NUTRITION IN SURGERY

Outline
• Basics
• Enteral nutrition
• Parenteral nutrition

(1) BASICS
Introduction
• 50% of all hospitalised surgical patients have evidence of malnutrition (biochemical or anthropometric)

Problems with undernutrition

• Poor wound healing
• Impaired immunity to battle infection
• Increased perioperative morbidity and mortality
• Prolong hospital stays and increased institutional costs

Causes of undernutrition
• Reduced intake
◦ Dysphagia, anorexia, vomiting, enforced post op fasting, poverty
• Reduced absorption
◦ Post gastrectomy
◦ Short bowel syndrome
◦ Blind loop syndrome
◦ Malabsorption syndrome
◦ Pancreatico-biliary disease
• Increased losses
◦ Fistula
• Hypercatabolism
◦ Surgery
◦ Malignancy
◦ Major trauma
◦ Burns
◦ Sepsis

Nutritional assessment
• Research methodologies
◦ Fluid displacement
‣ Submerging a patient in water and measuring the displaced fluid
‣ Most sensitive way of determining lean body mass
‣ But this is not practical
◦ Labelled ion exchange
‣ Radiolabeled isotopes injected and volumes of various body compartments calculated (Total blood volume, ECF,
ICF)
‣ Then these measures are used to estimate lean body mass
• Clinical methodologies
◦ History and examination
‣ History
• Weight loss
◦ How much?
◦ Duration?
◦ Intentional or unintentional?
‣ Clinically significant involuntary (unintentional) weight loss
• Loss of 4.5kg OR >5% of total body weight over a period of 6-12 months
‣ Protein energy malnutrition
• Loss of >10% of total body weight
• Dietary history
• Reasons for weight loss
◦ Poor intake?
‣ Anorexia ‣ H/o chronic illness
‣ Dysphagia ‣ N/V
‣ Odynophagia ‣ Unavailability of food (i.e: poverty)
 ◦ Losses?
‣ Diarrhoea
‣ Chronic bleeding
◦ Poor absorption?
‣ Past bowel or gastric surgery
◦ Increased catabolism?
‣ H/o chronic illness
‣ Malignancy
• Disability by the undernutrition
◦ Activities of daily living affected or not
‣ Examination
• Cachexia
◦ Muscle wasting
◦ Loose fitting clothes
• Dehydration
• Pallor
• Angular stomatitis
• Glossitis
• Koilonychia (spoon nails)
• Ankle edema
◦ Anthropometrics
‣ BMI
• <19 is under nutrition
‣ Mid arm circumference
‣ Triceps skin fold thickness
◦ Biochemical parameters
‣ S. albumin (<30g/L is undernutrition)
‣ S. ferritin
‣ Prealbumin
◦ Nitrogen balance
‣ Positive nitrogen balance - anabolic status
‣ Negative nitrogen balance - catabolic status
‣ How to calculate the nitrogen balance
• 24 hour urine collection → do urinary urea nitrogen test → obtain the nitrogen loss in urine
• Add 4 to that (fudge factor that accounts for nitrogen loss from other means - skin, wounds, faeces) → total
nitrogen loss
• Determine the nitrogen intake by dividing the total protein intake per day in grams by 6.25 (another fudge
factor)
• Intake - Loss = Nitrogen balance
◦ Immunologic function
‣ Delayed cutaneous hypersensitivity test is suggestive of undernutrition
‣ Total lymphocyte count <1500 is also suggestive
◦ Dynamometric
‣ Hand grip strength

Grading of nutritional status

• Severe malnutrition
◦ History: Loss of >10% of BW unintentionally in <1 month
◦ Examination
‣ Severe muscle wasting
‣ Oedema
◦ Biochemical: Albumin <30g/L
• Moderate malnutrition
◦ No obvious physical evidence
◦ But dietary history suggesting impaired intake
• Near normal nutrition
◦ Underlying pathology is likely to cause malnutrition if nutritional support is withheld
• Normal nutrition
◦ Underlying pathology is unlikely to affect nutrition even if nutritional support is temporarily withheld
• Overweight and obese
Nutritional requirement
• Nutritional requirement = Basal requirement (acc to age, sex, weight) + Additional losses due to catabolism

