Blood Products & Transfusion

Nutrition in Surgery
Water & Electrolyte Balance

Dr.Ramesh Parajuli
MS (ORL-HNS)
Chitwan Medical College Teaching Hospital, Bharatpur-10, chitwan, Nepal
 Blood Transfusion:
Blood Product :- Any
therapeutic substances
prepared from human
blood

Blood & Blood Products:

1.Whole Blood
2.Blood & Plasma
components
3.Plasma Derivatives:
albumin, coagulation
factors, immunoglobulin
 Human Blood Groups

23 human blood group systems

eg. ABO,MN, Duffy, Lewis, Kell

ABO-most important

RBC Cell surface: A ,B,AB antigens

Plasma : anti-B, anti-A, anti-A & anti-B

- IgM antibody
 History

1900- Karl Landsteiner discovered A,B,O

1902-Decastrello & Sturli discovered AB
1939-Levine & Stetson
1940-Landsteiner & Weiner Rh system
 Rh System

Rh antigens-RBC membrane

About 15% population= Rh

Negative

Rh antibody=IgG antibody

Anti-Rh antibody= ‘‘rhogam”

 Blood Grouping

1.Before a person gets blood donation

2.Before a person donates blood
3.Before a person donates an organ for transplantation
4.Before surgery
5.Women planning to become pregnant or has first becomes
pregnant
6.To show whether two people could be blood relatives
7.To check identity of a person suspected of committing
crime
 Who can receive blood from whom?

Blood Antigens Antibodie Can give Can

group s blood to receive
blood from
A A anti-B A & AB A&O

B B anti-A B & AB B&O

AB A&B NONE AB AB,A,B,O

O NONE A&B AB,A,B O

&O
Complications & Risks:
For the Donor:
1.Vasovagal syncope
2.Bruise at the needle site
3.Hematoma at the needle site
4.Fatigue
5.Nausea & vomiting

For the Patient:

1.Febrile non hemolytic reaction
2.Vol.overload
3.Iron overload
4.Graft vs host disease
5.Acute hemolytic reactions
Donor unit-
Must be refrigerated to prevent bacterial growth
Must begin within 3o min after taking out of
fridge
Intravenously
Personal details of the patients to be matched
with the donor to prevent transfusion
reactions
 Contraindications for being a Blood
Donor
For Recipient Safety
1.Donor who recently received transfusion
2.Recent pregnancy
3.History of cancer eg. leukemia, lymphoma
4.Current infection

For Donor Safety

1.Donors not healthy enough
2.Nutritional status
3.Age-17 to 70 yrs
Blood products

Apheresis

Platelet Red cell Plasma

components components components &
derivatives
Red cell Plasma Plasma
components components derivatives
Red cell Fresh frozen Albumin
concentrate plasma
Coagulation
Red cell Liquid plasma factors
suspension (red
cells + additive Freeze-dried Immunoglobulin
solution) plasma

Buffy coat Cryoprecipitate-

depleted red cells depleted plasma

Leukocyte- Viral-inactivated
depleted (filtered) plasma
red cells
Cryoprecipitate
 Centrifugation at different rpm and duration

PRP FFP Cold room

 Definition :
The transfusion of safe blood products to treat a condition
leading to significant morbidity or mortality that can’t be
prevented or managed effectively by other means.

-Can save life

-Improve health
1.Homologous Transfusion
Blood Transfusion

2.Autologous Transfusion
Functions of anticoagulant-preservative
solution in blood collection pack
Solutions Functions
C Sodium citrate Binds with calcium ions in blood
in exchange for the sodium salt
so the blood does not clot

P Phosphate Supports metabolism of the red

cells during storage to ensure
they release oxygen readily at
tissue level

D Dextrose Maintains the red cell

membrane to increase storage
life
A Adenine Provides energy source
 Whole Blood:

1.Sterile, disposable plastic pack

2.Anticoagulant-Preservative:-CPDA
3.Volume up to 510ml (63 ml anticoagulant,450ml blood)
4.Hb-12gm/dl,Hct-35%
5.No functional platelets
6.No labile coagulation factors (V & VIII)
 Whole Blood

Indications
– Red cell replacement in acute blood loss with
hypovolemia
– Exchange transfusion
– Patients needing red cell transfusions where red
cell concentrates or suspensions are not available

Contraindications – (Risk of volume overload)

– Chronic anemia
– Incipient cardiac failure
Effects of storage on whole blood
Reduction in the pH

Rise in plasma potassium concentration

Progressive reduction in the red cell content of 2,3

diphosphoglycerate (2,3 DPG)

Loss of all platelet function in whole blood within 48 hours

of donation

Reduction in Factor VIII to 10–20% of normal within 48

hours of donation. Coagulation factors such as VII and IX
are relatively stable in storage
Administration
– Must be ABO and Rh compatible with the
recipient
– storage:2-6*C
– Use within 35 days
– Transfuse within ½ hrs of removal from
refrigerator
– Complete transfusion within 4 hrs of
commencement
– Never add medication to a unit of blood
 Advantages:

