Surgical NutritionSurgical Nutrition

Raymundo F. Resurreccion, MD, FPCSRaymundo F. Resurreccion, MD, FPCS

ObjectivesObjectives

Differentiate metabolic responses to Differentiate metabolic responses to starvation and starvation and traumatrauma

Explain the energy utilization in Explain the energy utilization in patients undergoing injury and patients undergoing injury and stressstress

Recognize the role of nutritional Recognize the role of nutritional support in patients undergoing support in patients undergoing stress and surgerystress and surgery

ObjectivesObjectives

Determine basic nutritional Determine basic nutritional requirements in the surgical patientrequirements in the surgical patient

Determine the appropriate route for Determine the appropriate route for delivery of nutritiondelivery of nutrition

Recognize the dangers of Recognize the dangers of overfeeding overfeeding

Metabolic Response to InjuryMetabolic Response to Injury

Physiological responses to InjuryPhysiological responses to InjuryInjury, infectionInjury, infection

Diminished intakeDiminished intakeIncreased expenditureIncreased expenditure

Tissues / blood Tissues / blood mononuclear cells, mononuclear cells,

endotheliumendothelium

BrainBrain

SNS HPA

NERCytokines

Metabolicresponse

Inflammatoryresponse

Immuneresponse

Mediators in SIRS/SepsisMediators in SIRS/SepsisMEDIATORMEDIATOR EFFECTSEFFECTS

Interleukin-1Interleukin-1 Fever, proteolysisFever, proteolysis

ProstaglandinsProstaglandins VasodilationVasodilation

CorticosteroidsCorticosteroids HypermetabolismHypermetabolism

GlucagonGlucagon GluconeogenesisGluconeogenesis

NorepinephrineNorepinephrine HypermetabolismHypermetabolism

Growth, thyroid hormonesGrowth, thyroid hormones Acute catabolismAcute catabolism

Complement, anaphylatoxinsComplement, anaphylatoxins Microcirculatory damageMicrocirculatory damage

Kinin system, serotonin histamineKinin system, serotonin histamine VasodilationVasodilation

Oxygen free radicalsOxygen free radicals Membrane damageMembrane damage

Tumor necrosis factorTumor necrosis factor Tissue injury, shockTissue injury, shock

Myocardial depressant factorMyocardial depressant factor Cardiac dysfunctionCardiac dysfunction

Nitric oxideNitric oxide Vasodilation, hypotensionVasodilation, hypotension

Stress Response to InjuryStress Response to Injury

Local Wound1. Cytokines2. Neutrophil products 3. Oxygen radicals4. Prostanoids

Systemic Response1. O2 consumption2. metabolic rate 3. Blood flow maldistribution4. temperature5. Protein catabolism

Endocrine Response1. Catecholamines2. Glucagon3. Cortisol4. HGH

Modulation by CNS1. Pain2. Anxiety3. Hypothermia4. Hyperthermia

SystemicInflammation

AFFERENT ARC

EFFERENT ARC

Neuro-endocrine ResponseNeuro-endocrine Response

Massive receptor stimulus Massive receptor stimulus Hypothalamo–pituitary axis Hypothalamo–pituitary axis CatecholaminesCatecholamines Gluco + mineralo corticoids Gluco + mineralo corticoids GlucagonGlucagon ADHADH InsulinInsulin

Hormonal Response to InjuryHormonal Response to Injury

Hormonal Hormonal LevelsLevels

Glucose Glucose ProductionProduction

ProteolysisProteolysis Protein Protein SynthesisSynthesis

CatecholsCatechols

CortisolCortisol

GlucagonGlucagon

InsulinInsulin

HGHHGH

TestosteroneTestosterone ——

Starvation vs. Severe StressStarvation vs. Severe Stress

Starvation Starvation ContinuumContinuum Stress Stress

Resting energy Resting energy expenditureexpenditure Respiratory Respiratory quotientquotient 0.650.65 0.850.85

