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1. N U T R I T I O N A L A S S E S M E N T A N D
M A N A G E M E N T I N S U R G I C A L P A T I E N T S
B Y : D A W I T ( M D , G S R 1 )
M O D E R A T O R : D R . D A W I T T
( C O N S U L T A N T S U R G E O N )
J I M M A S P E C I A L I Z E D H O S P I T A L
12/21/2015
1

2. Outline
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 Introduction
 Nutritional assessment in surgical patients
 Nutritional requirments and interventions
 Nutrition in specific disease conditions
 Summary and recommendations

3. Objectives
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 To elaborate causes and consequences of
malnutrition in the surgical patient
 To clarify objective nutritional assessment methods
 To discuss on the different methods of providing
nutritional support and their complications

4. Introduction
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 Health is strongly influenced by nutritional
status
 Rates up to 50 percent in certain
populations
 1936=33% vs 3.5%(mortality)
 Identification
 Minimizes unwanted outcome in surgery

5. Consequence of malnutrition in surgical patients
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 Increase susceptibility to infection
 Poor wound healing
 Increase frequency of decubitus ulcer
 Over growth of bacteria in GIT
 Abnormal nutrient losses through the stool

6. Factors Affecting Nutritional Intake during
Illness
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Medications our role ????
Fear and Anxiety
Pain
Inappropriate
Diet Orders

7. ASSESSMENT OF NUTRITIONAL STATUS
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 The possibility of malnutrition should form part
of the work up of all patients
 A clinical assessment of nutritional status
involves:
 Focused Hx
 Focused P/E
 Focused Ixs

8. Nutritional ass’t…cont’d
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1. Clinical History
 History of poor nutrient intake
 Loss of body weight
 Social & economic condition that may lead
to poverty & malnutrition
 Gastrointestinal symptoms
 Other chronic medical illnesses

9. Nutritional ass’t…cont’d
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2. Physical Examination
 G/A
 V/S
 Anthropometry
 Body Mass Index

10. CONT’D
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BMI INTERPRETATION
<18.5 underweight
18.5-24.9 normal
25-29.9 Over wt
30-34.9 Obesity GI
35-39.9 Obesity GII
>/= 40 Extreme obesity GIII

11. HEENT
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Signs deficiencies
Alopecia, Easily plukablity PEM
Angular palebritis Vit B2
Bitot’s spots,conjuctival xerosis Vit A
Angular stomatitis Vit B2,6,12
Bleeding gum Vit C

12. Cont’d
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 Cardiovascular: Evidence of heart failure or high-
output state
 Neck: Thyromegaly
 Extremities: Edema, muscle wasting
 Skin: Ecchymoses, petechiae, pallor, pressure
ulcers, assessment of surgical wound healing and
signs of wound infection (if postoperative).
 Neurologic: Evidence of peripheral neuropathy,
reflexes, tetany, mental status

13. Nutritional ass’t…cont’d
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3. Laboratory Investiaton
 To detect subclinical nutritional deficiencies
• Nitrogen Balance
• Serum Albumin
• Creatinine excretion
• Immunological function assessment(TLS)

14. Nitrogen balance
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 Provides an index of protein gain/loss
1 g protein =6.25 g nitrogen
Nitrogen intake – loss{90%urine,intugumentary 5%,5%
stool}
overall protein status
effectiveness of a nutrition intervention
Serum albumin
 fall during acute stress b/c of
 Increase incirculating extravascular volume
 TNF alpha mediated inhibition of synthesis

15. Cont’d
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 Serum albumin
 most abundant
 liver
 = t1/2, 18-20 days
=2.2 g/dl marker of –ve catabolic state
Serum transferrin =t1/2, 8-9 days
 215–380 mg/dL
Serum prealbumin(transthyretin)=t1/2, 2-3
days. 19 to 43 mg/dL
Retinol binding protien

16. Creatinine excration
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 Metabolic product of skeletal muscle
 Produced constantly indirect proportion to skeletal
mass
 1g creatinine=18.5 fat free skeletal muscle
 CHI
 24-hour urine creatinine (mg)
 expected 24-hour urine creatinine (cm)

17. TOTAL ENERGY EXEDITURE
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 Definition
 BEE 60% of TEE
 Basal energy requirement is the function of the
individual's weight,height, age, gender, activity
level and the disease process

18. Basal energy expenditure (BEE)
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 Estimated using the Harris-Benedict equations:
 BEE(men)=66.47+13.75(W)+5(H)-6.67(A)
 BEE(women)=655.1+9.56(W)+1.85(H)-
4.68(A)
 where W = weight in kilograms; H = height in
centimeters; and A = age in years.

