Nutrition in the surgical patient

Yonas Ademe
September, 2017

1
 Introduction
• Majority of elective surgical patients are well
nourished/healthy, have uncomplicated major
surgical procedures, have sufficient fuel
reserve, and can withstand brief period of
catabolic insult and starvation of 7 days

2
 Cont.
• The goal of nutritional support in the surgical
patient is to prevent or reverse the catabolic
effects of disease or injury and also to meet the
energy requirements for essential metabolic
processes and tissue repair

• The ultimate validation for nutritional support in

surgical patients should be improvement in
clinical outcome and restoration of function
3
 Cont.
• Allowing a patients nutritional state to
deteriorate results in measurable outcomes
related to nosocomial infection, MOD, wound
healing, and functional recovery

• Rates of under nutrition in hospitalized patients

is between 35- 50 %
– Attributed to both deprivation of food while in
hospital and to their illness
4
 Cont.
• Causes of malnutrition in surgical patients
• Impaired intake
• Long NPO hours
• Unappetizing food
• Anorexia secondary to cancer, sepsis, or liver disease
• Poor intake caused by esophageal or GI obstruction
• Impaired digestion and or absorption
• Major gastric resection, short-bowel syndrome, IBD
• Excess nutrient losses
• GI fistulas, protein-losing enteropathies
• Altered metabolic nutrient requirements
• Stressed states 5
 Cont.
• Consequences of malnutrition
– Impaired immune response
• Predisposition to infections
– Impaired wound healing
• Increased risk of wound infection, wound dehiscence, anastomotic breakdowns,
and development of postsurgical fistulae
– Reduced muscle strength
• Contributes to reduced ventilatory performance and prolonged ventilator
dependence
– Impaired GI structure and function
– Impaired psycho-social function
– Impaired thermoregulation
– High incidence of operative complications and death (~ 30%)
– Increased length of stay and costs 6
 Body compartments
CARBO + OTHER
(1%)

PROTEIN (6%)
PROTEIN (14%) PROTEIN (14%) PROTEIN (12%)

FAT (15%) FAT (23%)

FAT (25%)
FAT (30%)

WATER (72%)
WATER (70%)
WATER (60%)
WATER (55%)

NORMAL OBESE STARVATION CRITICAL CARE

7
 Nutritional assessment
• It is the evaluation of nutritional needs of individuals
based upon appropriate biochemical, anthropometric,
physical, and dietary data to determine nutrient needs
and recommended appropriate nutrition intake including
enteral and parenteral nutrition

• In several studies, a careful history plus physical

examination by a seasoned clinician yields the same
accuracy as extensive testing for the estimation of
nutritional risk, particularly when functionality is assessed
8
 Hypoalbuminaemia could occur

Cont. because of alterations in body fluid

composition and/or increased
capillary permeability related to on-
going sepsis
• Anthropometery
– BMI, arm circumference muscle area, and skinfold thickness
• Biochemical studies
– Albumin level, prealbumin level, transferrin level, immunologic markers (TLC,
skin test), and creatinine excretion
• Clinical evaluation
– Weight loss (10% within 6 months or 5% within 1 month)
– Chronic illnesses
– Assessment of loss of muscle and adipose tissues, organ dysfunction, subtle
changes in skin, hair, or neuromuscular function
• Dietary history
– Dietary habits
• Environmental factors
– Social habits and economic factors 9
Estimation of Nutritional Requirements

• Energy
– Basal energy expenditure (BEE) may be estimated
using the Harris-Benedict equations:
• BEE (men) = 66.47 + 13.75 (W) + 5.0 (H) – 6.76 (A) kcal/d
• BEE (women) = 655.1 + 9.56 (W) + 1.85 (H) – 4.68 (A) kcal/d

10
 Cont.
• Cont.
– Provision of 30 kcal/kg/day will adequately meet
energy requirements in most postsurgical patients,
with a low risk of overfeeding
• After trauma or sepsis, greater non-protein calories are
required beyond calculated energy expenditure
– These are usually 1.2 to 2.0 times greater than calculated resting
energy expenditure, depending on the type of injury

11
 Cont.
• Cont.
• Healthy adults
• Calories: 25-3O kcals/kg/day (1300-1800 kcal/day)
• Carbohydrate 60-70% and lipid 15-30%
• Protein: 0.8-1 gm/kg/day
• Fluids: 30 ml/kg/day (individualised)

