NUTRITION IN THE SURGICAL

PATIENT
Azis S. Santican, MD, FPCS, FPSGS, FPALES, FICS
Goal of Nutritional Support
• Prevent or Reverse the Catabolic Effects Of
Disease Or Injury

• the ultimate validation for nutritional support

in surgical patients should be Improvement in
clinical outcome and restoration of function
 Estimation of Energy Requirements
• All patients admitted to the hospital should have
their nutritional status assessed
• to determine the:
• severity of nutrient deficiencies or excess
• To aid in predicting nutritional requirements
Estimation of Energy Requirements
• Pertinent information include:
• presence of weight loss
• chronic illnesses
• or dietary habits that influence the quantity and quality of
food intake
• Social habits predisposing to malnutrition
• the use of medications that may influence food intake or
urination should also be investigated
Estimation of Energy Requirements
• Physical Examination
• assess loss of muscle and adipose tissues
• organ dysfunction
• and subtle changes in skin, hair, or neuromuscular
function reflecting frank or impending nutritional
deficiency
 Estimation of Energy Requirements
• biochemical determinations
• Anthropometric data:
• weight change
• skinfold thickness
• and arm circumference muscle
area
• creatinine excretion
• albumin level
• prealbumin level
• total lymphocyte count and
transferrin level may be used to
substantiate
 Estimation of Energy Requirements

• For critically ill and injured patients

• validated scoring systems such as the Nutritional Risk Screening (NRS) or the
245

Nutrition Risk in the Critically Ill (NUTRIC)

• should be performed in conjunction with assessment of GI tract function and risk
of aspiration

• Appreciation for the stresses and natural history of the disease process
• combination with nutritional assessment, remains the basis for identifying
patients in acute or anticipated need of nutritional support
Estimation of Energy Requirements
• fundamental goal of nutritional support:
• meet the energy requirements for essential metabolic processes
and tissue repair
• Failure to provide adequate nonprotein energy sources
• will lead to consumption of Lean tissue stores
Estimation of Energy Requirements
• indirect calorimetry
• gold standard in hospitalized patients and is recommended for the
critically ill
• However, the use of indirect calorimetry, particularly in the
critically ill patient, may not be available or feasible
• lead to an overestimation of caloric requirements, which has
been associated with increased risk of infectious
complications
Estimation of Energy Requirements
• Alternately, a simple weight-based equation with current
recommendations from ASPEN (American Society of Parenteral and
Enteral Nutrition)
Estimation of Energy Requirements
• second objective of nutritional support:
• to meet the substrate requirements for protein synthesis

• Protein nutritional support is especially important for maintaining immune

function and lean body mass and is more closely linked to positive outcomes
than total caloric intake
• Mean requirement = 0.8 g/kg per day
Vitamins and Minerals
• can be met easily in the average patient with an uncomplicated
postoperative course
• vitamins usually are not given in the absence of preoperative
deficiencies
• Patients maintained on elemental diets or parenteral
hyperalimentation
• require complete vitamin and mineral supplementation
Vitamins and Minerals
• It is necessary to ensure that adequate replacement is available in the
diet or by supplementation
• Numerous commercial vitamin preparations are available for
intravenous or intramuscular use
• most do not contain vitamin K and some do not contain vitamin B or folic
acid
Vitamins and Minerals
• Supplemental trace minerals
• intravenously via commercial preparations
• Essential fatty acid supplementation
• may be necessary patients with depletion of adipose stores
Overfeeding
• results from overestimation of caloric needs, as occurs when actual
body weight is used to calculate the BEE such as the critically ill with
significant fluid overload and the obese
• Estimated dry weight should be obtained from preinjury records or
family members
Overfeeding
• Overfeeding may contribute to clinical deterioration:
• increased oxygen consumption
• increased carbon dioxide production
• prolonged need for ventilatory support, fatty liver, suppression of
leukocyte function, hyperglycemia, and
• increased risk of infection
ENTERAL NUTRITION
• Enteral nutrition (EN) is preferred over parenteral nutrition (PN)
• lower cost of enteral feeding
• Associated risks of the intravenous route, including vascular access
complications

• Consequences of gastrointestinal tract disuse:

