Surgical nutrition

2. 
 Introduction
 Review of physiology
 Nutritional Assessment
 Nutritional Support
 Enteral
 Parenteral
 Conclusion
Outline

3. 
 Surgical nutrition is important in
 Well nourished and mildly malnourished patients
who cannot take oral food for more than one week
post operatively to avoid prolonged starvation.
 Severely malnourished patients undergoing general
surgery procedures.
 All critically ill patients (Sepsis patients, Multiple
Injury patients, Burn patients, etc).
 Patients whom you predict cannot use their gut for
prolonged period of time (Short gut syndrome, EC
fistula, etc).
Introduction

4. 
 Nutritional screening
 Nutritional assessment ABCD
 Nutritional requirements
 Nutritional support
Critical issues

5. 
There are two broad classes of nutrients:
◦ Those that provide energy
 Carbohydrates, fats and proteins
◦ Those that are incorporated in tissue synthesis
 Proteins, vitamins, electrolytes, trace elements and water
◦ Carbohydrates
 30-60%
 Stores depleted in 48hrs after starvation but within 24 hrs of
stress
◦ Proteins
 Not stored; 2.5% daily turnover
 2-4g/day is depleted in starvation but 30-50g/d after severe
stress
◦ Lipids
 25-40% of total calories
 Depleted in prolonged starvation and stress
Review of Physiology

6. 
The Cori cycle

7. 
ENERGY/NUTRIENT REQUIREMENT
Energy requirement is increased in catabolic state.
Neonates/infants require about 3X energy
requirements in adults.
The basal requirements are:
◦ Energy J/kg 125-146
◦ Proteins [g] 0.7-1.0
◦ Carbohydrates [g] 4.2-6
◦ Fat [g] 1.5-2
◦ Water [ml] 30-35 [45 -50]
◦ Electrolytes
◦ Vitamins

8. 
ESTIMATION OF ENERGY REQUIREMENT
 Harris-Benedict equation estimates BEE at rest.
 Men 66 + (13.7x weight) + (5x height) –(6.8 x age).
 Women 65 + (9.6 x weight) + (1.7 x height) – (4.7 x
age)
 Most require 25-35 kcal/kg/day.
 Stress increases these values.
 Requirements are increased by activity, surgery,
trauma, fever, infection, burns, head injury, renal
failure.
 Decreased by sedation, paralysis, B blocker

9. 
 Short term starvation
 During the first 48-72 hrs increased use of fat
stores, and most tissues except RBCs, WBCs,
and renal medulla oxidize lipid stores.
 Brain has an obligate glucose requirement, over
3-5 days uses fatty acids for energy.
 Reserves can maintain this demand for 12hrs
but this can elongated by gluconeogenesis from
lactate, glycerol and amino acids.
 Prolonged starvation
 Hepatic and renal gluconeogenesis drops
 Brain cells use ketone bodies for energy.
Human catabolism

10.  Protein
 Proteolysis and synthesis [energy and acute phase reactant
proteins by the liver]; negative nitrogen balance
 Nitrogen loss:
 5-8 gm/d normally
 2-4 gm/d after several days of unstressed starvation
 30-50 gm/d under severe stress (multiple trauma, sepsis,
burns)
 Lipids
 Lipolysis
 Carbohydrates
 Glycogenolysis and gluconeogenesis
 Insulin resistance
This response is stimulated by:
 Hormones ACTH, GH, glucagon
 Catecholamines
 Cytokines associated with acute stress response
Human catabolism [stress]

11. 
Anthropometric measurement
◦ Length/ height; Weight/BMI; MUAC/skin fold thickness
◦ Weight [<10%BW, <80% Ideal, 5% in 1month]
Biochemical findings
◦ Serum protein [<30g/l]
◦ FBC [PCV-anemia; Lymphocyte count <1500/mm3]
◦ Immune competence [delayed hypersensitive reaction, antigen tests]
Clinical findings
◦ History-weight loss, persistent nausea, anorexia, vomiting,
diarrhoea, malaise, dysphagia
◦ Signs: fluffy hair, pallor, skin rash, cheilosis, glossitis, neuropathy,
dementia, muscle wasting, edema, Ascites
Dietary recall
 How often, how much, how well
1. Indirect calorimetry
 Oxygen consumption, determination of respiratory quotient
1. Measurement of nitrogen balance
2. Measurements of immunologic function
Nutritional assessment –
‘ABCD’

12.  Calculate total energy requirement [use equation]
 Distribute thus:
 Carbohydrates 50%
 Fats 35%
 Proteins 15%
 Calculate nitrogen requirement -1.25g/kg BW
 Trace elements
 Electrolytes
 Vitamins
 Fluid 3L
 Determine route
 Enteral
 Parenteral
Nutritional requirement

13. Aims
◦ To provide energy, protein, trace elements and vitamins; To
supply fluids and electrolytes
Routes
◦ Enteral
 Oro-enteric
 Naso-enteric [NGT-NDT-NJT]
 Needle catheter jejunostomy
 Percutaneous endoscopic Gastrostomy/Jejunostomy
◦ Parenteral
 Peripheral /Central
 Supplementary/Total
 Temporary/permanent
Nutritional support

