​What is Surgery – Nutritional Support In Malnourished

​What is Surgery – Nutritional Support In Malnourished 

DEFINITION
Oral nutritional support: Provision of fortified foods and/or supplements. 

Enteral nutrition is a type of nourishment that is delivered through the GI system and comprises oral nutritional supplements as well as tube feeding via the oral, nasal, or percutaneous routes. 

Parenteral nutrition is the administration of nutrients, electrolytes, and fluids through the veins. 

EPIDEMIOLOGY 
On admission, around 40% of patients are malnourished. 

HISTORY 
Weight loss, a loss of appetite, and indications of an underlying illness or problems are all possible outcomes. 

EXAMINATION
Cachexia symptoms and physical appearance. Weight, BMI, mid-arm circumference, and triceps skin-fold thickness are all anthropometric metrics. 

PATHOLOGY/PATHOGENESIS 
Glycogen breakdown in the liver is the first source of glucose. Hepatic gluconeogenesis (using glycerol from fatty acids and amino acids from protein breakdown) occurs after 24 hours. Glycerol and free fatty acids are released during lipolysis, and the liver converts them to ketone bodies.

INVESTIGATIONS 
SGA (subjective global assessment), albumin, Ca, Mg, P04, Zn, nutritional screening/evaluation on admission 

MANAGEMENT
 Should be coordinated/monitored by a multi-disciplinary team consisting of a dietitian, SALT and medical staff. 

INDICATIONS 
Oral nutritional support.:Those at risk of malnutrition (defined as a BMI of 18.5 kg/m2 and unintentional weight loss of more than 10% in the preceding 3–6 months, or a BMI of 20 and accidental weight loss of more than 5% in the previous 3–6 months).

Enteral: malnutrition, dysphagia, blockage of the upper gastrointestinal tract (stricture, tumour), sedation (in ICU). 

Pancreatitis (reduces infective consequences and improves mortality in severe pancreatitis), poor stomach motility, gastric outflow obstruction, and patients at risk of aspiration are all treated with the Nasojejunal. 

When the gastrointestinal system is not functioning or available, such as in small bowel syndrome, high fistula, or persistent ileus/obstruction, parenteral nutrition is used. 

CONTRAINDICATIONS 
Enteral: Bowel obstruction, no peristalsis, and terminal sickness (unless the patient requests otherwise). 

Parenteral: Use with caution if you have kidney or liver disease, or if you have an egg or soy allergy. 




TYPES AND METHOD OF NUTRITIONAL SUPPORTS 

Feeds: Nutritionally, enteric formulas might be comprehensive or incomplete (supplement only). Standard formulas include macro- and micronutrients, complete protein, lipid (long-chain triglycerides) with or without fibre, and lipid (long-chain triglycerides) with or without fibre. Disease-specific formulae, immune-modulating formulae, low- or high-energy formulae, high-protein, whole-protein, peptide-based, free amino acid (elemental), high-lipid, and highly mono-unsaturated fatty acid formulations are among the others. 

Tube feeding by nasogastric, orogastric, nasojejunal, percutaneous endoscopic gastrostomy (PEG), PEG with jejunal extension, radiologically inserted gastrostomy (RIG), or surgical jejunostomy are some of the options for enteral feeding. 

TPN (parenteral nutrition): It's usually given by central venous access, but it can also be made for peripheral channels. While on TPN, keep an eye on the following: U&E, LFT, P04, Ca2 +, Mg2 +, glucose, Alb, CRP, Hb, WCC (do above 3 a week after initial 5 days unless issues). Triglycerides and iron studies are discussed every week. Selenium, copper, zinc, manganese, vitamin A, and vitamin E are all needed on a monthly basis. 

COMPLICATIONS
Impaired wound healing, immunological dysfunction, muscle weakness, susceptibility to infection, pressure sores, hospital stay, readmission rates, and mortality are all symptoms of malnutrition.

Enteral nutrition: Refeeding syndrome (possibly deadly metabolic shift characterised by hypophosphataemia, hypokalaemia, and hypomagnesaemia when individuals with depleted body stores of minerals such as K, Mg, and P04 have a carbohydrate source provided), fatty liver, and reduced renal function. Diarrhoea, vomiting, nausea, and abdominal discomfort are all mechanical symptoms. 
Sepsis and thrombosis are linked to parenteral feeding. 

Metabolic acidosis, abnormal LFTs, and fatty liver, hyperglycemia, bacterial translocation, renal failure, acute cholecystitis (bile stasis), and refeeding syndrome are all feed-related conditions. 

PROGNOSIS Malnourished patients have 2–3 times the number of problems as nourished people.