12
 Cont.
• Vitamins and Minerals
– The requirements for vitamins and essential trace
minerals usually can be met easily in the average
patient with an uncomplicated post-operative
course
• Therefore, 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
13
Nutritional support

14
 Introduction
• Nutritional support is an alternate means of
providing nutrients to people who cannot eat any
or enough food

15
 Cont.
• Indications
– Pre-op
• Severe undernutrition
– Unintentional weight loss >10% within 6 months or >5% in 1 month
– BMI <18.5 kg/m2
– MUAC <17 cm
– Albumin <3 g/dl

– Failure to thrive on pediatric growth and development curves

• Catabolic disease
– Significant burns, polytrauma, severe sepsis
• Anticipate that patient will be unable to meet caloric requirements within
7-10 days perioperatively
– Bowel obstruction
– Enteric fistula
– Malabsorption
16
 Cont.
• Cont.
– Post-op
• Critically ill
• GI obstruction
• Prolonged paralytic ileus (lasting for >4 days)
• Enteric fistula
• Short bowel syndrome
• Malabsorption

17
 Cont.
• Types
– Enteral
– Parenteral
– Both

18
Enteral nutrition

19
 Introduction
• Advantages of enteral nutrition over parenteral nutrition
– More physiological (liver not bypassed)
– Lesser cardiac work
– Safer and more efficient
– Better tolerated by the patient
– Lower cost
– Decreased consequences of GIT disuse
• Intestinal mucosal atrophy
• Altered mucosal defenses
– Diminished secretory IgA and cytokine production
• Bacterial overgrowth
– Decreased risks of the intravenous route
– Reduced infectious complications
– Reduced metabolic complications
– Decreased overall morbidity and mortality
20
 Cont.
• Early enteral nutrition is associated with better small-
intestinal carbohydrate absorption, shorter duration of
mechanical ventilation, lower infectious complications,
and shorter time in the ICU
– Exceptions
• Closed-head injury
– Early gastric feeding was frequently associated with underfeeding and calorie
deficiency due to the difficulties in overcoming gastroparesis and the high risk
of aspiration
• Burn
– Current evidence remains inconclusive
» There is reason to believe that early enteral nutrition may positively
modulate the initial hypermetabolic response and help to maintain
mucosal immunity
21
 Cont.
• In summary, enteral nutrition is preferred for
most critically ill patients, including those with
trauma, burns, head injury, major surgery, and
acute pancreatitis

• For ICU patients who are hemodynamically stable

and have a functioning GIT early enteral feeding
(within 24 to 48 hours of arrival in the ICU) has
become a recommended standard of care
22
 Cont.
• There is no evidence to support withholding enteric
feedings for patients after bowel resection or for
those with low-output enterocutaneous fistulas of
<500 mL/d
– In fact, a recent systematic review of studies of early
enteral feeding (within 24 hours of GI surgery) showed no
effect on anastomotic leak and a reduction in mortality
– Early enteral feeding is also associated with reduced
incidence of fistula formation in patients with open
abdomen

23
 Cont.
• For patients undergoing elective surgery,
healthy patients without malnutrition who are
undergoing uncomplicated surgery can tolerate
10 days of partial starvation (i.e., maintenance
IV fluids only) before any clinically significant
protein catabolism occurs

24
 Cont.
• Earlier intervention is likely indicated for patients
with:
– Preoperative protein-calorie malnutrition
– Permanent neurologic impairment
– Oropharyngeal dysfunction
– Short-bowel syndrome
– Bone marrow transplantation

25
 Cont.
• Principles of enteral feeding
– Initiation of enteral nutrition should occur immediately
after adequate resuscitation, most readily determined by
adequate urine output
• Enteral feedings in the critically ill patient should be delayed
until adequate resuscitation has been achieved
– The presence of bowel sounds and the passage of flatus
or stool are not absolute prerequisites for initiation of
enteral nutrition
– 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 26
 Access for Enteral Nutritional Support
• Nasoenteric Tubes
– Nasogastric feeding should be reserved for those with intact
mentation and protective laryngeal reflexes to minimize risks of
aspiration
• Even in intubated patients, nasogastric feedings often can be recovered
from tracheal suction
– Nasojejunal feedings are associated with fewer pulmonary
complications including risk of pneumonia, but access past the
pylorus requires greater effort to accomplish
• It is more reliable for delivering nutrition than NG feeding