19. Cont’d
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 It will be adjusted in stress conditions
 Total calories=BEE X stress factor X activity factor
 Activity factor=1.2 in bed rest
=1.3 out of bed
conditions Kcal/kg/day Above BEE
Normal 25-30 1.1
Mild stress 25-30 1.2
Moderate stress 30 1.4
Sever stress 30-35 1.6
burns 35-40 2

20. ENERGY REQUIRMENT….cont’d
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 Rest Energy Expenditure
Adults (18-65)………………….. 20-30 kcal/kg
Elderly (65+)……………………. 25 kcal/kg
For burns Patients…………….. 30-35kcal/kg
 Other factors:
Pregnancy………………………..Add 300 kcal/day
Lactation………………………… Add 500 kcal/day
Obese or Super obese……… 15-20 kcal/kg

21. ENERGY REQUIRMENT….cont’d
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21Stress Factors
• Peritonitis……………………+ 15%
• soft tissue traum ………..+ 15%
• Fracture……………………..+ 20%
• fever (per oC rise)……….+ 13%
• Moderate infection………..+ 20%
• Severe infection ……………+ 40%
• <20% BSA Burns…………..+ 50%
• 20-40% BSA Burns…………+ 80%
• >40% BSA Burns……………+ 100%

22. NUTRITIONAL REQUIREMENTS…cont’d
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22FAT
 Requirement =3 g/kg/day
 30-40 percent of nutrition
 Liver can synthesize most fatty acids, but humans
lack the desaturase enzyme needed to produce n-3
and n-6 fatty acid series
 Therefore linoleic acid should constitute at least
2% and linolenic acid at least 0.5% of daily
caloric intake to prevent essential fatty acid
deficiency

23. NUTRITIONAL REQUIREMENTS…cont’d
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23CARBOHYDRATE
 40-50 percent of total nutrition
PROTEIN
 The basic requirement for nitrogen 0.10–0.15 g/kg
per day
 Additional protein burn injuries, open wounds,
protein losing Enteropathy / Nephropathy
 A lower protein intake may be necessary in patient
with chronic renal insufficiency who are not treated
by dialysis and certain patients with hepatic
encephalopathy

24. NUTRITIONAL REQUIREMENTS,
PROTEIN…cont’d
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Clinical condition requirement
normal 0.8
Metabolic stress (illness, injury) 1.0-1.5
Acute renal failure (undialyzed) 0.8-1.0
hemodialysis 1.2-1.4
Peritoneal dialysis 1.3-1.5

25. NUTRITIONAL INTERVATION
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 Goal
 To alter the course and outcome of
critical illness
 To supply the substrate necessary to meet
the metabolic needs of patients in who
adequate nourishment cannot be provided by
mouth

26. Indications for nutritional intervention
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 General indication
 pre existing nutritional deprivation
 Anticipated/actual inadequate energy
intake

27. Specific Indications for nutritional
intervention
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Inadequate intake for 5-7 days or anticipated
no intake for the same period
Serum albumin less than 3gm/dl
Weight loss of greater than 10% body wt in 6months.
Current wt less than 80% of the ideal wt
Anticipated severe insult to the body
Concurrent medical problem

28. ARTIFICIAL NUTRITIONAL SUPPORT
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 Nutritional support, via either enteral or parenteral
routes, is used in three main settings:
To provide adequate nutritional intake during
recuperative phase of illness or injury
to support the pts during systemic response to
inflammation, injury or infection during an extended
critical illness
pts with permanent loss of intestinal length or
function

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30. ENTERAL FEEDING
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 Delivery of nutrients into the gastrointestinal tract
 This can be achieved with
oral supplements (sip feeding) or
variety of tube-feeding techniques (NG, ND,NJ tubes)
Surgical techniques
 Percutaneous endoscopic gastrostomy (PEG)
 Surgical gastrostomy
 Percutaneous endoscopic Jejunostomy (PEJ)
 Surgical Jejunostomy
 A variety of nutrient formulations are available for
enteral feeding

31. ENTERAL FEEDING...cont’d
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 Long term feeding (>6 wk) usually requires
gastrostomy or jejunostomy tube
 Enteral feeding is often required in pts with
anorexia, impaired swallowing, or bowel disease
 Enteral formulas: standard (osmolality- 300) and
modified

32. ENTERAL FEEDING....CONT’D
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Why Preferable?
 Physiologic & matabolic benefits
 Immunologic function
 Cost benefits
 Safety benefits
Fewer infectious complicationsa
 44% reduction in infectious complications
Less hyperglycemia → neutrophil inhibition

