For the Surgical Patient

Kelly Sparks LDN, RD

 Lecture Outline

Energy Sources
Nutrition Requirements
Diet Advancement
Micronutrients for wound healing
Enteral versus Parenteral Nutrition
Case studies
 Energy Sources
Carbohydrates
Limited storage capacity, needed for CNS function
Yields 3.4 kcal/gram
Pitfall: too much=lipogenesis and increased CO2 production
Fats
Major endogenous fuel source in healthy adults
Yields 9 kcal/gm
Pitfall: too little=essential fatty acid (linoleic acid deficiency-dermatitis
and increased risk of infections
Protein
Needed to maintain anabolic state (match catabolism)
Yields: 4 kcal/gm
Pitfall: must adjust in patient with renal and hepatic failure
Elevated creatinine, BUN, and/or ammonia
 Nutrition Requirements
Healthy Adults
Calories: 25-35 kcals/kg
Protein: 0.8-1 gm/kg
Fluids: 30 mls/kg
Requirement Change for the Surgical Patient
Special Considerations
Stress
Injury or disease
Surgery

Pre-hospital/pre-surgical nutrition
 Nutrition

The surgical patient

Extraordinary stressors (hypovolemia,
hypervolemia, bacteremia, medications)
Wound Healing
Anabolic state, appropriate vitamins (A, C, Zinc), and
adequate kcals/protein.
Poor Nutrition=Poor Outcomes
For every gram deficit of untreated
hypoalbuminemia there is ~30% increase in
mortality
 Post-Operative Nutrition Requirements

Calories:
Increase to 30-40 kcals/kg
Patient on ventilator usually require less
calories ~20-25 kcal/kg
Protein:
Increase to 1-1.8 grams/kg
Fluids:
Individualized
 Diet Advancement

Traditional Method:
Start clear liquids when signs of bowel function
returns.
Rationale: Clear liquid diets supply fluid and
electrolytes in a form that require minimal digestion
and little stimulation of the GI tract.
Clear liquids are intended for short-term use due to
inadequacy
 Diet Advancement

Recent Evidence:
Suggests that liquid diets and slow diet progression
may not be warranted!!
Clinical study:
Looked at early post-operative feeding using
regular diets or very fast progression vs. traditional
methods of NPO until bowel function with slow diet
progression and found no difference in post-
operative complications. (emesis, distention, NGT
reinsertion, LOS,)
 Keep in Mind

Per SLP
When using liquid diets, patients must have
adequate swallowing functions.
Even patients with mild dysphagia often require
thickened liquids.
Therefore, be specific in writing liquid diet orders
for patients with dysphagia
 Micronutrients in Wound Healing

Vitamin Supplementation to promote healing

has been somewhat disputed.
Some studies show no significant effect unless
there is a clinical vitamin deficiency
Serum vitamin levels are not always accurate;
therefore, must use subjective diet history and
clinical judgment to determine deficiency.
 Key Nutrients for Wound Healing

Vitamin A:
Cellular differentiation, proliferation, epithelialization,
collagen synthesis, counteract catabolic effect of steroids.
RDA=3333 International Units
Appropriate dose=25,000 IU per day x 10 days in setting of high dose
steroids or deficiency.
Avoid long term supplementation due to high risk of toxicity with fat-
soluble vitamins.

No vitamin A with renal failure due to greater potent ional for

toxicity. (Can exceed the binding capacity of retinol binding
protein leading to elevated circulating levels.)
 Key Nutrients for Wound Healing

Vitamin C:
Collagen synthesis
RDA=50-90 mg/day
Low levels are common in high risk population (elderly,
smokers, cancer, liver disease).
Appropriate dose: 500 mg x 10 days

No vitamin C with renal failure due to risk for renal

oxalate stone formation.
 Key Nutrients for Wound Healing
Zinc:
Protein synthesis, cellular replication, collagen formation; large
wounds, chest tubes, and wound drains contribute to further zinc
loses.
Appropriate dose: 220 mg per day of Zinc Sulfate or
50 mg of elemental Zinc x 10 days.
Prolonged Zinc supplementation interferes with copper
absorption and can lead to copper deficiency which delays wound
healing by impairing collagen synthesis.
MVI with minerals:
1 tablet daily to compensate for any general micronutrient losses.
 What is nutrition support?
An alternate means of providing nutrients to people who cannot eat
any or enough food

When is it needed?
Illness resulting in inability to take in adequate nutrients by
mouth
Illness or surgery that results in malfunctioning gastrointestinal
tract

Two types:
Enteral nutrition
Parenteral nutrition
 Indications for Enteral Nutrition

Malnourished patient expected to be unable to

eat adequately for > 5-7 days
Adequately nourished patient expected to be
unable to eat > 7-9 days
Adaptive phase of short bowel syndrome
Following severe trauma or burns
 Contraindications to Enteral Nutrition Support