1.Requires only simple & inexpensive single collection pack

2.Supplies all components & volume

Disadvantages:
1.Risk of circulatory overload, transmitting infection

2.No functional platelet or labile clotting factors

 Production of Whole Blood
Donor –whole blood-ABO & RhD testing
I
Test for infectious diseases markers
I
Negative positive
I I
Quarentine refrigerator discard
I
release
I
Blood bank refrigeratorcompatibility testcompatible pts
Red cell Concentrate
(Packed Red cells)
Prepared by allowing the blood to
separate under gravity in refrigerator at
2-6*C overnight
or
By centrifuging
Red Cell Concentrate
150-200ml red cells
Hb approx. 20gm/dl(not<45gm per unit)
Hct 55 -75%

Indications
– Replacement of red cells in anemic patients
– Use with crystalloid replacement fluids or colloid
solution in acute blood loss
Administration
– Same as whole blood
– To improve transfusion flow, normal saline (50–
100 ml) may be added using a Y-pattern infusion
set
 Advantages:
simple, cheaper

Disadvantages:
-Increases viscosity
-Febrile Non haemolytic Transfusion Reaction
Red cell Suspension
150–200 ml red cells with minimal residual plasma

110 ml normal saline, adenine, glucose, mannitol

solution (SAG-M) or an equivalent red cell nutrient
solution added

Hb approximately 15 g/dL (not < 45 g per unit)

Hct – 50–70%

Indications – Same as red cell concentrate

Contraindications – exchange transfusion of

neonates
 Administration
– Same as whole blood
– Better flow rates than red cell concentrate
or whole blood

Advantages:
-Reduces viscosity
-Better preservation of the red cells
-Permits separated use of platelets & plasma

Disadvantages:
-Cost a special blood collection set
-Expensive equipment (refrigerated centrifuge)
Leucocyte-Depleted (Filtered) Red cells
or Whole Blood

Red cell suspension or concentrate containing < 5 x 106

white cells per pack

Preparation – filtration through a leucocyte-depleting filter

Leucocyte depletion removes the risk of transmission of

cytomegalovirus (CMV)
Indications
– Minimizes white cell immunization in
patients receiving repeated transfusion
– Reduces risk of CMV transmission
– Patients who have experienced two or
more previous febrile reactions to red cell
transfusion

Contraindications
– Will not prevent graft-vs-host disease
 Advantages:
-Decreases development of immunity to
white cells
-Decreased transfusion reaction
-Decreases chance of transmitting viral
infection eg; CMV

Disadvantages:
-Special instrument & blood pack needed
-Skilled & trained operator needed
 Buffy Coat Depleted Red Cells

-White cells & platelets are removed by

controlled centrifugation
Advantages:
-Red cells & only about 10% of the
white cells remains in concentrate
-Use to prepare platelets concentrates
Disadvantages
-Expensive procedure
-More skilled manpower needed
 Platelet Concentrates
Single donor unit in a volume of 50–60 ml of
plasma should contain:
– At least 55 x 109 platelets
– <1.2 x 109 red cells
– <0.12 x 109 leucocytes

Single donor unit : platelets prepared from one

donation

Pooled unit : platelets prepared from 4 to 6 donor

units ‘pooled’ into one pack to contain an adult
dose of at least 240 x 109 platelets

Bacterial contamination affects about 1% of

pooled units
 Indications

Treatment of bleeding due to:

Thrombocytopenia
Platelet function defects
Prevention of bleeding due to
thrombocytopenia, such as in bone marrow
failure
Contraindications

– Not generally indicated for prophylaxis of

bleeding in surgical patients, unless known
to have significant pre-operative platelet
deficiency

– Not indicated in:

ITP
TTP
DIC
Thrombocytopenia associated with
septicemia, until treatment has
commenced or in cases of
hypersplenism
Dosage
– 1 unit of platelet concentrate/10 kg body
weight : in a 60 or 70 kg adult, 4–6 single
donor units containing at least 240 x 109
platelets should raise the platelet count by
20–40 x 109/L

– Increment will be less if there is:

Splenomegaly
DIC
Septicemia

Contd.
Administration

-After pooling, platelet concentrates should be

infused as
soon as possible generally within 4 hours

– Must not be refrigerated before infusion as this

reduces platelet function

– 4–6 units of platelet concentrates should be

infused through a fresh standard blood
administration set

– Special platelet infusion sets are not required

– Platelet concentrates should be
infused over about 30 minutes

– Platelet concentrates prepared from

Rh D positive donors should not be
given to a Rh D negative potential
child-bearing female

– Platelet concentrates that are ABO

compatible should be given
whenever possible
Complications

– Febrile Non-hemolytic Reactions

– Allergic Urticarial Reactions
– Pooling increases transmission of infection
FRESH FROZEN PLASMA
 Fresh Frozen Plasma
Pack containing the plasma separated from one
whole blood donation within 6 hours of collection and
then rapidly frozen to –25°C or colder

Contains normal plasma levels of stable clotting

factors, albumin and immunoglobulin
Factor VIII level at least 70% of normal fresh plasma
level

