

Tuberelatedcomplications/Tubeclogging

ComplicationsofEnteralNutrition

Tuberelatedcomplications

Tubemalpositioncanberesponsibleforbleedingandforperforationofthetracheaorthegastrointestinaltract.IfaPHlessthan5isrecordeditwillnormallybesafetoconcludethatthetipofthetubeisinthestomach.Radiologicalexaminationofthetubepositionisrecommendedincaseofanydoubt.Thepresenceofthefeedingtubeitselfmaycausenecrosis,ulcerationatnosopharyngeal,esophageal,gastricandduodenumpointsofcontact.

Theseproblemscanbereducedbyuseofmodernfine-boretubes.

GastrointestinalMechanicalMetabolism30

ComplicationsofEnteralNutrition

GastrointestinalMechanicalMetabolismMechanicalcomplications---

Aspiration/Tuberelatedcomplications/TubecloggingTubeclogging(obstrution)

Mostcloggingissecondarytocoagulationorinadequateflushingofthetubeafterfeeding.

Tounclogfeedingtube,thefollowingshouldbeconsidered

RangingfromwarmwateralternatingwithgentlesuctionTotheuseofpancreaticenzymessolutiontohelpdigesttheprecipitate.31

ComplicationsofEnteralNutrition

MetaboliccomplicationsofEN

MetaboliccomplicationsofENare,infact,verysimilartothoseoccurringduringPN,despitetheirlowerincidenceandseverity,carefulmonitoringcanhelptoreduceorpreventthoseproblems.GastrointestinalMechanical

Metabolism32

ComplicationsofEnteralNutrition

TableThemostfrequentmetaboliccomplicationsofENTypecausesolutionHyponatraemiaOverhydrationChangeformula/RestrictfluidsHypernatramiaInadequatefluidintakeIncreasefreewaterHyperglycaemiaExcessiveenergyintakeAssessenergyintakeAdjustinsulindosageHypokalaemiaDiarrhoeaAdjustforK+depletionEvaluatecausesofdiarrhoeaHyerkalaemiaExcessiveK+intakerenalinsufficiencyChangeformulaGastrointestinalMechanical

Metabolism33Typesofsolutionsavailable

forenteralfeedingWithfiber——MixedElemental(Aminoacids)EneralTubeFeedingSolutionsWholeProteinModifiedProteinDiseaseSpecificAdultPediatricWithfiber——MixedWithoutfiberWithoutfiberAdultPediatricSemi-elemental(Di-/tri-peptides)Elemental(Aminoacids)Semi-elemental(Di-/tri-peptides)Respiratory(AlteredCHO:fatratio)Renal(lowprotein,lowelectrolyte,highenergylowfluid)AIDS/HIV(Modifiedfat/peptides,addsfiber,energydense)IntensiveCare(Addedglutamine/n3fattlyacids/arginine)Hepatic(Addedbranchedchainaminoacids)Cardiacinsufficiency(lowsodium)milkintolerance(Soybased)

RoutesforenteraltubefeedingEnteralNutritionProteinandenergyenricheddietOralTubeFeedingSipfeedingGastricDuodenalJejunalNasogastricPharyngostomOesophagostomyGastrostomyNasoduodenalExtendedgastrostomyPEGorG-tubeRadiologicallyinsertedgastrostomySurgicalgastrostomyNasojejunalExtendedgastrostomysurgicaljejunostomyDirectaccessFineneedleCatheterThechoiceoffeedingroutewilldependontheunderlyingpathology,theanticipateddurationoftubefeedingandpreferenceofthepatient.

TheadvantagesofenteralnutritionHighefficiencyofnutrientabsorptionandutilization

（Throughtheportalveinorthegut）Toprotecttheintestinalmucosalmechanicalbarrier

(Villusheight,intercellularjunctions)Toprotecttheintestinalbiologicalbarrier

(thebalanceofintestinalmicroflora,thenormalgrowthofnaturalflora)Toprotecttheintestinalimmunebarrier

(theintestinallgAsecretion)Toprotecttheintestinalchemistrybarrier

(gastricacidandpepsasesecretion)Makehepatopancreasmetabolismmoreconformtothephysiologicalprocessandreducetheassociatedcomplications

(PNmakethebody'smetabolismdeviatefromphysiologicalprocess)36

Parenteralnutrition——PNPNisthemeansbywhichnutrientsareprovidedintravenously

PNcanbedividedinto

DefinitionTotalPN

Allnutrientneedsareprovidedintravenouslywithoutanyoralorenteralintake.PartialPN

Aportionofthenutrientneedsisprovidedviagastrointestinaltract,theremainderisprovidedintravenously.37

MethodsofdeliveringparenteralnutritionCentralVenousCatheters(CVC)（Viaacatheterwithtiplocatedinacentralvein）PeripherallyInsertedCentralCatheter(PICC)(CatheterisinsertedatBasilicvein/Cephalicvein,withatipislocatedinthesuperiorvenacava.)PeripheralVenousCatheters(PVC)Basilicvein/CephalicveinSubclavianorjugularvein↓↓→38