• diminished soluble IgA production and cytokine production
• bacterial overgrowth
• altered mucosal barrier function and immune defenses
ENTERAL NUTRITION
• EN is recommended as the first choice for nutritional support in
patients who can tolerate it
• benefits of enteral feeding in patients undergoing elective surgery
appear to be linked to their preoperative nutritional status
• studies comparing postoperative enteral and parenteral nutrition in
patients undergoing gastrointestinal surgery:
• reduced infectious complications and acute phase protein production in
those fed by the enteral route
ENTERAL NUTRITION: Early vs. Late Feeding
• Current recommendations support early enteral nutrition (within 48
hours) in critically ill patients
• Early “full nutrition”
• likely to be harmful and is associated with a higher infection rate
• aim therefore is a caloric target below the actual energy expenditure,
with the goal of providing >80% of estimated total energy goals
gradually by 3 to 4 days
ENTERAL NUTRITION: Early vs. Late Feeding
• “permissive underfeeding”
• total calories provided average 1500 kcal/d
• with 40 gm/d of protein from hypocaloric nutrition which has the same total
calories with 140 gm/d protein
• Hypocaloric nutrition
• currently recommended for critically ill obese patients
• also benefit nonobese patients especially during the early acute period of
critical illness
ENTERAL NUTRITION: Early vs. Late Feeding
• Patients undergoing elective surgery
• healthy patients without malnutrition who are undergoing
uncomplicated surgery can tolerate 10 days of partial starvation
(maintenance intravenous fluids only)
• Initiation of enteral nutrition should occur as soon as feasible after
adequate resuscitation, most readily determined by adequate urine
output
ENTERAL NUTRITION: Early vs. Late Feeding
• The presence of bowel sounds and the passage of flatus or stool are
not absolute prerequisites for initiation of enteral nutrition
• but in the setting of Gastroparesis feedings should be administered
distal to the pylorus
• Gastric residuals of 200 mL or more in a 4- to 6-hour period or
abdominal distention
• cessation of feeding and adjustment of the infusion rate
ENTERAL NUTRITION: Early vs. Late Feeding
• Early enteral feeding is also associated in reduced incidence of fistula
formation in patients with open abdomen
• enteral feeding should also be offered to patients with short-bowel
syndrome or clinical malabsorption
• but necessary calories, essential minerals, and vitamins should be
supplemented using parenteral modalities
ENTERAL NUTRITION: Intermittent vs.
Continuous Enteral Feeding
• Enteral nutrition can be administered either continuously or
intermittently
• standard choice for critically injured adults:
• continuous enteral feeding (CEF)
• lower complication rates
• promote protein anabolism by inhibiting protein breakdown
ENTERAL NUTRITION: Enteral Formulas
• “Immunonutrients”
• provision of immunemodulating nutrients, termed
“immunonutrition”
• is one mechanism by which the immune response can be
supported and an attempt made to lower infectious risk
• amino acids (glutamine and arginine)
• lipids (omega-3 PUFAs)
• and micronutrients (e.g.,vitamin C and selenium)
ENTERAL NUTRITION: Enteral Formulas
• “Immunonutrients”
• Glutamine
• most abundant amino acid in the human body
• nearly two thirds of the free intracellular amino acid pool
• a nonessential amino acid
• necessary substrate for nucleotide synthesis in most dividing
cells
• provides a major fuel source for enterocytes
• Stress state - rapidly depleted
ENTERAL NUTRITION: Enteral Formulas
• “Immunonutrients”
• Arginine
• a nonessential amino acid
• Has immunoenhancing properties
• wound-healing benefits
• and association with improved survival in animal models of
sepsis and injury
ENTERAL NUTRITION: Enteral Formulas
• “Immunonutrients”
• omega-3 polyunsaturated fatty acids (PUFAs, canola oil, or
fish oil)
• reduces the proinflammatory response from prostaglandin
production
• However, no demonstrated improvement in respiratory
complications in severe trauma patients and possible benefits
in patients with mild sepsis
ENTERAL NUTRITION: Standard Polymeric
Formulas
• polymeric formulas provide a caloric density from 1 to 2 kcal/mL
• Approximately 1500 to 1800 mL are required to meet daily
requirements
• Compositions:
• baseline carbohydrates, protein, electrolytes, water, fat, and fat-
soluble vitamins (somedo not have vitamin K)
ENTERAL NUTRITION: Fiber-Containing
Formulas
• Isotonic formulas
• Fiber contain soluble and insoluble fiber
• fiber-based solutions delay intestinal transit time and may reduce
the incidence of diarrhea compared with nonfiber solutions
• inclusion of prebiotic fibers with the goal of positively impacting
bacterial targets in the gut as well as gut barrier function
ENTERAL NUTRITION: Immune-Enhancing
Formulas
• Immune-enhancing formulas are fortified with special nutrients that
are purported to enhance various aspects of immune or solid organ
function as previously discussed
• additives include glutamine, arginine, omega-3 fatty acids, and
nucleotides
ENTERAL NUTRITION: Calorie-Dense Formulas
• greater caloric value for the same volume
• provide 1.5 to 2 kcal/mL and therefore are suitable for patients
requiring fluid restriction
• or those unable to tolerate large-volume infusions
• solutions have higher osmolality than standard formulas and are
suitable for intragastric feedings
ENTERAL NUTRITION: High-Protein
Formulas/Bariatric Formulas
• available in isotonic and nonisotonic mixtures
• proposed for critically ill or trauma patients with high protein
requirements
• there has been support for highprotein, hypocaloric feeding in obese
patients
• Enteral formulas termed “bariatric formulas”
• unclear whether clinical outcomes with respect to survival and
infectious complications
 ENTERAL NUTRITION: Elemental Formulas
• predigested nutrients and provide proteins in the form of small
peptides
• Complex carbohydrates are limited, and fat content, in the form of
MCTs and LCTs, is minimal
• primary advantage:
• formula is ease of absorption
• inherent scarcity of fat
• associated vitamins
• and trace elements limits its long-term use as a primary source of nutrients

