Scene 1

NUTRITION  MANAGEMENT  FOR  POST    OPERATION   OF   WOUND   DEBRIDEMENT    OF   FOURNIER’S   GANGRENE

PRESENTED   BY   : WAN  NURAISHAH  BINTI  WAN   HAIRIL B.Sc.   of   Dietetics   with   Honours    Universiti   Kebangsaan   Malaysia

INTERNATIONAL   VIRTUAL   UNDEGRADUATES   SYMPOSIUM   ON   CLINICAL   DIETETICS   2021

Scene 2

Nutrition  Focused    Physical   Findings

Scene 3

Scene 4

Deterioration   of   nutritional   status    Induce   catabolism

POST   OPERATIVE    NUTRITION    MANAGEMENT

GOALS Improve  nutritional  status    Improve   functional   recovery    including   quality   of   life

ESPEN   guideline:   Clinical   nutrition   in   surgery

Scene 5

M o r b i d i ty   Mortality Length   of   hospital   stay

(ESPEN   guideline:   Clinical   nutrition   in   surgery,    Marik   et   al.,   2010,   Bedi   et   al.,   2010)

IMMUNE   MODULATING   FORMULA Protect   and   stimulate   the   immune    system Decreasing  post-operative    infections  in  surgery  patients    Shorter   length   of   hospital   stay

Scene 6

(Morpurgo   et   al.,   2002,   Clayton   et   al.,   1990)

An  acute  necrotic  infection  of  the  scrotum;  penis;  or  perineum  which    commonly   affects   men Sign   &   Symptoms: Sudden   scrotum  pain and   redness    Local  death   of  soft   tissue Tissue   sloughing

Scene 7

Surgery/   wound   debridement (Thwaini   et   al.,   2006,   Taken   et   al.,   2016,   Rosyid,   2017)

Scene 8

Post   operation   day   4   secondary   of    suturing   right   medial   thigh   and   right    inguinal  +  SSG  of  testes (donor  from  left    anterior   thigh)

Surgical   history: P o st 	o p e r a ti o n 	 d a y 	 3 9 	 E U A 	 + 	 W D 	o f   Fournier   gangrene Post   operation   day   24   WD   of   perineum,    lower   abdominal   thigh

55   years   old   /   Chinese   /   Male. Admitted  on   2   March  2021  with   presented   of   scrotal   swelling   and   pain   x4/7

REASON   OF   REFERRAL: HIGH   PROTEIN   DIET   FOR   POST   OPERATION

Newly   Diagnosis: T2DM   (HbA1C:   10.8%) Current   Diagnosis: Fournier   gangrene Necrotizing   fasciitis   involving    perineum,  lower   abdominal   thigh

Family   history: Both  parents  have  DM Social  history:    Married  and  works as    salesman

Scene 9

Scene 10

Estimated height  =  162cm    Estimated weight  =  50kg   BMI  =  19  kg/m2  (  Normal    UBW  =   70   kg   (a   month  ago)

2 8 %   o f   w e i g h t   l o s s   i n 	 1   m on t h   indicates   severe   weight   loss

RBC   :  3.8  g/l   ↓   Hb   :   12.1   g/dl ↓ Platelet   :  147  g/l   ↓

Scene 11

Scene 12

ADL   dependent   and   bed-    ridden  since  the  first  day    of   admission   in   March    2021

He   was   previously   fully   ADL independent

MUSCLE   AND   FAT   WASTING No   muscle   and   fat  wasting   noted

Scene 13

FOOD   AND   NUTRITION-    RELATED   HISTORY

Scene 14

Good   CHO  distribution   throughout  the   day BF=   2exc/   MT=   1exc/   L=   4exc/   AT=   1exc/   D=3exc/   S=2exc

Scene 15

Inadequate   protein   intake   (NI-5.6.1) related   to physiological  cause   increasing   needs   of   protein optimization as  evidenced   by current  estimated  intake  of  protein  only  achieve    63%   of   requirement

Scene 16

Scene 17

To   achieve   optimal   energy    and	 protein	 at  least 75%    requirement  through  orals    and  ONS

02  To  promote  wound  healing    of   post   operation

To  maintain  the    nutritional   status    after   surgery

To  reduce  the    infectious    c om pli c a t i o n s

To  decrease  the    length  of  hospital    stay

To  aim  for  near  to    normal	blood   glucose    level   (<10   mmol/l)

