INTRODUCTION

N U T R I E N T:

Food or liquids that supply the body with chemicals necessary for

metabolism. Essential nutrients are those entities that body cannot

s yn t h e s i z e o r c a n n o t s y n t h e s i z e i n s u f f i c i e n t q u a n t i t i e s t o m e e t

needs.

NUTRITION:[L.nutritio,nourish]

Al l t h e p r o c e s s i n v o l v e d i n t a k i n g i n & u t i l i z a t i o n o f f o o d b y

w h i c h g r o w t h , r e p a i r ,m a i n t e n a n c e o f a c t i v i t i e s i n t h e b o d y a s a w h o l e

or in any of its part are accomplished. These processes include

ingestion,digestion,absorption & cellular metabolism.

Nutritional requirem ent:

In day to day requirement nutritional requirement is much lower

t h a n i n p o s t o p e r a t i v e & h yp e r m e t a b o l i c s t a t e s . A h e a l t h y a d u l t

u s u a l l y r e q u i r e 1 5 0 0 - 2 0 0 0 n o n p r o t e i n c a l o r i e s p e r d a y f o r e n e r g y.

The carbohydrate provide a 4 Kcal/gm, whereas fat provides

9Kcal/gm. A healthy in normal states require about 40 gm of protein

o r 6 g m o f n i t r o g e n p e r d a y. I n h yp e r c a t a b o l i c s t a t e s p r o t e i n

requirement go up 3-4 times . vitamins are essential for the

maintenance of normal metabolic functions & they are not

s yn t h e s i z e d i n b o d y . t h e w a t e r s o l u b l e v i t B & C h e l p i n c o l l a g e n

f o r m a t i o n & w o u n d h e a l i n g . Vit C i s m o r e d e p l e t e d p r e o p e r a t i v e l y

in patient on aspirin therapy or barbiturate therapy or in anorexia or

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i n e x c e s s i v e s m o k i n g . Vit B 1 2 i s d e p l e t e d i n c r o h n s d i s e a s e , i l e a l

r e s e c t i o n o r b yp a s s , b l i n d l o o p s y n d , r e d u c e d p a n c r e a t i c s e c , e x e c e s s

a l c o h o l i n t a k e , a n t i c o n v u l s a n t t h a e r a p y 7 a f t e r g a s t r i c s u r g e r y. F a t

s o l u b l e v i t a m i n s e g : A, D , E , K a r e d e p l e t e d i n s t e a t o r r h e a & a b s e n c e

o f b i l e . Vit A m a y b e g i v e n a f t e r s u r g e r y i n t h e d o s e o f 5 0 0 0 u n i t s

p e r w e e k . Vit K i s p a r t i c u l a r l y g i v e n i n c a s e o f o b s t r u c t i v e j a u n d i c e

where bile is not available from the ileum & when there is bleeding

t e n d e n c y. T h i s i s g i v e n i n t h e d o s e o f 5 - 1 0 m g I . M w e e k l y.

M i n e r a l & Tra c e e l e m e n t s :

Sodium,potassium,iron ,calcium ,magnesium deficiencies must be

identified & made good. Zinc deficiency is manifested as rash on

face & perineum which does not respond to antifungal therapy

,stomatitis,aguesia& alopecia. Copper deficiency result in

leucopenia & anemia with lack of chromium may give rise to glucose

intolerance. The 14 trace elements that are considered essential for

normal activites include manganese,cobalt,molybdenum& vanadium.

It is to be remembered that long term parenteral nutrition can also

result in depletion.

Wi t h a d v e n t o f i n t r a v e n o u s a l i m e n t a t i o n & b e t t e r u n d e r s t a n d i n g

of principles of enteral nutrition,the nutritional assessment &

management have become part of standard surgical practice.

Nutritional support is essential in managing seriously ill patients

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with preexisting weight loss,depleted energy reserves & to shorten

post operative recovery phase & to minimize no.of complications.

