VI Nutrition and the Surgical Patient

A Sources of energy Humans store and utilize three sources of caloric energy: fat, glucose, and protein. Protein requires conversion to glucose via hepatic gluconeogenesis in order to be used as a caloric fuel source. Glucose can be stored as glycogen and used as a short-term reservoir of energy. The majority of energy is stored as fat and to a lesser degree as protein in the form of skeletal muscle. B Requirements The body requires protein and caloric needs to met in order for normal metabolic functions to occur. Although protein can be used as a caloric source for energy, adequate protein intake is important for muscle mass maintenance and other protein-dependent, nonenergy-producing processess.

Caloric requirements. The basal metabolic rate (BMR) is the amount of energy utilized by an unstressed, fasted individual at rest. The resting energy expenditure is the amount of energy utilized by an unstressed, nonfasted individual at rest and is 1.2 times the BMR or approximately 25 kcal/kg/day. The total energy expenditure (TEE) is the actual amount of energy that an individual utilizes and is equal to the resting energy expenditure (REE) multiplied by a stress factor that is determined by the magnitude of hypermetabolic change. The TEE can be increased significantly above the REE by hypermetabolic conditions such as surgery, trauma, sepsis, and burns. Fever increases the TEE approximately 10% for each degree centigrade over normal. Major polytrauma or large burns can increase daily energy expenditure by nearly twice the BMR. The TEE can be increased by voluntary work, such as exercise. Conversely, during starvation, the BMR decreases as the body adjusts to conserve body mass. An accurate measurement of caloric requirements can be performed by indirect calorimetry or the Fick equation. Protein requirements are normally very low because each protein molecule has a specific purpose and is therefore not generally available as an energy source. Some protein is lost daily as shed epithelium (e.g., bowel mucosa, skin) and must be replaced, and some protein is metabolized for energy during daily periods of starvation. Generally, daily protein requirements are only 0.8-1.0 g/kg/day, which is significantly less than the average American eats daily. The amount of protein required to meet catabolic losses is determined by measuring the nitrogen balance (Nitrogenin Nitrogenout). Typically, the nitrogen balance should be slightly positive. A negative nitrogen balance is indicative of inadequate protein intake to meet catabolic losses. o During starvation, the body makes every attempt to conserve protein. Because glycogen stores are metabolized within the first 24 hours of starvation, another source of glucose must be found for the tissues that cannot, or usually do not, use fats (i.e., brain cells, red and white blood cells). Proteins are broken down and converted to glucose in the liver by gluconeogenesis to supply the brain and blood cells with glucose. In unstressed starvation, protein catabolism can be prevented by exogenous administration of glucose. During starvation, the brain adapts to use ketones, which are produced when fat is metabolized. This decreases the amount of protein that must be metabolized as a glucose source. After all of the available fat is metabolized, protein is degraded at a high rate until the total body protein stores are approximately one half of baseline, at which time death occurs. o During severe illness, the body is not able to conserve energy and protein stores as it does during starvation. The hormonal milieu increases the BMR, decreases the ability to utilize fats and ketones, and thereby increases the dependence on glucose as an energy source. This glucose can come only from protein that is being degraded and converted to glucose. As the degree of illness or injury increases, the catabolic rate increases accordingly, leading to a rapid breakdown of protein stores and multiorgan dysfunction, if not

checked. During the acute phase of severe illness or stressed starvation, protein catabolism is minimally affected by exogenous administration of glucose. Primary treatment in these conditions is to eliminate the underlying cause of the stress response and to provide enough calories and protein to replace metabolic and catabolic losses. As the illness begins to subside, the hormonal milieu changes, which leads to less retention of salt and water and a change from a catabolic protein environment to an anabolic environment. The nitrogen balance is positive, meaning that less nitrogen is lost than is administered to the patient. This balance represents protein that is being laid down and thus improvement of the patient's health.

