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Nutrition in surgical patients

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Discussion about nutrition in surgical patients.

Veröffentlicht in: Gesundheit & Medizin
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Nutrition in surgical patients

  1. 1. Enteral and Parenteral Nutrition Support Dr Ashish Tripathi Gen Surgery PGT, RTIICS, Kolkata.
  2. 2. Enteral Nutrition Definition Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum) —Tube feedings —Must have functioning GI tract —IF THE GUT WORKS, USE IT! —Exhaust all oral diet methods first.
  3. 3. Conditions That Require Other Nutrition Support Enteral —Impaired ingestion —Inability to consume adequate nutrition orally —Impaired digestion, absorption, metabolism —Severe wasting or depressed growth Parenteral —Gastrointestinal incompetency —Hypermetabolic state with poor enteral tolerance or accessibility
  4. 4. Considerations in Enteral Nutrition 1. Applicable 2. Site placement 3. Formula selection 4. Nutritional/medical requirements 5. Rate and method of delivery 6. Tolerance
  5. 5. Formula Selection The suitability of a feeding formula should be evaluated based on Functional status of GI tract Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity) Macronutrient ratios Digestion and absorption capability of patient Specific metabolic needs Contribution of the feeding to fluid and electrolyte needs or restriction Cost effectiveness
  6. 6. Enteral Access: Clinical Considerations Duration of tube feeding —Nasogastric or nasoenteric tube for short term —Gastrostomy and jejunostomy tubes for long term Placement of tube —Gastric —Small bowel
  7. 7. Placement Site Access (medical status) Location (radiographic confirmation) Duration Tube measurements and durability Adequacy of GI functioning
  8. 8. Enteral Tube Placement
  9. 9. Advantages—Enteral Nutrition Intake easily/accurately monitored Provides nutrition when oral is not possible or adequate Costs less than parenteral nutrition Supplies readily available Reduces risks associated with disease state
  10. 10. More Advantages— Enteral Nutrition Preserves gut integrity Decreases likelihood of bacterial translocation Preserves immunologic function of gut Increased compliance with intake
  11. 11. Disadvantages—Enteral Nutrition GI, metabolic, and mechanical complications —tube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax Costs more than oral diets Less “palatable/normal” Labor-intensive assessment, administration, tube patency and site care, monitoring
  12. 12. Complications of Enteral Feeding Access problems (tube obstruction) Administration problems (aspiration) Gastrointestinal complications (diarrhea) Metabolic complications (overhydration)
  13. 13. Aspiration Pneumonia Can result from enteral feeds High-risk patients —Poor gag reflex —Depressed mental status
  14. 14. Reducing Risk of Aspiration Check gastric residuals if receiving gastric feeds Elevate head of the bed >30 degrees during feedings Postpyloric feeding —Nasoenteric tube placement may require fluoroscopic visualization or endoscopic guidance —Transgastric jejunostomy tube
  15. 15. Rate and Method of Delivery* Bolus—300 to 400 ml rapid delivery via syringe several times daily Intermittent─300 to 400 ml, 20 to 30 minutes, several times/day via gravity drip or syringe Cyclic—via pump usually at night Continuous—via gravity drip or infusion pump *Determined by medical status, feeding route and volume, and nutritional goals
  16. 16. Lower Osmolality Large (intact) proteins Large starch molecules
  17. 17. Higher Osmolality Hydrolyzed protein or amino acids Disaccharides
  18. 18. Tolerance Signs and symptoms: —Consciousness —Respiratory distress —Nausea, vomiting, diarrhea —Constipation, cramps —Aspiration —Abdominal distention
  19. 19. Tolerance—cont’d Other signs and symptoms —Hydration —Labs —Weight change —Esophageal reflux —Lactose/gluten intolerances —Glucose fluctuations
  20. 20. How to Determine Energy and Protein kcal/ml x ml given = kcal % protein x kcal = kcal as protein kcal as protein x 1 g/4 kcal = g protein Example: Patient drinks 200 cc of a 15.3% protein product that has 1 kcal/ml 1 kcal/ml x 200 ml = 200 kcal 0.153 % protein x 200 kcal = 30.6 kcal 30.6 kcal x 1g protein/4 kcal= 7.65 g protein
  21. 21. Energy in Formulas 1 to 1.2 kcal/ml = usual concentration 2 kcal/ml = highest concentration
  22. 22. Protein From 4% to 26% of kcal is possible 14% to 16% of kcal is usual 18% to 26% of kcal—considered to be high-protein solution
