1. Nutritional Support in the Surgical Patient Celso M. Fidel, MD, FPCS,FPSGS Diplomate Philippine Board of Surgery Fellow Philippine Society of General Surgeons Fellow Philippine Society for the Surgery of Trauma Fellow Philippine Association of Laparoscopic & Endoscopic Surgeons FEUNRMF and OLFU

17. Indications for Nutritional Support ESOPHAGECTOMY COLON REPLACEMENT CAUSTIC INGESTION, ESOPHAGEAL STRICTURE

18. Indications for Nutritional Support Duodenal Leak Gastro-duodeno-pancreatectomy

29. Effect of Nutritional Support Post-op Course Sepsis Well-nourished   Moderately Malnourished  if supplemented by arginine, RNA, omega-3 fatty acid  if given very early (30-40% increase) prefer nutritional support 5-10 days post-op Severely Malnourished  

30. Effect of Nutritional Support   Severely Malnourished  if supplemented by arginine, RNA, omega-3 fatty acid  if given very early (30-40% increase) prefer nutritional support 5-10 days post-op Moderately Malnourished   Well-nourished Sepsis Post-op Course

31. Effect of Nutritional Support Post-op Course Sepsis Well-nourished   Moderately Malnourished  if supplemented by arginine, RNA, omega-3 fatty acid  if given very early (30-40% increase) prefer nutritional support 5-10 days post-op Severely Malnourished  

32. Effect of Nutritional Support Post-op Course Sepsis Well-nourished   Moderately Malnourished  if supplemented by arginine, RNA, omega-3 fatty acid  if given very early (30-40% increase) prefer nutritional support 5-10 days post-op Severely Malnourished  

34. Decision Making GIT functional? YES NO ENTERAL ROUTE PARENTERAL ROUTE Short term Long term Short term Long term NGT Gastrostomy, Jejunostomy Peripheral PN Central PN

43. Gastric Anatomy

44. ENTERAL NUTRITION

45. ENTERAL NUTRITION Gastric feeding Jejunal feeding Solution used Hypertonic or isotonic Isotonic Infusion rate Bolus or continuous Continuous Initiation of infusion 25-30mL/hr Increments 25-30 mL/hr daily Intolerance Vomiting Distention, diarrhea, colic, reflux to NGT

46. ENTERAL NUTRITION Nutritional Support Needed?

47. ENTERAL NUTRITION Nutritional Support Needed

51. ENTERAL NUTRITION

52. ENTERAL NUTRITION DISEASE-SPECIFIC FORMULAS

53. Nutritional Support? TPN X ?

54. Nutritional Support? TPN ? ☺

55. Nutritional Support? TPN ? ☺

62. Venous Access

63. Subclavian Access

64. Venous Access

65. PARENTERAL NUTRITION Peripheral Central Dextrose content < 5% > 10 Calorie delivery Less More Volume delivery More Less Calorie source* Mostly fats Mostly CHO Calorie distribution CHO 30% CHON 20% Fats 50% CHO 55-60% CHON 15-20% Fats 25%

78. Parenteral Nutrition

79. Parenteral Nutrition Peripheral Central

82. Calculation of Caloric Needs Condition Kcal/kg/day Protein/kg/day NPC : N ratio Normal to moderate malnutrition 25 - 30 1 150 : 1 Moderate stress 25 - 30 1.5 120 : 1 Hypermetabolic, stressed 30 - 35 1.5 – 2.0 90-120 : 1 Burns 35 - 40 2.0 – 2.5 90-120 : 1

88. Surgical Nutrition Roberto B. Acuña, MD, FPCS, FPSGS, FPSLS General and Cancer Surgery Laparoscopic Surgery Hepato-biliary Surgery FEU-NRMF MEDICAL CENTER

90. Thank You