33. Contraindications
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Short bowel syndrome
Bowel obstruction
GI bleeding
Protracted vomiting & diarrhea
Fistulas, Ileus
GI ischemia
Gastroparesis, GOO
Repeated aspiration(reflux)

34. Complications
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Tube related
 malposition
Blockage
Aspiration
Local complication
 mainly aspiration pneumonia and diarrhoea

35. Delivery Methods
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35 Sip feeding
Commercially available supplementary sip feeds are
used in patients who can drink but whose appetites
are impaired
 Nasogastric tube
less expensive, easier to secure and maintain
Diabetics and patients with severe head injuries
may have profound gastroparesis

36. Contraindications to NGT
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 delayed gastric emptying Gastric residuals of
200 mL or more in a 4- to 6-hour period
 gastric outlet obstruction
 a history of repeated aspiration due to
reflux
 inability to protect the airway (a relative
contraindication to gastric feeding)

37. Delivery Methods….cont’d
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37 Post pyloric access via
a duodenal or jejunal nasoenteric tube is preferred
when gastric feedings are not tolerated and/or when
patients are at risk for aspiration
Gastrostomy
 The placement of a tube through the abdominal wall
directly into the stomach if patients require enteral
nutrition for prolonged periods (4–6 weeks)
 Surgical vs PEG

38. Delivery method….cont’d
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38 Jejunostomy
 Jejunal feeding has become increasingly popular
 uses:
 associated with a reduction in aspiration
 enhanced tolerance of enteral nutrition
 in patients with severe pancreatitis
 The only absolute contraindication is distal
intestinal obstruction.

39. Feeding Tolerance
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39 Pts will tolerate
If GI output’s ˂600ml/d
Isotonic formula of 30ml/hr administered
 Poor tolerance
Vomiting & severe abdominal cramp
Gastric residuum >50% over past 4hrs
Increased abdominal distension
Worsening diarrhea
 NB: Parenteral nutrition if any of the above

40. Enteral Formulas
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 Low-Residue Isotonic Formulas
 Isotonic Formulas with Fiber
 Immune-Enhancing Formulas
 Calorie-Dense Formulas
 High-Protein Formulas
 Elemental Formulas

41. low-residue isotonic formulas
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 Most low-residue isotonic formulas provide a caloric
density of 1.0 kcal/Ml
 standard or first-line formulas for stable patients
with an intact gastrointestinal tract
Elemental Formulas
 predigested nutrients and provide proteins in the
form of small peptides
 ease of absorption
 malabsorption, gut impairment, and pancreatitis

42. Parenteral nutrition
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Definition
considered
7-10 days
enteral feeding is not feasible

43. Parenteral nutrition....cont’d
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TYPES
 Peripheral parenteral nutrition (PPN)
osmolarity 1,000 mOsm (approximately 12%
dextrose solution) to avoid phlebitis
 large volumes (>2,500 mL) are needed
Temporary (<2weeks)
solutions that contain more than 3%
aminoacid and 5% glucose are poorly
tolerated peripherally
Generally intended as supplement to oral
feeding and is not optimal for critically ill pts

44. Parenteral nutrition, PPN....cont’d
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45. Parenteral nutrition, types....cont’d
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 Total/central parenteral nutrition
(TPN/CPN)
provides complete nutritional support
The solution, volume of administration, and
additives are individualized based on an
assessment of the nutritional requirements
Catheters placed into the central venous system
terminate in the vena cava
catheter inserted via
 subclavian or
 internal/external jugular vein

46. Parenteral nutrition, TPN....cont’d
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46TYPES OF TPN FORMULATIONS
 TPN formulation without lipid (2-in-1
solution)
Calories from amino acids--- 20 to 25%
Calories from dextrose------- 75-80%
 TPN formulation with lipid ( 3-in-1 solution)
calories from amino acids----- 20 to 25%
calories from lipids------------- 20%
calories from dextrose--------- 55 to 60 %

47. Parenteral nutrition, TPN....cont’d
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 Special solutions
 Additives
Electrolytes should be adjusted daily
If the serum bicarbonate is low, the solution should
contain more acetate
The calcium:phosphate ratio must be monitored to
prevent salt precipitation

48. Parenteral nutrition, TPN....cont’d
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 Medications:
Albumin, H2-receptor antagonists, heparin, iron,
dextran, insulin, and metoclopramide can be
administered in TPN solutions
However, not all medications are compatible with
3-in-1 admixtures
Regular insulin should initially be administered
subcutaneously according to a sliding scale
After a stable insulin requirement has been
established, insulin can be administered in the TPN
solution, generally at two thirds of the daily
subcutaneous insulin dose