– If nasoenteric feeding will be required for longer than 30 days,

access should be converted to a percutaneous one
27
 Cont.
• Cont.
– Several methods have been recommended for the passage of
nasoenteric feeding tubes into the small bowel
• Right lateral decubitus positioning
• Use of prokinetic agents
• Gastric insufflation
• Application of clockwise torque
• Tube angulation

• The successful placement of feeding tubes by these methods is highly variable

and operator dependent
• Success rates for intubation past the duodenum into the jejunum by these
methods are <20%
– Fluoroscopy-guided intubation past the pylorus has a >90% success rate
• Same with endoscopy guided method
28
 Cont.
• Percutaneous Endoscopic Gastrostomy (PEG)
– The most common indications include:
• Impaired swallowing mechanisms
• Oropharyngeal or esophageal obstruction
• Major facial trauma

29
 Cont.
• Percutaneous Endoscopic Gastrostomy-
Jejunostomy
– A 9F to 12F tube is passed through an existing PEG
tube, past the pylorus, and into the duodenum
– This can be achieved by endoscopic or fluoroscopic
guidance

30
 Cont.
• Direct Percutaneous Endoscopic Jejunostomy
– Uses the same techniques as PEG tube placement
but requires an enteroscope or colonoscope to
reach the jejunum

31
 Cont.
• Surgical Gastrostomy and Jejunostomy
– For a patient undergoing complex abdominal or
trauma surgery, thought should be given during
surgery to the possible routes for subsequent
nutritional support
– The only absolute contraindication to feeding
jejunostomy is distal intestinal obstruction
• Relative contraindications: severe edema of the intestinal
wall, radiation enteritis, IBD, ascites, severe
immunodeficiency, and bowel ischemia

32
Cont.

33
 Enteral Formulas
• Factors that influence the choice of enteral formula
include:
– The extent of organ dysfunction (e.g., renal, pulmonary,
hepatic, or GIT)
– The nutrients needed to restore optimal function and healing
– The cost of specific products

• In general, feeding formulas to consider are GI tolerance-

promoting, anti-inflammatory, immune-modulating,
organ supportive, and standard enteral nutrition

34
 Cont.
Mumbai formula
• Option 1 • Option 2
• 1 Lt. milk • 1Lt. Water
• 4 Large eggs • 9 Tablespoon milk
• 2 Bananas • 3 Large eggs
• 50g sugar • 3 Bananas
• 1333.5kcal • 3 Tablespoon sugar
• Prt 4.09% • 1000kcal
• fat 3.7% • Prt 4.09%
• Crbs 10.27% • fat 3.7%
• Crbs 10.27%

35
 Complications
• Bowel related
– Nausea and vomiting
– Abdominal distention
• Mechanical
– Aspiration
– Epistaxis, sinusitis, nasal necrosis, esophageal injury
– Tube malpositioning and dislodgment
• Solute overloading
– Diarrhea, dehydration, and electrolyte imbalance
(hypokalemia, hypomagnesemia)
– Hyperglycemia (hyperosmolar-nonketotic coma)
36
 Contraindications
• Hemodynamic instability
• Intractable vomiting and/or diarrhea (refractory to
medical management)
• GI obstruction
• Paralytic ileus
• Distal high-output intestinal fistulas
• Severe short bowel syndrome
• Severe GI malabsorption
• Inability to gain access to GI tract
37
Parenteral nutrition

38
 Introduction
• Parenteral nutrition is the continuous infusion of a
hyperosmolar solution containing carbohydrates,
proteins, fat, and other necessary nutrients through
an indwelling catheter inserted into the SVC

• To obtain the maximum benefit, the calorie:protein

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

39
 Cont.
• After severe injury, parenteral nutrition is
associated with higher rates of infectious risks than
is enteral feeding
• Parenteral feeding with complete bowel rest results
in augmented stress hormone and inflammatory
mediator response to an antigenic challenge

• Parenteral feeding still is associated with fewer

infectious complications than no feeding at all
40
 Cont.
• Routine post-op use of parenteral nutrition is
not shown to have clinical benefit and may be
associated with a significant increase in
complication rate

41
 Rationale
• The principal indications for parenteral nutrition
are:
– Malnutrition
– Sepsis
– Surgical or traumatic injury in seriously ill patients
for whom use of the GIT for feedings is not possible