  23. 23. Recommended Water Healthy adult: 1 ml/kcal or 35 ml/kg Healthy infant: 1.5 ml/kcal or 150 ml/kg Normal tube feeding: 1 kcal/ml; 80% to 85% water Elderly: consider 25 ml/kg with renal, liver, or cardiac failure; or consider 35 ml/kg if history of dehydration
  24. 24. Sources of Fluid (“Free Water”) Liquids Water in food Water from metabolism With tube feeding, nurse will flush tube with water about 3 times daily—include this amount in estimated needs —Example: “flush with 200 cc tid”
  25. 25. Administration: Feeding Rate Continuous method = slow rate of 50 to 150 ml/hr for 12 to 24 hours Intermittent method = 250 to 400 ml of feeding given in 5 to 8 feedings per 24 hours Bolus method = may give 300 to 400 ml several time a day (“push” is not desired)
  26. 26. French Units—Tube Size Diameter of feeding tube is measured in French units 1F = 33 mm diameter Feeding tube sizes differ for formula types and administration techniques.
  27. 27. Enteral Nutrition Monitoring
  28. 28. Routes of Parenteral Nutrition Central access —TPN both long- and short-term placement Peripheral or PPN —New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis <2000 kcal required or <10 days
  29. 29. PPN vs. TPN Kcal required (10% dextrose max. PPN conc.) Fluid tolerance Osmolarity Duration Central line contraindicated
  30. 30. Venous Sites from Which the Superior Vena Cava May Be Accessed
  31. 31. Advantages—Parenteral Nutrition Provides nutrients when less than 2 to 3 feet of small intestine remains Allows nutrition support when GI intolerance prevents oral or enteral support
  32. 32. Indications for Total Parenteral Nutrition GI non functioning NPO >5 days GI fistula Acute pancreatitis Short bowel syndrome Malnutrition with >10% to 15 % weight loss Nutritional needs not met; patient refuses food
  33. 33. Contraindications GI tract works Terminally ill Only needed briefly (<14 days)
  34. 34. Calculating Nutrient Needs Avoid excess kcal (> 40 kcal/kg) Adults kcal/kg BW Obese—use desired BMI range or an adjusted factor
  35. 35. Adjusted Body Weight Adjusted IBW for obesity Female: ([actual weight – IBW] x 0.32) + IBW Male: ([actual weight – IBW] x 0.38) + IBW
  36. 36. Parenteral Components Carbohydrate glucose or dextrose monohydrate 3.4 kcal/g Amino acids 3, 3.5, 5, 7, 8.5, 10% solutions Fat 10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/ml
  37. 37. Protein Requirements 1.2 to 1.5 g protein/kg IBW mild or moderate stress 2.5 g protein/kg IBW burns or severe trauma
  38. 38. Carbohydrate Requirements Max. 0.36 g/kg BW/hr Excess glucose causes: Increased minute ventilation Increased CO2 production Increased RQ Increased O2 consumption Lipogenesis and liver problems
  39. 39. Lipid Requirements 4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as lineoleic acid Usual range 25% to 35% max. 60% of kcal or 2.5 g fat/kg
  40. 40. Other Requirements Fluid—30 to 50 ml/kg Electrolytes Use acetate or chloride forms to manage acidosis or alkalosis Vitamins Trace elements
  41. 41. Calculating the Osmolarity of a Parenteral Nutrition Solution 1. Multiply the grams of dextrose per liter by 5. Example: 50 g of dextrose x 5 = 250 mOsm/L 2. Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L 3. Fat is isotonic and does not contribute to osmolarity. 4. Electrolytes further add to osmolarity. Total osmolarity = 250 + 300 = 500 mOsm/L
  42. 42. Compounding Methods Total nutrient admixture of amino acids, glucose, additives 3-in-1 solution of lipid, amino acids, glucose, additives
  43. 43. Administration Start slowly (1 L 1st day; 2 L 2nd day) Stop slowly (reduce rate by half every 1 to 2 hrs or switch to dextrose IV) Cyclic give 12 to 18 hours per day
  44. 44. Monitoring and Complications Infection Hemodynamic stability Catheter care Refeeding syndrome
  45. 45. Refeeding Syndrome Hypophosphatemia Hyperglycemia Fluid retention Cardiac arrest
  46. 46. Monitor Weight (daily) Blood Daily Electrolytes (Na+ , K+ , Cl- ) Glucose Acid-base status 3 times/week BUN Ca+, P Plasma transaminases
  47. 47. Monitor—cont’d Blood Twice/week Ammonia Mg Plasma transaminases Weekly Hgb Prothrombin time Zn Cu Triglycerides
  48. 48. Monitor—cont’d Urine: Glucose and ketones (4-6/day) Specific gravity or osmolarity (2-4/day) Urinary urea nitrogen (weekly) Other: Volume infusate (daily) Oral intake (daily) if applicable Urinary output (daily) Activity, temperature, respiration (daily) WBC and differential (as needed) Cultures (as needed)
  49. 49. Problems PPN Site irritation TPN 1. Catheter sepsis 2. Placement problems 3. Metabolic
  50. 50. Document in Chart Type of feeding formula and tube Method (bolus, drip, pump) Rate and water flush Intake energy and protein Tolerance, complications, and corrective actions Patient education
  51. 51. Now the onus is on you.