Epidemiology:

10-20% patients undergoing surgery can be expected to manifest

significant malnutrition. In the selected surgical population this

figure may be as high as 50%.

Causes of malnutrition

a. preoperative malnutrition is often due starvation or failure of

digestion of food before operation. Such malnutrition may develop

in:

Cases of poverty

C a s e s o f d ys p h a g i a

Cases of excessive vomiting

Carcinoma of stomach,pancreas,liver or biliay tracts giving

rise to failure of proper digestion & jaundice

I n b l i n d l o o p s yn d r o m e & i n t e s t i n a l f i s t u l a

In elderly & alcoholics who dont care to take proper food

b. postoperative malnutrition is quite common & occurs in almost

c a s e s i n t r a n s i e n t f o r m . As s o o n a s t h e p a t i e n t r e c o v e r s f r o m

postoperative period & starts taking normal diet such malnutrition

disappears .

c . H y p e r c a t a b o l i c s t a t e s : a f t e r s e v e r t r a u m a , e x t e n s i v e s u r g e r y,b u r n

severe sepsis,high fever & hyper catabolic renal failure there is

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excessive utilization 7 unless generous calorie intake is given,the

body quickly proceeds to breakdown fat& muscle protein in appor

equal proportion to provide necessary calorie for survival.

Pathophysiological changes of malnutrition & their surgical

relevance

1 . c a r d i o v a s c u l a r / r e s p i r a t o r y: t h e v e n t i l a t o r y r e s p o n s e t o h y p o x i a i s

reduced. The patient is more prone to develop congestive heart

failure during vigorous nutritional & volume repletion with

infection 7 during other physical stresses.

2. Blood: blood volume ,hematocrit,serum albumin, transferring &

lymphocyte counts are decreased R.B.C production.

3 . I m m u n e s ys t e m : c e l l m e d i a t e d i m m u n i t y i s i m p a i r e d a s s h o w n b y

tests, whereas antibody response are generally intact. Common

o p p o r t u n i s t i c i n f e c t i o n s c a n l e a d t o i n c r e a s e d m o r b i d i t y & m o r t a l i t y.

4 . Wou n d h e a l i n g : a l l w o u n d s & i n c i s i o n s h e a l m o r e s l o w l y . w o u n d

dehiscence is also common.

Rationale for nutritional therapy:

There is wide variation of opinion about the efficacy of

n u t r i t i o n a l s u p p o r t i n c l i n i c a l s u r g e r y. W h i l e t h e r e i s n o d o u b t i n

some clinical settings nutritional support can be life saving & in

other hospital stay is reduced is reduced & convalescence is

reduced.

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 Af t e r 3 - 4 d a y s o f n u t r i t i o n a l r e p l e t i o n , l o n g b e f o r e t h e r e i s a n y

demonstrable increase in tissue protein, there is improvement [10-

2 0 % ] i n m a n y p h ys i o l o g i c a l f u n c t i o n e v e n t h o u g h i t i s n o t

accompanied by demonstrable protein gain.

Af t e r t h e s e i m p r o v e m e n t s f u r t h e r i m p r o v e m e n t s & r e s t o r a t i o n t o

normality depends upon accretion of total body protein. It has been

s h o w n t h a t t h e c o n s i d e r a b l e d e c r e a s e i n m u s c l e ATP & AD P t h a t

occur in malnourished surgical patients return to normal &

nutritional repletion.

Nutritional assessment

It is essential for clinician to be aware of need to assess the state

of malnutrition of a patient & if malnutrition present or threatens ,

to consider the nutritional requirements & then to use methods of

s u s t a i n i n g n o r m a l i t y o r r e c t i f y i n g a n y d e f i c i e n c y.

Assessment

A malnourished patient has characteristic appearance ,lean &

hungry in most cases of starvation, lean 7 apathetic in post

traumatic depletion ,with a superimposed hectic flush around sunken

c h e e k s & p i n c h e d n o s e i n h yp e r c a t a b o l i c s t a t e . T h e f o l l o w i n g

parameters are commonly used to evaluate the nutritional status of

hospitalized patient.