Usual volume of pack is 200–300 ml

Smaller volume packs may be available for children

Very low risk of infection if treated with methylene

blue/ultraviolet light inactivation
Indications

– Replacement of multiple coagulation factor

deficiencies, e.g: -

Liver disease

Warfarin overdose

Depletion of coagulation factors in pts

receiving large volume transfusions

DIC

TTP
Dosage – Initial dose of 15 ml/kg

Administration
-Must normally be ABO compatible to avoid risk of
hemolysis in recipient
– No cross matching needed
– Before use, should be thawed in water which is
between 30°C and 37°C.
– Higher temperatures will destroy clotting factors and
proteins
– Infuse using a standard blood infusion set as soon
as possible after thawing
– Labile coagulation factors rapidly degrade; use
within 6 hours of thawing
– Cant be refrozen for further storage
Cryoprecipitate
 Cryoprecipitate

Prepared from FFP by collecting the

precipitate formed during controlled thawing
and re suspending it in 10–20 ml plasma

Contains about half of the Factor VIII and

fibrinogen in the donated whole blood: e.g.
Factor VIII: 80–100 I.U./pack; fibrinogen:
150–300 mg/pack

Usually supplied as a single donor pack or a

pack of 6 or more single donor units
 Indications

– As an alternative to Factor VIII

concentrate in the treatment of inherited
deficiencies of:

Von Willebrand Factor (von

Willebrand’s disease)

Factor VIII (haemophilia A)

Factor XIII

As a source of fibrinogen in acquired

coagulopathies: e.g. (DIC)
 Factor VIII Concentrate
Partially purified Factor VIII prepared from large
pools of donor plasma
Vials of freeze-dried protein usually about 250 i.u.
of Factor VIII

Indications
– Treatment of hemophilia A
– Treatment of von Willebrand’s disease

Factor VIII prepared in vitro using recombinant

DNA methods is commercially available
 Human Albumin Solutions
Prepared by fractionation of large pools of donated
human plasma
Preparations
– Albumin 5%: contains 50 mg/ml of albumin
– Albumin 20%: contains 200 mg/ml of albumin
– Albumin 25%: contains 250 mg/ml of albumin
– Stable plasma protein solution (SPPS) and plasma
protein fraction (PPF): similar albumin content to
albumin 5%
Indications
– Replacement fluid in therapeutic plasma exchange
Contraindications - Not for use as IV nutrition
 Volume of Blood Products
Blood product Volume
Whole blood (CPDA-1) 350 ml
Whole blood for component 450 ml
separation
Packed red blood cells (CPD) 150-200 ml
Packed red blood cells (SAGM) 200-250 ml
Fresh frozen plasma 100-150 ml
Cryo poor plasma 100-150 ml
Platelet rich plasma 100-150 ml
Platelet concentrate 50-70 ml
Cryoprecipitate 15-20 ml
Buffy coat 50-70 ml
 Component Storage
Blood & blood products Storage Temp. Duration

Whole blood (CPDA-1) 2-60C 35 days

Packed red blood cells (CPD) 2-60C 28 days
Packed red blood cells (CPDA- 2-60C 35 days
1)
Washed red blood cells 2-60C 24 hrs
Packed red blood cells 2-60C 42 days
(SAGM)
Fresh frozen plasma -200C 3-6 mths
Fresh frozen plasma -300C 6-12 mths
Cryo poor plasma -300C or less 6-12 mths
Platelet concentrate 22-240C 3 days
Cryoprecipitate -300C 6-12 mths
Buffy coat 220C 4-6 hrs
 Transfusion Reactions
Acute complications of transfusion
Category 1: Mild reactions
Mild hypersensitivity: allergic, urticarial reactions
Category 2: Moderately severe reactions
Moderate–severe hypersensitivity (severe urticarial reactions)
Febrile non-hemolytic reactions:
— Antibodies to white cells, platelets
— Antibodies to proteins, including IgA
Possible bacterial contamination (early signs)
Pyrogens
Category 3: Life-threatening reactions
Acute intravascular hemolysis
Bacterial contamination and septic shock
Fluid overload
Anaphylactic reactions
Transfusion-associated Acute lung injury (TRALI)
Delayed complications of transfusion
Transfusion-transmitted infections :
HIV-1 and HIV-2
HTLV-I and II
Viral hepatitis B and C
Syphilis
Chagas disease
Malaria
Cytomegalovirus
Other rare infections: e.g. human parvovirus B19 and
hepatitis A
Other delayed complications of transfusion :
Delayed hemolytic reaction
Post-transfusion Purpura
Graft-vs-host disease
Iron overload
 Management of Transfusion Reactions
Category Signs Symptoms
Category 1: Localized cutaneous Pruritus (itching)
Mild reactions reactions: Urticaria, Rash
Category 2: Flushing Anxiety
Moderately Urticaria Pruritus (itching)
severe Rigors Palpitations
reactions Fever Mild dyspnoea
Restlessness Headache
Tachycardia
Category 3: Rigors Anxiety
Life- Fever Chest pain
threatening Restlessness Pain near infusion site
reactions Hypotension (fall of ≥20% in Respiratory
SBP) distress/SOB
Tachycardia (rise of ≥20% in HR) Loin/back pain
Haemoglobinuria (red urine) Headache
Unexplained bleeding (DIC) Dyspnoea
CATEGORY 1: MILD
1.Slow the transfusion

2.Administer antihistamine IM (e.g.

chlorpheniramine 0.1 mg/kg or
equivalent).

