Nutrition in the surgical patients

• Dr Tassew Tadesse
• General surgeon
• Y12HMC
 Objectives
This presentation will explain:
•The need for nutritional support

•Consequences of malnutrition

•Methods of assessing malnutrition

•Types of nutritional support & its indications

• Routes of providing nutritional support

•Complications
 ADEQUATE DIET IS NECESSARY TO
MAINATAIN NORMAL BODY
COMPOSITION AND ORGAN FUNCTIONS
 4

The goals of nutrition support:

• To minimize protein breakdown
• Preserve lean body mass
• Promote protein synthesis
• Optimize immune responses.
 Definition

Nutritional support is adjuvant therapy used to

support the surgical patients until they are able
to sustain themselves with adequate spontaneous
nutrition by mouth.
• Malnutrition in hospitalized patients is common

• Up to 50% may have moderate malnutrition

• Malnutrition increases morbidity and mortality

• Damaging effects on psychological status,

activity level and appearance

• Prolongs hospital stay

 ENDOGENOUS ENERGY STORES
CARBOHYDRATE - GLYCOGEN

• Just enough to last one day

• Liver- 400 kcal

• Muscle- 1600 kcal -- not readily available

• Essential for RBC, WBC, bone marrow, eye , renal medulla &
peripheral nerves

• Brain- normally uses glucose, switches to fat in starvation

• 1 Gm. = 4 kcal
 ENDOGENOUS ENERGY STORES
FAT- ADIPOSE TISSUE

• Largest fuel reserve

• 120,000 kcal in a 70-kg man

• 1 Gm. = 9kcal

• Survival during starvation depends upon the amount

of endogenous fat reserve
 ENDOGENOUS ENERGY STORES
PROTEIN

• Lean body mass- 13 Kg in a 70 Kg man

• 30,000 kcal energy store

• Inefficient source of energy

• Used for essential nitrogenous substances for

maintenance and growth

• Synthesis requires non protein calorie source

 SIMPLE POST-SURGERY
STARVATION STARVATION

↓ energy expenditure ↑ hormonal stimulation

↑ use of fat for fuel ↑ cellular activity

↑ lipolysis ↑ metabolic rate

↓ nitrogen loss ↑ energy expenditure

↓ glucose use by brain* ↑ gluconeogenesis

↑ protein breakdown
* RBC, WBC, renal medulla, ↑ nitrogen loss
neurons, muscles & intestinal
mucosa supply maintained ↑Lipolysis
 Aim of nutritional support measures

• The provision of nutrients with therapeutic intent

(prevent / reverse the catabolic effects of disease or injury).

• Identify in a timely manner patients in need of

nutritional support

• Provide nutritional requirements by most appropriate

route to minimise complications
 MAIN CONSIDERATIONS IN
NUTRITIONAL SUPPORT

• Which patient requires nutritional support

• Select the appropriate substrate

• Obtain and maintain access for delivery

WHICH PATIENT?
 ASSESSMENT OF NUTRITIONAL
STATUS
• History :

Altered oral intake

Unintentional weight loss ( 10-15% in 4-6 months)

• Physical examination:

Body weight / BMI = wt. in kg/ height in m² ( normal- 18.5-24.9)

Mid arm muscle circumference <60% ( M 25.5 cm, F 23 cm )

Triceps skin fold <60% ( M 12.5mm, F 16.5mm )

 ASSESSMENT OF NUTRITIONAL STATUS

 Laboratory evaluation:
Complete blood count
Lymphocyte count < 1800/cmm
Serum albumin < 30G/L

 Immune competence:
Delayed cutaneous hypersensitivity to intra-dermal antigens

 Functional evaluation:
Ability to do daily functions, hand grip
 PREOPERATIVE NUTRITIONAL SUPPORT

 Improves outcome in severely malnourished

 If possible, delay surgery

 5-7 days nutritional support

 Avoid tumor feeding: limit calorie & protein to match need

 Continue nutritional support postoperatively

 ASSESSMENT OF NUTRITIONAL REQUIREMENTS

Optimal nutrition should provide adequate requirements of :

Calories- Carbohydrate & fat

Protein
Water
Electrolytes
Trace elements
Vitamins
 Energy requirements in adults

 Energy : Uncomplicated patients- 25 Kcal/ kg/ day

Complicated/ stressed pts. 30-35 Kcal/kg/day

 Energy source : Carbohydrates 70- 80 %

Lipids 20 %
Caloric requirements - Energy expenditure

• Harris Benedict Equation  W = IBW in kg, A = age in

yrs, H = ht in cm.