1. Dietary intake: the 24 hour recall is a method of determining the

d i e t a r y i n t a k e f o r p r e v i o u s 2 4 h o u r s o r f o r a t y p i c a l d a y. A d i e t a r y

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history is a method of evaluating factors that affect eating

patterns ,nutrient intake, & nutritional status.

2.Body weight: careful weighing on a bed weighing machine is the

obvious way of detecting progress of the patient. The desirable

weight of patient can be checked by reference to the appropriate

t a b l e s o r b y a p p l yi n g t h e b o d y m a s s i n d e x [ B M I ]

BMI=wt (kg) height (m2)

A women should have an index of 20,21,23. a men should have

20.5,22,23.5 according to sizes of frame [ small, medium,large]

3 . An t h r o p o m e t r i c m e a s u r e m e n t s : An t h r o p o m e t r i c d a t a h a v e b e e n

traditionally used to estimate stores of subcutaneous fat & lean

s k e l e t a l m u s c l e . Tr i c e p s s k i n f o l d t h i c k n e s s h a s b e e n u s e d t o

estimate the subcutaneous fat stores,which would constitute about

50% of total body fat stores. Measured with calipers,triceps skin

fold thickness has been shown to correlate with patient out come in

some clinical studies. The measurements in midarm circumference

together with triceps skin fold thickness have been used to estimate

m i d a r m m u s c l e a r e a . As s k e l e t a l m u s c l e m a k e s u p t o 6 0 % o f b o d y

protein composition,some have argued that that the estimates should

reflect total body protein stores. Nevertheless,some studies have

found no relation between muscle mass & estimate of lean body

mass.

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 A p o t e n t p i t f a l l o f a n t h r o p o m e t r i c d a t a a n a l ys i s i n v o l v e t h e d a t a

comparison of patient data to population data bases derived from a

healthy non hospitalized population.

4. Serum protein: serum protein levels are dependent on three

variables a. protein synthesis , b)protein catabolic rate c) volume of

distribution. The rate of synthesis of any serum protein depends on

a d e q u a t e p r e c u r s o r a v a i l a b i l i t y & h e p a t i c s yn t h e s i s c a p a b i l i t y.

Al b u m i n , p r e a l b u m i n & t r a n s f e r r i n g a r e t h r e e c o m m o n l y m e a s u r e d

serum proteins used in nutritional assessment . with a serum half

l i f e o f 2 0 d a ys , a l b u m i n i s m o s t c o m m o n l y m e a s u r e d s e r u m

p a r a m e t e r u s e d t o a s s e s s g l o b a l h e a l t h p a r a m e t e r.

H yp o a l b u m i n a n e m i a h a s b e e n g r a d e d b a s e d o n s e v e r i t y:

1. mild: 2.8-3.5 gm/dl

2. moderate: 2.2-2.7 gm/dl

3. severe:<2.7 gm/dl

Serum alubumin levels are the best single nutritional parameter

for the predicting outcome in hospitalized patient & hpoalbuminemia

h a s b e e n d i r e c t l y c o r r e l a t e d w i t h 3 0 d a ys h o s p i t a l m o r t a l i t y.

interpretation in trauma patient is not reliable.

Wi t h s e r u m h a l f l i f e o f 8 d a y s t r a n s f e r r i n g , a n i r o n c a r r i e r p r o t e i n

is affected by both nutritional status & iron metabolism.

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Transferring shorter half life renders it a attractive serum marker

than albumin for the evaluation of short term nutritional changes.

Wi t h s e r u m h a l f l i f e o f 2 - 3 d a y s p r e a l b u m i n m a y b e a n i n d i c a t o r

o f t h e m o s t r e c e n t n u t r i t i o n a l s t a t u s o f a p a t i e n t . As p r e a l b u m i n i s

renally excreted,its interpretation in trauma patient is not reliable.

