Nutrition Support of the

Surgical Patient

Randa Jaroudi, Pharm.D

Clinical Coordinator
TPN Coordinator
KKUH
Nutrition

Nutrition allows the body to be provided with all

basic nutrients substrates and energy required for
maintaining or restoring all vital body functions
from carbohydrate and fat and for building up
body mass from amino acid.
Malnutrition

Malnutritioncome from extended inadequate

intake of nutrient or severe illness burden on the
body composition and functionaffect all systems
of the body
Type of Malnutrition
Marasmus
Protein calorie malnutrition
The patient's oral diet may include an acceptable
protein:calorie ratio but is inadequate in quantity and calories.

(depleted somatic proteins, normal visceral proteins)

Normal Albumin and transferrin
Patients look thin and malnourished.

e.g. Patients with mild to moderate starvation, common severe burns,

injuries, systemic infections, cancer etc or conditions where patient
does not eat like anorexia nervosa
Clinical Manifestations

Weight loss
Reduced basal metabolism
Depletion skeletal muscle and adipose (fat) stores
Decrease tissue turgor
Bradycardia
Hypothermia
Type of Malnutrition
Kwashiorkor (Kwa-shior-kor)
Protein malnutrition
the diet contains various amounts of nonprotein calories
(inadequate, adequate, or excessive) from carbohydrates and fats,
but is deficient in total protein and essential amino acids.

(normal somatic proteins depleted visceral proteins)

Serum Albumin and transferrin
Patients appear normal or overweight

e.g. Hypercatabolic critical care patients, chronic diarrhea, chronic kidney

disease, trauma , burns, hemorrhage, and liver cirrhosis
Clinical Manifestations

Marked hypoalbuminemia
Anemia
Edema and ascites
Muscle atrophy
Delayed wound healing
Impaired immune function
Diagnosis
Mixed
Marasmus-Kwashiorkor:
(depleted somatic and visceral proteins)
All above data are reduced
Patients appear cachexic and severely malnourished.
e.g. *Chronic hypercatabolic patients (250 to 500g loss of weight)
*Prolonged starvation

Marasmic-kwashiorkor is a mixed form of any PCM

symptoms.
It frequently occurs when the marasmic patient experiences
the catabolic stress of illness or trauma.
Medical causes (Risk factors for malnutrition)

Recent surgery or trauma

Sepsis
Chronic illness
Gastrointestinal disorders
Anorexia, other eating disorders
Dysphagia
Recurrent nausea, vomiting, or diarrhea
Pancreatitis
Inflammatory bowel disease
Gastrointestinal fistulas
Cancer
 Metabolic Rate
Major burn Sepsis Trauma Partial starvation Total starvation
180
Resting metabolism (% of normal)

160

140

120

100 Normal range

80

60
0 10 20 30 40 50
Days Long CL, et al. JPEN 1979;3:452-6
 Protein Catabolism
Major burn Trauma Sepsis Partial starvation Total starvation

30
Nitrogen excretion (g/day)

25

20

15

10 Normal range

0
0 10 20 30 40
Days
Long CL. Contemp Surg 1980;16:29-42
The Goals of Preoperative Nutrition
Support

surgical mortality
surgical complications and infection
Reduce the catabolic state and restore anabolism
the hospital length of stay
Speed the healing/recovery process
 Indications
Aggressive nutritional support (enteral or
parenteral) should be considered in minimum 3
of:
Looks clinically malnourished.
Has a low serum albumin <3.5g/dL.
Has a recent loss of 10% or greater within
Has a history of recent poor intake.
Who as a consequence of his illness is going to be or
has been NPO for 5-7 days.

The term If gut works, use it remains the golden rule. However, recently this was
changed to: If gut works use it; and if gut works partially, use it partially.
 Preoperative Nutrition Assessment-1
1. Medical & Nutritional History
Medical history includes acute or chronic disease, medication,
surgeries, & other therapies (i.e., chemotherapeutics,
immunosuppressive)

Nutrition History includes recent changes in appetite or

weight, activity level, use of diet.