Counter regulatory Counter regulatory hormoneshormones ——

Primary fuelPrimary fuel FatFat Fat + amino acidsFat + amino acids

ProteolysisProteolysis ++ ++++++Branched-chain Branched-chain oxidationoxidation ++ ++++++

Starvation vs. Severe StressStarvation vs. Severe Stress

Starvation Starvation ContinuumContinuum Stress Stress

Hepatic protein Hepatic protein synthesissynthesis ++ ++++++

Acute-phase protein Acute-phase protein productionproduction —— ++++++

Constitutive protein Constitutive protein productionproduction Urinary nitrogen Urinary nitrogen losseslosses ++ ++++++

GluconeogenesisGluconeogenesis ++ ++++++Ketone body Ketone body productionproduction ++++++++ ++

Metabolic Response to InjuryMetabolic Response to Injury

Rapid glycogenolysis Rapid glycogenolysis HH22O + NaCl retention O + NaCl retention edema edema

Glucose intolerance Glucose intolerance Gluconeogenesis Gluconeogenesis Protein synthesis redirected to acute Protein synthesis redirected to acute

phase proteins + wound healing phase proteins + wound healing Muscle wasting Muscle wasting

Metabolic Response to InjuryMetabolic Response to Injury

Increased energy expenditureIncreased energy expenditure• Pain, anxiety, feverPain, anxiety, fever• Muscular effort-work of breathing, shiveringMuscular effort-work of breathing, shivering

Physiologic stress response: Catabolic Physiologic stress response: Catabolic phasephase• increased caloric needs, inadequate intakeincreased caloric needs, inadequate intake• gluconeogenesis gluconeogenesis wasting of endogenous wasting of endogenous

protein stores, increased urinary nitrogen protein stores, increased urinary nitrogen losseslosses

Energy UtilizationEnergy Utilization

Hypermetabolic state Hypermetabolic state increases demandsincreases demands less efficient use of nutrients for less efficient use of nutrients for

energy energy more nutrients used to meet the more nutrients used to meet the

demands demands Negative energy balance is highly Negative energy balance is highly

correlated to complications in critically ill correlated to complications in critically ill patientspatients

Surgical trauma is Surgical trauma is accompanied by a accompanied by a negative nitrogen negative nitrogen balancebalance

Nitrogen balance is Nitrogen balance is more negative than more negative than during pure fastingduring pure fasting

Effects of Surgical Trauma on Resting Effects of Surgical Trauma on Resting Energy ExpenditureEnergy Expenditure

Long CL, et al. JPEN 1979;3:452-456

Substrate UtilizationSubstrate Utilization

Muscle is metabolized as gluconeogenic substrate to supply the brain, kidney, tumor etc

Glutamine

Weight Loss after Surgical TraumaWeight Loss after Surgical Trauma

Where?Where?• MuscleMuscle• FatFat

Why?Why?• Reduced food intakeReduced food intake• Increased energy expenditureIncreased energy expenditure• Derangements in protein/fat metabolismDerangements in protein/fat metabolism

Oxidation of Carbohydrate and Fat Oxidation of Carbohydrate and Fat in Sepsisin Sepsis

Sepsis score 0

Fatoxidationg/m2/h

8

3

0

Stoner et al Br J Surg 1983

Glucoseoxidationg/m2/h

10 20 30

Sepsis score 0 10 20 30

SurgerySurgery

AnesthesiaAnesthesia

PatientPatientOperativeOperativeRiskRisk

Magnitude of RiskMagnitude of Risk

Risk factors associated with death, Risk factors associated with death, analyzed by a multiple regression modelanalyzed by a multiple regression model