3.If no clinical improvement within 30

minutes or if signs and symptoms
worsen, treat as Category 2.
 CATEGORY 2: MODERATELY SEVERE
1. Stop the transfusion. Replace the infusion set and keep
IV line open with normal saline

2. Notify the doctor and the blood bank immediately.

3. Send blood unit with infusion set, freshly collected urine

and new blood samples (1 clotted and 1 anticoagulated)
from vein opposite infusion site to blood bank and
laboratory for investigations.

4. Administer antihistamine IM (e.g. chlorpheniramine 0.1

mg/kg or equivalent) and oral or rectal antipyretic (e.g.
paracetamol 10 mg/kg: 500 mg – 1 g in adults). Avoid
aspirin.
5. Give IV corticosteroids and bronchodilators if there are
anaphylactoid features (e.g. bronchospasm, stridor).

6. Collect urine for next 24 hours for evidence of

hemolysis and send to laboratory.

7. If clinical improvement, restart transfusion slowly with

new blood unit and observe carefully.

8. If no clinical improvement within 15 minutes or if S/S

worsen, treat as Category 3.
 CATEGORY 3: LIFE-THREATENING
1. Stop the transfusion. Replace the infusion set and keep
IV line open
2. Infuse NS (initially 20–30 ml/kg) to maintain SBP. If
hypotensive, give over 5 minutes and elevate patient’s
legs.
3. Maintain airway and give high flow oxygen by mask.
4. Give adrenaline (as 1:1000 solution) 0.01 mg/kg body
weight by slow intramuscular injection.
5. Give IV corticosteroids and bronchodilators if there are
anaphylactoid features (e.g. bronchospasm, stridor).
6. Give diuretic: e.g. frusemide 1 mg/kg IV or equivalent.
7. Notify the doctor and the blood bank immediately.
8. Send blood unit with infusion set, fresh urine sample and
new blood samples (1 clotted and 1 anticoagulated) from
vein opposite infusion site to blood bank and laboratory
for investigations.

9. Check a fresh urine specimen visually for signs of

haemoglobinuria (red or pink urine)

10. Start a 24-hour urine collection and I/O charting. Maintain

fluid balance.

11.Assess for bleeding from puncture sites or wounds. If

there is evidence of DIC, give platelets (adult: 5–6 units)
and either cryoprecipitate (adult: 12 units) or FFP (adult:
3 units). Use virally-inactivated plasma coagulation
products, wherever possible.
12. Reassess. If hypotensive:
Give further saline 20–30 ml/kg over 5 minutes
Give ionotrope, if available

13. If urine output falling or laboratory evidence of acute

renal failure :
Maintain fluid balance accurately
Give further frusemide
Consider dopamine infusion, if available
Seek expert help: the patient may need renal dialysis

14. If bacteremia is suspected, start broad-spectrum

antibiotics IV, to cover pseudomonas and gram
positives.
 Massive Blood Transfusion
Defined as the replacement of blood loss
equivalent to or greater than the patient’s total
blood volume with stored blood in < 24 hours
(70 ml/kg in adults, 80–90 ml/kg in children or
infants)

Complications
– Acidosis
– Hyperkalemia
– Citrate toxicity and hypocalcaemia
– Depletion of fibrinogen and coagulation factors
– Depletion of platelets
– DIC
– Hypothermia
– Reduced 2,3 diphosphoglycerate (2,3 DPG)
– Microaggregates
Autologous Blood Transfusion

(1)Preoperative Blood Deposit (PAD)

(2)Acute Normovolaemic Haemodilution

(3)Blood salvage
– Gauze filtration
– Simple suction collection systems
– Automated suction collection systems
– Modified drain
 Artificial Oxygen Carrier

(1)Hemoglobin-based Oxygen Carriers (HBOC)

(2)Products based on Perfluorocarbons (PF)

Advantage
– Can be sterilized
– Do not have any blood group
– Could be stored for a long time
Disadvantage
-Very short half life=around 24 hrs
-High flow O2 required
 Other Methods to Reduce Red Blood Cell
Transfusion

1.Recombinant Erythropoietin

2.Fibrin Glue:
1st Syringe-calcium & human thrombin
2nd Syringe- human fibrinogen
Injected simultaneously over the minor cutaneous bleeding
sitesfibrin clot(glue)hemostasis

3.Tranexamic acid
Transfusions of blood products
can save lives, but are not without
risks or costs

Safe blood is a scarce and

valuable resource that is
expensive to collect, process and
administer
Limiting Transfusion to patients
whose chance of survival or quality of life is
improved with blood will help to decrease
the high demand for blood products and
will reduce unnecessary exposure of
patients to the risks of transfusion.
 Maximum Blood Ordering Schedule