C Evaluation of nutritional status

The thin, cachectic patient with hollowed cheeks, no body fat, and very little muscle is obviously in a poor nutritional state. Generally, patients who have acutely lost 10% of their body weight are considered malnourished and need nutritional support. The obese patient and the well-developed patient may need as much nutritional support as the patient in a poor nutritional state, depending on the underlying disease process. Previously well-nourished people generally are able to endure a major operation and 5-10 days of starvation without an increase in morbidity or mortality. If the period of starvation extends beyond 10 days, nutritional support is necessary. Patients with severe illness who will be unable to eat for more than 10 days should receive nutritional support earlier. Because it takes several days for nutritional support to take effect, it is more effective to begin such support if there is any question of nutritional deficit rather than to wait until there is a severe deficit to correct.

D Therapy

Goals. The overall goal of nutritional support is to supply adequate energy in the form of calories and adequate protein for building proteins in the body. A ratio of 150 cal:1 g of protein is optimal, and most forms of nutritional support adhere closely to this ratio. Mineral and trace elements have been extensively researched and are included in most formulas in adequate amounts to prevent deficiencies or toxicities. The average hospitalized patient requires approximately 2000 cal daily and approximately 60 g of protein. o Energy. An adequate amount of energy substrates (i.e., carbohydrates, fats) should be supplied to provide enough calories to allow the tissues of the body to function properly and to decrease protein catabolism. Excessive caloric provision should be avoided. There are four ways to determine caloric requirements: Indirect calorimetry: Measures amount of oxygen inhaled minus amount of oxygen exhaled to determine amount of oxygen consumed. Since oxygen consumption (VO2) measured in mL O2/min is directly correlated to kcal/day (1 mL O2/min equals approximately 7 kcal/day), measurement of the amount of O2 consumed can determine daily caloric requirements. Fick equation: Amount of oxygen consumed, and therefore kcal required, is determined by multiplying the cardiac output by the arterial-venous oxygen content difference. Harris-Benedict equations: Daily caloric requirements are determined by calculating the REE from gender-based equations using gender, height, weight, and age variable and then multiplying by an estimated stress factor. Estimated REE (25 kcal/kg/day) multiplied by an estimated stress factor. o Protein. The approximate protein requirement for most adults is 0.8 g/kg/day or 56 g for the hypothetical 70-kg man. During severe illness with a high catabolic rate, this requirement