Risk FactorRisk Factor OROR11 Confidence Confidence intervalinterval

MalnutritionMalnutrition22 1.871.87 1.01-3.341.01-3.34

Presence of Presence of cancercancer 2.072.07 1.03-4.151.03-4.15

Age ≥ 60y/oAge ≥ 60y/o 2.302.30 1.26-4.211.26-4.21

Surgical Surgical treatmenttreatment 0.16*0.16* 0.08-0.350.08-0.35

* p < 0.051 OR = odds ratio2 Moderate and severe malnutrition

Correia and Waitzberg, Clin Nutr 2003; 22:235-239

Consequences of MalnutritionConsequences of Malnutrition

Loss of lean body massLoss of lean body mass Poor wound healing, anastomotic Poor wound healing, anastomotic

breakdownbreakdown Compromised immune defenseCompromised immune defense Impaired organ functionImpaired organ function Increased mortality ratesIncreased mortality rates

Predictors of Poor Surgical OutcomePredictors of Poor Surgical Outcome

ParameterParameter PredictorPredictor

AgeAge Increased (>70 years)Increased (>70 years)

Type of SurgeryType of Surgery Emergent, contaminated, open abdominal, thoracic or Emergent, contaminated, open abdominal, thoracic or aortic surgery, prolonged surgeryaortic surgery, prolonged surgery

ASAASA > Class 3> Class 3

CardiacCardiac Presence of S3 gallop, jugular venous distention, MI Presence of S3 gallop, jugular venous distention, MI within 6 mos, > 5 PVC, aortic stenosis, unstable angina, within 6 mos, > 5 PVC, aortic stenosis, unstable angina, absence of beta-blockadeabsence of beta-blockade

PulmonaryPulmonary COPD, FEVCOPD, FEV11 , 1.0, L PaO , 1.0, L PaO22 <60 , PCO <60 , PCO22 > 50, fatigue with > 50, fatigue with

walking (steps)walking (steps)

NeurologicNeurologic Impairment, decreased function, nonambulatory statusImpairment, decreased function, nonambulatory status

RenalRenal Decreased creatinine clearance, BUN > 50 mg/dlDecreased creatinine clearance, BUN > 50 mg/dl

NutritionNutrition Hypoalbuminemia, hypokalemiaHypoalbuminemia, hypokalemia

FrailtyFrailty Weakness, early exhaustion, dependencyWeakness, early exhaustion, dependency

American College of Physicians

Loss of Lean Mass and Mortality Loss of Lean Mass and Mortality

*assuming no preexisting loss

Complications Relative to Loss of Lean Body Mass*Complications Relative to Loss of Lean Body Mass*

Lean Body Mass(% loss of total)

Complications(related to lost lean mass)

Associated Mortality (%)

10Impaired immunity, increased infection

10

20Decreased healing,weakness, infection

30

30Too weak to sit, pressure

sores, pneumonia, no healing50

40Death, usually from

pneumonia100

Goals of Surgical Nutritional SupportGoals of Surgical Nutritional Support

Maintain host defenses Maintain host defenses Support metabolic response Support metabolic response Reduce the catabolic state and Reduce the catabolic state and

preserve lean body masspreserve lean body mass Support the depleted patient Support the depleted patient

throughout the catabolic phase of throughout the catabolic phase of recoveryrecovery

Goals of Surgical Nutritional SupportGoals of Surgical Nutritional Support

Improve patient outcomesImprove patient outcomes• Decrease surgical mortality Decrease surgical mortality • Decrease surgical complications and Decrease surgical complications and

infectioninfection Prevent/treat macro/micronutrient Prevent/treat macro/micronutrient

deficienciesdeficiencies Speed the healing / recovery process Speed the healing / recovery process

(Decrease the LOS)(Decrease the LOS)

SurgerySurgery

Full Wound healing

Full Restoration of metabolic and immune homeostasis

Endocrine, metabolic, and immunologic alterations

Nutrition Support in SurgeryNutrition Support in Surgery

Adequate Adequate body reservesbody reserves

food intakefood intake

Nutrition Support in SurgeryNutrition Support in Surgery

Surgery

Wound healing

Restoration of metabolic and immune homeostasis

Endocrine, metabolic, and immunologic alterations

Incomplete restoration of organ functions

Multiple organ dysfunction, failure, and death

Inadequate body reserves

Inadequate food intakeNutrition SupportNutrition Support

Prospective randomized studiesProspective randomized studies

2-3 days: No improvement in outcome2-3 days: No improvement in outcome

5-7 days: Influence in outcome5-7 days: Influence in outcome

7-10 days: Benefits outcome7-10 days: Benefits outcome

Reduction of postop morbidity and mortalityReduction of postop morbidity and mortality