• Protein requirement
◦ 0.75-1g/kg/day (approximately 60g)
‣ This should be taken from food that gives high quality protein (eggs, liver)
◦ This value can be more than double in burns, multiple trauma
◦ 20% should be essential amino acids (there are 9, and they should be taken from meal as body cannot produce them -
histidine, leucine, isoleucine, lysine, methionine, phenylalanine, threonine, tryptophan, valine!)
◦ We need protein mainly for anabolic activities
• Calorie/energy requirement
◦ Total calorie requirement is 25-40 Kcal/kg/day for basal energy expenditure/BEE (BMR is determined by Harris
Benedict equation)
◦ This should come from
‣ Carbohydrates 50% (each glucose 1g will yield 4Kcal, dextrose 1g - 3.4 Kcal)
‣ Fat 35% (Fat 1g will yield 9Kcal)
‣ Protein 15% (Protein will also yield 4Kcal/g)
• One of the major goals of nutritional support is to provide energy/calorie requirement by non-protein
sources, so that protein is utilised for anabolic activities of the body
◦ In stressful conditions the BEE is multiplied by a fudge factor (Injury factor)
‣ Minor surgery - 1.2 (20% increase)
‣ Skeletal trauma - 1.35 (35%)
‣ Major sepsis - 1.6 (60%)
‣ Severe burn - 2.1 (110%)
◦ Then this value is multiplied by another fudge factor (activity factor) depending on the patient's confinement to the
bed
‣ Confined to bed - 1.2
‣ Not confined to bed - 1.3
◦ Overall caloric need in a patient with injury = BEE x injury factor x activity factor

Ways that we can give nutrition

• Oral food
• Oral supplementation
• Enteral feeding (feeding with a tube) nutritional
• Parenteral nutrition support

Indications for nutritional support/supplement in a surgical patient

• Pre-op
◦ Severe malnutrition → should be corrected before surgery
◦ Moderate malnutrition or near normal nutrition → Surgery shouldn't be delayed
• Post-op
◦ Enforced starvation (patient is kept nil orally for >5 days)
◦ Prolonged ileus
◦ Enterocutaneous fistula
• Catabolic states
◦ Trauma - Polytrauma patients
◦ Burns
◦ Severe sepsis
◦ Severe inflammation
‣ Severe IBD
‣ Severe pancreatitis
◦ Advanced malignancy
 (2) ENTERAL NUTRITION
Definition
• Enteral nutrition
◦ Feeding the gastrointestinal tract with
‣ Food
‣ Oral supplements
‣ Or via a tube!
• Enteral feeding
◦ Administration of nutrients directly into the gastrointestinal tract via a tube
◦ It does not mean optimisation of oral intake with diet and nutritional supplements (the other 2 entities of "enteral nutrition")

Indications and contraindications

• Indication
◦ Those with functional GI tract, but are unable to meet their requirements with usual diet/food fortification/oral
nutritional supplements
• Contraindications
◦ GI obstruction (mechanical or functional)
‣ If mechanical obstruction is proximal to pylorus - post pyloric feeding is possible
◦ GI fistula

Routes for enteral feeding

• Intragastric feeding
◦ Indications
‣ Patients with functioning stomach without vomiting or aspiration, but oral feeding is not possible
• Those with impaired swallowing - stroke, MND, Parkinsonism
• Altered level of consciousness
• Ventilated patients
‣ Patients who require to be supplemented an inadequate oral intake
• Cystic fibrosis
• Hypercatabolic states (burns)
• Facial injury
• HIV related wasting
• Psychological reasons (anorexia nervosa)
◦ Methods
‣ NG - for short term <4 weeks
‣ PEG - for long term
◦ Advantages
‣ More physiological
◦ Disadvantages
‣ Aspiration risk!