Scene 18

Method  I:    Mifflin   St-Jeor    Equations    (1990)

=   9 . 9 9   ( 5 0 )   +   6 . 2 5   ( 1 6 2 )   –   4 . 9 2   ( 55 )   +   5 =   1 2 4 6 . 4   k c a l

Energy   requirement =   1 2 4 6 . 4   k c a l   x   1 . 0   A F   x   1 . 2   S F =   1 4 9 5 . 68   k c a l   ( ~ 1 5 00 k c a l )

Method  II:    Quick   method    (ESPEN   2017)

25-30   kcal/kg   BW   (for   post-surgery) =   2 5 - 3 0   k c a l / k g   x   5 0   k g =   1 2 5 0   -   1 5 0 0   k c a l / d a y

Estimated  energy    requirement   for   this    patient  is  1500  kcal    per   day.

A F   1 . 0   f o r   b e d   r e s t   S F   1 . 2   f o r   s u r g e r y   (Rosalinda   1996)

Scene 19

Based   on   ESPEN   2017   for   Guideline   Clinical   Nutrition   in   Surgery,   1.5   g   protein/kg   ideal   body   weight   was    recommended   for   post-surgery.

1 . 5   g / k g   I B W   ( f o r   p o s t - s u r g e r y ) =   1 . 5   g / k g   x   5 0   k g =   7 5   g / d a y

Estimated   protein   requirement   for   this   patient   is   1.5   g/kg   IBW/day   (75   g/day)

Scene 20

Based   on   MNT  for   Type   2   Diabetes   2013,   the   CHO   recommendation   is   between   45   to   60  %  of   TEI  per   day.

50%   x   1500   kcal =   7 5 0   k c a l =   1 87 . 5   g   ( 1 2 . 5 e x c )

Estimated   CHO   requirement   for   this   patient   is   187.5   g   (50   %   or   12.5exc)   per   day

Scene 21

Food   and/or   Nutrient   Delivery To   increase   the   frequency   of  ONS   as  regime  below: 2   ½  scoops  Neoumune  +   100  mL  water,  3x/day This   will   provides  270   kcal/day   (20%   of   EER),   16.5   g/day   (22%   of   protein    requirement)   and   11.25   g   CHO/serving Food   and/or   Nutrient   Delivery To   indent  2  boiled   egg  for   breakfast   in   ward

Scene 22

Scene 23

Scene 24

DIET   INTAKE   PROGRESS Nutrition Diagnosis    Previous   ND   resolved

Scene 25

Start   s/c   actrapid   6   unit  TDS   +   top   up   scale    Increase   s/c   insulatard   12   unit   ON

Scene 26

DIET   INTAKE   PROGRESS Nutrition   Diagnosis Inadequate  oral  intake  (NI-2.1)  related  to  limited  food acceptance due  to    unsupported  belief  as  evidenced  by  patient  only  achieved  66%  of  ER  and    55%  of   protein   requirement   which   are   inadequate.

Skip   2   meals   (AT   and    S)  because  concern    about  the  blood    glucose  level  will    increase

Scene 27

Scene 28

Nutrition   Counselling Reinforce   patient   to   have   at   least   5  meals   in   a   day   to   control   blood   glucose Reinforce	 patient	on	 stress	induced	 hyperglycemia	 that	 possibly	 happened	 after   post   operation   which   lead   to   high   blood   glucose   level Food   and/or   Nutrient   Delivery Introduce	patient	 to	specialized	 formula	 for	 diabetes	 mellitus,	 Resurge	 DM	 as   patient   concern   about   his   blood   glucose Suggest   patient   to   consume   1x   of  Neomune   and   2x   of   Resurge   DM   in   a   day   as    following  regime: 3   scoops  of   Neomune  +  150ml  water,  x1/day This   will   provide:  108kcal,  6.6g   protein/day,  13.5g CHO/serving 2   ½  scoops  of   Resurge   DM  +  150ml  water,  x2/day This   will   provide:   360kcal,   17.5g   protein/day,   16g   CHO/servings

Scene 29

Adequate   protein-energy   nutrition   is    therefore  crucial  to  support  recovery  and    reduce   mortality   rate To  encourage  wound  healing  in    diabetic   patients ,   the   amount,   timing,    and distribution  of  carbohydrate    consumed   during   the   day   must   be    optimized

Nutrition   therapy   helps	 to    obtain   adequate   nutrition   for    recovery  from   surgery    especially   in   protein   intake