Meguid: Am J Surg 1990; 159:345Meguid: Am J Surg 1990; 159:345

**ENDPOINTS: **ENDPOINTS: Monitor nutrient intake (Calorie Count)Monitor nutrient intake (Calorie Count)Total lymphocyte countTotal lymphocyte count

Necessary Length of Preoperative Nutrition in Necessary Length of Preoperative Nutrition in Malnourished PatientsMalnourished Patients

ASPEN GuidelinesASPEN Guidelines

Preoperative SNSPreoperative SNS should be administered should be administered to to moderately or severely malnourished moderately or severely malnourished patientspatients undergoing major undergoing major gastrointestinal surgery for gastrointestinal surgery for 7 - 14 days7 - 14 days if if the operation can be safely postponed.the operation can be safely postponed.

Postoperative SNSPostoperative SNS should be should be administered to patients whom it is administered to patients whom it is anticipated will be unable to meet their anticipated will be unable to meet their nutrient needs orally for a period of 7 to nutrient needs orally for a period of 7 to 10 days.10 days.

A.S.P.E.N. Board of Directors, JPEN 2002

Nutritional AssessmentNutritional Assessment

Body composition (anthropometric Body composition (anthropometric measurements)measurements)

Biochemical dataBiochemical data Clinical assessmentClinical assessment

Subjective Global Assessment (SGA)Subjective Global Assessment (SGA) Indirect calorimetryIndirect calorimetry

Computing Nutritional RequirementComputing Nutritional Requirement

Total caloric requirement (TCR)Total caloric requirement (TCR) Total protein requirement (TPR)Total protein requirement (TPR) Fluid requirementsFluid requirements Micronutrient/Vitamin requirementsMicronutrient/Vitamin requirements

Nutritional RequirementsNutritional Requirements

NutrientsNutrients CarbohydrateCarbohydrate ProteinProtein FatFat VitaminsVitamins MineralsMinerals WaterWater

Calories ProvidedCalories Provided

4 kcal/g4 kcal/g

4 kcal/g4 kcal/g

9 kcal/g9 kcal/g

--

--

--

National Research Council: Recommended Dietary Allowances,10th ed National Academy Press, 1989

Nutritional RequirementsNutritional Requirements

Calculations are based on:Calculations are based on:• ageage• sexsex• weight and heightweight and height• stress factorstress factor• activity levelactivity level

Total Caloric Requirement (kcal/ day)Total Caloric Requirement (kcal/ day)

1. Harris-Benedict Equation (BEE)1. Harris-Benedict Equation (BEE)Male: 66.47 + (13.75 x BW) + (5 x height) - Male: 66.47 + (13.75 x BW) + (5 x height) - (6.76 x Age) x (6.76 x Age) x AFAF x x SFSFFemale: 655.1 + (9.56 x BW) + (1.85 x height) - Female: 655.1 + (9.56 x BW) + (1.85 x height) - (4.67 x age) x (4.67 x age) x AFAF x x SFSF

TCR = BEE x TCR = BEE x AF AF x x SFSF

Nutritional RequirementsNutritional Requirements

Nutritional RequirementsNutritional Requirements

Activity factorsActivity factors• Confined to bed = Confined to bed =

1.21.2• Ambulatory = 1.3Ambulatory = 1.3

Stress FactorsStress Factors• Minor surgery = 1.2Minor surgery = 1.2• Trauma = 1.3 - 1.4Trauma = 1.3 - 1.4• Sepsis = 1.4 - 1.8Sepsis = 1.4 - 1.8• Burns = 2.0 - 2.2Burns = 2.0 - 2.2

2. Short Method2. Short Method• Non stressed: 25 - 30 kcal/kgNon stressed: 25 - 30 kcal/kg• Stressed: 30 - 35 kcal/kgStressed: 30 - 35 kcal/kg