49. Parenteral nutrition, TPN....cont’d
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TPN- macronutrient solutions
 Crystalline Aas containing 40-50% essential and 50-
60% non essential Aas are used to provide protein
needs
rich in branched chain for hepatic encephalopathy
rich in essential Aas for renal insufficiency pts
 Glucose in IV solutions is hydrated
While there is no absolute requirement of glucose in
most pts, providing >150g glucose/d maximizes
protein balance
 Lipid emulsions are available as 10% (1.1kcal/ml) or
20% (2 kcal/ml) solutions and provide energy as well
as source of essential fatty acids
 Rate of infusion should not exceed 1 kcal/kg/h

50. INDICATIONS
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 Entero-cutaneous
fistula
 Renal failure (ATN)
 Short bowel syndrome
 Severe burns
 Hepatic failure
 Crohn’s disease
 Anorexia nervosa
 Acute radiation
enteritis
 Acute chemotherapy
toxicity
 Prolonged ileus
 Weight loss preliminary
to major surgery
50
Parenteral nutrition, TPN....cont’d

51. Parenteral nutrition, TPN....cont’d
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51ADMINISTRATION OF TPN
Introduction of TPN should be gradual
E.g, approximately 1,000 kcal is provided the first
day
If there is metabolic stability (i.e.normoglycemia),
this is increased to the caloric goal over 1 to 2
days
 Continuous vs cyclic administration

52. ADVANTAGES DISADVANTAGES
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Bed side technique
Avoids complications of
central venous catheter
Avoid multiple venous
cannulations
Hypertonic solutions can
be given
Trained personnel is
needed
Line blockage
Mal position
Phlebitis
Line sepsis
thrombosis
52
Parenteral nutrition....cont’d
PICC line

53. 12/21/2015
53

54. ADVANTAGES DISADVANTAGES
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Central access needed
Multiple lumen can be
used in acute emergency
Hypertonic solutions can
be given
Can be placed for more
than 6 weeks
Inserted in theatre
Increase infection rate
Multiple complications
54
Parenteral nutrition....cont’d
Central Catheter(Non Tunneled)

55. ADVANTAGES DISADVANTAGES
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Convenient exit site
Long lasting than
non tunnels
Hypertonic solutions
can be given
Removal needs
surgical dissection
Catheter related
sepsis
Other complications
55
Parenteral nutrition....cont’d
Central Catheter(Tunneled)

56. Parenteral nutrition....cont’d
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Discontinuation of TPN
 When the patient can satisfy 75% of his or her
caloric and protein needs with oral intake or enteral
feeding
 To discontinue TPN, the infusion rate should be
halfed for 1 hour, halved again the next hour, and
then discontinued
 Tapering in this manner prevents rebound
hypoglycemia from hyperinsulinemia
 It is not necessary to taper the rate if the patient
demonstrates glycemic stability

57. comparison
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Enteral Parenteral
Cost $10-20 per day $100 or more per day
Gut Preserves intestinal
function
May be associated with
gut atrophy
Infection Very small risk of
infection
High risk/incidence of
infection and sepsis

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59. Burns
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 Extensive burns double or tripple REE &
urinary nitrogen losses
 Increase in metabolic demand is proportional to
ungrafted body surface
 Other interations ?
 Enteral feeding is preferred when tolerated
 Start within 6-12hrs postburn to reduce hyper
metabolism & improve survival

60. Burns.... Cont’d
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 Require 40kcal/TBSA in addition to the
maintenance
 Increased Pr⁻ requirement frm the normal
 0.8g/kg/d to 2.5g/kg/d
 During the hyper metabolic phase of burn injury
(0–14 days), the ability to metabolize fat is
restricted
diet that derives calories primarily from
carbohydrate is preferable

61. NUTRITION REQUIREMENTS IN HEAD
INJURY
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 Energy requirement calculation
 2 wks after HI
120% to 250% above their basal energy expenditure
Enteral administration is preferred for acute
neurological patients.
Nutrition therapy should start early: within 24
to 48 hours of admission to the intensive care unit.

62. CONT’D
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 Enteral formulas: Complete and isotonic
formulas should be initially chosen.
 Start with 30ml/hr
 Check G.residue Q 4hr ,stop if >125ml
 Increase by 15-25ml Q 12-24hr as tolerated until
desired rate is achieved
 The Brain Trauma Foundation recommends
that total nutritional support should be achieved
within 7 days of the injury
 Prokinetic drugs???