5. Immunologic response:

Malnutrition impairs both cellular & humoral immunity with

c e l l u l a r i m m u n i t y a f f e c t e d f i r s t . Lym p h o c y t e c o u n t l e s s t h a n

1500/mm3 indicates an impaired cellular defence mechanism.

Candida skin test: a negative reaction also means defective cell

m e d i a t e d i m m u n i t y.

6.Nitrogen balance studies:

The total nitrogen intake is compared with the loss from all

sources,such as urine,fistula drainage & nasogastric aspirate( 1 litre

= 1 gm nitrogen). A greater loss than intake indicates a negative

balance & tissue breakdown. A positive balance means anabolic

tissue synthesis.

7.Derived indices:Prognostic nutritional index(PNI)

PNI makes use of both serum measurements (alubmin & transferrin

levels) & clinical parameters ( triceps skinfold thickness & skin test

r e a c t i v i t y) . T h e g r e a t e s t v a l u e o f t h e i n d i c e s l i e s i n t h e i r a b i l i t y t o

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predict which patients are at greater risk of preoperative

complications due to their malnourished state.

Objectives of nutritional therapy

1. to prevent nutritional complications of surgery:

a. infection

b.wound dehiscence

2. to shorten the convalescence of surgical therapy

Basic principles of nutrition

1. Nutritional mixing: Optimum nutrition is essential to keep up

with the increased calorie demand & to decrease the rate of

catabolism or use of body protein for fuel. The objective is first to

provide the calorie & protein demands. The second objective is to

provide the appropriate nutrient mix. The total calorie requirement

can be calculated by using standard equations like Harris Benedict

equation(BMR) or by using a simpler method of calculation that is

,to provide 35Kcal/kg/day for the maintenance , 45Kcal/kg/day for

anabolic requirements.

2. Micronutrients: these should be given in increased quantities (5-

10 times the normal) to keep up with increased metabolism &

q u i c k l y r e s t o r e d e f i c i e n c y.

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3. Timing : It is essential to initiate nutrient support as soon as

possible after catabolic insult or evidence of malnourished state.

Nutritional support should be given within 48 hours.

4. Route: The most beneficial route is enteral route ,which is

usually only route available to outpatients or chronic care patients.

The parentral route is usually only required for acutely ill or injured

hospitilazied patient with with catabolic disease & a non functional

G I T. I f p r i o r m a l n u t r i t i o n h a s r e s u l t e d i n i n t e s t i n a l m u c o s a l a t r o p h y

& malabsorption is present ,supplemental glutamine 10-20 gm/day

should be given along with nutrient supplements ,usually protein

h yr o l a s a t e , u n t i l m u c o s a l f u n c t i o n i m p r o v e s .

Oral intake is usually not sufficient to meet either the energy or

protein needs in a catabolic or malnourished patients. Nutritional

s u p p l e m e n t s a r e i n v a r i a b l y n e c e s s a r y.

5. Nutritional supplements: Increased macronutrients demands

especially these needed for restoration of lean body mass,usually

exceed that which a compromised patients can achieve with intake of

food alone. The concept of using supplements to achieve goals is

particularly well documented in the management of wounds in

compromised patients. The addition of protein supplements to

increase intake to 1.5-2 gm/kg/day has been shown to increase the

healing rate. In fact healing rate correlates best with protein intake.