frequently in patients with malabsorption, gut

impairment, and pancreatitis
ENTERAL NUTRITION: Renal-Failure Formulas
• lower fluid volume and concentrations of potassium, phosphorus,
and magnesium needed to meet daily calorie requirements
• contains essential amino acids and has a high nonprotein-calorie to
nitrogen ratio
• does not contain trace elements or vitamins
ENTERAL NUTRITION: Hepatic-Failure
Formulas
• 50% of the proteins in hepatic-failure formulas are branched-
chain amino acids
• Protein restriction should be avoided
• 1.5 gm protein/kg per day improves clinical outcomes in these patients
• Goal:
• reduce aromatic amino acid levels
• and increase the levels of branched-chain amino acids
• which can potentially reverse encephalopathy in patients with
hepatic failure
Access for Enteral Nutritional Support

•
PARENTERAL NUTRITION
• continuous infusion of a hyperosmolar solution containing
carbohydrates, proteins, fat, and other necessary nutrients through an
indwelling catheter inserted into the superior vena cava

• To obtain the maximum benefit, the calorie to protein ratio must be

adequate (at least 100 to 150 kcal/g nitrogen), and both
carbohydrates and proteins must be infused simultaneously
PARENTERAL NUTRITION

• short-term use of parenteral nutrition (PN) in critically ill patients

(duration of <7 days)

• increased mortality associated with PN may have been associated

with excessive caloric delivery
 Rationale for Parenteral Nutrition
• Indications for parenteral nutrition: whom use of the gastrointestinal
tract for feedings is not possible
• Malnutrition
• Sepsis
• or surgical or traumatic injury in seriously ill
• PN can also be used to supplement EN after 1 week of use if use of EN
is unable to meet >60% of energy and protein requirements
• As with enteral nutrition, the fundamental goals:
• sufficient calories and nitrogen substrate to promote tissue repair
• to maintain the integrity or growth of lean tissue mass
Total Parenteral Nutrition
• also referred to as central parenteral nutrition
• large-diameter vein to deliver the entire nutritional requirements of
the individual
• Dextrose content of the solution is high (15%–25%), and all other
macronutrients and micronutrients - deliverable by this route
Peripheral Parenteral Nutrition

• allows its administration via peripheral veins

• lower osmolarity of the solution used
• Some nutrients cannot be supplemented because they cannot be
concentrated into small volumes
• considered if central routes are not available or if supplemental
nutritional support is required
• used for short periods (<2 weeks)
Complications of Parenteral Nutrition
• Technical Complications:
• sepsis secondary to contamination of the central venous catheter
• earliest signs of systemic sepsis: sudden development of glucose
intolerance
• complications related to catheter placement:
• pneumothorax, hemothorax, hydrothorax, subclavian artery injury,
thoracic duct injury, cardiac arrhythmia, air embolism, catheter
embolism, and cardiac perforation with tamponade
Complications of Parenteral Nutrition

• Metabolic Complications:
• Hyperglycemia – in patients with latent diabetes and in patients
subjected to severe surgical stress or trauma
• hepatic steatosis or marked glycogen deposition
• Cholestasis and formation of gallstones
• Mild but transient abnormalities of serum transaminase, alkaline
phosphatase, and bilirubin levels
Complications of Parenteral Nutrition

• Intestinal Atrophy - Lack of intestinal stimulation

• intestinal mucosal atrophy
• diminished villous height
• bacterial overgrowth
• reduced lymphoid tissue size
• reduced immunoglobulin A production
• and impaired gut immunity
• “Educating the mind without educating the heart is no
education at all.”
― Aristotle

• Thank you!