Underweight: Actual BW x 25-35 kcal/kgUnderweight: Actual BW x 25-35 kcal/kg

Overweight: Ideal BW x 25-35 kcal/kgOverweight: Ideal BW x 25-35 kcal/kg

TCR = wt (kg) x 25 - 35 kcalTCR = wt (kg) x 25 - 35 kcal

Nutritional RequirementsNutritional Requirements

Conditions Affecting Caloric NeedsConditions Affecting Caloric Needs

REE ChangeREE Change

Fever (per°C)Fever (per°C) +10 to 15%+10 to 15%

SepsisSepsis +20 to 60%+20 to 60%

TraumaTrauma +20 to 50%+20 to 50%

BurnBurn +40 to 80%+40 to 80%

TreatmentsTreatmentsMech. VentilationMech. Ventilation -25 to -35%-25 to -35%Nutritional supportNutritional support +20%+20%

AgitationAgitation +50 to 100%+50 to 100%

Chiolero R, Nutrition 1997

Drugs Affecting Caloric NeedsDrugs Affecting Caloric Needs

DrugDrug REE ChangeREE Change

OpiatesOpiates -9%-9%

SedationSedation -20 to -55%-20 to -55%

BarbituratesBarbiturates -32%-32%

Muscle relaxantsMuscle relaxants -42%-42%

CatecholaminesCatecholamines +32%+32%

ββ-blockers-blockers -6 to -7%-6 to -7%

+20%+20%

AgitationAgitation +50 to 100%+50 to 100%

Chiolero R, Nutrition 1997

3. Indirect calorimetry3. Indirect calorimetry• Gold standard for measuring REEGold standard for measuring REE

• Calculated by measuring OCalculated by measuring O2 consumption (VO consumption (VO2) )

and COand CO2 production (VCOproduction (VCO2) using the ) using the

abbreviated Weir equation: REE = [3.9 (VOabbreviated Weir equation: REE = [3.9 (VO2) + ) +

1.1 (VCO1.1 (VCO2)] x 1.44.)] x 1.44.

• Performs better than predictive equations with Performs better than predictive equations with added stress factorsadded stress factors

• Measurements made over 20-30 min and 24hr Measurements made over 20-30 min and 24hr EE is extrapolatedEE is extrapolated

Nutritional RequirementsNutritional Requirements

Non-Stressed: 0.8 -1 gm/kg/day Non-Stressed: 0.8 -1 gm/kg/day Mild-Moderately Stressed: 1.2 - 1.5 Mild-Moderately Stressed: 1.2 - 1.5

gm/kg/daygm/kg/day Severely Stressed -Severely Stressed - >1.5-2.5 gm/kg/day>1.5-2.5 gm/kg/day Lefor et al.Critical Care. Lefor et al.Critical Care.

20042004

Protein should comprise approximately Protein should comprise approximately

20% of the total calories during stress20% of the total calories during stress

Protein RequirementsProtein Requirements

Non-Protein CaloriesNon-Protein Calories

CarbohydrateCarbohydrate FatsFats

• NPC combinationsNPC combinations• acute stress: 70% carbo 30% fat• usual: 60% carbo 40% fat• infections: 50% carbo 50% fat• pulmonary: 40% carbo 60% fat

HYPERGLYCEMIA

(Effects in stressed patients)

Impaired wound healing Insulin resistance

Risk of LBM loss

Skeletal muscle proteolysis

Risk of infection Oxidative stress

(proinflammatory)

Supplying Large Amounts of Supplying Large Amounts of Carbohydrates Leads to HyperglycemiaCarbohydrates Leads to Hyperglycemia

VitaminsVitamins

Fat SolubleFat Soluble• Vitamin AVitamin A • Vitamin DVitamin D

Water SolubleWater Soluble • Folic AcidFolic Acid• Pantothenic AcidPantothenic Acid• BiotinBiotin• Niacin Niacin • RiboflavinRiboflavin