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 Nutrient supplements should be selected based on the following

criteria:

Need for high calorie-moderate to high protein

Need for high protein-moderate calorie

Quality of contained nutrients

Route of administration

Palatability & tolerance

C o m p l i c a t i o n s ( l i k e h yp e r o s m o l a l i t y,h y p e r g l y c e m i a & f a t

intolerance)

In patient or chronic care setting,adequate energy is usually not the

major issue,because carbohydrate intake is usually adequate. The

major problem is adequate protein,because protein food are not

taken in sufficient quantities. Therefore a palatable protein

supplements become essential. Micronutrients are compound found

in small quantities in all tissues. They are essential for cellular

function & therefore for survival. Marked deficiencies in key

micronutrients occur during the severe stress response due to

increased losses,increased consumption during metabolism &

inadequate replacement. The micronutrients include key amino acids

such glutamine,arganine,organic compounds(vitamins) & inorganic

compounds(minerals). These compounds are both utilized & excreted

at more rapid rate after injury ,leading to deficiencies. However

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,because measurements of levels are difficult,if not possible,

prevention of a deficiency is accomplished only by providing

intake.

Postoperative fluid balance & nutrition

As a g e n e r a l r u l e , w h e n e v e r p o s s i b l e t h e p a t i e n t s h o u l d b e f e e d &

watered via GIT .As far requirements are concerned the patient ,if

able to respond ,is the best judge & will indicate hunger & thirst

when asked .

Gut mobility is commonly compromised by trauma & surgery even

if the gut is not directly involved. In the majority of patients only a

day or two is required to regain normal function & in a previously

f i t p a t i e n t a l l t h a t i s n e e d e d a r e c l e a r f l u i d s t o m a i n t a i n h yd r a t i o n .

In uncomplicated situations the IV fluid should be maintained at

the rate of 2 litres per 24 hours for the first 24 hours & then raising

t o 3 l i t r e s / d a y,t h e r e a f t e r u n t i l p a t i e n t c a n t a k e o r a l f l u i d s .

Nutritional support will be needed unless patient is able to resume a

normal diet within 3 days.

Where jaws are wired ,the resumption of diet means a liquidized

feed & care must be taken to ensure that a patient can cope with

clear fluids without coughing & choking. Sips of water are given

initially gradually increasing if tolerated. Bowels sound should be

p r e s e n t w i t h n o n a u s e a . As f o r f e e d i n g , a n o r m a l d i e t f i n e l y

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liquidized is excellent & more palatable than most proprietary

preparations.

In major trauma nutrient becomes very important,especially when

m u l t i s y s y t e m t r a u m a i s i n v o l v e d . As a b o v e , t h e a i m s h o u l d t o f e e d

enterally if possible & a nasogastric tube can be used for this

purpose. The tube should be aspirated noted. When the aspirate falls

below 30 ml/hr & bowl sounds are present,30 ml of water can be

g i v e n e v e r y h o u r. T h i s c a n b e g r a d u a l l y i n c r e a s e d i f i t i s a b s o r b e d

,building up through half strength to full strength in 3-4 days. For

long term nasogastric feeding ,a fine boric silastic tube should be

substituted for ordinary nasogastric tube, as the ordinary tube can

cause oesophageal stricture. It is necessary initially however

initially as sialastic tube is too fine to allow aspiration.

T h e c h o i c e o f f e e d d e p e n d s l a r g e l y o n a v a i l a b i t i t y. W h a t e v e r i s

used should be of sufficient consistency to flow down a narrow bore

sialastic tube. It should always given continuously over the 24 hours

& b e o f l o w o s m o l a l i t y,b o t h o f w h i c h r e d u c e i n c i d e n c e o f d i a r r o h e a

which is one of complications of nasogastric feeding.

The actual content of feeding in terms of metabolic requirements

s h o u l d b e b a l a n c e o f p r o t e i n , f a t s & c a r b o h yd r a t e t o p r o v i d e a p p o r.

75-87 gm protein & 2000-2500 non protein cal per day in adults,the

l a t t e r b e i n g c a r b o h yd r a t e & f a t i n r a t i o o f 4 : 1 . I t m u s t c o n t a i n f u l l

range of vitamins & minerals

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Rationale of using anabolic agents:

Successful correction of PEM & prevention of severe protein

deficiency in the presence of catabolic illness require the restoration

of normal protein partitioning (to restore lean body mass & wound

healing). However the process means use of protein for protein

s yn t h e s i s & n o t e n e r g y. R e s t o r a t i o n o f k e y c o m p o n e n t s o f n u t r i t i o n

is essential before considering an anabolic agent.

