Surgical nutrition

2.  Nutrix – to nurse
 Nutrire – to suckle
 (breast milk – best food for children up to 2
years old)
 Nourish – to provide with substances necessary
to sustain life and promote growth of living
organisms
 Process by which living organism assimilates
food and using it for growth and replacement
of tissues
 FOOD

3.  To meet increased energy requirements for
◦ Basal metabolic processes
◦ Maintenance of core temperature
◦ Tissue repair
 To provide adequate substrates for protein
synthesis in order to minimize protein
breakdown
 To reduce mortality and morbidity following
surgical stress and trauma

4.  (need of patient to sustain nutrition)
 Amount of heat necessary to raise
temperature of 1000g (approx 1 L) of water
by 1°C
 WEIGHT (clinical manifestation)

5.  Basal metabolism
 Physical activity
 Specific dynamic action (thermic effect) of
food (how food is broken down)

6.  Basal metabolism
 Physical activity (decreased)
 Specific dynamic action (thermic effect) of
food
 Stress of injury and surgery (↑↑↑)

7.  3 main sources
◦ CHO = 4 kCal/g
◦ CHON = 4 kCal/g
◦ CHOH = 9 kCal/g
 Alcohol = 7 kCal/g

8.  Most important source of energy
 Filipino diet: 60% total caloric allowance
 Should not be less than 100g/day for
efficient oxidation of fats
◦ 1 cup of white rice = 200 kCal
◦ 200 kCal ÷ 4 kCal/g = 50g

9.  Functions
◦ Immediate needs for energy
 Excess glycogen – liver, muscle, adipose tissue
◦ Spares protein
◦ For normal oxidation of fat
 Prevents production and accumulation of ketones
◦ Synthesis of B-complex vitamins
◦ Provide chemical substances that serve as starting
point for synthesis of non essential amino acids
◦ Stimulate peristalsis, absorb, and hold water
◦ Synthesis of nerve and cartilage

10.  Mainly for synthesis and repair of body structures if
sufficient calories are available
 Filipino diet: 20% total caloric allowance
 Recommended intake: 1.12g/kbw/day
 6.25g CHON = 1 g dietary nitrogen
 Essential and non essential amino acids
 Functions:
◦ Enzymes
◦ Antibodies
◦ Blood proteins
 Osmotic pressure regulation
 Water and acid/base balance
 Excess amino acid is de-aminized in the liver and
nitrogen is secreted in urine as urea and the rest is
oxidized in energy or stored as adipose tissue

11.  Stored as adipose tissue in unlimited amount
 Recommended for Filipinos = 20-25% of total
caloric allowance
 Functions
◦ Spares protein as energy source
◦ Maintain constant body temperature by providing
effective insulation
◦ Facilitate absorption of fat-soluble vitamins (ADEK)
◦ …essential and non essential fatty acids…
◦ …phospholipids…

12.  Energy
 Carbon dioxide
 Water
 Ketones from fat
 Ammonia and nitrogen from protein
 Lactic acid (during anaerobic metabolism)
from carbohydrates

13.  Vitamins
 13 essential (fat & water-soluble)
 Minerals
 Maintain acid/base balance
 Catalyze metabolic reactions
 Transmit nerve impulses
 Regulate contractility of muscles
 For bone & Tooth formation
 Provide components for essential body
compounds

14.  Pseudovitamins
◦ Choline
◦ Inositol
 Water
◦ 60% total body water in adults
◦ Recommended intake: 1 cc/kCal
◦ Consumed = 2-2.5L or 8-10 glasses/day
◦ Function:
 Universal solvent
 Chemical reactant
 Takes up heat
 Structural component of cells

15.  Dietary management
 How much food should be given?
 What kind of food should be given?
 How will this food be given?
 How much food should be given?
Determine:
 Energy requirements per day
◦ Basal energy expenditure (BEE)
◦ Estimated energy expenditure (EEE)
 How much CHO, CHON, CHOH?

16.  Energy needs/day
 For resting, nonstressed adults
◦ BEE (in kCal/day)
◦ Harris-Benedict equation
◦ (men) = 66 + 13.8(w) + 5.0(h) – 6.8(a)
◦ (women) = 655 + 9.6(w) + 1.8(h) – 4.7(a)
 For stressed adults
◦ EEE
◦ Non ventilated = 629 – 11(a) + 25(w) – 609(o)
◦ Ventilated = 1925 – 10(a) + 292(t) + 5(w) + 281(s) +
851(b)
◦ a = age in yrs
◦ w = weight in kg
◦ h = height in cm
◦ O = obesity
◦ T = trauma
◦ B = burns (1=present; 0=absent)
◦ S = sex (1=male; 0=female)

18.  Energy needs/day
 Example: 70 kg / male / 40 yo / 173cm
◦ BEE = 66 + 13.8(70)+5(173) – 6.8(40)
◦ BEE = 1,625 kCal/day
 Blunt chest trauma, on ventilatory support
◦ EEE = 1,925 – 10(40) + 292 + 5(70) + 281
◦ EEE = 2,448 kCal/day
 Percentage C, P, F
◦ Carbohydrates = 60%
◦ Proteins = 20%
◦ Fats = 20%

19.  Example: 70 kg / male / 40 yo / 173cm
◦ BEE = 66 + 13.8(70)+5(173) – 6.8(40)
◦ BEE = 1,625 kCal/day
◦ C = 60% =975 kcal/day
◦ P =20% = 325 kcal/day
◦ F =20% = 325 kcal/day
◦ C= 975 kCal/4 kCal/g = 243.75 g = 244 g
◦ P= 325 kCal/4 kCal/g = 81.25 g = 62 g
◦ F = 325 kCal/9 kCal/g = 36.11 g = 36 g

20.  What kind of food shall be given?
 How will this food be given?
 Determine:
 Can the gut be used safely?
◦ Yes?
 NPO?
 Oral feeding?
 Enteral feeding?
◦ No?
 NPO?
 Parenteral nutrition?

