Gen Sx - Nutrition

Survival during starvation depends upon the amount of

endogenous fat reserve

Nutriton ***

The taking in and metabolism of nutrients so that metabolic growth can take place

Malnutrition***

A disorder of nutrition or condition where there is an energy and protein deficiency due largely to wasting, inadequate intake or inadequate metabolism

Inefficient source of energy because it is used for essential nitrogenous substances for maintenance and growth

Protein

We have just enough carbs to last

one day

Electrolyte needs (calculated for a 70kg person) - Na

1.61 - 2.41 g/day

Electrolyte needs (calculated for a 70kg person) - K

1.91 - 2.73 g/day

Electrolyte needs (calculated for a 70kg person) - Ca

0.38 -0.41 g/day

Electrolyte needs (calculated for a 70kg person) - Mg

0.30 -0.38 g/day

Battling HTN keep Na

< 2 g

Is fluid nutrition

No

Fluid Requirements

Most clinicians aim for 2-2.5 L per day ***

Why are patients in fight or flight during surgery

Under stress and are usu fasting 8 hrs prior to surgery**

Why do we want to decrease nitrogen loss in a simple anorexic state

no nitrogen = can't make proteins, WBCs, RBCs

In a Simple anorexic state - we want to do what with glucose

decrease glucose use by brain (preservation)

Patients with severe protein depletion have greater incidence of

post op complications

PNA

delay of wound healing

Stages of Surgical Convalescence - Shock phase - can last up to

24 hours

Stages of Surgical Convalescence - shock state purpose

survival state and hemodynamic stabiltiy

Stages of Surgical Convalescence - shock state, you are ___ sparing

protein sparing (nitrogen excretion is really low)

Stages of Surgical Convalescence - catabolic phase is ____ after sx

24-73 hrs (day1-3)

Stages of Surgical Convalescence - catabolic phase purpose

mobilize energy reserves for healing

Stages of Surgical Convalescence - catabolic phase - what is lost if not supoprted by nutritonal intake

nitrogen - it is pulled by the muscles

Stages of Surgical Convalescence - Early anabolic phase is ____ post op

3-8 days

Stages of Surgical Convalescence - if malnoursihed harder to covert into the ____ phase

early anabolic phase

Stages of Surgical Convalescence - what phase does food intake or enteral feeding begin

early anabolic phase

Stages of Surgical Convalescence - early anabolic phase purpose

tissue repair and nitrogen retention

Stages of Surgical Convalescence - late anabolic phase is ____ post op

varies from weeks to months

Stages of Surgical Convalescence - late anabolic phase purpose

final tissue healing and return to homeostasis

Stages of Surgical Convalescence - late anabolic phase hallmark

slow weight gain is the hallmark of the return back to normal body weight

A pt is malnourished if they

Have lost more than 10% of their lean body mass (in last month)

Have not taken oral nutrition for > or = to 7 days

Complications that a malnourished patient is at risk for

Surgical site infection - aggressive and early

Surgical wound dehiscence or non union

Intraoperative morality

Nutritional assessment - signs of depleted reserves

muscle wasting, loss of SQ fat, albumin < 30, weight loss 10-15%

What objective measurements for Nutritional Assessment you can use besides Physical Examination?

BMI < 18.5

Prior h/o of anorexia

IBW calculation

Percent IBW

Labs

IBW formula

Hamwi Formula

Hamwi formula men

106lbs for first 5 ft + 6lbs for every inch

Hamwi formula for females

100lb. for first 5 feet + 5lb. for each extra inch

Percent IBW

(Actual body weight/Ideal Body Weight) x 100

Percent IBW

Severe malnourished

Overwight

Morbid obsese

< 69% **

> 120%

200%

Normal serum albumin

3.5-5.5 g/dL

Chronic measurement for malnorusihment

serum albumin

Acute measurement for malnoruishement

serum PRE-albumin***

Normal serum pre-albumin

15.7 - 29.6

Reflects very recent changes in protein and caloric intake

Influenced by vitamin A intake

Serum retinal binding protein

Nitrogen losses are proportional to

catabolic state

energy needed to keep you alive

BMR

BMR males

Weight in kg

BMR females

0.9 kcal/kg/hour x 24 hrs

energy needed to keep you alive PLUS activity factor

Total Energy Expenditure

Total Energy Expenditure

BMR x Activity Factor

Quick Determination of Total Energy Expenditure ***

Weight in kg x Activity factor

Quick Determination of Total Energy Expenditure ***

activty factors

Minimal/bed ridden = 25 kcal x kg

Normal activity/ambulatory = 30 kcal x kg

Moderate activity/exercise 3x per week = 35 kcal x kg

Increased activity/5 per week = 40 kcal x kg

Intense activity/daily = 45 kcal x kg

Enteral

Aka feeding tube, a special liquid food mixture containing protein, carbs, fats, vitamins, minerals, given through a tube in the stomach PEG or PEJ tube.

PEJ

bypasses pyloric sphincter and goes right into jejunum

Indications for PEJ

gastroperesis, peptic ulcer, malabsorption*, chronic aspiration **

Often ____ 24-48 hours postop

NPO

Post op need to wait for

return of bs/passage of flatus

True sign of bowel function

FLATUS NOT BOWEL MOVEMENT***

Alimentation if PO intake is restricted moves to

NGT

NG feeding = start at _____ and increase incrementally to the goal value for 24 hours

20 cc/hr

ex: **for example. Increase by 20cc/hr every 4 hrs if residual is less than 200cc

??

Check residual volumes if residual is over _____, hold or reduce feeding rate

200 cc

Post-op Enteral Nutritional Complications

Aspiration****

Esoph erosions

N/V/D

PPN

peripheral parenteral nutrition - peripheral vein - 5-7 days max - inadequate calories

TPN

total parenteral nutrition = central line or PICC - 5-7 days - adequate nutrition

TPN needs a

Dedicated line

Look at types of specialized feeding slide

*

Look at IV fluids slide

*