The various choices are :

1. elderly frail population-human growth hormone(HGH),

Tes t o s t e r o n e

2. chronic non healing wound-oxandrolon

3.trauma- oxandrolone

A limiting factor to restoration of lean mass & improving wound

h e a l i n g i s t h e o u t p u t o f t h e p r o t e i n s yn t h e s i s p a t h w a y,w h i c h i s

dependent on adequate substrate plus an anabolic stimulus. During

catabolic disease & even during the recovery phase of catabolic

disease the anabolic activity is decreased.

The action of the anabolic agents currently in clinical use is 2

folds

1. the aminoacids are driven into protein synthesis pathway

2. catabolic activity is decreased.

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Methods of feeding:

These are predominantly enteral & less commonly parentral

1.Enteral nutrition:

A) By mouth: this is obviously the most convenient & effective

route to provide nutrition. This being physiological route,wherever

possible,this route should be choosen to provide nutrition.

b) By nasogastric tube: a nasogastric tube which has been passed to

allow regular gastric aspiration to be performed can also be used for

feeding liquidized diet. Fine boring tubing can be used instead,being

favourably received by most patients as not too irritating as the

larger tube. It is invaluable when passed with aid of an endoscope

through an esophageal stricture into the stomach,enabling thereby

the effects of starvation to be reversed. In some patients the tube

can be sited in deuodenum,especially if there are problems of gastric

stasis or esophageal reflux. In case of oesophageal carcinoma a

special tube in the form of Souttars tube or Celstein tube should be

passed by endoscopy to provide nutrition through this tube.

Unwanted effects: nausea ,vomiting & pulmonary aspiration are

avoided by regular infusion rate & insuring gastric emptying.

C) By tube enterostomy: Tube enterostomy is the operative

placement of a tube or catheter into GIT tract. It is indicated when

the passage of fine bore nasogastric tube is not possible or when

more than 4 week of enteral feeding is anticipated. The common

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contraindications include complete or partial gastric or intestinal

obstruction. The tube is placed as a special surgical procedure or as

a n a d j u n c t t o i n t r a a b d o m i n a l s u r g e r y.

Gastrostomy: This is perfomed when feeding can not be provided

by mouth as well as naso gastric tube. This is particularly required

in cases of oesophageal carcinoma or high gastric carcinoma. A

plastic tube of about 8-10mm in diameter is passed through a

separate stab incision through the upper left rectus muscle or

through short muscle splitting incision. The tube is passed through a

small incision in the anterior wall of stomach using two rows of

purse string sutures around the tube on the stomach wall. The tube

should be directed towards the fundus of the stomach. The tube is

secured to the skin with adhesive strapping or silk suturing.

Contrindications

Gastric disease

Impaired gastric emptying

Significant gastro-esophageal reflex

Loss of gag reflex

Jejunostomy: When gastrostomy is not possible either due to

earlier gastrectomy or due to carcinoma involving the stomach,

tube jejunostomy is performed for feeding. Jejunostomy seems to

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b e a m o r e s u c c e s s f u l m e t h o d o f f e e d i n g t h a n g a s t r o s t o m y,e v e n

when stomach is available e.g oesophageal carcinoma.