Subject Global Assessment (SGA)

 Preoperative Nutrition Assessment-2
2. Physical examination
Logical assessment from head to toe

3. Anthropometric parameters
% of IBW = Actual weight x 100/Ideal body weight
Triceps Skinfold Thickness (TSF) for assessing fat reserve. It is decreased when fat stores
are depleted.
Midarm muscle circumference (MAC) to assess the degree of somatic protein depletion.
TSF and Mid Arm Circumference are no more recommended as an accurate measurement.
Creatinine Height Index (CHI) to assess somatic protein stores.
Serum Protein Determination to assess the degree of visceral protein depletion, e.g.
Albumin, Transferring, Prealbumin.
Measure Total Lymphocyte Count (TLC) to assess Immune function becomes impaired

4. Lab assessment
Fat, Anthropometric parameters

Assessment of body fat

Triceps Skinfold Thickness (TSF) for
assessing fat reserve. It is decreased when
fat stores are depleted.
Protein (Somatic Protein)
Assessment of the fat-free muscle mass (Somatic Protein)
depletion
Mid-upper-arm circumference (MAC)
TSF and MAC are no more
recommended as an accurate measurement
Creatinine-height index (CHI )

[measured urinary creatinine (24hr)/ Ideal urinary creatinine for a

given height]

Ideal Cr = IBW x 23 mg/kg male

= IBW x 18 mg/kg female

CHI > 80 mild depletion

CHI 60 80 moderate
CHI < 60 severe
Average Body Mass Index (BMI) for
Adult

Classification BMI (kg/m2) Obesity Class

Underweight <18.5
Normal 18.5-24.9
Overweight 25.0-29.9
Obesity 30.0-34.9 I
Moderate obesity 35.0-39.9 II
Extreme obesity >40.0 III
 Nutrition Provides

Energy
Amino Acid
Fluid & Electrolyte
Trace minerals (elements)
Vitamin
Certain drugs
Fluid Requirement
Fluid Requirement

Amount of fluid requirement needed depend on age

Pediatric: 1st 10kg = 100ml/kg
2nd 10kg = 50ml/kg
3rd 10kg & up 20ml/kg

Adult: 30-35ml/kg

Additional fluid for vomiting, nasogastric tube

output, diarrhea, large open wound, fever,
hyperventilation, fistula drainage.
Fluid Requirements

Special situation for fluid restriction:

Fluid overload,
Cardiac, Renal, or Liver failure
Elderly
Medication
NRC* recommends 1 to 2 ml of water for each
kcal
of energy expenditure
*NRC= National research council
Energy Requirements
Total Energy Expenditure

TEE (kcal/day) = BEE x stress/activity factor

BEE:
The Harris-Benedict equation is a mathematical
formula used to calculate BEE
 Harris-Benedict Equation

Women =
655 + (9.6 x wt) + (1.7 x ht) - (4.7 x age)

Men =
66 + (13.7 x wt) + (5 x ht) - (6.8 x age)

Calories Multiply by stress factor

A correlation factor that estimates the extent
of hyper-metabolism

1.15 for bedridden patients

1.10 for patients on ventilator support
1.25 for normal patients
The stress factors are:
1.3 for low stress
1.5 for moderate stress
2.0 for severe stress
1.9-2.1 for burn
 Calories Requirements

Obesity: 18-20kcal/kg/day of IBW

Normal need: 25-30kcal/kg/day

Elective surgery: 28-30kcal/kg/day

Severe injury: 30-40kcal/kg/day

Extensive trauma/burn: 40-45kcal/kg/day

 Carbohydrate

Primary energy substrate

The amount of carbohydrate is determined by
patients calorie requirement
glucose oxidation rate
optimal balance of carbohydrate and fat

Maximum oxidized rate 4 - 7mg/kg/min (adult).

Carbohydrate
Provide from a non nitrogen source

Energy requirement depends on number of

factors!

Stress factors, increase calories requirements

60% - 80% of caloric requirement as glucose

CHO Oxidation Rate

1gm = 3.4kcal
Kcl 3.4 x 1000 1440 wt kg =
not more than 5mg/kg/min
e.g. 1700 3.4 x 1000 1440 70 =
4.9mg/kg/min
or
5 mg x 3.4 1000 x wt x 1440
5 x 3.4 1000 x 70 x 1440 = ~ 1700 kcal
 Carbohydrate Source

Starting with:
200 - 250 gm or 15% dextrose solution started or 2.5
mg/kg/min
100 - 150 gm or 10% - 15% dextrose solution in
stress & DM

Increase gradually up to 5 mg/kg/min,

Max 7 mg/kg/min
 How to Calculate Percentage

Total volume of fluid x 3.4 x %

e.g. 2000ml x 3.4 x 0.20 = 1360 kcal.