• Vitamin EVitamin E• Vitamin KVitamin K

• ThiamineThiamine

• Vitamin BVitamin B66

• Vitamin BVitamin B1212

• Vitamin CVitamin C

ElectrolytesElectrolytes

Sodium

Potassium

Chloride

Calcium

Phosphorus

Magnesium

ZincZinc

CopperCopper

ChromiumChromium

ManganeseManganese

SeleniumSelenium

IodineIodine

IronIron

Fluid RequirementsFluid Requirements

How much volume to give?How much volume to give? Cater for maintenance & on going Cater for maintenance & on going

losses losses Normal maintenance requirements Normal maintenance requirements

• By body weightBy body weight• Alternatively, 30 to 50 ml/kg/dayAlternatively, 30 to 50 ml/kg/day

Maintenance Water RequirementsMaintenance Water Requirements

Weight (kg)Weight (kg) mL/kg/hrmL/kg/hr mL/kg/daymL/kg/day

1 – 101 – 10 44 100100

11 – 2011 – 20 22 5050

21 – n21 – n 11 2020

ChildrenChildren

Adults 30 ml/kg/dayAdults 30 ml/kg/day

Water lossesWater losses

Add on-going losses based on I/O chartAdd on-going losses based on I/O chart• Urine: 800 to 1500 ml/dayUrine: 800 to 1500 ml/day• Stool: 250 ml/dayStool: 250 ml/day

Consider insensible fluid losses alsoConsider insensible fluid losses also• 8-12 ml/kg/day8-12 ml/kg/day• Cutaneous insensible losses increase by 10% Cutaneous insensible losses increase by 10%

for every 1°C above >37°Cfor every 1°C above >37°C

Maintenance Water RequirementsMaintenance Water Requirements

Change in Fluid RequirementsChange in Fluid Requirements

IncreasedIncreased DecreasedDecreased

FeverFever Renal failureRenal failure

FistulasFistulas Congestive heart failureCongestive heart failure

DiarrheaDiarrhea Cirrhotic ascitesCirrhotic ascites

NG suctionNG suction Pulmonary diseasePulmonary disease

NUTRITIONAL ASSESSMENT

Functioning GI Tract?

YES NO

ENTERAL NUTRITION PARENTERAL NUTRITION

Tube feeding for more than 6 weeks?

YES NO

Nasoenteric TubeEnterostomy

Risk for pulmonary aspiration?

YESYES NO NO

Nasogastric Tube

Nasoduodenal or Nasojejunal Tube

Gastrostomy

Jejeunostomy

Clinical Decision Making Algorithm for Nutritional SupportClinical Decision Making Algorithm for Nutritional Support

GI FUNCTION

NORMAL COMPROMISED

Standard Formula Specialty Formula

FORMULA TOLERANCE

PN for more than 4 weeks?

YES NO

Central PN Peripheral PN

GI FUNCTION RETURNS?

YESNO

Adequate

Inadequate

Progress to More Complex Diet and Oral Feedings as Tolerated

PN Supplementation

Progress to Total Enteral Feedings

Oral FormulaSupplements

Preferential Use of Enteral NutritionPreferential Use of Enteral Nutrition

EN delivery has two main routes: EN delivery has two main routes: gastric and post-pyloric gastric and post-pyloric

Use of the gut stimulates GALT & Use of the gut stimulates GALT & MALT MALT →→ enhanced immune responseenhanced immune response

Early feeding can trigger gut Early feeding can trigger gut immunity and thereby improve immunity and thereby improve outcomesoutcomes

McClave, J Clin Gastro, Sept 2002McClave, J Clin Gastro, Sept 2002

Preferential Use of Enteral NutritionPreferential Use of Enteral Nutrition

Delay or failure may promote a Delay or failure may promote a proinflammatory state with proinflammatory state with ↑↑ disease disease severity & morbidityseverity & morbidity

Early EN in the post-operative period is a Early EN in the post-operative period is a viable option to address recuperation viable option to address recuperation needs, malnutrition and its complicationsneeds, malnutrition and its complications