63. Acute pancreatitis
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 The DX of pancreatitis often mandates strict bowel
rest for extended periods of time
 Patients with three or fewer Ranson criteria should
be treated with: fluid replacement, nasogastric
suction, and bowel rest for at least a week before
considering parenteral nutrition
Most of these patients can resume an oral diet and
do not benefit from TPN
 Those with more than three Ranson criteria should
receive nutritional support

64. Ranson’s Criteria
Surg Gynecol Obstet 138:69, 1974
 Hct decreases > 10%
 Calcium falls to < 8.0 mg%
 Base deficit > 4 mEq/L
 BUN increases > 5 mg%
 PaO2 is < 60 mmHg
If > 3 are present within 48 hours of admission,
60% die

65. Cont’d
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 If severe, initiate early nutrition support (within 72
hours)
 jejunal feeding is superior to TPN

66. Summary of Ideal Feeding Solutions in
Acute Pancreatitis
 Parenteral: Crystalline amino acids, hypertonic
glucose solutions (IV fat emulsions tolerated)
 Enteral: Low fat, elemental, hypertonic
solutions given into jejunum

67. Nitrogen and Fat Needs
in Pancreatitis
 Nitrogen: 1.0 – 2.0 gm/kg/d
Nitrogen balance study is helpful
 Fat: Fat well tolerated IV and to limited degree in
jejunum, no oral fat should be given

68. Renal-Failure Formulas
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 The primary benefits of renal formulas are the lower
fluid volume and concentrations of potassium,
phosphorus, and magnesium needed to meet daily
calorie requirements.
 This type of formulation almost exclusively contains
essential amino acids
 Has a high nonprotein-calorie:nitrogen ratio;
however, it does not contain trace elements or
vitamins.

69. Pulmonary-Failure Formulas
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 In pulmonary-failure formulas, fat content is usually
increased to 50% of the total calories, with a
corresponding reduction in carbohydrate content.
 The goal is to reduce carbon dioxide production and
alleviate ventilation burden for failing lungs.

70. cancer
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 over two-thirds of patients with cancer develop
malnutrition
 Malnutrition associated death in 20–40% of these
patients
 Rx can worsen preexisting malnutrition
 REE increases by 20-30% in some malignancies
 Lactic acidosis from high anaerobic metabolism in
neoplastic tissue
 Neoplastic tissues act as nitrogen traps
 Cancer cachexia manifests as: progressive involuntary
weight loss, fatigue, anemia, wasting, and tissue
depletion
 It may occur at any stage of the disease

71. Cancer….cont’d
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71
 Nutrition support has become an essential adjunct
in caring for the cancer patient
 Nutritional supplementation in cancer patients may
reduce :
 infectious complications
 perioperative morbidity
 But convincing evidence of improvement in overall
survival is lacking
 Ample evidence that nutritional supplementation
stimulate tumor growth

72. Short bowel syndrome
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 SB ˂ 200cm or ˂ 150cm with ileocecal valve
 Minimum SB length required to become
independent of TPN is 120cms
 Inadequate intestinal absorptive surface leads to
malabsorption, excessive water loss, electrolyte
derangements and malnutrition
 Usually need temporal parenteral nutrition
 Supplement TPN with oral intake
 Frequent small meals, avoiding hyperosmolar
foods, Restricting fat intake and limiting
consumption of high oxalate foods

73. SBS.... Cont'd
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73 Adaptation to short gut occurs over time, and initial
management should be directed at
avoiding electrolyte imbalance and dehydration
providing daily caloric requirements through TPN
 Uniquely formulated diets containing glutamine and
human growth hormone have shown promise for
accelerating intestinal adaptation
Adaptation - Increase in villous height
- Luminal diameter
- Mucosal thickness

74. summary
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 The gut should always be the preferred route
for nutrient administration
 Subjects receiving intravenous feedings and bowel
rest had significantly exaggerated response to injury
 During parentral nutrition close monitoring of;
Serum Na, K on alternative days has
LFT, triglycerides weekly to be
Renal parameters biweekly remembered

75. REFERENCES
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 Uptodate 20.1
 Bailey & Loves short practice of surgery,
25th and 26th edn.
 Schwartz's principles of surgery,9th and 10th edn.
 Medscape general surgery
 Nutrition therapy and pathophysiology ,Marcia
nelms
 ACS, Principles & Practice of Surgery, 6th edn.
 Greenberg 6th edt

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