may increase to 2 g/kg/day of protein or greater. Adequacy of protein nutrition can be determined by the following: Nitrogen balance: The majority of catabolized protein is lost as urinary urea nitrogen with approximately 2-4 g of nitrogen lost in stool. Protein grams divided by 6.25 equals nitrogen grams. Amount of nitrogen intake minus nitrogen output should be positive if adequate nitrogen is being administered. Additional assessment of adequacy of protein nutrition is the measurement of visceral proteins (e.g., albumin, transferrin, prealbumin). Due to the long half-life of albumin, it should only be used as an assessment of malnutrition in outpatient and elective surgery patients. Prealbumin has a shorter half-life and is more reflective of protein nutrition in hospitalized patients. Weight gain in hospitalized patients is probably the poorest method of determining adequacy of protein nutritional support. Because most patients needing nutritional support in the hospital are stressed, they tend to retain water and become edematous. Also, because they are stressed, they will be catabolic and losing lean body weight, despite the increase of their actual body weight from fluid gain. When the acute phase of the stress is over and the patient becomes anabolic, weight gain is a useful measure of nutritional adequacy. The best overall method to determine adequacy of protein nutrition is to observe the overall condition of the patient, obtain nitrogen balances (maximum of twice weekly), follow visceral proteins (prealbumin twice weekly), and increase protein administration as needed. There is no limit to the maximum amount of protein that can be administered. When more protein is administered than can be utilized, it is burned as an energy source or stored as fat, with the excess nitrogen being excreted as urea. If urea production exceeds the kidneys' ability to excrete the urea, the BUN levels will rise. Enteral nutrition. The preferred route to provide nutrition is enterally. This can be performed by standard oral intake or by administration directly into the stomach or small intestine via a feeding tube. The provision of enteral nutrition maintains gut mucosal integrity and reduces complications. There is compelling evidence that the gut is important in critically ill patients; if unused for even brief periods, the mucosa begins to atrophy and lose its barrier function. This atrophy and loss of barrier function allows bacteria and toxins contained in the bowel to enter the bloodstream (bacterial translocation). Bacterial and toxin translocation has been associated with the systemic inflammatory response syndrome, sepsis, and multiorgan dysfunction. In addition to the translocation phenomenon, the atrophied mucosa is unable to digest food when food is ultimately presented, which leads to further delays in adequate nutrition and to possible infections of the GI tract (e.g., bacterial overgrowth, pseudomembranous colitis). o Formula compositions. When possible, patients should be fed by mouth. However, for many reasons such as critical illness, aspiration risk, depressed mental status, or inability to take adequate calories or protein orally, the oral route may not be feasible. In these situations, the administration of enteral feeding formulas is necessary. These formulas are designed to provide adequate nutrition and may be routine formulas or ones that are highly specialized to serve the nutritional needs of unique patient populations. Standard formulas provide a balanced calorie-to-protein ratio with approximately 50%-65% of calories from carbohydrates, 10%-20% from proteins, and the remaining calories from fats. Caloric density is approximately 1.0-1.2 kcal per milliliter, and they include the essential fats, minerals, and trace elements. Most patients can be maintained on standard formulas. Elemental formulas are amino acid or small peptide-based for ease of digestion and lower residue. Patients with short gut syndrome or distal enterocutaneous fistulas benefit from these formulas.

Caloric-dense formulas contain more calories per milliliter than standard formulas, typically 1.5-2.0 kcal per milliliter. Patients needing fluid restriction or very high caloric requirements may benefit from these formulas. Protein-dense formulas provide increased protein (20%-25% of calories) compared with other formulas and are used for patients with very high protein needs. Fat-based formulas provide more calories from fats rather than glucose compared with other formulas. These formulas attempt to reduce CO2 production by altering the respiratory quotient and may be beneficial in patients with compromised minute ventilation such as severe COPD and ARDS patients. Immunomodulating formulas provide glutamine and typically omega fatty acids in an attempt to enhance immunologic function. Efficacy of these formulas appears limited, and at this time, their use should be infrequent, most commonly in major trauma patients. o Route of administration. Enteral nutrition formulas can be delivered by tubes placed into the GI tract directly (gastrostomy, feeding jejunostomy) or via the nose (nasogastric, nasoduodenal, or nasojejunal). An abdominal radiograph to determine proper tube placement should be obtained prior to starting tube feedings on feeding tubes placed orally or nasally at the bedside. Postpyloric placement (jejunostomy, nasoduodenal, nasojejunal) of feeding tubes are associated with decreased risk of aspiration and earlier tolerance but are more difficult to place, leading to potential delays in initiation of enteral nutrition. Early initiation of enteral nutrition is associated with better tolerance and should be considered even in the immmediate postoperative period following abdominal surgery or trauma. o Rate of administration. Enteral nutrition should be started as continuous infusion via a properly placed gastric or postpyloric tube. A reasonable starting point is full strength at 20 mL/hour and increased by 20 mL/hour every 6-12 hours until the goal rate is obtained or excessive residuals are noted. The goal rate is determined by the patient's caloric needs and the caloric density of the formula. Gastric residual volumes of tube feedings should be checked every 4 hours to determine if excessive residual volumes are present, even if feedings are postpyloric. The volume of residual that is excessive is controversial but typically is considered the greater of 200 mL or four times the rate. If residual volumes are high, the infusion should be stopped and then resumed after 4 hours. o Complications of enteral feeding. Aspiration of gastric contents is the most common complication of enteral nutrition but can be reduced by monitoring residual volumes; postpyloric placement, especially jejunostomy; and maintaining the head of bed up 45 degrees. Bloating, mesenteric ischemia (rare), and diarrhea may occur with tube feedings, but adjustments in composition and rate can minimize these issues. Inadequate nutritional supplementation caused by frequent stopping of the tube feeding is not uncommon unless concerted efforts are made to avoid unnecessary cessations. Parenteral (intravenous) nutrition. Total parenteral nutrition (TPN) allows the provision of adequate nutrition when the GI tract is not able to be utilized due to malabsorption, obstruction, fistulas, or anatomic changes. When possible, nutrition should be provided enterally, and combined enteral and parenteral administration is sometimes beneficial. o Formula composition. TPN solutions should contain components of nutritional requirements, since other sources may not be available. The components are usually composed of various amounts of the following: Carbohydrates, predominantly as glucose solution, providing approximately 50% of total calories and causing TPN to have a high osmolality. Partial parenteral nutrition (PPN) contains lower concentration of glucose and is not significantly hyperosmolar. Amino acid solution, providing approximately 10% of total calories but more importantly providing essential amino acids for protein metabolism, especially in hypercatabolic patients