Elective Surgical Procedure

Agreement between Surgeons,
Anaesthesiologists & Haematologists

Procedure Blood Order

Tumor of palate G&S
Laryngectomy 2 units
RND 2 units
Commando 4 units
Getting The Right Blood to the Right
Patient at the Right Time
Nutrition in Surgery
30% – 50% of hospitalized patients – malnourished

Malnutrition a/w increased morbidity and mortality

Most healthy patients can tolerate 7 days of starvation (with

adequate glucose and fluid replacement)

Preoperative nutritional support can significantly reduce

perioperative morbidity and mortality in patients with severe
malnutrition
Protein Requirements
– Avg. healthy adult : approximately 0.8 g/kg
body weight
– Physiologically stressed : 1.2 – 2.5 g/kg/day
– protein intake of 6.25 g equivalent to 1 g of
nitrogen
– 15% of normal energy expenditure
– 1 gm of protein = 4 kcal
Carbohydrate Requirements
– 40-60 % of normal energy expenditure
– 400 kcal of CHO/day minimizes protein
breakdown, particularly after adaptation to
starvation
– 1 gm of Enteral CHO = 4 kcal &
1gm of Parenteral CHO = 3.4 kcal/g

Lipid Requirements :
– 25% to 45% of normal energy expenditure
– 1 gm of lipid = 9 kcal
Daily Vitamins Requirements
Daily Trace elements Requirements
The Metabolic Response to Critical Illness
 Nutritional Assessment
History
– Weight fluctuation or a change in dietary habits
– Recent weight loss
5% in the last month
10% over 6 months
Current body weight of 80% to 85% (or less)
of ideal body weight
Physical Examination
– Muscle wasting (especially thenar, temporal &
gluteal muscles)
– Loose or flabby skin
– Peripheral edema and/or ascites
– Skin rash, pallor, glossitis, gingival lesions, hair
changes, hepatomegaly, neuropathy, and
dementia
Anthropometric measurements
– Triceps skinfold thickness
– Mid-upper arm circumference
– BMI
Laboratory tests
– Serum albumin < 3.5 g/dL
– Half-life is 14 to 20 days.
– Serum Prealbumin (indicator of acute changes) :
10 to 17 mg/dL – mild depletion
5 to 10 mg/dL – moderate depletion
< 5 mg/dL – severe depletion
half-life is 2 to 3 days.
– Serum transferrin < 200 mg/dL
half-life is 8 to 10 days.
Immune Function
– Delayed-type hypersensitivity (anergy
to common skin antigens)
– Total lymphocyte count (TLC)
1,500 to 1,800/mm3 – mild
depletion
900 to 1,500/mm3 – moderate
depletion
< 900/mm3 – severe depletion
 Nutritional Indices
Body Mass Index (BMI)
BMI = weight (kg)/[height (m)]2
BMI: Normal 18.5–24.9
Overweight 25–29.9
Obese 30–40
Morbid Obesity >40
Prognostic Nutritional Index (PNI)
PNI = 158 - 16.6 (Alb) - 0.78 (TSF) - 0.2 (TFN) - 5.8 (DH)
DH: >5 mm induration = 2; 1–5 mm induration = 1; anergy
=0
PNI: >50% = high risk for complications
40%–49% = intermediate risk
<40% = low risk

Alb, albumin (g/dL); DH, delayed cutaneous hypersensitivity; TFN, transferrin (mg/dL); TSF,
triceps skinfold thickness (mm); UUN, 24-hr urine urea nitrogen excretion (g)
Estimation of Caloric Requirements

TEE = BEE + EEA + EET

TEE : Total Daily Energy Expenditure

BEE : Basal Energy Expenditure
EEA : Energy Expenditure of Activity (25 %)
EET : Energy Expenditure of Thermogenesis (10%)
 Calculating BEE :
Harris - Benedict Equation
Men:
BEE=
66.5 + [13.75 x weight(kg)] + [5 x height(cm)] –[6.78 x
age(yrs)]
Women:
BEE=
65.5 + [9.56 x weight(kg)] + [1.85 x height(cm)] –
[4.68xage(yrs)]
– 25 kCal/kg – 35kCal/kg
TEE = BEE x specific stress factors
Starvation 0.80–1.00
Elective operation 1.00–1.10
Adult respiratory distress syndrome or 1.30–1.35
sepsis
 Caloric requirements may be 150% more than the basal
energy expenditure in pts undergoing major surgery

Phases following Surgery

(1)Phase I: Catabolic phase lasting 3-7 days, increased
protein consumption
(2)Phase II: Protein consumption & production are equal
(3)Phase III: Anabolic phase, protein production exceeds
consumption
(4)Phase IV: Restoration of lipid stores
 Pre-operative Preparation
In patients with severe nutritional risk, start nutrition
supplement 2 wks prior to surgery

