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외과적 영양 ( 外科的 營養 ) Surgical Nutrition. 인제대학교 부산백병원 일반외과 · 장기이식센터 이 병 욱 Department of General Surgery & Organ Transplantation Center, Inje University, Pusan Paik Hospital Byong Wook Lee, M.D. bwleemd@ijnc.inje.ac.kr potrac@thrunet.com. Inflammatory Response. POTraC 2000.

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surgical nutrition

외과적 영양 (外科的 營養)Surgical Nutrition

인제대학교 부산백병원

일반외과 · 장기이식센터

이 병 욱

Department of General Surgery &

Organ Transplantation Center,

Inje University, Pusan Paik Hospital

Byong Wook Lee, M.D.

bwleemd@ijnc.inje.ac.krpotrac@thrunet.com

slide6

Gluconeogenesis from 3 carbon presursors

- Cori (lactate) and Alanine Cycle (pyruvate)

POTraC 2000

slide7

Gluconeogenesis from 3 Carbon precursors

- glutamine, pyruvate

POTraC 2000

metabolism after injury
Metabolism after Injury
  • Sustained activities of macroendocrine hormones
  • Immune cell activation

POTraC 2000

metabolism after injury energy balance
Metabolism after Injury- Energy Balance
  • Increase in energy balance directly with severity of injury
  • Increased activity of SNS
  • energy required for ion pump action to maintain normal transmembrane concentration overcoming increased cell membrane sodium permeability

POTraC 2000

metabolism after injury lipid metabolism 1
Metabolism after Injury- Lipid Metabolism 1
  • Free fatty acid; predominant energy source afer injury
  • Increased lipolysis by catecholamine, and other stress hormones and reduction in insulin level
  • Continuation of net lipolysis during flow phase; oxidation for cardiac and skeletal muscle energy source
  • Fatty acid induced inhibition of glcolysis in moderate injury;

not in severe injury, hemorrhage, or sepsis (persistent glycolysis and net proteolysis)

    • Lipoprotein lipase in endothelium
    • Cytokine

POTraC 2000

metabolism after injury lipid metabolism 2
Metabolism after Injury- Lipid Metabolism 2
  • High concentration of intracellular fatty acids and elevated concentration of glucagon

 inhibition of fatty acid synthesis

 simulate transport of acyl CoA into mitochondria for oxidation and

ketogenesis in liver

  • Keotgenesis
    • variable and inversely correlated with severity of injury
    • Decreased after major injury, severe shock and sepsis
    • Suppressed by increases in levels of insulin and other energy substrates
    • Suppressed by increased uptake and oxidation of free fatty acids
    • Suppressed by an associated counter regulatory hormone response

POTraC 2000

metabolism after injury carbohydrate metabolism
Metabolism after Injury – Carbohydrate Metabolism
  • A state of relative insulin resistance
  • Net gluconeogenic response due to active control of glucagon with permissive requirement for cortisol + Proinflammatory mediators
  • Reduced glucose oxidation; mediator induced reduction of skeletal muscle pyruvate dehydrogenase activity  shunting of 3-carbon skeleton to liver
  • Increased hepatic gluconeogenesis  Hyperglycemia

 energy source of nervous system, wound, RBC, WBC

  • Wound;
    • increase in glucose uptake associated with an increased in activity of phosphoructokinase
    • dereased insulin sensitivity and failed glucose uptake and glycogenolysis in response to insulin

POTraC 2000

metabolism after injury protein metabolism
Metabolism after Injury – Protein Metabolism
  • Net proteolysis
  • Skeletal muscle depletion with relative preservation of visceral tissue
  • Extracellular hormonal millieu, proinflammatory cytokines
  • Ubiquitin-dependent proteolytic pathway upregulated by intracellular oxidative intermediates and antioxidants
  • Greater release of glutamine and alanine than normal concentration of muscle
  • Glutamine; major energy source for lymphoytes, fibroblasts, and GI tract

POTraC 2000

nutrition in the surgical patients
Nutrition in the Surgical Patients
  • Obligatory increases in energy expenditure and nitrogen excretion
  • Post-injury metabolic environment precluding efficient oxidation of fat and ketone production

 continued erosion of protein pools

 critical organ failure

POTraC 2000

nutritional supprot of the surgical patient protein
Nutritional Supprot of the Surgical Patient- Protein
  • Requirement
    • Average normal requirement; 0.8 g/Kg/d
    • Essential amino acids
    • On parenteral nutrition, 200-250 nitrogen/Kg/d

