General surgery 2

General Surgery

Mosul university- College of dentistry-oral & maxillofacial surgery department
Dr. Ziad H. Delemi B.D.S, F.I.B.M.S (M.F.)
Nutrition in Surgical Patient

Mosul university- College of dentistry-oral & maxillofacial surgery department

Malnutrition
Causes: -Pre-operative: starvation(self neglect, poverty, dysphagia)failure of proper digestion. -Post-traumatic: -Hypercatabolic:sever sepsis, burn

Mosul university- College of dentistry-oral & maxillofacial surgery department

Effects of Malnutrition
Poor wound healing (dehiscence). Delay callus formation. Coagulation disorder. Impaired drug metabolism in the liver. Depress immunity. Decrease tolerance to radiotherapy & chemotherapy. Sever mental apathy.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Indication of nutrition
Pre-operative nutritional problems. Post operative complications(ileus more than 4days, sepsis). Intestinal fistula. Massive bowel resection. Management of malabsorption. Anorexia nervosa.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Indication of nutrition
Intractable vomiting. Maxillofacial trauma. Multiple trauma. Malignant disease. Burn. Renal failure, liver disease.


Mosul university- College of dentistry-oral & maxillofacial surgery department
Assessment of the nutritional status of the patient
A- characteristic appearance: lean & hungry, apathic, superimposed hectic flush around sunken cheeks & pinched nose. B- physical examination: Skin: rash, hyperkeratosis, nail deformity. Eyes: keratoconjectivitis, night blindness. Mouth: chelosis, glossitis, mucosal atrophy. Hair: recent loss. CNS: peripheral neuropathy, psychiatric problems.

Assessment of the nutritional status of the patient

C- special test:Body weight, body mass index wt/heightІ.Upper arm circumference indicated if <23 cm ♀ or 25 cm in ♂.Triceps skin fold thickness, min. 13 mm ♀, 10 mm ♂Serum Albumin not less than 35 g/LLymphocyte count <1500 /mmіCandida skin test N2 – balance studies.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Nutritional requirement
1- calories(energy):provided by CHO & fat. healthy adult at rest need 1500 – 2000 nonproteinous calories /day.2- N2: min. for +ve N2 balance 40 gm of protein & ↑in Hypercatabolic state.3- H2O: 2500-300ml/day.4- electrolytes: N+ 100mmol/dl, K+ 60mmol/dl, Ca++ 20 mmol/dl, Mg+ 30 mmol/dl, Cl- 100mmol/dl

Nutritional requirement

5- vitamins: water soluble vit. C& B, vit. C 70 mg/day & vit. B12 500µg /week IM.Fat soluble vit. A 6000 IU /week, K 8mg/week IM, E 10 mg/day ,D 5 µg/day.Vit. A&C affect Wound healingVit. D Rickets, osteomalaciaVit. E Anemia, ataxia, nystagmus, edema, myopathy.Thiamine Encephalopathy Vit. B6 neuropathy…6- minerals: iron 50 µmol/day, zinc 50 µmol/day, copper 15 µmol/day, iodine 5µmol/day.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Constituents of TPN
CHO: Dextrose 20%, 50%, 70%.Fat : Intralipid 10-20%.Protein: Vamine, Freamine, Nephramine, Hepatomine .Water 1500cc/day.Electrolytes K+, Na+, Cl-, Ph-, Ca++VitaminsTrace elements: Mg, Fe, Zn, …Albumin: 60 gm/day.Insulin: to keep blood glucose 150-200 mg/dl.Heparin: 1000 U/L protect central line & for lipolysis

Mosul university- College of dentistry-oral & maxillofacial surgery department

Methods of Nutrition
A- Enteral: 1- mouth: if there is no contraindication (?) start with liquid then semisolid then solid. 2- NG tube: used for regular gastric aspiration& for feeding of liquid diet. 3- tube enterostomy: used if NG tube is not possible & if more than 4 weeks enteral feeding is indicated, types ( Gastrostomy, Jejunostomy).


Mosul university- College of dentistry-oral & maxillofacial surgery department
Methods of Nutrition
B- parenteral nutrition: By IV feeding, it indicated when enteral feeding is not possible or not enough. Routes of administration: 1- central venous line: usually hyperosmolar solution administered directly in to central vein, so they are rapidly diluted by fast flow of blood to avoid thrombosis & thrombophlebitis, example Hickman catheter.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Methods of Nutrition
2- peripheral venous line: Lower osmolarity solutions may be administered through peripheral veins, usually changed 3-4 days due to infusion thrombophlebitis.

Methods of Nutrition

Mosul university- College of dentistry-oral & maxillofacial surgery department
Complications of TPN
1- malposition of catheter tip. 2- infection specially septicemia. 3- essential fatty acid deficiency. 4- hypophosphatemia. 5- jaundice. 6- metabolic acidosis. 7- metabolic & electrolytes disturbances.