Complications of enteral feeding:

1. Malposition of the catheter

2 . As p i r a t i o n r e s u l t i n g f r o m s u d d e n c h a n g e s i n g a s t r i c p r e s s u r e

3. Inappropriately rapid administration of hypeosmolar solutions

c a n c a u s e d i a r r h e a , d e h yd r a t i o n , e l e c t r o l y t e b a l a n c e &

h yp e r g l y c e m i a ( w i t h g l u c o s e c o n t a i n i n g s o l u t i o n s )

4. Bowel necrosis

5. Bowel perforation

Consider parentral route when:

1. the gut is short

2. the gut is blocked

3. gut is unable is to cope

4. gut is fistulated

2. Parentral nutrition:

Indications:

a. When enteral feeding is contraindicated I.V feeding becomes

mandatory

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b . W h e n u t i l i z a b l e s o u r c e o f n i t r o g e n & c a r b o h yd r a t e i s r e q u i r e d

by I.V route only

c. When a severely ill patient is unable to adequqte oral nutrition

either voluntary or through nasogastric tube,after 3 days I.V

nutrition must be considered

d. The aim of treatment is to prevent large early losses by

beginning treatment early enough & thereby restoring internal

environment towards normalcy as soon as possible

e. I.V nutrition not only provides calories or nitrogen but also

provide electrolyte & maintenance of serum of oncotic pressure

f. When there is excessive extraenal loss e.g ulcerative colitis or

intestinal colitis

g. It is particularly indicated in marked catabolic response of

severe injuries such as severe burns ,prolonged coms or

h ye r m e t a b o l i c r e n a l f a i l u r e .

Contraindications

There are certain contrindications to I.V or parentral

nutrition. These are severe hepatocellular damage ,renal

damage, congestive cardiac failure,uncontrolled diabetes &

s e v e r e b l o o d d ys c r a s i a .

T h e m a j o r i t y o f s o l u t i o n s a r e h yp e r o s m o l a r . t h i s m e a n s t h a t

they must be administered through large central vein. A principle

vein tech is possible but is limited. Canulation of a central vein

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has problem related to both insertion tech & to sepsis which

require meticulous attention to deal with regard to dealing of

intravenous infusion & additives. The feeding line must not be

used for other purposes such as sampling ,measuring or blood

transfusion. When these are necessary another route must be

f o u n d . As i n e n t e r a l n u t r i t i o n , t h e a i m i s t o g i v e a b a l a n c e d

formulations of protein ,fats carbohydrate plus vitamins &

minerals.

Protein sources:

These come as L amino acids & many preprations such as

a m i n o p l e x - 1 2 a r e a v a i l a b l e i n t h e m a r k e t . Var i o u s a m i n o a c i d s

are given in proportions approximating to normal serum

concentration.the essential aminoacids must be well represented

& i n b a l a n c e s p a r t i c u l a r l y a m i n o a c i d s ( s u c h a s g l yc i n e ) t o

make up nitrogen content is probably inadvisable,if only because

the renal threshold may be exceeded & the aminoacid wasted.

For utilization ( formulation of muscle protein),a sufficiency of

non protein calorie should be given simultaneously in the ratio

of 120-200 Kcal/g nitrogen.

Energy sources:

Carbohydrates- provides 4 kcal/gm & dextrose is preferred.

Fructose has been used,but excessive administration can give

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rise to lactic acidosis & sorbitol can only be utilized after its

conversion to fructose.

Infusion of glucose may be complicated by insulin

r e s i s t a n c e a s m e n t i o n e d e a r l i e r ,s o t h a t e x o g e n o u s i n f u s i o n o f

insulin is commonly required. This is potentially highly

d a n g e r o u s a s i f g i v e n e x c e s s i n s u l i n , m a y c a u s e h o yp o g l y c e m i c

c o m a , e q u a l l y i f g i v e n t o o l i t t l e i t m a y c a u s e h yp e r o s m o l a r s t a t e .

Additionally sharp fall in the serum potassium may be seen

,repeated estimation of blood glucose 7 serum potassium is

essential.

Fat emulsions( soyabean oil e.g intralipid)

It provides 9 kcal/gm & are additionally iso-osmolar & of

n e u t r a l P h . C a r b o h yd r a t e i s n e c e s s a r y f o r f a t u t i l i z a t i o n & s o n o t

more than 50% of total Kcalorie/day should be fat. Care is

needed to make sure that fat is being cleared from serum & this

can be checked by inspection of the supernatant serum of a blood

sample. This should be clear & not milky within 4 hours of

ending a fat infusion.