Or

1400 3.4 2000ml = 20% as started then

1700 3.4 2000ml = 25% full requirement
 Protein (Amino Acid)
AAs are the vital components of body protein. The
primary aim of providing AAs to the body is to
prevent:

Disease related catabolic state.

The development of manifest protein deficiency with
subsequent impaired wound healing.
Disturbances of blood clotting.
The impairment of hepatic and renal function.
A reduced immuno-competence.
Protein (Amino Acid)
1g of protein = 4 Kcal
1g of nitrogen is equivalent to 6.3g of protein
Non-protein k.cal: nitrogen
150-200: 1 (normal patient)
Note:
In renal and hepatic failure the ratio is 1:300-400.

Adult dose: Normal patients requirement 0.8-1.0 g/kg

max. 2.5g/kg depend on patient status
Renal failure patient 0.6 g/kg
Protein (Amino Acid)
12% - 16% of calories as protein

Note:
Products containing only essential Aas have been
formulated for renal failure.

BCAA (Branched Chain Amino Acids) are used

for Hepatic Encephalopathy or in severely stressed
patients.
Fat Emulsion

Essential linoleic acid stabilized by egg yolk

phospholipids
Delivered in the form of an emulsion
fat emulsion has no isotonicity by itself, glycerol
is added to render emulsion isotonic (300 mosm/l).
Concentrated source of calories
Source of essential fatty acids (EFAs)
Substitute for carbohydrate in diabetic & fluid
restricted patients
Fat Emulsion
Fat should provide 20-40% of total calories.

Fat provides a concentrated caloric source. 1g provide 10

Kcal.

Also fat is an alternative source to dextrose to the patients

with compromised respiration since it does produce little
CO2 in its metabolism. While dextrose, when oxidized, it
produces CO2 which must be eliminated via lungs.

Start with 0.5g/kg/d gradually up to1.5g/kg/d.

Fat Emulsion
The caloric density
10% FE is 1.1 kcal/ml
20% FE is 2 kcal/ml
30% FE is 3 kcal/ml
There is LCT, and MCT/LCT products
1gm = 9kcal of fat
Each 1ml = 2kcal

Lipid emulsions contain glycerol, so lipid emulsion does not have 9

kcal per gram as it would if it were pure fat. Some use 10 kcal/gm for
lipid emulsions.

Propofol: Soybean oil in water emulsion, 1ml - 1.112kcal

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Fat Emulsion Contraindications
Hyperlipdemia
Acute pancreatitis
Previous history of fat embolism
Severe liver disease
Allergies to egg, soybean oil or safflower oil
Electrolytes

Na, K, CL, Ca, Mg, PO4, & acetate.

Electrolytes given to maintain normal serum

concentration or to correct deficit.

Requirements for specific electrolytes will vary

according to the patients disease state

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Restrict electrolytes

Severe renal dysfunction.

Edema & congestive heart failure.
Patients on corticosteroids.
Metabolic acidosis, acute pancreatitis fistulas, or
diarrhea.
Metabolic alkalosis, vomiting.

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Multivitamins
B Complex: Co-enzyme in absorptive and metabolic processes,
transfer of energy from protein, fat and carbohydrate to the cells and their
storage as ATP.
Ascorbic Acid: Required for collagen synthesis, wound healing. An
additional amount may be required in major burns, traumas, and extensive
surgeries.
Vitamin A: Essential for vision, the production of mucus-secreting
epithelial cells and bone growth.
Vitamin D: For calcium and phosphate hemeostasis and boncalcification.
Vitamin K: For prothrombin generation (Fibrin Fibrinogen).
Vitamin K

TPN solution does not contain vitamin K and it

can predispose patient to deficiency

Vitamin K 10 mg should be given weekly IV or

IM if patient is on long-term TPN
 Multivitamin and Trace Minerals

Standard form of multivitamin & trace mineral use.

Zinc, copper, manganese & chromium.
Additional of trace mineral required depend on GI
losses.
Renal failure patients reduce dose
Biliary stasis disease, avoid copper & manganese

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Additives
INSULIN: For hyperglycemia when glucose is spilling in urine.

HEPARIN: To promote blood circulation (especially with peripheral

TPN) and to prevent thrombophlebitis.

