Nutrition in Surgical Patients

Ronald Merrell, MD Chairman of Surgery Virginia Commonwealth University

What?
Carbohydrate Lipid Protein Trace elements Vitamins

Who?
Malnourished (>10% lean body mass) Incapable of eating (>10 days)

Why?
Risks of malnutrition including infection, poor healing and higher mortality Malnutrition is exacerbated by physiological stress

When?
Preoperative? Early? Late? ---after initial resuscitation following injury or surgery

How?
Parenteral Enteral Total Partial

Issues
Metabolic response to injury Cytokines, inflammation, hormones Biology of substrates Enteral vs. Parenteral

Ashen faces, a thready pulse and cold clammy extremities

The Ebb Phase Cuthbertson, Quart. J. Med.25:233,1932

The Ebb Phase

Hypometabolic Hypothermic Hypoinsulinemic Hypoperfusion Hypercortisolism Hyperglucagonemia Hyperglycemia Hypercatecholemia

The patient warms up,cardiac output increases and the surgical team relaxes
The Flow Phase Cuthbertson. Lancet 1:233, 1942

The Flow Phase

Hypermetabolic Hyperthermic Catabolic Hyperinsulinism Hypercortisolism Hyperglucagonemia High cardiac output

Nutritional Assessment
Body weight Body mass index creatinine height index Serum proteins:albumin, prealbumin, transferrin Immune competence: lymphocytes, DH Nitrogen balance

Caloric Requirement
Formula Indirect calorimetry PRN for nitrogen balance Approximation

Nutritional Requirements
25 cal/kg/day carbohydrate ~70% Lipid 15-30% Protein 1.5-2.0g/kg/day. Not for calories Additional 50% to 100% for stress as in ICU patients

Nutritional Goals
Nitrogen balance Preserve or restore visceral protein Reduce morbidity Reduce mortality Reduce hospital stay

Early Enteral Feeding: a metaanalysis

Eight prospective randomized trials with trauma and high risk surgical patients(118 enteral, 112 parenteral) Septic complications:enteral 18%, parenteral 35% Moore. Ann. Surg. 216:172,1992

Parenteral requirements
Dilution in right heart return because of hyperosmolarity.Central Venous Line Delivery of simple carbohydrate (20%glucose) Lipid emulsion Amino acids

Enteral Requirements
Delivery into the GI tract by tube with minimum risk of aspiration or patient effort Delivery of nutrients with minimal need for digestion Control of rate to prevent osmotic diarrhea

Advantages of enteral nutrition

Easier GI bacterial translocation Cheaper Fewer specific complications

Nutrients with specific putative contributions

Branch chain amino acids Glutamine Arginine Nucleotides Omega-3 fatty acids

Immune Enhancing Diet

Arginine, nucleotide, fish oil Shorter stay, fewer infections Bower Critical Care Medicine. 23:436, 1995

Parenteral Nutrition Immunosuppressive IF...

Poorly administered Hyperglycemia No nucleotides No arginine No taurine Excessive fats

Overfeeding with parenteral diets

Carbohydrate: hyperglycemia, hypercarbia, fatty liver Lipids: hypertriglyceridemia, hypoxia, infection Protein: azotemia

Conclusions
Nutrition is a powerful determinate of patient outcome The proper provision of nutrition is a component of basic patient care Nutrition is a precise and potentially very hazardous form of intervention