– In some instances, intravenous nutrition may be

used to supplement inadequate oral intake
42
 Indications
• Newborn infants with catastrophic GI anomalies
– TEF, massive intestinal atresia, gastroschisis, or omphalocele
• Infants who fail to thrive due to GI insufficiency
– Short-bowel syndrome, malabsorption, enzyme deficiency,
meconium ileus, or idiopathic diarrhea
• Adult patients with short-bowel syndrome secondary to
massive small-bowel resection
– <100 cm without colon or ileocecal valve or <50 cm with intact
ileocecal valve and colon
• Patients with normal bowel length but with malabsorption
– Sprue, enzyme or pancreatic insufficiency, regional enteritis, or
IBD
43
 Cont.
• Patients with enteric fistulas
– High-output enterocutaneous fistulas (>500 mL/d),
enteroenteric, enterocolic, or enterovesical
• Surgical patients with prolonged paralytic ileus
– After major operations (>7 to 10 days), multiple injuries, or
blunt or open abdominal trauma
• Patients in whom attempts to provide adequate
calories by enteral tube feedings or high residuals have
failed
• Critically ill patients who are hypermetabolic for >5
days or for whom enteral nutrition is not feasible
44
 Cont.
• Summary
– Children
• Neonates with severe GI anomalies
• Infants with SBS and/or mabsorption syndromes
– Adults
• IO
• Prolonged paralytic ileus
• SBS
• Malabsorption syndromes
• Enteric fistulas
• Failure or inadequate enteral feeding
45
 Contraindications
• Patients experiencing hemodynamic instability
• Patient with severe metabolic derangement
– Severe hyperglycemia, azotemia, encephalopathy,
hyperosmolality, electrolyte disturbances
• Patients for whom GIT feeding is feasible
• Patients with good nutritional status
• Infants with <8 cm of small bowel
– Because virtually all have been unable to adapt sufficiently
despite prolonged periods of parenteral nutrition
• Patients who are irreversibly decerebrate or otherwise
dehumanized
46
 Types
• Total Parenteral Nutrition (central parenteral nutrition)
– Requires access to a large-diameter vein to deliver the entire
nutritional requirements
– Dextrose content of the solution is high (15% to 25%)
– All macronutrients and micronutrients are deliverable by this route
• Peripheral Parenteral Nutrition
– Administration via peripheral veins
• Because of lower osmolarity of the solution, secondary to reduced levels of
dextrose (5% to 10%) and protein (3%)
– It is not appropriate for repleting patients with severe malnutrition
• It can be considered if central routes are not available or if supplemental
nutritional support is required
– Typically, it is used for short periods (<2 weeks)
47
 Complications
• Technical Complications
– Injury to other structures
• Pneumothorax, hemothorax, hydrothorax, subclavian
artery injury, thoracic duct injury, cardiac arrhythmia, air
embolism, catheter embolism, and cardiac perforation
with tamponade

48
 Cont.
• Infectious complications
– Catheter associated infection
• Sepsis secondary to contamination of the central
venous catheter
• 80% staphylococcus, 15% fungal, and 5% gram negative
bacteria
• Diagnosis
– Clinical + Blood culture + Catheter tip culture
– Other infections

49
 Cont.
• Intestinal complications
– Diminished villous height, bacterial overgrowth,
reduced lymphoid tissue size, reduced IgA
production, and impaired gut immunity
– The most efficacious method to prevent these
changes is to provide at least some nutrients
enterally

50
 Cont.
• Metabolic Complications
– Hypoglycemia or hyperglycemia
– Hypertriglyceridemia
– Derangement of liver enzymes
– Cholestasis and formation of gallstones
– Azotemia
– Metabolic bone disease

51
 Cont.
• Overfeeding complications
• Increased oxygen consumption and increased
carbon dioxide production
• Hyperglycemia
• Fatty liver

52
 Parenteral formulas
• The basic solution for parenteral nutrition
contains a final concentration of 15% to 25%
dextrose and 3% to 5% crystalline amino acids

• IV vitamin preparations also should be added to

parenteral formulas

53
 Overfeeding
• This usually results from overestimation of
caloric needs, as occurs when actual body
weight is used to calculate the BEE in patient
populations such as the critically ill with
significant fluid overload and the obese
– In these instances, estimated dry weight should be
obtained from preinjury records or family members

54
 Cont.
• Overfeeding may contribute to clinical
deterioration via:
– Increased oxygen consumption and increased
carbon dioxide production with subsequent
prolonged need for ventilatory support
– Hyperglycemia
– Fatty liver
– Suppression of leukocyte function and increased risk
of infection

55
End!

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