Malnourished patient expected to eat within 5-7 days

Severe acute pancreatitis
High output enteric fistula distal to feeding tube
Inability to gain access
Intractable vomiting or diarrhea
Aggressive therapy not warranted
Expected need less than 5-7 days if malnourished or
7-9 days if normally nourished
 Enteral Access Devices
Nasogastric
Nasoenteric
Gastrostomy
PEG (percutaneous endoscopic gastrostomy)
Surgical or open gastrostomy
Jejunostomy
PEJ (percutaneous endoscopic jejunostomy)
Surgical or open jejunostomy
Transgastric Jejunostomy
PEG-J (percutaneous endoscopic gastro-jejunostomy)
Surgical or open gastro-jejunostomy
 Feeding Tube Selection

Can the patient be fed into the stomach, or is

small bowel access required?

How long will the patient need tube feedings?

 Gastric vs. Small Bowel Access

If the stomach empties, use it.

Indications to consider small bowel access:

Gastroparesis / gastric ileus
Recent abdominal surgery
Sepsis
Significant gastroesophageal reflux
Pancreatitis
Aspiration
Ileus
Proximal enteric fistula or obstruction
 Short-Term vs. Long-Term
Tube Feeding Access

No standard of care for cut-off time between

short-term and long-term access

However, if patient is expected to require

nutrition support longer than 6-8 weeks, long-
term access should be considered
 Choosing Appropriate Formulas

Categories of enteral formulas:

Polymeric (Jevity)
Whole protein nitrogen source, for use in patients with normal
or near normal GI function
Monomeric or elemental (Perative, Optimental)
Predigested nutrients; most have a low fat content or high % of
MCT oil (medium-chain triglycerides); for use in patients with
severely impaired GI function
Disease specific (Nepro, Nutrahep, Glucerna)
Formulas designed for feeding patients with specific disease
states
Formulas are available for respiratory disease, diabetes, renal
failure, hepatic failure, and immune compromise
*well-designed clinical trials may or may not be available
 Enteral Nutrition Prescription Guidelines
Gastric feeding
Continuous feeding:
Start at rate 30 mL/hour
Advance in increments of 20 mL q 8 hours to goal
Check gastric residuals q 4 hours
Bolus feeding:
Start with 100-120 mL bolus
Increase by 60 mL q bolus to goal volume
Typical bolus frequency every 3-8 hours
Small bowel feeding
Continuous feeding only; do not bolus due to risk of dumping
syndrome
Start at rate 20 mL/hour
Advance in increments of 20 mL q 8 hours to goal
Do not check gastric residuals
 Aspiration Precautions

To prevent aspiration of tube feeding, keep

HOB > 30 at all times

Do not use methylene blue to test for

aspiration; regular blue food dye OK but not
proven effective method of detecting
aspiration
 Complications of Enteral Nutrition Support

Nausea and vomiting / delayed gastric

emptying
Malabsorption
Common manifestations include unexplained weight
loss, steatorrhea, diarrhea
Potential causes include gluten sensitive
enteropathy, Crohns disease, radiation enteritis,
HIV/AIDS-related enteropathy, pancreatic
insufficiency, short gut syndrome
 Enteral Nutrition Case Study
78-year-old woman admitted with new CVA
Significant aspiration detected on bedside swallow
evaluation and confirmed with modified barium
swallow study; speech language pathologist
recommended strict NPO with alternate means of
nutrition
PEG placed for long-term feeding access
Plan of care is to stabilize the patient and transfer her
to a long-term care facility for rehabilitation
 Enteral Nutrition Case Study (continued)

Height: 54 IBW: 120# +/- 10%

Weight: 130# / 59kg 100% IBW
BMI: 22
Usual weight: ~130# no weight change
Estimated needs:
1475-1770 kcal (25-30 kcal/kg)
59-71g protein (1-1.2 g/kg)
1770 mL fluid (30 mL/kg)
 Steps to determine the Enteral Nutrition
Prescription

1. Estimate energy, protein, and fluid needs

2. Select most appropriate enteral formula
3. Determine continuous vs. bolus feeding
4. Determine goal rate to meet estimated needs
5. Write/recommend the enteral nutrition
prescription
 Enteral Nutrition Prescription
Tube feeding via PEG with full strength
Jevity 1.2
Initiate at 30 mL/hour, advance by 20 mL q 8 hours
to goal
Goal rate = 55 mL/hour continuous infusion
Above goal will provide 1584 kcal, 73g protein, 1069 mL free
H2O
Give additional free H2O 175 mL QID to meet
hydration needs and keep tube patent
Check gastric residuals q 4 hours; hold feeds for
residual > 200 mL
Keep HOB > 30 at all times
 What is parenteral nutrition?