• Post-pyloroic feeding
◦ Indications
‣ Feeding a functioning GI tract when stomach needs to be bypassed
• GOO (mechanical - pyloric tumour or stricture, functional - critical illness)
• Risk of aspiration with intragastric feeding
‣ When pancreas needs to be bypassed
• Severe pancreatitis
◦ Methods
‣ NJ tube - for short term feeding
‣ Percutaneous endoscopic gastrojejunostomy (PEGJ)
‣ Percutaneous endoscopic jejunostomy (PEJ) for longterm feeding
‣ Open feeding jejunostomy
◦ Advantages
‣ Less aspiration risk
◦ Disadvantages
‣ Less physiological
Details about each type
• NG
◦ 2 types
‣ Fine bore tubes - for feeding (even in patients with varices, this can be safely passed)
‣ Wide bore tubes (Ryles) - for aspiration (since this can cause damage to oesophagus and later strictures should it
be kept for longer times, it shouldn't be used for feeding)
• PEG
◦ Details in PEG insertion operative notes
• NJ
◦ Bengmark is a specifically made NJ tube
◦ It will spontaneously cross the pylorus in 70-80% of patients with normal gasproduodenal motility, specially with
metoclopramide 10mg
◦ If stomach is atonic, NJ placement should be done with endoscopy help
‣ Distal end should be kept beyond the DJ flexure, otherwise it will definitely come back to the stomach
◦ Plane X-ray abdomen is needed to ensure placement
• PEGJ and PEJ
◦ No real benefit over an open jejunostomy tube unless the patient is not fit for GA
• Surgical jejunostomy
◦ Needle jejunostomies inserted using a large needle tunnelled subserosally
‣ Better in terms of leakage
‣ But if poorly managed easily blocked
◦ Insertion of Foley catheter
‣ Leakage is high

Types of enteral feeds

• Polymeric feeds
◦ Contains whole protein, CHO, fat at a standard energy supplementation of 1Kcal/mL
• Elemental feeds
◦ Protein in amino acid form, CHO in glucose form, and very low fat
◦ Useful in
‣ malabsorption
‣ Crohn's disease
◦ Because they are in high osmolality should not be used in short bowel syndrome
• Disease specific foods
◦ High energy and low electrolyte diets for dialysis patients
◦ Low CHO and high fat diets for CO2 retention patients (those on ventilators)
• Immune-modulating feeds
◦ Contain substrates that can alter the immune and inflammatory response
‣ Glutamine, arginine, RNA, omega-3 FA, antioxidants

Precautions when giving enteral feeds

• Ensure placement of the tube
• Should be fed in 30-45º reclined position ideally
• Continuous pump infusion or intermittent bolus (50-250mL) over 10-30 minutes by syringe
• Wash tube before and after feeds, and every 4-6 hourly also!