Solid foods allowed up to 6 hrs

Liquid foods allowed up to 4hrs

Clear liquid allowed up to 2 hrs

Preoperative carbohydrate loading, the night before and

2 hr before surgery recommended
 Access- Possibilities for Nutrition

Nasogastric tube

Whole food
PP TPN by mouth
N
Intravenous Alimentation

Gastrostomy tube
Nasoduodenal tube

Jejunostomy tube

Nasojejunal tube
 Enteral Nutrition
Preferred over the Parenteral route

Simple, physiologic, relatively inexpensive, and well

tolerated by most patients

Maintains the GI tract cytoarchitecture and mucosal integrity

(via trophic effects), absorptive function, and normal
microbial flora

Indications : patients who have a functional GI tract but are

unable to sustain an adequate oral diet

Contraindications : intestinal obstruction, ileus, GI

bleeding, severe diarrhea, vomiting, enterocolitis, or a high-
output enterocutaneous fistula
 Enteral Feeding Products

– Standard Solutions – 1 kcal/ml

- Calorically concentrated solutions – >1 kcal/ml
-Dietary Formulations
Nutritionally complete formulas (standard
enteral diets)
Chemically defined formulas (elemental
diets)
Modular formulations (in specific clinical
situations)
 Enteral Feeding Protocols

Bolus Feedings
– Reserved for patients with nasogastric or gastrostomy
feeding tubes
– Administered by gravity
– Begin at 50 to 100 mL every 4 hours, and increased in
50-mL increments until goal intake reached (usually 240
to 360 mL every 4 hours)
– Tracheobronchial aspiration is a potentially serious
complication
 Continuous Infusion

– Administered by a pump

– Generally required for nasojejunal, gastrojejunal,

or jejunal tubes

– Initiated at 20 mL/hour and increased in 10 to

20mL/hour increments every 4 to 6 hours until
the desired goal reached

– Can be infused over 8 to 12 hours at night

Conversion to Oral Feeding
– Resumed gradually
– Enteral Feeding modified as
Providing fewer feedings
Holding daytime feedings
Decreasing the volume of feedings
When oral intake provides approximately 75% of
the required calories, tube feedings can be
stopped
Administration of medications
– Many oral medications can be administered
– Not suitable for administration through a feeding
tube include
Enteric-coated medications
Drugs in gelatinous capsules
Medications that are designed for sublingual
use
Most sustained-release medications
Complications of Enteral Nutrition

Metabolic Complications

Clogging (prevented by careful routine flushing of the

feeding tube)

Tracheobronchial Aspiration

High Gastric Residuals

Diarrhea
 Parenteral Nutrition
Indicated for patients
– Who cannot meet their needs through oral intake
– Enteral feeding is contraindicated or not tolerated
Peripheral parenteral nutrition (PPN)
– Osmolarity of PPN solutions limited to 1,000 mOsm
(approximately 12% dextrose solution) to avoid phlebitis
– Unacceptably large volumes (>2,500 ml) necessary
– Temporary nutritional supplementation
Total parenteral nutrition (TPN)
– Complete nutritional support
– Central venous catheter required
– Replaced for unexplained fever or bacteremia
TPN Solutions

– 3-in-1 admixture
Protein, as amino acids (10%; 4 kcal/g)
Carbohydrate, as dextrose (70%; 3.4 kcal/g)
Fat, as a lipid emulsion of soybean or safflower oil
(20%; 9 kcal/g)
– Alternatively, the lipid emulsion can be administered
as a separate intravenous infusion
– Standard preparations available
Additives
– Electrolytes : sodium, potassium, chloride, acetate,
calcium, magnesium, phosphate adjusted daily
– Number of cations and anions must balance
– Calcium : Phosphate ratio must be monitored to
prevent salt precipitation

Medications
– Albumin, H2-receptor antagonists, heparin, iron,
dextran, insulin, and Metoclopramide
– Regular Insulin after adjusting dose
Other additives
– Trace elements added daily eg. commercially
prepared mixture
– Multivitamins generally added daily using a
commercially prepared mixture (e.g., 10 mL MVI-12)
– Vitamin K not included in most multivitamin mixtures
and must be added separately (10 mg once a week)
– Vitamins A and C and zinc essential for proper wound
healing.
Routine Physiologic and Laboratory Monitoring
– On a scheduled basis

– More frequently whose postoperative course has not

stabilized

– Vital signs and serum glucose every 6 hours

– Weight, serum electrolytes, and blood urea nitrogen

daily

– Triglycerides, CBC, PT, liver enzymes, and bilirubin

weekly
 Administration of TPN
Introduction of TPN
– Gradual. e.g. approximately 1,000 kcal in 1st day
– Caloric goal achieved over 1 to 2 days
TPN solutions
– Continuous infusion
Cyclic administration of TPN solutions
– Useful for selected patients
Discontinuation of TPN
– Satisfies 75% of his or her caloric and protein needs
with oral intake or enteral feeding
 Complications Associated with TPN
Catheter-Related Complications
Metabolic Complications – Na overload, CHF,
electrolyte imbalance, hyperglycemia and
hyperosmolarity
(hyperglycemia may be the first indication of occult
infection)
Refeeding Syndrome – in severely malnourished
patient
Hepatic Dysfunction – steatosis, raised AST,
ALT, ALP & Bil. finally cirrhosis
Cholecystitis – Acalculous type d/t Cholestasis
 Adverse Effects and Risks