HYDROCORTISONE: To prevent thrombophlebitis in patients

receiving peripheral TPN.

ACETATE: For acidosis.

ZINC: Extra amount is needed for patient with severe stress,

diarrhea, and ileostomy.
Status of Organic failure
Hypermetabolism
Tachycardia, Tachypnea, Fever, Leucocytosis

Hypercatabolism
Hyperglycemia, Uremia, Hypertriglyceridemia, -NB
Renal Failure Considerations

Present with problems of volume limitation and

poor tolerance of nitrogen wastes.

Treated with 0.5-0.6g/kg amino acid, higher

glucose and lipid concentration.

Limit amounts of sodium, potassium, magnesium,

and phosphate.

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Liver Failure Considerations
Inability to tolerate large fluid volume and difficulty with
nitrogen loads

Maintain glucose

Supply moderate protein(1.0-1.3g/kg) and fat intake up to

30% of T.k.calorie

Restrict fluid and salt intake

BCAA

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Fluid Restricted Considerations

As pulmonary, cardiac failure, head injuries, and elderly.

Special concentrated TPN solution.

High fat emulsion, low glucose.

Normal protein requirement.

Normal electrolyte.

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Respiratory Failure

Non-protein calories to nitrogen ration is not a major

consideration.

Major problem total calories, either from CHO or fat

or both

Protein increases oxygen consumption demands and

that is not indicated to reducing protein

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Going to surgery
In postoperative surgical patients;
TPN is indicated if the patient is indicated
to stay NPO for 5 7 days in malnourished
patients, and 7 10 days in well-nourished
patients.

In preoperative patients;
TPN should be considered in patients who
cannot or should not eat for more than 3 5
days.
 Practice Guidelines Preoperative

NS should be administered for 7-14 days to

moderately or severely malnourished patients
undergoing major GI surgery

PN should NOT be routinely given in the

immediate postoperative period to patients
undergoing major GI procedures
OR Patient
Hold TPN during OR if it more than 1 1/2 hrs
2hrs pre-operation:
TPN rate 50% for 1hr
Hold TPN
Start D10% infusion at same TPN rate

6hrs post operation

Start new TPN bottle at 50% of TPN rate for 1hr
TPN rate as in order

MONITORING BLOOD SUGAR

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Routes of Nutrition Support
Enteral Nutrition
Enteral Nutrition Indication

Inability to consume or absorb adequate nutrition

e.g. who do not eat or receive nutrition support for 10-14 days after
hospital admission

Functional or partially functional gut

e.g. who are unable or not allowed to eat, or partial functional gut
Potential benefits of EN over PN

Nutrients are metabolized and utilized more

effectively via the enteral than parenteral route

Gut and liver process EN before their release into

systemic circulation

Gut and liver help maintain the homeostasis of the

AA pool and skeletal muscle tissue
EN (Immunologic)

Gut integrity is maintained by enteral feeding and

prevent the bacterial translocation from the gut
and minimize risk of gut related sepsis
Enteral nutrition (EN)
Long-term nutrition:
Gastrostomy
Jejunostomy

Short-term nutrition:
Nasogastric feeding
Nasoduodenal feeding
Nasojejunal feeding
Benefits of EN
Physiological/metabolic benefits
The gut can be used for administration of complex nutrients that cannot be
given intravenously e.g. intact protein, peptides, fiber

Safety benefits
Safer than PN and less side effects

Cost benefits
Contraindication to EN

Terminal illness
Short bowel
Obstruction
GI bleeding
Vomiting and diarrhea
Fistulas
GI ischemia
Illues
GI inflammation
A. pancreatitis
Enteral Nutrition Complications
Mechanical complication
During placement of feeding tube
Airway injury, infection, ICP
Presence of a feeding tube
Tube clogging
Declogging methods
Aspiration
GI complication
Gastroesophageal reflux duodenal gastric reflux
Diarrhea
Metabolic complication
Enteral Nutrition Complications
Metabolic complication
Hyperglycemia
Electrolyte and mineral deficiences
Refeeding syndrome
Total Parentral Nutrition
Total Parenteral Nutrition Indication

When normal oral feeding is not possible.

e.g.: Chrons disease, gastric & esophageal carcinoma, paralytic ileus,
generalized peronitis, GI. obstruction, intractable vomiting.
When food is incompletely absorbed.
e.g.: Major burns, multiple injuries, radiation therapy, ulcerative colitis,
chemotherapy treatment, short bowel syndrome.
When food intake is undesirable, in case it is prudent to
rest the bowel.
e.g.: Post GIT surgery, chronic inflammatory diseases, intractable
diarrhea.
Total Parenteral Nutrition Indication

