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Surgery > Nutrition And Fluid Therapy > Flashcards

Nutrition And Fluid Therapy Flashcards

1
Q

Metabolic response to starvation

A

12 hours of fasting.
Glycogenolysis.
From liver. 200 g.
From muscle through cori cycle. 500 g.

24 hours of fasting.
Protein catabolism. Gluconeogenesis. Breakdown of 75 g muscle protein.

48-72 hours of fasting.
Lipolysis. Ketogenesis. Breakdown of muscle protein decreases to 55 g.

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2
Q

Reduction in baseline energy requirements in starvation

A

From 25-30 kcal/kg to 15-20 kcal/kg

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3
Q

Starvation in presence of trauma and sepsis

A

Increased counter regulatory hormones of adrenaline. Noradrenaline. Cortisol. Glucagon. Growth hormone.
Energy requirements increased to 40kcal/kg.
Preferential lipolysis but
Decreased ketogenesis.
Increased protein catabolism and gluconeogenesis that is not reversed on giving glucose.
Fluid retention with hypoalbuminemia.

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4
Q

Bioelectrical Impedence Analysis - BIA

A

To assess intra and extracellular fluid volumes

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5
Q

Clinical assessment of nutritional status of patient

A

Subjective Global Assessment
And use of
MUST
Malnutrition Universal Screening Tool

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6
Q

Daily requirements of sodium

A

50-90 mM/day

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7
Q

Daily requirements of potassium

A

50 mM/ day

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8
Q

Daily requirements of calcium

A

5 mM/day

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9
Q

Daily requirements of magnesium

A

1 mM/ day

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10
Q

Crystalloid and colloid solutions

A 
5% dextrose water 
Hartman solution 
Normal saline 
Haemacel 
Hetastarch 
Gelofusine
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11
Q

Hartmans solution

A

Contains lactate 29 mmol/L

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12
Q

Dextrose water

A

No electrolyte replacement and modest caloric values (1 litre contains 400kcal)

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13
Q

Replacement fluid for intestinal losses

A

Normal saline which contains supplemental potassium

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14
Q

Blood transfusion is required at which hematocrit level

A

When it falls below 21 percent

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15
Q

Essential fatty acids

A

Linoleic acid and lenolenic acid.

In soybean and sunflower oil.

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16
Q

Fat emulsions

A

Long chain triglycerides (LCTs)
9 kcal/g
Infusion rate of 0.15 g/kg per hour.
Used in parenteral nutrition with glucose.
Glucose requirements of 100-200g/day and essential fatty acid requirements of 100-200 g/week

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17
Q

Vitamins for wound healing and collagen formation

A

Vitamin B and C.

Post operative vitamin C requirement is 60-80 mg / day

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18
Q

Supplemental vitamin B 12 given to patients

A

Who have undergone intestinal and gastric resection and have long term alcohol dependency in history

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19
Q

Fat soluble vitamins ADEK reduced in those

A

Who have steatorhea and absence of bile

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20
Q

Risk of long term parenteral nutrition

A

Trace elements which are normally absorbed by gut are not delivered to the patient

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21
Q

Inflammatory response decreases levels of

A

Magnesium
Zinc
Iron

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22
Q

Daily monitoring in feeding regimens

A 
Body weight 
Fluid balance 
FBC and U/E 
Blood glucose
Temperature 
Urinary losses
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23
Q

Weekly monitoring in feeding regimens

A

Thiamine
LFTs. Clotting factors.
Albumin.

24
Q

Fortnightly monitoring in feeding regimens

A

Serum vitamin B12
Folate
Iron

25
Q

Function of the ileum

A

Critical in water and sodium reabsorption.

Absorbs bile salts and vitamin B12.

26
Q

Loss of the ileum leads to

A

Water and sodium loss.
Bile salts go into the colon where they don’t let colonic mucosa absorb the already excessive incoming water and sodium.
Also fat malabsorption

27
Q

Resection of the ileum

A

Enhancement of gastric motility and acceleration of intestinal motility

28
Q

Loss of 100 cm ileum

A

Give oral cholestyramine to absorb bile salts

29
Q

Loss of greater than 100 cm ileum

A

Dietary fat restriction

30
Q

Loss of 200 cm ileum with colectomy and jejunostomy

A

Either
Net absorbers
Or
Net secretors

31
Q

Net absorbers

A

Absorb adequately water and sodium.

More than 100 cm of functional jejunem

32
Q

Net secretors

A

Secrete water and sodium in the stoma.

Less than 100 cm of functional jejunum

33
Q

Treatment of net secretors

A

Dietary restriction of free fluid.
Administration of Glucose and saline with atleast 90 mmol/L sodium.
WHO cholera solution can be used for this purpose.