Complications of enteral feeding

• Caused by the feeds
◦ Diarrhoea
‣ Commonest complication - 5-60%
‣ Due to increased osmoles and dumping syndrome
‣ Should exclude other explanations first
• Clostridium difficile
• Colitis
• Malabsorption
‣ Treatment
• Antidiarrhoeal medication
• Try post-pyloric enteral feeding
• Failing which parenteral feeding has to be started
 ◦ Constipation
‣ Due to reduced water and opiates
‣ Management
• Laxatives
• Fiber
◦ Vomiting and aspiration
‣ This is mainly with NG and PEG
‣ Management
• Patient should be fed reclined at 30-45º
• Antiemetic and prokinetics
• Change from bolus to continuous feeding
• Convert to post pyloric feeding
◦ Metabolic complications
‣ Over feeding
• Giving calories in excess can cause fatal metabolic complications
◦ This can occur when we forget that patients also get energy from non-feed sources like propofol,
glucose in dialysate
• Hyperglycaemia
• Hypercapnoea
◦ Because CHO in diet also greatly contributes to CO2
◦ Can cause problems with weaning from the ventilator
• Hypertonic dehydration
◦ Occurs in those who are dehydrated and consume excess protein which leads to inability to excrete
nitrogenous waste
‣ Refeeding syndrome
• Severe fluid and electrolyte shifts occurring in malnourished patients undergoing refeeding
• Excess CHO stimulates insulin release → substantial cellular uptake phosphate, magnesium, potassium
◦ Leads to hypophosphatemia
◦ Hypomagnesaemia
◦ Hypokalaemia
• Can cause dangerous cardiac arrhythmia and neurological events
• Prevention
◦ Emaciated patients should not be over fed! Their initial feeding should not exceed > 20Kcal/kg
◦ Phosphate, magnesium and potassium should be monitored daily
‣ Vitamin and trace element deficiency
• Caused by the tubes
◦ NG/NJ
‣ Removal by patient
‣ Oesophageal ulceration and stricture
‣ Malpositioning
• To lung
• Intracranially
‣ Blockage
• To prevent tubes should be flushed before starting and after completion of a feed, before and after
medication, every 4-6 hourly also
• If blocked can use soda water or pancreatic enzymes can be used to break the protein coagulum
◦ Cola drinks should not be used as it can exacerbate the problem
◦ PEG/PEGJ/PEJ
‣ Early ‣ Late
• Pain • Stoma infection
• Haemorrhage • Tube blockage
• Peritonitis • Aspiration
• Pneumoperitoneum • Buried bumper syndrome
• Gastrocolic fistula due to ◦ Migration of internal fixator in to the plane between
inter positioning of the the stomach and the anterior abdominal wall.
colon between abdominal ◦ Surgery is required to remove this
wall and stomach • Tumour tract seeding
• Overgranulation at the stoma site causing bleeding or pain
◦ Steroid cream/silver nitrate
 (3) PARENTERAL NUTRITION
Types of PN and their role
• As primary therapy (Total parenteral nutrition - TPN)
◦ In gastrointestinal-cutaneous fistula
‣ Allows bowel rest
‣ Reduces fistula output
‣ Improves nutritional status
‣ Facilitates fistula closure
‣ But has not improved mortality
◦ In short bowel syndrome
◦ In ARF
‣ Has shown to reduce mortality
‣ Specially in acute tubular necrosis, PN has shown to facilitate early recovery
◦ In hepatic insufficiency
‣ These patients need protein to ameliorate malnutrition
‣ But they are also intolerant to protein due to encephalopathy
‣ So need to give solutions enriched with branched chain AA and decreased aromatic AA
◦ In IBD
‣ Allows bowel rest
‣ Improves nutritional status → optimises for surgery
• As secondary therapy (Supportive parenteral nutrition - SPN)
◦ Radiation enteritis and chemotherapy toxicity
◦ Prolonged ileus
◦ Preoperative support for severely malnourished patient
‣ Risk of infection with PN should be weighed against benefits of nutritional supplementation
‣ Optimum duration for preoperative nutritional repletion is not known, but usually between 7-10 days!
◦ Pancreatitis
‣ PN does not alter the course of acute pancreatitis
‣ Enteral route is preferred to prevent bacterial translocation
‣ But in severe pancreatitis, PN can be supportive
◦ Respiratory insufficiency
‣ If overfed CHO, CO2 retention occurs
‣ Branched chain AA appears to increase ventilatory drive
◦ Cancer
‣ Only indication for PN is when patient is so severely malnourished that they won't survive the surgery or RT/CT