In patients who are able to ingest food, but refuse to do

so.
e.g.: Geriatric post-operative patients, adolescents with anorexia nervosa,
some psychiatric patients with prolonged depression.
In patients who, as a consequence of their illness are
going to be, or have been NPO for 5 7 days.
Administration
Parenteral Nutrition

Central Nutrition Peripheral nutrition

Subclavian line Peripheral line
Long period Short period < 14days
Hyperosmolar solution Low osmolality
Full requirement < 900 mOsm/L
Minimum volume Min. requirement
Expensive Large volume
More side effect Thrombophlebitis
Routes of TPN
Central TPN
(usual osmolarity = 2000 mosmol/L)
Advantages:
Can provide full nutritional support (No
limits in concentration of dextrose and amino acids)
No risk of thrombophlebitis, No pain.
Disadvantages:
Requires surgery
More risk of sepsis than peripheral TPN
High risk of mechanical complications
Routes of TPN
Peripheral TPN
maximum osmolarity;
neonates = 1100/L, Pediatrics = 1000/L, Adults = 900/L

Advantages:
Does not require surgery
Less risk of sepsis than central TPN
No risk of mechanical complications
Disadvantages:
High risk of thrombophlebitis
Painful
Does not provide full nutrition support. Needs more
fluids to provide more nutrition. (maximum dextrose
= 7.5% and AA = 2.5%).
 Note

PPN can infuse through central line but

central TPN can NOT infuse through
the peripheral line
Calculating the Osmolarity of a
Parenteral Nutrition Solution
Multiply the grams of dextrose per liter by 5.
Example: 100 g of dextrose x 5 = 500 mOsm/L

Multiply the grams of protein per liter by 10.

Example: 30 g of protein x 10 = 300 mOsm/L

Multiply the (mEq per L sodium + potassium + calcium +

magnesium) X 2
Example: 80 X 2 = 160

Total osmolarity = 500 + 300 + 160 = 960 mOsm/L

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Monitoring
Monitoring

Avoid overfeeding
Avoid respiratory problem
Promote nitrogen retention
Triglyceride clearance
Fluid and electrolyte
Weight
Liver function

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Monitoring for Complications

Malnourished patients at risk for refeeding syndrome should

have serum phosphorus, magnesium, potassium, and glucose
levels monitored closely

In patients with diabetes or risk factors for glucose intolerance,

insulin infusion should be initiated with a low dextrose infusion
rate and blood and urine glucose monitored closely.

Blood glucose should be monitored frequently upon initiation,

any change in insulin dose, and until measurements are stable.

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Monitoring for Complications

Serum electrolytes (sodium, potassium, chloride, and

bicarbonate) should be monitored frequently until
measurements are stable.

Patients receiving intravenous fat emulsions should have

serum triglyceride levels monitored until stable and when
changes are made in the amount of fat administered.

Liver function tests should be monitored periodically in

patients receiving PN.

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Complications of TPN
Complication

Mechanical: occlusion, catheter removal, improper rate,

thromboses, pneumothorax.

Infection: catheter related

Metabolic: re-feeding syndrome, hyperglycemia, fluid &

electrolyte disturbance

(cont..)

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Complication

Organic system:
hepatobiliary complication
respiratory
cardiovascular
renal

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Transitional Feeding
Maintain full PN support until pt is tolerating 1/3 of needs via
enteral route

Decrease TPN by 50% and continue to taper as the enteral

feeding is advanced to total

TPN can reduce appetite if >25% of calorie needs are met via
PN

TPN can be tapered when pt is consuming greater than 500

calories/d and d-cd when meeting 60% of goal

TPN can be rapidly d-cd if pt is receiving enteral feeding in

amount great enough to maintain blood glucose levels
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Defense Against NS Complications

Select appropriate patients to appropriate nutrition

Aseptic technique
Do not overfeed
Maintain glycemic control <150-170 mg/dl
Limit lipids to 1 gm/kg and monitor TG levels
Adjust protein based on metabolic demand and organ
function
Monitor fluid/electrolyte/mineral status
Provide standard vitamin and trace element preps
daily
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Thank you