Parenteral Nutrition Early Enteral Nutrition

Procedure-related
Overfeeding complications
Hyperglycemia High gastric residuals
Infectious Complications Bacterial colonization of
the stomach
Gut Mucosal Atrophy?
Aspiration Pneumonia
Bacterial translocation?
Water & Electrolyte Balance
 Body Fluid Compartments
Na+,
Cl-,
HCO3-

Male – 60 %
Female – 50
% K+, Mg+,
PO4-,
Proteins
 Principles of Fluid Management
2,000-2,500 ml daily requirement
Daily water losses
– 1,000-1,500 ml in urine (minimum UO to excrete
catabolic end products of metabolism – 400 ml)
– 250 ml in stool
– 750 ml insensible loss (increase with hypermetabolism,
fever & hyperventilation)
Maintenance
– Maintain urine output of 0.5 to 1 ml/kg/hour in
adult & 1 to 2 ml/kg/hr in children
eg. in adult UO at least 30 ml/hr

– Estimation of Maintenance Fluid

First 10 kg – 100 ml/kg/day
Second 10 kg – 50 ml/kg/day
Then for subsequent kg – 20 ml/kg/day
Na+ - 1 to 2 mmol/kg/day
K+ - 0.5 to 1 mmol/kg/day

Maintenance Fluid formula:-

4 ml/kg/h for the first 10 kg
2 ml/kg/h for the next 10 kg
1 ml/kg/h for every kg over 20 kg

Therefore a 70 kg patient using the calculation:

40+20+50=110
will require 110 ml/h

Preoperative management
 Estimation of Intraoperative
Intraoperative Fluid Loss and Guide for
fluid management
Replacement
Replacement
– duration of the case
Preoperative deficit Maintenance IVF × hr NPO, plus
– hemorrhage preexisting deficit related to
– third-space lossesdisease state
Maintenance fluids Maintenance IVF × duration of
case
Third-space and 1–3 mL/kg/hr for minor procedure
insensible losses (small incision)
3–7 mL/kg/hr for moderate
procedure (medium incision)
9–11 mL/kg/hr for extensive
procedure (large incision)
Blood loss 1 mL blood or colloid per 1 mL
blood loss, or 3 mL crystalloid per
1 mL blood loss
 Postoperative Fluid Management

– Sequestration of ECF can continue for > 12

hours after operation
– Maintain Urine Output
– GI losses from NG or Gastrostomy tube suction
Replaced with an equal volume of Crystalloid
– Mobilization of Peri-operative third-space fluid
losses typically begins 2 to 3 days after
operation
 Commonly Used Parenteral Solutions
IV Osmolality [Glucose] [Na+] [Cl-] [HCO3-]
solution (mOsm/L) (g/L) (mEq/L) (mEq/L) equivalents
(mEq/L)
D 5W 278 50 0 0 0
D10W 556 100 0 0 0
D50W 2778 500 0 0 0
0.225% 77 0 38.5 38.5 0
NaCl
0.45% NaCl 154 0 77 77 0

0.9% NaCl 308 0 154 154 0

3% NaCl 1026 0 513 513 0
Lactated* 274 0 130 109 28
Ringer's

*Also contains 4 mEq/l K+, 1.5 mEq/l Ca++, and 28 mEq/l lactate.
IV solution Osmolality [Glucose] [Na+] [Cl-] HCO3-
(mOsm/L) (g/L) (mEq/L) (mEq/L) equivalent
s (mEq/L)

6% 310 0 154 154 0

hetastarch

10% 300 50/0* 0/154* 0/154* 0

dextran-40

6% 300 50/0* 0/154* 0/154* 0

dextran-70

5% albumin$ 330 0 130–160 130–160 0

25% 330 0 130–160 130–160 0

albumin$

*
Dextran solutions available in 5% dextrose or 0.9% NaCl
$
< 2.5 mmol/L K+
 Composition of Gastrointestinal Secretions

Volume Na+ HCO3-

Source K (mmol/L) Cl (mmol/L)
+ -
(mL/24 hr) (mmol/L) (mmol/L)
Salivary 1,500 10 26 10 30
(500–2,000) (2–10) (20–30) (8–18)
Stomach 1,500 60 10 130 0
(100–4,000) (9–116) (0–32) (8–154)
Duodenum (100–2,000) 140 5 80 0

Ileum 3,000 140 5 104 30

(80–150) (2–8) (43–137)
Colon (100–9,000) 60 30 40 0

Pancreas (100–800) 140 5 75 115

(113–185) (3–7) (54–95)
Bile (50–800) 145 5 100 35
(131–164) (312) (89–180)
 Sodium
Serum conc. – 135 to 145 mmol/L
Potential sources of significant Na+ loss – sweat, urine,
and GI secretions
Posm – 290 to 310 mOsm/L

• Hyponatremia – [Na+] <135 mEq/L

• Hypernatremia – [Na+] >145 mEq/L
Hyponatremia
C/F :

– Predominantly Neurologic
– Lethargy, confusion, nausea, vomiting, seizures, and
coma
– Chronic hyponatremia often asymptomatic until serum
Na+ concentration < 110 to 120 mEq/L
Rx :