21. Oral feeding? Yes.
 Consistency modification
◦ Solid
◦ Soft
◦ Liquid – clear or full
 Composition modifications
◦ Regular
◦ Low residue
◦ Bland

22.  Oral feeding – liquid diet
 Clear
◦ Supply fluids with no residue
◦ Intends to allay thirst, replace water loss and start
oral nourishment
◦ No nutritional essentials
◦ Sugar dissolved in clear liquid
◦ Water
◦ Tea/coffee (should not exceed 2 cups in 24 hours)
◦ Intended for 1-2 days only
 *just to jump start oral nutrition

23.  Full
◦ Satisfy normal calorie requirement of energy
◦ Requiring little effort in digestion and absorption
◦ Liquid, strained semi-liquid food, food that liquefy
at body temperature
◦ Can be used for prolonged periods
◦ Free from cellulose, spices, and condiments
◦ Calorie content can be increased (by adding sugar
or baker’s yeast)
◦ *ileus – patient might vomit
 Cold liquid
◦ Ice cream
◦ To minimize oozing and prevent bleeding after
tonsillectomy

24. Oral feeding – soft diet
 Provides adequate nutrition
 Simple, easily digested, mildly flavored food
 Low in fiber, free from tough connective
tissue
 A transition from full liquid to regular diet
 May be prolonged if unable to chew
Oral feeding – soft diet
 Residue diet
 To produce bowel movement
 Inadequate in vitamins and minerals (because
the purpose is to make the patient defecate)

25.  Oral feeding – soft diet
 Bland diet
 Nutritionally adequate
 To avoid stimulation of a diseased gut (gastric
ulcers, colitis, recent UGIB from esophageal
varices, etc.)
Oral feeding? No; gut intact
 Enteral feeding
◦ Nasogastric
 white:6, black:8, blue:10, green:14, orange:16, red:18
 adult patients – between level 2 and 3
 signs that the tube is inside: reflux of gastric juice, gurgling
sound onset

26. ◦ Stomal
 Pharyngostomy
 Esophagostomy
 Gastrostomy (surgery or PEG – percutaneous
endoscopic gastrostomy)
 Jejunostomy (20-30 cm after ligament of Treitz)
 *duodenostomy – not done d/t duodenum’s
retroperitoneal position and immobility
 *ileostomy – not done d/t less absorption of food in
the ileum

28.  Nasogastric/nasoenteral feeding
 Easiest to perform
 Uncomfortable, cause nasal irritation and
chronic sinusitis
 Osteorized/blenderized
◦ For patients that cannot tolerate feeding by
mouth(comatose, severe burns, paralysis of
swallowing mm)
◦ Fed thru a polyvinyl nasogastric tube (NGT)
◦ Consists of natural food with egg and milk as base
◦ 1 cc of liquid/calorie of formula
◦ Highly fibrous, spicy, strongly flavored food are
avoided

31.  Stromal Feeding
 Osteorized/blenderized
◦ For pharyngostomy, esophagostomy, gastrostomy
 Elemental diet
◦ For jejunostomy
◦ Synthetically formulated
◦ Readily and completely absorbed from upper GIT
◦ Low residue, bulk-free
◦ *predigested
 25-50 cc/hr/day as tolerated
 Begun at ½ strength with increasing
concentration

32.  Gut cannot be used safely
 Total Parenteral Nutrition (TPN)
◦ Provide necessary nutritional elements directly into
the blood
◦ Must be given by intravenous (IV) infusion into a
central vein
◦ TPN Indications

33.  4 categories of problems for TPN use
 Pre-operative preparation of
malnourished patients
 Post-operative surgical complications
 Inflammatory bowel disease requiring
prolonged bowel rest
 Insufficient oral intake but with marked
increase metabolic requirements

34.  Newborn with GI malformation
 Short bowel syndrome
 GI fistulas
 Inflammatory bowel disease
 Moderate to severe pancreatitis
 Prolonged ileus (sepsis)
 Severe ARF
 Patients with decubitus ulcers in which fecal
contamination is a problem
 Patients who aspirate enteral feedings
 Patients with cancer in which malnutrition might
interfere with therapy

35. ◦ Central venous access
 Subclavian vein – most common
 Jugular vein
 Femoral vein – less common

 Monitor catheter position by CXR or plain abdominal
film = *always mandatory
 *CXR – to determine presence of pneumothorax or
obstructive shock
 *plain abdo film – expect to find catheter in common iliac
vein

36. ◦ Components
 Energy
 Calories come from carbohydrates ± fat
 Glucose (10-35% dextrose)
 Lipid emulsions have linoleic acid (5-20%)
 Standard TPN solutions provide 1.4 kCal/mL

37.  Protein
 Provided as amino acids as 5% mixture
 Vitamins
 Minerals
 Electrolytes
 Na
 P
 Mg
 K
 Ca
 Measurements done at least OD for 1 wk until levels have
stabilized

38. ◦ Complications
 Central venous catheter sepsis
 Mechanical/technical
 Pneumo/hemothorax
 Air/catheter embolism
 Cardiac tamponade/perforation
 Metabolic
 Hyper/hypoglycemia
 Electrolyte imbalance
 Acid/base disorders
 Fluid overload/depletion
 Liver dysfunction
 Hyperlipidemia