Fats, administered either continuously or intermittently as lipid emulsion, are necessary to avoid essential fatty acid deficiency. Lipid emulsions also provide the most calories in the smallest volume (fat has the highest caloric density) and produce less carbon dioxide (lowest respiratory quotient), which may be important in patients with volume restrictions or compromised ventilation. Administration of lipid emulsions can lead to hypertriglyceridemia, and levels should be routinely monitored in patients receiving lipids. The fat emulsions can be administered separately (preferred) or mixed with the other components. Electrolytes, including the monovalent cations, sodium and potassium; the divalent cations, calcium and magnesium; and the anions, chloride and acetate (converted to bicarbonate in the liver), which can be adjusted according to patient needs but must be administered in appropriate combinations to maintain ionic neutrality Vitamins and trace elements must be provided to avoid acquired deficiencies. Specifically, the exogenous administration of B vitamins, vitamin E/selenium (lipid peroxidation and free radical scavaging), zinc (wound healing, immunity), and chromium (insulin sensitivity) should be considered in patients receiving TPN. Medications may be incorported into TPN, although this is not often done routinely. Parenteral stress ulcer prophylaxis medications are the most frequently added medications, and after dosing stabilization, insulin may also be added. Route of administration. The usual route of administration of TPN is via a percutaneously placed venous line with the tip located in the superior vena cava. The high osmolality of TPN causes phlebitis and sclerosis if infused into a peripheral vein; therefore, a large, high-flow central vein that quickly dilutes the TPN is necessary. Typically, a subclavian vein approach is used, but peripherally inserted central catheter (PICC) lines and the internal jugular vein approach can be used. Because PPN is less hyperosmolar and therefore does not cause phlebitis, it can be delivered via a peripheral vein. Rate of administration. TPN is typically provided continuously at a rate that provides adequate calories to meet the patient's needs and is dependent of caloric density and degree of hypermetabolism. Frequently, patients are started at half the goal rate for 12 hours before advancing to full rate to avoid severe hyperglycemia. Similarly, some advocate decreasing the TPN rate by half for 6-12 hours prior to stopping to avoid hypoglycemia. Cycling of TPN to allow patients to be disconnected for periods of time during the day can be accomplished but should only be prescribed by experienced personnel and on selected patients. Complications of parenteral nutrition. Complications of parenteral nutrition include those related to line placement (hemothorax, pneumothorax); infections (line sepsis, pneumonia, acalculous cholecystitis); hyperglycemia (associated with increased infection risk and death); hepatic dysfunction; and abnormalities in electrolytes, vitamins, fatty acids, and trace elements. TPN is associated with higher morbidity and mortality than enteral nutrition. In patients unable to receive adequate enteral nutrition, this increased risk is unavoidable but should not be incurred if sufficient enteral nutrition can be provided.