POTraC 2000

nutritional support of the surgical patient calories
Nutritional Support of the Surgical Patient – Calories
  • Caloric Sources
    • Amino acids 15% (BCAA 6-7%)
    • Fat 70-75%
    • Carbohydraes 10-15%
  • Calorie-Nitrogen Ratio
    • Normal ratio for protein synthesis; 100-150:1
    • Changes in different disease states;

100:1 for sepsis, 400:1 for uremia

POTraC 2000

nutritional support of the surgical patient energy requirement
Nutritional Support of the Surgical Patient – Energy Requirement
  • BEE

=66.5 + 13.7 x weight (Kg) + 5.0 x height (cm) – 6.8 x age (yr.) [male]

= 655.1 + 9.56 x wt + 1.85 x ht – 4.68 x age [female]

POTraC 2000

nutritional support of the surgical patient carbohydrates
Nutritional Support of the Surgical Patient - Carbohydrates
  • Supplement calories without elevating glucose concentration
  • Lipid supplementation; replacing glucose as energy source
  • lipid not efficient in severe sepsis

POTraC 2000

nutritional support of the surgical patient fat
Nutritional Support of the Surgical Patient - Fat
  • Caroric source
  • Source of essential fatty acids providing precursors of PG’s
    • Modifying inflammatory and immunologic response
  • 25% of nonprotein calories as fat; optimal for hepatic protein synthesis
  • Fat overload syndrome

< 2 g/Kg/d for adults

< 4 g/Kg/d for infants

POTraC 2000

nutritional assessment
Nutritional Assessment
  • Estimate changes in body nutritional composition to predict risk for surgery
  • Evaluation of nutritional system; measurement of functional lean body mass (muscular, respiratory, cardiac, hepatic, renal, immunologic and host defense function)
  • Prognostic Nutritional Index (PNI)
    • = 158- 16.6 alb – 0.78 TSF – 0.20 TFN – 5.8 DH

POTraC 2000

slide27

Bases of PNI

POTraC 2000

malnourished patients at risk
Malnourished Patients at Risk
  • Recent weight loss > 10% body weight and/or body weight 80-85% ideal body weight
  • Serum albumin in a stable, hydrated patient < 3.0 g/dl
  • Anergy to injected skin recall antigens
  • True transferrin < 200 mg/dl
  • History of functional impairment
  • Significant deficits in hand dynamometry or muscle response to nerve stimulation

POTraC 2000

indication for nutritional support
Indication for Nutritional Support
  • Premorbid state
  • Nuritional status
  • Age
  • Duration of starvation
  • Degree of anticipated insult
  • Likelihood of resuming normal intake soon
  • Weight loss of 15%
  • Serum albumin level < 3.0 g/d

POTraC 2000

route of administration enteral route
Route of Administration- Enteral route
  • More physiologic
  • Costs less
  • Protects and improves hepatic function
  • Mimics normal ingress of nutrients to liver
  • Maintains gut mucosal integrity
  • early gut feedings resulting in lower mortality and septic complication rates in posttraumatic situation
    • Prevention of bacteria and/or their products from translocating the gut mucosa

releasig catecholamines and other counter regulatory stimuli,  preventing hypercatabolism

    • Increased substrate supply to the liver

 improved hepatic acute phase protein synthesis

POTraC 2000

enterocyte specific nutritional substrates glutamine
Enterocyte-specific Nutritional Substrates- Glutamine
  • Conditionally essential amino acid
  • 40% of available glutamine taken up by gut from general circulation
  • Addition of 2% glutamine to parenteral nutrition maintains jejunal or ileal mucosal thickness, protein content and DNA
  • Prevention or healing of chemotherapeutic or radiation toxicity
  • Regrowth after massive small bowel resection

POTraC 2000

enterocyte specific nutrients short chain fatty acids
Enterocyte-specific Nutrients – Short Chain Fatty Acids
  • Acetoacetate (10%), propionic acid (50%), butyrate (80%)
  • Produced by fermentation of soluble pectin by colonic bacteria
  • Disruption of colonic mucosa in deficient state
  • BHBA
    • wall thickening and increased protein content of ileum and colon
    • 70% of energy supply to colonic mucosa
    • Stimulation of ketogenesis, increased ATP generation, lipolysis, absorption of sodium and potassium

POTraC 2000

principles of eneral feeding
Principles of Eneral Feeding
  • Stmach;principal defense against an enteral osmotic load
  • Duodenum; calcium,iron and other metal absorption
  • Small bowel: principal area for nutreint absorption
  • Terminal ileum; enterohepaic circulation
  • Bile and pancreatic juice; fat and protein absorption
  • Immunologic functions of the gut
    • largest immunoogic organ in the body; GALT, secretory Ig’s
    • Secretion of mucin
    • Gut mucosal barrier function