34
Q

What is short bowel syndrome

A

Less than 150 cm of small intestine remains after surgical resection.

35
Q

Consequences of short bowel syndrome

A

Peptic ulcer. Due to gastric hypersecretion.
Cholelithiasis due to interruption of enterohepatic bile salt cycle
Renal stones due to excessive absorption of Oxalates in colon.
Sometimes a syndrome of slurred speech. Ataxia and altered effect. Due to fermentation of malabsorbed carbohydrates in colon and absorption of D lactate. Rx is dietary carbohydrate restriction

36
Q

Drugs to be given in short bowel syndrome

A 
H2 blockers 
Omeprazole 
Octreotide 
Loperamide 
Codeine phosphate (last 2 are anti motility drugs)
37
Q

Indications for artificial nutritional support

A

Patient has sustained or likely to sustain 5-7 days of no food intake

Patients of crohns
Pancreatitis
Gastrointestinal resections

38
Q

Enteral Nutrition

A 
1- sip feeding 
2- tube feeding techniques 
3- fine bore tube insertion 
4- gastrostomy 
5- jejunostomy
39
Q

Enteral feeding formulas

A

Most contain
1-2 kcal/ml energy
0.6 g/ml protein.

Polymeric feeds have intact proteins.
Monomeric feeds have amino acids or peptides.

40
Q

Sip feeding

A

Usually a 200 ml carton that supplies 200 kcal and 2 g of protein

41
Q

Gastrostomy

A

Ryle tubes

Shifted to fine bore tube insertion if feed is to maintained for more than 1 week. (As it normally lasts 4-6 weeks)

42
Q

Tube feeding techniques

A

Normally 20-30 ml is administered per hour.
Feeding discontinued at night for 4-6 hours to prevent aspiration.
Aspirates taken regularly. If above 200 ml in 2 hour period. Feed is discontinued

43
Q

Washing of tubes

A

Flushed with water twice daily.

If solidified food then chymotrypsin and papain given.

44
Q

Gastrostomy

A 
Either surgical 
Or percutaneous endoscopic gastrostomy. 
Later done by 2 methods 
1- direct stab technique 
2- transoral and push through technique
45
Q

How to confirm position of tube

A

Abdominal X-ray

Injecting 5 ml of air and hearing bubbling over the stomach via steth

46
Q

Drawbacks of gastrostomy

A

Necrotising fasciitis
Intra abdominal wall abscess
Gastric fistula
Sepsis

47
Q

Jejunostomy

A

Nasojejunal tube
Or
Needle jejunostomy

48
Q

Benefits of post pyloric feeding such as jejunostomy

A

Reduction in aspiration risk.

In severe pancreatitis as there can be a degree of gastric outlet obstruction.

49
Q

Complications of enteral feeding

A

Tube Malposition. Displacement. Blockage. Leakage.
GI nausea vomiting constipation
Vitamin mineral and trace element deficiency
Infections such as nosocomial enteric infections due to contamination of feed. (Should he kept in sealed containers at 4 degree Celsius and discarded after opening)

50
Q

Indications of TPN

A

Massive resection
Intestinal fistula
Intestinal failure

51
Q

Peripheral TPN

A

For short term. 2 weeks
Peripherally inserted central venous catheter (PICC) lasts for 7 days and has to be reset on contralateral wrist.
Risk of thrombophlebitis

52
Q

Central TPN routes

A 
Subclavian vein 
Internal 
Or 
External jugular vein 
Hickman lines 
Or PICC into cephalic vein directed into brachiocephalic and then superior vena cava

Tip is always in distal superior vena cava. Confirmed by chest x ray

53
Q

Complications of parenteral nutrition.

A

Fluid overload.
Check weight daily.
Troublesome is gain is greater than 1 kg per day.
Hyperglycaemia due to insulin resistance in surgical patients.
Fatty liver. Hepatomegaly. Reduce fat content of feed.
Hypercholesterolemia
Lipoprotein X
Hypertriglyceridemia
Hypercholremic metabolic acidosis. Aminoacidemia if excess amino acids.
Catheter infection. Damage of adjacent vessels or thoracic duct during insertion. Pneumothorax. Pleural effusion. Air embolism. Hydromediastinum. Cardiac perforation or tamponade.
Refeeding syndrome

54
Q

Refeeding syndrome occurs in which patients

A

Overfed
And
Have alcohol dependency

55
Q

Refeeding syndrome

A

Hypocalcemia
Hypomagnesemia
Hypophosphatemia

Altered cardiac and respiratory function with seizures

Surgery (10 decks)

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