Alcohol(ethanol)

It has sometimes been used as a calorie source & is a

constituent of some complete parentral nutrition

solution(Aminoplex5) which contains a balance of aminoacids &

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c a l o r i e s . I t s u s e , i f a t a l l s h o u l d b e r e s t r i c t e d t o t h e yo u n g f i t t e r

patient.

Minerals & vitamins:

Vit a m i n s & h e m a n t i n i c s n e e d e d t o b e a d d e d t o t h e r e g i m e .

Aminoacids solutions & some dextrose solution contain

e l e c t r o l yt e s i n v a r y i n g a m o u n t . An a p p r o p r i a t e s o l u t i o n c a n b e

choosen for each individual ,for instance,a low sodium content,if

sodium retention is a problem for high potassium content where

t h e s e r u m c o n c e n t r a t i o n o f p o t a s s i u m i s l o w. S o m e s o l u t i o n s

contains magnesium,phosphate,zinc & other elements.

It is advisable to give extra folic acids in addition to that

c o n t a i n e d i n v i t a m i n p r e p a r a t i o n s . An i n t r a m u s c u l a r i n j o f 1 5 m g

m a y b e p r e s c r i b e d t w i c e w e e k l y. S i m i l a r l y a n i n c r e m e n t o f v i t

B12( 1000 ugm weekely) & additional iron are frequently

required either by intramuscular or intravenous infusion.

Urea production

24 hour urine urea mmol/24 hours + ( change in plasma urea

over the previous 24 hours multiplied by 60% of body weight in

kg)

Nitrogen loss gm/24hours= urea production multiplied by

0.028. 10% should be added for nitrogen losses other than

urea(creatnine ,urate) & further 1.5 gm should be added for loss

from other sources such as skin & gut. Clearly enormous losses

21
will be impossible to balance,simply because of sheer volume of

fluid involved. It is extremely difficult to replace more than 18

gm of nitrogen per day & usually 12-15 gm is practical limit &

wound need approximately 2000 Kcal for utilization. Every

opportunity to begin enteral feeding is sought when this present

itself,there should be gradual change over to the enteral route

over a few days & then parentral route discontinued.

Composition of intravenous nutrition to be given per 24 hours

In first 8 hours half liter aminosol 3.3% ,fructose 15%,

etanol2.5% plus 26 mEq kcal (2gm),1/2 litre 20% intralipid &

5000units of heparin

In second 8 hours-half liter 3.3% aminosol,fructose 15%

ethanol 2.5% plus 26meq KCL & half liter 10% aminosol.

In third 8 hours half liter 3.3% aminosol,fructose

15%,ethanol2.5% plus 26meq KCL & half liter 20% intralipid

plus 5000 units of heparin.

Complications of parentral nutrition

1. technical complications

Complications of catheter placement

Pneumothorax

Arterial lacerations

Hemothorax

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 Mediastinal hematoma

Nerve injury

H yd r o t h o r a x

S ya m p a t h e t i c e f f u s i o n

Thoracic duct injury

Air embolism

B. Late technical complications

Erosion of catheter into bronchus,right atrium or other

structures

Subclavian thrombosis

Septic thrombosis

2. Metabolic complications:

Plasma electrolyte abnormalities

Trace metal deficiencies

Essential fatty acid deficiency

Disorder of glucose metabolism

3. Septic complications

Catheter infection

Infection of unsterile prepration

References

1. A Concise textbook of surgery by S.Das

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2.Short practice of surgery by Bailey & love

3. Oral & Maxillofacial Surgery- Gustav O. Kruger

4. Surgery of Mouth & Jaws by J.R Moore

5. Oral & Maxillofacial surgery by Daniel M Laskin vol1

6. Oral & Maxillofacial trauma Raymond J Fonseca vol1

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