MethodsofdeliveringparenteralnutritionPPN(PeripheralPN)CPN(CentralPN)Periodsofnutritiontherapy

<oneweek>oneweekosmolalityoffluids<850mmol/L>1000mmol/Lenergy/proteinelectrolyte(potassium)lowhighphlebitis/thrombosis＋±septiccomplicationsofintravascularcatheters±＋＋39WhenthegutisnotfunctionallyforEN(perforation/obstruction/ileusoninadequateabsorptiveorpropulsivecapacity)Whenthegutisphysicallyinaccessible(anatomicalreasons)Whentubefeedingisunsafe(ischemicboweldisease/intractablevomiting)PNcanberequiredoverprolongedperiodsduetopermanentgastrointestinalproblems(suchastheshortbowelsyndrome)

PNisnotregardedasthefirstchoicewhenthepatientscantakeadequatefoodthroughmouthortubefeeding.

IndicationsforPN40Complicationsassociatedwithcentralcatheterinsertionandcare

Thecomplicationsalsocanbecharacterisedbytheirnatureinto

Technicalcomplicationsinclude:

FailuretoachieveproperinsertionandpositionLocalhaematomaorabscess/Catheterembolism/Airembolism/Haemothorax/Pneumothorax/Thrombosis

theriskofcomplicationsPreventionofthrombosiscanbeachievedbyappropriateselectionoftheinsertionsite,propercathetertiplocation,meticulousinsertion,infusionandflushingtechniquesanduseofsubcutaneousheparinintheimmediatepost-insertionperiod.

ComplicationsofParenteralNutrition

SepticTechnicalThrombotic41SepticcomplicationsassociatedwithcentralcatheterinsertionandpreventionTheclinicalpictureofcatheterrelatedseveresepsishaslocaland/orgeneralmanifestationThelocalsignsinclude:

redness,pain,swelling,orpurulentfluidattheexitsiteinflammatorystreakalongthesubcutaneoustunnel/painful

Thegeneralsigns:

Theearlynonspecificsignsmaypresentasfever,oftenaccompaniedbychill,symptomsoftenappear1-3hoursafterstartingainfusion.Catheterrelatedinfectionmaypresentverydifferentclinicalpictureschangingwithtimeandleadingtothepatient'sdeathwhennotrecognizedandtreatedpromptlyandeffectively.

ComplicationsofParenteralNutrition

TechnicalThromboticSeptic42

ComplicationsofParenteralNutrition

TechnicalThromboticSepticpreventionThemostimportantpreventionmeasuresarefullbarrierprecautionsduringinsertion,aseptichandingofallconnectionsanddressingchangesaccordingtoaprotocol,supervisedandfollowedbythenutritionalteam.Inmostcasesofexitsiteinfection,thecathetershouldberemovedanditstipculture.Aswobfromtheskinaroundtheexitsiteandbloodshouldalsobesentforculture.43Consequencesofpoorplanningofnutritionalintake

BadplanningLownutrientintakeWeightlossDeficiencyMacronutrientoverdosageBadmacronutrient/micronutrientsrelationsRefeedingsyndromeMentaldisturbancesAciosisParestesiasParaplegiasCardiacarrhytmiasCirculatoryfailureRespiratoryfailureShockDeathHealthySickWeightgainSeconddiseaseHyperglycaemiaHyperlipidaemiaUraemiaLiversteatosisDecreasedimmunocopetenceLate-liverdisease,metabolicsyndrome,heartfailure,renalinsufficiency,etc

SubstratesusedinPNandEN

Learningobjectives1TobeinformedabouttheeffectsofloworveryhighenergyintakeduringnutritionalsupportandtheenergyneedsduringENandPN2Todistinguishthedifferencebetweenenergyneedsinstableandcriticallyillpatient45

Requirementsofenergy/Carbohydrates/

Lipid/Protein(aminoacids)Water/electrolytes/vitamins/traceelementsinENandPN(inacutediseasestage/incriticallyillpatients)Energyrequirements20-30kcal/kg.dIntheadultpatientenergyrequirementsdependonthestageofdiseaseandonnutritionalstatus.46Energy(1)Incriticalillnessenergyintakeshouldminimizenegativeenergybalanceandlossesofleanbodymass.Aninappropriatelyhigh-intake(overfeeding)ofpatientsisassociatedwithuntowardsideeffectsandmetabolicalterations.Hyperalimentationbyitselfcouldnotreversetheadditionalcatabolismbysevereinjuryandinfection,butcouldproduceunwantedsideeffects.47Energy(2)Criticallyillheamodynamicallyunstablepatient.Usually,stabilizationofbloodpressureandtissueperfusionisthetreatmentpriorityatthisstage.Properenergyutilizationisunlikelyandthereforeenergyintakeshouldnotexceed30-50%ofestimatedenergyexpenditureuntilstablehemodynamicparametersareestablished.Inseverelymalnourishedpatients:energyintakeshouldbeintroducedslowlytoavoidprecipitatingtherefeedingsyndrome,startingat20-30%ofrequirementsandincreasingtomeetfullrequirementovera