Parenteral Nutrition
also called "total parenteral nutrition," "TPN," or
"hyperalimentation."
It is a special liquid mixture given into the blood via
a catheter in a vein.
The mixture contains all the protein, carbohydrates,
fat, vitamins, minerals, and other nutrients needed.
Indications for Parenteral Nutrition Support

Malnourished patient expected to be unable to

eat > 5-7 days AND enteral nutrition is
contraindicated
Patient failed enteral nutrition trial with
appropriate tube placement (post-pyloric)
Enteral nutrition is contraindicated or severe
GI dysfunction is present
Paralytic ileus, mesenteric ischemia, small bowel
obstruction, enteric fistula distal to enteral access
sites
 PPN vs. TPN
TPN (total parenteral nutrition)
High glucose concentration (15%-25% final dextrose
concentration)
Provides a hyperosmolar formulation (1300-1800 mOsm/L)
Must be delivered into a large-diameter vein through central
line.
PPN (peripheral parenteral nutrition)
Similar nutrient components as TPN, but lower concentration
(5%-10% final dextrose concentration)
Osmolarity < 900 mOsm/L (maximum tolerated by a
peripheral vein)
May be delivered into a peripheral vein
Because of lower concentration, large fluid volumes are
needed to provide a comparable calorie and protein dose as
TPN
 Parenteral Access Devices

Peripheral venous access

Catheter placed percutaneously into a peripheral
vessel
Central venous access (catheter tip in SVC)
Percutaneous jugular, femoral, or subclavian
catheter
Implanted ports (surgically placed)
PICC (peripherally inserted central catheter)
 Writing TPN prescriptions
1. Determine total volume of formulation based on individual
patient fluid needs
2. Determine amino acid (protein) content
Adequate to meet patients estimated needs
3. Determine dextrose (carbohydrate) content
~70-80% of non-protein calories
4. Determine lipid (fat) content
~20-30% non-protein calories
5. Determine electrolyte needs
6. Determine acid/base status
7. Check to make sure desired formulation will fit in the total
volume indicated
 Parenteral Nutrition Monitoring
Check daily electrolytes and adjust TPN/PPN electrolyte
additives accordingly
Check accu-check glucose q 6 hours (regular insulin may be added to
TPN/PPN bag for glucose control as needed)
Non-diabetics or NIDDM: start with half of the previous days sliding
scale insulin requirement in TPN/PPN bag and increase daily in the
same manner until target glucose is reached
IDDM: start with 0.1 units regular insulin per gram of dextrose in
TPN/PPN, then increase daily by half of the previous days sliding
scale insulin requirement
Check triglyceride level within 24 hours of starting TPN/PPN
If TG >250-400 mg/dL, lipid infusion should be significantly reduced
or discontinued
Consider adding carnitine 1 gram daily to TPN/PPN to improve lipid
metabolism
~100 grams fat per week is needed to prevent essential fatty acid
deficiency
Parenteral Nutrition Monitoring (continued)

Check LFTs weekly

If LFTs significantly elevated as a result of TPN, then
minimize lipids to < 1 g/kd/day and cycle TPN/PPN over 12
hours to rest the liver
If Bilirubin > 5-10 mg/dL due to hepatic dysfunction, then
discontinue trace elements due to potential for toxicity of
manganese and copper
Check pre-albumin weekly
Adjust amino acid content of TPN/PPN to reach normal pre-
albumin 18-35 mg/dL
Adequate amino acids provided when there is an increase in
pre-albumin of ~1 mg/dL per day
 Parenteral Nutrition Monitoring
(continued)

Acid/base balance
Adjust TPN/PPN anion concentration to maintain
proper acid/base balance
Increase/decrease chloride content as needed
Since bicarbonate is unstable in TPN/PPN
preparations, the precursoracetateis used; adjust
acetate content as needed
Complications of Parenteral Nutrition

Hepatic steatosis
May occur within 1-2 weeks after starting PN
May be associated with fatty liver infiltration
Usually is benign, transient, and reversible in
patients on short-term PN and typically resolves in
10-15 days
Limiting fat content of PN and cycling PN over 12
hours is needed to control steatosis in long-term PN
patients
 Complications of Parenteral Nutrition Support
(continued)

Cholestasis
May occur 2-6 weeks after starting PN
Indicated by progressive increase in TBili and an elevated serum
alkaline phosphatase
Occurs because there are no intestinal nutrients to stimulate
hepatic bile flow
Trophic enteral feeding to stimulate the gallbladder can be
helpful in reducing/preventing cholestasis
Gastrointestinal atrophy
Lack of enteral stimulation is associated with villus hypoplasia,
colonic mucosal atrophy, decreased gastric function, impaired GI
immunity, bacterial overgrowth, and bacterial translocation
Trophic enteral feeding to minimize/prevent GI atrophy
 Parenteral Nutrition Case Study