–Correct the underlying disorder

–Fluid Restriction (1,000 mL/day)
–Hypovolemic hyponatremia – administer 0.9% NaCl to
correct volume deficits and replace ongoing losses.
Rapid correction should be avoided
Hypernatremia
C/F :
– Primarily Neurologic
– Lethargy, weakness, & irritability
– Fasciculations, seizures, coma, & irreversible
neurologic damage
Rx :
– Water deficit (L) = 0.60 × total body weight (kg) ×
[(serum Na+ in mmol/L/140) – 1]
– Gradual correction
– Treat specific cause
 Potassium

Serum conc. – 3.5 to 5 mmol/L

90 % of K+ excreted renally, remainder in stools

Hypokalemia – [K+] <3.5 mEq/L

Hyperkalemia – [K+] >5.0 mEq/L
 Hypokalemia

Causes :
– Inadequate intake

– GI losses (e.g., diarrhea, persistent vomiting,

Nasogastric suctioning)

– Renal losses (e.g., diuretics, fluid mobilization)

– Cutaneous losses (e.g., burns)

– Acute intracellular K+ uptake (insulin excess, metabolic

alkalosis, hypothermia, theophylline toxicity)

– Refeeding Syndrome – in malnourished patient after

initiation of TPN
C/F :
– Mild hypokalemia [K+ >3 mmol/L] generally
asymptomatic
– Severe K+ deficiency [K+ <3 mmol/L] – primarily
cardiovascular (ECG manifestations – ectopy, T-wave
depression, and prominent U waves)
– Fatigue, myalgias, and muscular weakness or cramps
of the lower extremities
– Constipation ,paralytic ileus
– Complete paralysis, hypoventilation, or
rhabdomyolysis
Rx :
– Oral replacement (40 to 100 mmol)
– Parenteral therapy (not exceeding 40 mmol/L & not
exceeding 20 mmol/hour)
 Hyperkalemia
Causes :
– Pseudohyperkalemia
– Abnormal redistribution of K+
Insulin deficiency
β-adrenergic receptor blockade
Acute acidosis
Rhabdomyolysis
Cell lysis (after chemotherapy)
Digitalis intoxication
Reperfusion of ischemic limbs
Succinylcholine
C/F :
– Mild Hyperkalemia [K+ = 5 to 6 mmol/L] generally
asymptomatic
– Severe Hyperkalemia [K+ >6.5 mmol/L] – arrhythmia
(ECG abnormalities : symmetric peaking of T waves,
reduced P-wave voltage, and widening of the QRS
complex, ultimately sinusoidal ECG pattern)
– Weakness, flaccid paralysis & hypoventilation
Rx :
– Mild Hyperkalemia :
Reduction of daily K+ intake
Loop diuretic
Withdrawal of drugs impairing K+ homeostasis
-Severe Hyperkalemia
Temporizing Measures
– Calcium gluconate
– Insulin with dextrose
– Inhaled β2-agonists
– NaHCO3

Therapeutic Measures
– Sodium polystyrene sulfonate (Kayexalate), a
Na+-K+ exchange resin
– Hydration in combination with a loop diuretic
– Dialysis
 Calcium

Serum Calcium – 2.23 to 2.57 mmol/L (8.9 to 10.3

mg/dL), exists in three forms
– Ionized (45%)
– Protein bound (40%)
– Complexed to freely diffusible compounds (15%)
Free ionized Ca2+ (4.6 to 5.1 mg/dL) is physiologically
active
Calcium Homeostasis – PTH, Vit. D & Calcitonin
 Hypocalcemia
Serum Calcium <8.4 mg/dL with a normal serum albumin
or an ionized calcium <4.2 mg/dL

Causes :
– Calcium sequestration (acute pancreatitis,
rhabdomyolysis, or rapid administration of blood)
– Vitamin D deficiency
– Total thyroidectomy
– Parathyroidectomy
– Acute alkalemia
C/F :
– Perioral Numbness and Tingling
– Tetany
ECG - QT-interval prolongation and ventricular
arrhythmias

Rx :
– Parenteral therapy (overt tetany, laryngeal spasm, or
seizures)
– Oral therapy (Ca & vit. D)
 Hypercalcemia
Serum Calcium >10.3 mg/dl with a normal serum albumin
or an ionized calcium >5.2 mg/dl

Causes :
– Malignancy
– Hyperparathyroidism
– Hyperthyroidism
– Vitamin D intoxication
– Immobilization
– Long-term total parenteral nutrition
– Thiazide diuretics
– Granulomatous disease
C/F :
– Mild Hypercalcemia (Calcium <12 mg/dl) is generally
asymptomatic
– Altered mental status, diffuse weakness, dehydration,
adynamic ileus, nausea, vomiting, and severe
constipation
– Hypercalcemia of hyperparathyroidism –associated
infrequently with classic parathyroid bone disease and
nephrolithiasis.

ECG - QT-interval shortening and arrhythmias

Rx :
– NaCl 0.9% and loop diuretics may
– Salmon calcitonin
– Pamidronate disodium
Cooperation
is the Key
to Success!!!

Thank you