Surg. Nutritional Supp.

OVERVIEW Artificial Nutrition: Importance and History antibiotics, blood transfusion, critical care monitoring, advances in anesthesia, organ transplantation, and cardiopulmonary bypass hyperalimentation  moderate nutritional supply nutritional pharmacology parenteral  parenteral & enteral

OVERVIEW Clinical Sequelae of Impaired Nutrition Impaire the body's ability to heal wounds and to support normal immune function reduced ventilation due to wasting of muscle limiting to all aggressive surgical and medical therapies Incidence of Malnutrition in Hospitalized Patients as many as 50% of hospitalized patients may be malnourished

Surgical Nutritional Support ： Provide adequate and proper nutrients to support the metabolism of the body, and to maintain the function and structure of the organs, to accelerate the recovery.

Questions Why should we provide nutritional support When it is provided What kind and amount of nutrients How to administrate the nutrients

METABOLIC ADAPTATIONS IN CATABOLIC STATES AND REGULATION OF NITROGEN BALANCE

Regulation of Intracellular Protein Synthesis and Degradation

Metabolic Changes in state of starving secretion of insulin declines; secretion of glycagon, growth factor, catecholamine increase; utilization of glucose is accelerated; gluconeogenesis continues proteolysis is initiated to provide energy lipid is oxidized to ketones consume great amount of protein

Metabolic changes in stress (trauma, sepsis) trauma activating the sympathetic nerve utilization of carbohydrates are inhibited, hyperglycemia is produced the secretion of insulin declines the blood level of glycagon, growth factor, catecholamine, thyroid hormone, ACTH, antidiuretic hormone increase The lipolysis is activated, gluconeogenesis and proteolysis is accelerated, large amount of protein are consumed to provide energy supply.

FUNDAMENTALS OF ARTIFICIAL NUTRITION

General Indications for Nutrition Support and Choice of Route of Administration The pre-morbid state (healthy or otherwise) Poor nutritional status (the current oral intake meets <50% of total energy needs) Significant weight loss (initial body weight less than the usual body weight by ≥10%, or a decrease in inpatient weight by >10% of the admission weight) The duration of starvation (>7 days' inanition) An anticipated duration of artificial nutrition (particularly for total parenteral nutrition [TPN]) of more than 7 days The degree of the anticipated insult, surgical or otherwise A serum albumin value less than 3.0 g/100 mL measured in the absence of an inflammatory state

Route of Administration Enteral nutrition (EN) more physiologic, and safe PARENTERAL ROUTE Parenteral nutrition (PN) Total parenteral nutrition (TPN)

Mulnutrtion Kwashiorkor (Protein Malnutrition) Adequate fat reserves with significant protein deficits Slight or no weight loss Low visceral proteins (albumin, prealbumin, transferrin) Edema often present Seen in acutely stressed patients Marasmus (Protein—Calorie Malnutrition) Weight loss with fat and muscle wasting Visceral proteins normal or slightly low Seen in chronic malnutrition

Nutritional Assessment Clinical History Body Composition Analysis Indirect Calorimetry Anthropomorphic Measurements Functional Studies of Muscle Function Biochemical Measurements

Nitrogen Balance total nitrogen intake – nitrogen expiration (most of it are excreted from urine, plus approximately 2~3gm for fecal and others lost of nitrogen)

Plasma proteins <1.6 1.6~1.8 1.8~2.0 2.0~2.5 Transferrin (g/L) <21 21~27 28~34 >35 Albumin (g/L) Severe Moderate Light Malnutrition Normal

Harris-Benedict equation BEE = 66.5 + (13.7 X weight [kg]) + (5.0 X height [cm]) - (6.8 X age [yr] [male]) BEE = 655.1 + (9.56 X weight [kg]) + (1.85 X height [cm]) - (4.68 X age [yr] [female]) (BEE = basal energy expenditure)

Calories Requirements The three major sources of energy are protein, carbohydrate, and fat. amino acids, 15% fat, 25 to 50% Carbohydrate, 35 to 65%

Nutrients Specific Fuels Carbohydrate Lipid Protein Plasma Electrolytes Vitamins and Micronutrients

Protein Requirements 70-kg man has between 10 and 11 kg of protein. Daily protein turnover is 250 to 300 g, or 3% the gut ， blood system, skin daily requirement 0.8 to 1.0 grams per kg per day, or 150 mg of nitrogen per kg per day 200 to 250 mg of nitrogen per kg of body weight or 1.7 g of protein per kg per day for patients in stress state

Calorie-Nitrogen Ratio 150:1 (150 nonpro-tein calories per gram of nitrogen) is required for protein synthesis in healthy persons 100:1 in sepsis 300:1 ~ 400:1 in uremia

PRACTICAL APPROACH TO ARTIFICIAL NUTRITION

Enteral Nutrtion Indications for Enteral Feeding Routes for Administration of Enteral Feeding Administration Enteral Formulas

Indications and Routes of EN Indications Gut works Oral intake not possible—altered mental state, ventilator, oral/pharyngeal/esophageal disorders Oral intake not sufficient for metabolic requirements—anorexia, sepsis, severe trauma/burns Presence of malnutrition and wasting Routes of administration Nasogastric tube, ending in stomach, duodenum or intestine; gastrostomy ； jejunostomy

Administration Osmolality ， volume ， and speed Enteral Formulas All nutrients, degraded products of protein Complications of Enteral Administration Tube, infection, diarriah, dilatation

Parenteral Nutrtion Indications for Parenteral Feeding Practical Approach to Calculation of the Ideal Parenteral Formula Catheter Issues in Parenteral Nutrition Metabolic Complications of Long-Term Parenteral Nutrition Administration

Indications of PN Enteral feeding not possible—GI obstruction, ileus Enteral intake not sufficient for metabolic requirements—chronic diarrhea/emesis, malabsorption, fistulas, chemotherapy, irradiation therapy Risk of aspiration Adjunctive support necessary for managing disease—pancreatitis, hepatic failure, renal failure, chylothorax Presence of malnutrition and wasting

Routes of PN Peripheral Administration Peripheral vein. Central Approach Subclavian vein internal jugular vein

Formula Glucose, 35~65% of energy expenditure. Lipid, 25~50% of energy expenditure. Amino acid, non protein energy: nitrogen=150: 1 Electrolyte: k, Na, Cl, Ca, Mg, P Vitamin: Vit A, Vit Bs, Vit E Trace metals: Zinc, Copper, Iron Water: 2500~3000ml

Complications of Parenteral and Enteral Nutrition Due to improper formula and administration Catheter relative Metabolic complications of long-term PN If the gut can be used, use it.

Summary History of artificial nutrition Metabolism Nutritional Assessment and Administration

Metabolism Metabolism of protein, carbohydrate, fat and energy production Stress metabolism

Nutritional Assessment Types of malnutrition Evaluation of the preexisting deficits Estimation of caloric and protein requirements

Administration of nutrition Indications Enteral Nutrition Parenteral Nutrition

Complications Due to improper formula and administration Catheter relative Metabolic complications of long-term PN

Surg. Nutritional Supp.

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Surg. Nutritional Supp.