55-year-old male admitted with small bowel

obstruction
History of complicated cholecystecomy 1
month ago. Since then patient has had poor
appetite and 20-pound weight loss
Patient has been NPO for 3 days since admit
Right subclavian central line was placed and
plan noted to start TPN since patient is
expected to be NPO for at least 1-2 weeks
 Parenteral Nutrition Case Study
(continued)

Height: 60 IBW: 178# +/- 10%

Weight: 155# / 70kg 87% IBW
BMI: 21
Usual wt: 175# 11% wt loss x 1 mo.
Estimated needs:
2100-2450 kcal (30-35 kcal/kg)
84-98g protein (1.2-1.4 g/kg)
2100-2450 mL fluid (30-35 mL/kg)
 Parenteral Nutrition Prescription
TPN via right-SC line
2200 mL total volume x 24 hours
Amino acid: 45 g/liter=
45g x 2.2 L= 99 grams x 4 kcals/gram =369 kcals
Dextrose 175 g/liter=
175g x 2.2 L= 385 grams x 3.4 kcals/gram= 1309 kcals
Lipid 20% 285 mL over 24 hours
285 mls x 2= 570 kcals
Above will provide 2275 kcal, 99g protein,
DIR=(385 g dex/ 70 kg /1440 minute in a day)*1000=
3.8mg/kg/min
LIR= (285 mls lipid * 20%)/ 70 kg=0.8 g/kg/day
 Parenteral Nutrition Prescription
Important items to consider:
Dextrose infusion rate should be < 4 mg/kg/minute
(maximum tolerated by the liver) to prevent hepatic
steatosis
Lipid infusion rate should be less than 1 g/kg/day to
minimize/prevent TPN-induced liver dysfunction
You may need to adjust/eliminate lipids if patient is
on propofol. (1 ml propofol =1.1 kcal)
Ex. Propofol @ 10 ml/hr would provide 264 kcals
(10 ml/hr x 1.1 kcal/ml, x 24 hrs)
Initiate TPN at ~ of goal rate/concentration and
gradually increase to goal over 2-3 days to optimize
serum glucose control
 Benefits of Enteral Nutrition
Over Parenteral Nutrition

Cost
Tube feeding cost ~ $10-20 per day
TPN costs up to $1000 or more per day!
Maintains integrity of the gut
Tube feeding preserves intestinal function; it is more physiologic
TPN may be associated with gut atrophy
Less infection
Enteral feedingvery small risk of infection and may
prevent bacterial translocation across the gut wall
TPNhigh risk/incidence of infection and sepsis
 Refeeding Syndrome
the metabolic and physiologic consequences of
depletion, repletion, compartmental shifts, and
interrelationships of phosphorus, potassium, and
magnesium
Severe drop in serum electrolyte levels resulting from
intracellular electrolyte movement when energy is
provided after a period of starvation (usually > 7-10
days)
Physiologic and metabolic sequelae may include:
EKG changes, hypotension, arrhythmia, cardiac arrest
Weakness, paralysis
Respiratory depression
Ketoacidosis / metabolic acidosis
 Refeeding Syndrome (continued)

Prevention and Therapy

Correct electrolyte abnormalities before starting
nutrition support
Continue to monitor serum electrolytes after nutrition
support begins and replete aggressively
Initiate nutrition support at low rate/concentration
(~ 50% of estimated needs) and advance to goal
slowly in patients who are at high risk
 Consequences of Over-feeding
Risks associated with over-feeding:
Hyperglycemia
Hepatic dysfunction from fatty infiltration
Respiratory acidosis from increased CO2 production
Difficulty weaning from the ventilator

Risks associated with under-feeding:

Depressed ventilatory drive
Decreased respiratory muscle function
Impaired immune function
Increased infection
 Questions

Reference:
American Society for Parenteral and Enteral Nutrition. The Science and Practice of Nutrition
Support. 2001.
Han-Geurts, I.J, Jeekel,J.,Tilanus H.W, Brouwer,K.J., Randomized clinical trial of patient-
controlled versus fixed regimen feeding after elective abdominal surgery. British Journal of
Surgery. 2001, Dec;88(12):1578-82
Jeffery K.M., Harkins B., Cresci, G.A., Marindale, R.G., The clear liquid diet is no longer a
necessity in the routine postoperative management of surgical patients. American Journal of
Surgery.1996 Mar; 62(3):167-70
Reissman.P., Teoh, T.A., Cohen S.M., Weiss, E.G., Nogueras, J.J., Wexner, S.D. Is early oral
feeding safe after elective colorectal surgery? A prospective randomized trial. Annals of
Surgery. 1995 July;222(1):73-7.
Ross, R. Micronutrient recommendations for wound healing. Support Line. 2004(4): 4.