Nutrition Support in the Surgical

Patient
 Hospital Malnutrition
• Malnutrition is observed in up to 60%
of surgical patients on admission to
hospital
• Significant implications on their
prognosis
Malnutrition remains underdiagnosed
in 70% patients in the hospital setting

Kahokehr AA, et al. European e-Journal Clin Nutr Metab 2010;5:e21-e25

 Nutritional Screening
of GI Surgery Patients

Routine: 20%

Occasional: 50%

Rarely: 20%

Never: 10%

Grass F. Eur J Clin Nutr 2011; 65: 642-647

 Nutritional Risk & Nutritional Support

2550 patients in 4 teaching hospitals of China

< 70 > 70 Overall
yrs yrs Nutritional Support Provided to

At Risk 32.6% 64.2% 41.5%

At Risk Not at Risk

No Risk 67.4% 35.8% 58.5% 47.6% 19.4%

Fang S, et al. Asia Pac J Clin Nutr 2013; 22 (1): 54-59

 Sequelae of Malnutrition in Hospital Setting

 Depression of immune system

 Impaired wound healing
 Muscle wasting
 Longer length of hospital stay
 Increased cost of care
 Increased mortality

Barker LA, Gout BS, Crowe TC. Int J Environ Res Public Health 2011; 8: 514-27
 Organizational Factors
Contributing to Malnutrition
• Failure to recognize malnutrition
• Lack of nutritional screening or assessment
• Lack of nutritional training
• Failure to record height and weight
• Failure to record patient intake
• Inadequate staff

Importance of nutrition unrecognized

Barker LA, Gout BS, Crowe TC. Int J Environ Res Public Health 2011; 8: 514-27
 Hospital Malnutrition
Combination of cachexia and malnutrition

Cachexia
Multifactorial syndrome
characterized by severe
body weight, fat and
muscle loss, and
increased protein
catabolism due to
underlying disease
Malnutrition
Imbalance of energy,
protein and other
nutrients causes
measurable adverse
effects on tissue/body
form and function, and
clinical outcome

Muscaritoli M, et al. Clin Nutr 2010; 29: 154-59

The benefits of a proper nutritional support

are acknowledged by most surgeons, and

current guidelines provide clear instructions

and tools. Implementation in daily clinical

practice remains to be improved.

Grass F. Eur J Clin Nutr 2011; 65: 642-647

 Gaps in Nutritional Practice
• An observational study across many countries
in 158 ICUs.
• Number of patients: 2946

Large gaps exist in actual practice

Average nutritional adequacy

Energy: 59%

Protein: 60.3%

Cahill NE, et al. Crit Care Med 2010; 38 (2): 395-401

Early feeding may be beneficial in reducing the risks

of anastomotic dehiscence, infection and reducing the

length of stay.

Lewis SJ. BMJ 2001; 323 (7316): 773-776

 Improving Patient Outcome
Suboptimal supply of substrates

Increased supply of amino acids

Increased susceptibility to infections

Impaired wound healing

Improved clinical outcome

 The development of postoperative insulin resistance

is clinically significant as it is associated with prolonged

hospital stay and greater postoperative morbidity and

mortality

J Clin Endocrinol Metab 2010; 95: 4338-44

NEJM 2001; 345: 1359-67

 Combinations of enteral and parenteral nutrition

should be considered in patients in whom there

is an indication For nutritional support and in whom

60% of energy needs cannot be met via the

enteral route

25-30 kcal/kg Ideal Body Weight

ESPEN Guidelines on Parenteral Nutrition-Surgery. Clin Nutr 2009; 28(4): 378-86

 Role of Ascorbic Acid

• Sepsis may develop as a consequence

of surgery

• Subnormal ascorbate concentrations

in plasma and leukocytes are common
features of the critically ill in general
and of patients with sepsis in
particular.
Wilson JX. Biofactors 2009; 35 (1): 5-13
 “Administering ascorbate
parenterally rather than orally
increases its effects on plasma
ascorbate concentration and
microvascular function..”

Wilson JX. Biofactors 2009; 35 (1): 5-13

 Role of Proline
• Under conditions of stress proline is
an energy source. It provides carbon
for the tricarboxylic acid cycle and
also participates in the proline cycle.

Phang JM, et al. J Nutrition 2008; 138: 2008S-2015S

 Role of BCAA’s
“After trauma & during sepsis, BCAA
oxidation is increased; evidence
indicates that skeletal muscles is the
major site of BCAA degradation..”

Supplementation with these important

nutrient substrates may be beneficial

Joseph B, et al. Eur J Trauma Emerg Surg 2010

 ESPEN Guidelines on Parenteral
Nutrition: Intensive care
• Increased metabolic needs related to stress are
likely to accelerate the development of malnutrition,
a condition associated with impaired clinical outcome.

• Insufficient provision of nutrients is likely to result

in undernutrition within 8–12 days following surgery
and/or ICU admission. In order to prevent
undernutrition and related adverse effects, all ICU
patients who are not expected to be on a full oral diet
within three days should receive EN.

ESPEN Guidelines on Parenteral Nutrition-Intensive Care. Clin Nutr 2009; 28(4): 387-400
 Recommendation
“All patients receiving less than their
targeted enteral feeding after 2 days
should be considered for
supplementary parenteral nutrition
(Grade C).”

ESPEN Guidelines on Parenteral Nutrition-Intensive Care. Clin Nutr 2009; 28(4): 387-400
 How much should be administered
to meet protein requirement?
Recommendation:
“When PN is indicated, a balanced
amino acid mixture should be infused
at approximately 1.3–1.5 g/kg ideal
body weight per day in conjunction
with an adequate energy supply
(Grade B)”

ESPEN Guidelines on Parenteral Nutrition-Intensive Care. Clin Nutr 2009; 28(4): 387-400
Combined Nutritional Support
 Oral and Parenteral Nutrition Support

AMINOVEL 600 Proten

Parenteral Nutrition Support Oral Nutrition Supplement

Strength 5% Each sachet provides

Proteins (g/L) 50 Proteins (g) 10
Sorbitol (g/L) 100 Carbohydrates (g) 27.7
Calories (kcal/L) 600 Fat (g) 5.8
Nonprotein Calories 400 Fiber (g) 1.4
Nitrogen (g/L) 8 Energy (kcal) 212
 AMINOVEL 600
BCAA

Arginine

Minerals and Vitamins

• Vitamin C
 AMINOVEL 600
• Dosage and administration
– 500 – 1000 mL via IV infusion
• Depending on the condition of the patient

– 500mL in4-6 hours

– 20-30 drops/minute
 Proten
• Food Supplement
• Soy powder, sucrose, vitamins, minerals,
maltodextrin
• Vanilla flavor
• Needed to increase and maintain health
• Serving Size: 1 sachet (52 grams)
 Proten
• Adults
– 1 sachet 2-6 times daily

• Children
– Day 1: half sachet twice daily
– Day 2 onwards: 1 sachet, 1-4 times a day

• Stir well before drinking

Oral Nutrition

Parenteral Nutrition
Thank you for your attention

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