Route of delivery
• Peripheral PN
◦ Useful when PN is needed only for a brief period (<2/52)
◦ But proper peripheral cannula care is needed to prevent peripheral thrombophlebitis
• Central PN
◦ Via a catheter placed in to a central vein terminating in the vena cava
‣ Temporary catheter
• PN for short period of time
• Can be done as a bed side procedure
• Using subclavian vein or IJV
‣ Indwelling catheter
• PN for prolong period of time
• Placed in the operating theatre
• Catheter is tunnel to an exit site in the skin
PN formulations
• CHO
◦ Always given as Dextrose
◦ Concentrations
‣ Usual 15%
‣ Renal formulations 47%
‣ Peripheral formulations 5%
• AA
◦ Given either as a
‣ Balanced composition
‣ Special composition in disease specific formulas (Hepatic PN formula, Renal PN formula)
• Lipids
◦ Concentration - 10-20%
◦ Can be given
‣ As separate lipid infusion (lipofundin)
‣ In the same solution as dextrose and AA
• Vitamins
◦ Vitamin K should be given weekly
• Insulin
◦ Since many patients who are on PN will develop abnormal CHO metabolism, intermittent insulin injections are
necessary
• Electrolytes
◦ Depending on levels, should be modified

Administration
• Catheter placement
• Position confirmation by X-ray
• Initiation
◦ First infusion is started at a rate of 40-50 mL/hr
◦ Then gradually rate can be increased by 20-25 mL every 8-24 hourly provided blood glucose is okay, until energy
requirement is met
• Monitoring
◦ Before initiation - weight, vital sings, baseline lab tests done
◦ After initiation
‣ vital signs, input/output measured every 8 hours!
◦ Glucose measure twice daily
◦ Weight is measured 3 times a week
◦ Electrolytes obtained EOD

Conversion after longterm TPN

• Once 75% of the calorie requirement is met by TPN, enteral feeding can be started
• Once 75% calorie requirement is met by enteral feeding, oral can be started

Complications
• Related to catheter insertion
◦ Pneumothorax (5% of CV line insertions)
◦ Arterial lacerations
◦ Haemothorax
◦ Hydrothorax (infusing directly in to the pleural cavity)
◦ Thoracic duct injury during L/s catheterisation
◦ Air embolism
◦ Guidewire embolism

• Vein complications
◦ Subclavian vein thrombosis
‣ It's a late complication
‣ Occurs in 5-10%
‣ Suspect when
• pain at the base of the neck
• upper arm swelling
‣ Management
• If thrombus suspected → remove catheter
• Confirm diagnosis with imaging
• Consider thrombolysis
• Start the patient on anticoagulation → continue for 6 months
◦ Septic thrombosis
‣ Life threatening
‣ Management
• Antibiotics
• Anticoagulation
• If no improvement with these two → consider Fogarty catheter embolectomy
• Septic complications
◦ These are responsible for most PN related deaths
◦ Bacteremia
‣ This is directly related to catheter sepsis, which is due to poor catheter care!
‣ If a patient who is on PN gets fever
• Stop PN
• Take solution and tubing for culture
• Start a new solution with a new tubing
• Obtain blood culture also → and start empiric antibiotics
◦ if blood culture shows gram +ve bacteremia
‣ remove the catheter over a guide wire, send the tip for culture, and reinsert a new catheter over
the guide wire
‣ If the catheter tip became positive, catheter should be removed completely
◦ If culture shows Gram negative bacteremia - catheter removal is not necessary as they don't implant easily -
giving antibiotics is enough!
◦ Fungemia
‣ Candida enters the blood stream through the GIT
‣ Candida colonisation = positive cultures at 2 separate sites (eg: Skin, Urine), patient should be treated with anti
fungal agents
‣ If candida is detected in the blood
• CV line should be removed
• All IV nutritional regimes should be stopped
• IV antifungals should be started
• Metabolic complications
◦ Electrolyte abnormalities
‣ Hyper/hypokalemia
‣ Hyper/hyponatremia
◦ Hyperglycemia/Hypoglycemia
◦ Liver dysfunction
‣ Cholestasis (decreased bile flow due to impaired secretion by hepatocytes)
‣ Biliary sludge and acalculus cholecystitis
‣ Steatosis (fatty liver)
‣ Elevated liver enzymes (but bilirubin doesn't increase)
‣ Hepatomegaly
◦ Deficiency states
‣ Essential fatty acid deficiency - flaky skin and alopecia
‣ Zinc deficiency - poor wound healing, taste disturbances, darkened skin creases, perioral pustular rash
◦ Refeeding syndrome