POTraC 2000

practical enteral feeding
Practical Enteral Feeding
  • Goals of Nutritional Support
    • Use the gut if possible
    • Administer at least 20% of caloric and protein requirement by gut
  • Smalllest possible nasgastric tube, tip at the duodenum
  • Constant infusion except at bed time, head up 30
  • For gastric feeding, first osmolality and then volume,

reversed for jejunal feeding

  • Complications
    • Malposition and/or aspiration
    • Diarrhea, dehydration, hyperglycemia and ions
    • Pneumaosis intestinalis with perforation
    • Hyperosmolar nonketotic coma
    • perforation

POTraC 2000

parenteral nutrition peripheral hyperalimentation
Parenteral Nutrition- Peripheral Hyperalimentation
  • Without protocol
  • Lipid system;

10-20% of caloric need as fat emulsion

+ 5% dextrose and amino acids

  • Hypocaloric amino acids and 5% dextrose or glycerol solution
    • Dextrose free amino acids by allowing utilization of endogenous fat secondary to low plasma insulin level
    • Minimize nitrogen breakdown for limited periods of time

POTraC 2000

parenteral nutrition central approach
Parenteral Nutrition- Central Approach
  • Silastic or Teflon-coated catheters
  • Percutaneous or open
  • Temporal or permanent
  • Enforced protocol for TPN
  • Nutritional requirements
    • 250 mg nitrogen/Kg/d
    • 35 Kcal/Kg/d
    • 20-25% of nonprotein calories as fat
    • Adequate vitamin and trace minerals

POTraC 2000

parenteral nutrition indications
Parenteral Nutrition - Indications
  • Primary Therapy
    • Efficacy shown
      • GI-cutaneous fistula
      • Renal failure
      • Short bowel syndrome
      • Acute burns
      • Hepatic Failures
    • Efficacy not shown
      • Crohn’s disease
      • Anorexia nervosa
  • Supportive therapy
    • Efficacy shown
      • Acute radiation enteritis
      • Acute chemotherapy toxicity
      • Prolonged ileus
      • Weight loss preliminary to major surgery
    • Efficacy not shown
      • Before cardiac surgery
      • Prolonged respiratory support
      • Large wound losses

POTraC 2000

complications of parenteral nutrition technical
Complications of Parenteral Nutrition- Technical
  • Placement complications
    • Pneumothorax
    • Arterial lacerations
    • Hemothorax
    • Mediastinal hematoma
    • Nerve injury
  • Late complications
    • Erosion of catheter
    • Subclavian thrombosis
    • Septic thrombosis
  • Sympathetic effusion
  • Thoracic duct injury
  • Air embolism
  • Hydrothorax
  • Catheter embolism

POTraC 2000

complications of parenteral nutrition metabolic complications
Complications of Parenteral Nutrition - Metabolic Complications
  • Plasma electrolyte abnormalities
  • Trace mineral deficiency
    • zinc, copper, chromium, selenium
  • Essential fatty acid deficiency
  • Disorders of glucose metabolism
    • Hypoglycemia
    • Hyperglycemia
    • Diabetic patient; hyperosmolar nonketotic coma
    • Liver function derangements

POTraC 2000

complications of parenteral nutrition septic complications
Complications of Parenteral Nutrition – Septic Complications
  • Catheter Infection
    • Absence of proocol
    • Degree of colonization of the pericatheter skin; > 103
    • G(+) organism from remote site seeding the fibrin sleeve along catheter; vs G(-) organism
    • Candida from the gut
  • Management of patient with suspected catheter sepsis

POTraC 2000

prevention of catheter complications
Prevention of Catheter Complications
  • Catheter Placement
  • Nutritional Support teams and Protocols

POTraC 2000

parenteral nutrition for pediatric patients
Parenteral Nutrition for Pediatric Patients
  • More rapid growth
  • High proportion of viscera with little fat or muscle
  • Incompletely developed enzyme system
  • Liable to heat loss
  • Nutritional Requirements in Pediatric Patients

POTraC 2000

home hyperalimentation
Home Hyperalimentation
  • Silastic catheters with long subcutaneous tunnel
  • Mean catheter life; 7 years
  • Overnight PN
  • Septic complications

POTraC 2000

nutritional pharmacology
Nutritional Pharmacology
  • Nutritional support to change either the milieu or the pathophysiology of a disease process to affect outcome
  • Arginine
  • Glutamine
  • Nucleotides
  • Omega 3-fatty acids
  • Ketone bodies

POTraC 2000