Reduce morbidity and cost compared with Reduce morbidity and cost compared with parenteral nutritionparenteral nutrition

Limitations Of EN DeliveryLimitations Of EN Delivery

Deranged motilityDeranged motility

Reduced exocrine Reduced exocrine

pancreatic functionpancreatic function

Intestinal Intestinal

hypoperfusion/ hypoperfusion/

bowel ischemiabowel ischemia

Gastric refluxGastric reflux

AspirationAspiration

Nausea, vomiting Nausea, vomiting

Abdominal Abdominal distention and distention and crampscramps

DiarrheaDiarrhea

MalabsorptionMalabsorption

Parenteral NutritionParenteral Nutrition

Essential form of sustenance for Essential form of sustenance for patients who cannot tolerate the oral patients who cannot tolerate the oral or tube feeding administered or tube feeding administered intravenously. intravenously.

Indications: Parenteral NutritionIndications: Parenteral Nutrition

General IndicationsGeneral Indications• Patients requiring long-term (>10 days) Patients requiring long-term (>10 days)

supplemental nutrition because they are supplemental nutrition because they are unable to receive all of their daily unable to receive all of their daily energy, protein, and other nutrient energy, protein, and other nutrient requirements through oral or enteral requirements through oral or enteral feedingfeeding

• Severe gut dysfunction or inability to Severe gut dysfunction or inability to tolerate enteral feedingstolerate enteral feedings

Indications: Parenteral NutritionIndications: Parenteral Nutrition

Inability to use the gastrointestinal tractInability to use the gastrointestinal tract• intestinal obstructionintestinal obstruction• peritonitisperitonitis• intractable vomitingintractable vomiting• severe diarrheasevere diarrhea• high-output enterocutaneous fistulahigh-output enterocutaneous fistula• short bowel syndromeshort bowel syndrome• severe malabsorption. severe malabsorption.

Need for bowel rest Need for bowel rest Palliative use in terminal patients is controversialPalliative use in terminal patients is controversial

ASPEN Board of Directors. JPEN 2002; 26 Suppl 1: 83SA

Composition of FormulasComposition of Formulas

Aminoacids

Water

VitaminsTrace

Elements

Electrolytes

Lipids

Dextrose

Parenteral Nutrition

Parenteral Access Parenteral Access

Nutrition Care PlanNutrition Care Plan

Computed calorie and protein Computed calorie and protein requirements based on disease, labs, requirements based on disease, labs, current complicationscurrent complications

Determine form & route of feedingDetermine form & route of feeding• Type of feedingType of feeding

• Oral • Enteral - NGT, PEG, Surgical tubes• Parenteral - peripheral, central

• Delivery method (pump or bolus)Delivery method (pump or bolus)

Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press, 1992

MonitoringMonitoring

MetabolicMetabolic GlucoseGlucose Fluid and Fluid and

electrolyte balanceelectrolyte balance Renal and hepatic Renal and hepatic

functionfunction Triglycerides and Triglycerides and

cholesterolcholesterol

AssessmentAssessment Body weightBody weight Nitrogen balanceNitrogen balance Plasma proteinPlasma protein

MonitoringMonitoring

FLUID BALANCES CALORIE COUNT

Dangers of OverfeedingDangers of Overfeeding

Secretory diarrhea (with EN)Secretory diarrhea (with EN) Volume overload, CHFVolume overload, CHF COCO2 production: ventilatory CO2 production: ventilatory

demanddemand O2 consumptionO2 consumption

Dangers of OverfeedingDangers of Overfeeding

Electrolyte problems: PO4 , K, MgElectrolyte problems: PO4 , K, Mg Hyperglycemia, glycosuria, Hyperglycemia, glycosuria,

dehydration, lipogenesis, fatty liver, dehydration, lipogenesis, fatty liver, liver dysfunctionliver dysfunction

Increased mortality (in adult studies)Increased mortality (in adult studies)

Thank you for your attention.Thank you for your attention.