Inadequate  oral  intake  for more    than   14   days   is   associated   with    a  higher  mortality  for  patient on    postoperative

Scene 30

Early  post   operative   nutrition    associated   with   significant  reductions    in   total   complications

Immunonutrition  specialized    nutrients  help  regulate  the    body’s  response  to  illness  and    injury

Help  optimize  immune  function    including   improving  defense    function   and   thus   resistance  to    infection ,   while   maintaining    tolerance

ONS can  be  initiated  after    surgery   since   it   prove  beneficial

Scene 31

Morpurgo,   E.,   &   Galandiuk,   S.   (2002).   Fournier's  gangrene.   Surg   Clin   North   Am,  82(6),   1213-1224.   doi:10.1016/s0039-    6109(02)00058-0 Clayton,   M.   D.,   Fowler,   J.   E.,   Jr.,   Sharifi,   R.,   &   Pearl,   R.   K.   (1990).   Causes,   presentation   and   survival  of   fifty-seven   patients   with    necrotizing  fasciitis  of   the   male  genitalia.  Surg   Gynecol   Obstet,   170(1),   49-55. Rosyid,   F.   N.   (2017).   Etiology,   pathophysiology,   diagnosis   and   management  of  diabetics’   foot  ulcer.  International   Journal  of    Research   in   Medical   Sciences,  5(10).  doi:10.18203/2320-6012.ijrms20174548 Shahar,   S.,   &   Pooy,   N.   S.   (2003).  Predictive   equations   for   estimation   of   stature   in   Malaysian   elderly   people.  Asia   Pac   J  Clin    Nutr,  12(1),  80-84. Taken,   K.,   Oncu,   M.   R.,   Ergun,   M.,   Eryilmaz,   R.,   Demir,   C.   Y.,   Demir,   M.,   &   Gunes,   M.   (2016).   Fournier's  gangrene:  Causes,    presentation  and   survival   of   sixty-five   patients.   Pakistan  journal   of   medical sciences,  32(3),  746-750.    doi:10.12669/pjms.323.9798 Thwaini,   A.,   Khan,   A.,  Malik,   A.,   Cherian,   J.,   Barua,   J.,   Shergill,   I.,   &   Mammen,   K.   (2006).   Fournier's  gangrene  and   its    emergency  management.  Postgraduate   medical  journal,   82(970),   516-519.   doi:10.1136/pgmj.2005.042069 W.H.O.   (2004).   Appropriate  Body   Mass   Index   for   Asian  Populations   and   Its   Implications   for  Policy   and   Intervention   Strategies.    The   Lancet,   363,   157-163.   doi:10.1007/s10120-011-0042-4 Marik  PE,   Zaloga   GP.   Immunonutrition   in   high-risk  surgical   patients:   a   systematic   review   and   analysis   of  the literature.  JPEN J    Parenter   Enteral  Nutr.  2010;34:378-386. Bedi NM   MS,  Burgess   AM,   Rawn   JD.   Use   of  an   immune   modulating  enteral  formula   in   post-operative   cardiac  surgery   patients    is associated   with   fewer   infectious complications   and   decreased   hospital  length   of   stay.   JPEN   J   Parenter  Enteral  Nutr. 2011;35(1):138.

PowerPoint Presentation

Scene 1 (0s)

Scene 2 (1m 11s)

Scene 3 (1m 33s)

Scene 4 (1m 55s)

Scene 5 (2m 25s)

Scene 6 (3m 11s)

Scene 7 (4m 15s)

Scene 8 (4m 53s)

Scene 9 (5m 41s)

Scene 10 (5m 58s)

Scene 11 (7m 23s)

Scene 12 (7m 30s)

Scene 13 (7m 50s)

Scene 14 (8m 0s)

Scene 15 (8m 37s)

Scene 16 (8m 52s)

Scene 17 (8m 58s)

Scene 18 (9m 25s)

Scene 19 (9m 59s)

Scene 20 (10m 23s)

Scene 21 (10m 42s)

Scene 22 (11m 5s)

Scene 23 (11m 12s)

Scene 24 (11m 22s)

Scene 25 (11m 35s)

Scene 26 (11m 58s)

Scene 27 (12m 44s)

Scene 28 (12m 52s)

Scene 29 (13m 28s)

Scene 30 (14m 7s)

Scene 31 (14m 37s)