14. 
 This should consider the following:
1. The patient's premorbid state (healthy or
otherwise)
2. Poor nutritional status (current oral intake
meeting <50% of total energy needs)
3. Significant weight loss (initial body weight
less than usual body weight by 10% or more or
a decrease in inpatient weight by more than
10% of the admission weight
4. The duration of starvation (>7 days' inanition)
Indications for nutritional support

15. 
5. An anticipated duration of artificial
nutrition (particularly total parenteral
nutrition [TPN]) of longer than 7 days
6. The degree of the anticipated insult, surgical
or otherwise
7. A serum albumin value less than 3.0 g/dL
measured in the absence of an inflammatory
state
8. A transferrin level of less than 200 mg/dL
9. Anergy to injected antigens
Indications for nutritional support

16. 
Nutrition in surgery: routes

17. 
Advantages
◦ Cheap, more physiological, more efficacious in traumatized
and burns patient
Options
◦ Blenderised
◦ Chemically defined
◦ Special purpose formulation
◦ Modular
Routes
◦ Oro-enteral
◦ Nasoenteral
◦ Needle Catheter Jejunostomy
◦ Percutaneous endoscopic gastrostomy/jejunostomy PEG/PEJ
Complications
◦ Tube –displacement, dislodge, blockage; bowel perforation,
reflux and aspiration pneumonia
◦ Feed-high osmolar feed cause severe diarrhoea
Enteral

18. 
 PEM with inadequate oral intake
 Dysphagia except for fluids
 Prolonged return to normal dietary intake after
trauma/ surgery
 Inflammatory Bowel Disease (IBD)
 Distal, low output enterocutaneous fistulas
 To enhance adaptation after massive enterectomy
Indications for enteral
feeding

19. 
 Mesenteric ischemia
 Small Bowel obstruction
 Sepsis
 Pancreatitis
 Fistula proximal small intestinal
 SBS
 Severe diarrhoea
Contraindications

20. 
Complications of enteral feeding
 Relating to the feeding
tube
 Malposition
 Dislodgement / migration
 Aspiration, sinusitis
 Peritonitis
 Fistula formation
 Intestinal obstruction
 Tube fracture/ blockage
 Oesophageal and gastric
mucosal erosions
 Pneumothorax
 Oesophageal stricture,
perforation
 Fatal arrhythmias
 Relating to the feeding
regimen
 Feed intolerance
(diarrhoea, vomiting)
 Hyperglycaemia
 Enteric infection

21. 
 Sources
 Carbohydrate-based
 Fat-based
 Formulations
 Intralipid 10%
 Intralipid 20%
 Vamin 9 glucose
 Synthamin 14
Parenteral

22. 
 When nutritional support is appropriate but
effective enteral nutrition is not possible
 Proximal intestinal fistula
 IBD (especially in the perioperative period)
 Massive intestinal resection (<100cm of small
bowel remains)
 Ileus
 Severe pancreatitis
 Acute burns
 Hepatic failure (acute decompensation on
cirrhosis
Indications

23. 
 Standard
 Glucose 250g 4200J
 Protein 500ml 4200J
 Amino acids 14g
 Na 100mmol
 K 100mmol
 Cl 191mmol
 Mg 19mmol
 Folic acid
 Water
Standard TPN

24. 
 Access
 Peripheral
 Central
 Protocol
 ‘Daily dose method’
 Calculate energy required
 Calculate VOLUME requirements/24h.
 Determine PROTEIN requirements g/kg/d.
 Calculate daily CALORIES kcal/kg/d.
 Determine % to be given as protein, CHO, fats.
 Add electrolytes, trace elements.
 Co-administer Lipids to prevent fatty acid deficiency.
TPN

25. 
 Monitoring
 Daily Clinical evaluation, input-output chart, weight,
urinalysis, blood glucose
 48-hrly EUC, blood pH, Clotting profile
 Weekly LFTs, Serum Ca, FBC

26. 
Advantages
◦ Improved survival
◦ Wound healing
◦ Resistance to infection
◦ Immunity is improved
◦ Synthesis of blood elements RBC, plasma proteins
Successful outcome
◦ GI fistula
◦ Bowel failure
◦ Burns
◦ Persistent ileus
◦ Pancreatic pseudocyst/ascites/fistulae
TPN

27. 1. Can be used for longer periods with hyperosmolar
fluids at larger volumes
2. Survival rate is improved and morbidity reduced.
3. Weight loss and tissue breakdown are minimized
4. Wound healing is enhanced
5. Resistance to infection and general immunity are
improved
6. Formation of RBCs and plasma proteins is
maintained
Advantages of TPN

28. 
Procedure
◦ Needle malposition
◦ Air embolism
◦ Fat embolism
◦ CCF
◦ Pulmonary embolism
◦ Septicaemia
Feed
◦ Acute reactions to fats and amino acids
◦ Hyperosmolarity-related complications
◦ Metabolic acidosis
◦ Hyperglycemia
◦ Rebound hypoglycemia
◦ Anaemia
◦ Zinc deficiency
◦ Jaundice
◦ Altered biochemical profile
◦ Refeeding syndrome
Complications of TPN

29. 
 Nutritional supplementation reduces the risk of
complications if given to severely malnourished patients
undergoing major surgical procedures and in patients
with severe sepsis, trauma and burns.
 One of the most important therapeutic modalities of the
20th century has been nutritional support, in particular,
IV feeding.
 The ability to intervene in and correct nutritional
deprivation states that cause significant mortality in
patients is germane hence it should not counted as a
luxury.
Conclusion