بسم الله الرحمن الرحيم
NUTRITION IN SURGERY
Principles of Nutrition Avoiding of malnutrition is the basic goal in nutrition therapy as malnutrition increases the morbidity and mortality of the disease process and prevents or delays the recovery. Malnutrition increases the chance of sepsis, prevents wound healing, increases the respiratory complications, and decreases the efficacy and tolerance to radiotherapy or chemotherapy.
Whenever possible enteral route of nutrition should be used . Overfeeding should be avoided as it leads into hyperglycaemia, hepatic steatosis, raised BUN, and excess CO2 production. Immunomodulators like glutamine, arginine and omega 3 fatty acids are also very useful.
Caloric requirement: Neonatal 100 kcal/kg/day. Adult 40 kcal/kg/day. Adult with catabolism 60 kcal/kg/day. It is given as: xx Carbohydrates 50%. xx Fat 30-40%. xx Protein 10-15%. Caloric values: xx Carbohydrate 4 kcal/g. xx Protein 4 kcal/g. xx Fat 9 kcal/g.
. Indications for Nutritional Support a-Preoperative nutritional depletion. b. Postoperative complications: Sepsis, ileus, fistula. c. Intestinal fistula d. Pancreatitis, malabsorption, ulcerative colitis, pyloric stenosis. e. Anorexia nervosa and intractable vomiting.
f. Trauma—multiple fractures, fasciomaxillary injuries, headand neck injuries.g. Burns.h. Malignant disease.i. Renal and liver failure.j. Massive bowel resection causing short bowel syndrome.
How to assess the nutritional status: Clinical parameters: Body weight. Body mass index. Triceps skin fold. Mid arm circumference.
Laboratory parameters: Serum albumin. Lymphocytic count. Skin hypersensitivity reaction.
NUTRITIONAL SUPPORT
Enteral Nutrition: Easy. Safe. Inexpensive. Preserves trophic hormones and the mucosal integrity of the gastro- intestinal tract. Less infectious complications.Side effects: Abdominal colic. Nausea and vomiting. Reflux and pulmonary complications. Diarrhoea. Esophageal irritation and ulceration.
Methods: Nasogastric tubes. Nasojejunal tubes. Gastrosotomy: Surgical Percutaneous endoscopy. Jejunostomy: Surgical Percutaneous endoscopy.
Complications Technical a. Air embolism. b. Pneumothorax. c. Bleeding. d. Catheter displacement, sepsis, blockage. e. Infection, thrombosis.
Biochemicala. Electrolyte imbalance: Hyponatraemia, hypokalaemia,hypophosphataemia.b. Hyperosmolarity.c. Hyperglycaemia—common.d. Dehydration.e. Altered immunological and reticuloendothelial function.f. Azotaemia.
Others a. Dermatitis. b. Anaemia and increased capillary permeability. c. Cholestatic jaundice: It is common. d. Severe hepatic steatosis. e. Metabolic acidosis. f. Candida infection (candidiasis), staphylococcal infection
REFEEDING SYNDROME xx Refeeding syndrome is occurrence of severe fluid and electrolyte imbalance in severely malnourished individual while starting the proper feeding enteral or parenteral nutrition. It is more common in TPN. hypophosphataemia leading into myocardial dysfunction, respiratory changes, altered liver functions, altered level of consciousness, convulsions and often death.
xx It causes hypomagnesaemia, hypocalcaemia and xxGradual feeding and correction of magnesium, phosphate and calcium and other electrolytes is important. xx Condition is common in chronic starvation, severe anorexia and alcoholic patients