• BMR for Male: 66 + (13.7 X W) + (5XH) - (6.8 X A)= kcal/d.

• BMR for Female: 55 + (9.6 X W) + (1.8XH) - (4.7 X A).

• Multiply X activity level / stress level:  

Well nourished and unstressed = 1. 
Confined to bed or minor surgery = 1.2.   Out of ppbed = 
1.3.   Mild starvation = 0.85-1.  Bone trauma = 1.35.  Major
sepsis = 1.6.  Severe burn = 2.1.  
 Protein

 Uncomplicated patients 1 g / kg/ day

 Complicated/ stressed pts. 1.3-2g / kg/ day

 Electrolytes:*

Sodium - 1 - 1.5 mEq / kg /day

Potassium 0.7 - 1 mEq/ kg/ day
Calcium 0.2-0.3 mEq/ kg/ day
Magnesium 0.35-0.45 mEq /kg /day
* adjusted daily
 Trace elements
 Vitamins
 Fluid requirements

 100 ml/kg/day – first 10 kg body wt.

50 ml / kg /day- for next 10 kg
20 ml / kg /day- for each additional kg
 1 ml of water / cal. / day

 Adjust in patients :
- who cannot tolerate large volume
- additional fluid loss
- febrile or septic
 ROUTES USED FOR NUTRITIONAL SUPPORT

Enteral nutrition:
Providing liquid formula diet in to a functioning
GIT to maintain or improve nutritional status

Parenteral nutrition:
Delivering predigested nutrients directly to venous system

Mixed ( enteral + parenteral ):

Tolerate low amount of enteral, weaning from parenteral
 Routes of enteral feeding

 Nasogastric tube feeding – for short periods

 Fine bore nasoenteric tube- positioned in stomach,

duodenum, jejunum, better tolerated

 Gastrostomy/ jejunostomy– surgical/ endoscopic / radiologic,

neurological diseases,
head/ neck carcinoma,
major upper GIT surgery
 Enteral feeding
 Intermittent bolus- suitable for stomach feeding

 Continuous - suitable for duodenum/ jejunum feeding

 Initiate at a slow rate, advance as tolerated

 Initially dilute feeds, gradually advance to full strength

 Feeding in semi-upright position particularly for stomach feeds

 Maintain this position for 2 hours after feeds

 Aspirate (stomach feeding) before next feeding.

If >150ml, delay next feed.
 Advantages of enteral feeding

 Simplicity
 Greater availability
 Lower cost
 Well tolerated
 Maintains gut integrity
 Fewer complications
 Contraindications to enteral feeding

 Intestinal obstruction
 Paralytic ileus
 High output entero-cutaneous fistula
 Short bowel syndrome
 Severe acute pancreatitis
 Malabsorption
 Complications of enteral feeding

 Mechanical: tracheobronchial intubation, erosion

blockage, displacement, bowel perforation

 Metabolic: Fluid/ electrolyte imbalance, hyperglycemia

Refeeding / overfeeding syndromes

 Gastrointestinal: Diarrhea, vomiting, pain

 Pulmonary: Aspiration

 Infection: Tube site

 Total parenteral nutrition- TPN

Delivering predigested nutrients via hyperosmolar

solution into venous system

 CVN ( central venous nutrition ) :

Subclavian / Internal jugular,
Catheter tip in SVC
Most commonly used

 PVN ( peripheral venous nutrition ):

Solution of lower calorie, lower dextrose and higher lipid Suitable
for 7-10 days feeding
 TPN - Indications

 Non-functioning GIT

Short bowel syndrome

Intestinal fistula
Severe pancreatitis
Intractable vomiting/ diarrhea
Severe inflammatory bowel disease
Developmental anomalies
Multiple organ failure

 Sever malnutrition ( unable to take orally )

 TPN - Administration
 Check all laboratory values before starting

 Nutrients given as 3in1 or 2+1

 Vitamin k given separately

 Heparin & insulin can be added

 Start with 1 L , increasing to desired level as tolerated

 Monitor- CBC, electrolytes, glucose , urea, creatinine, Ca., Mg.,

phosphorus, bilirubin, coagulation profile, ALP, ALT,AST

 Best managed by nutritional support team

 Home TPN

 Long term nutritional support

 Majority have malignancy

 Special catheter- e.g. Hickman

 Subclavian vein through subcutaneous tunnel

 Support system
 Complications of TPN

Catheter related:
Vessel injury, thrombosis,
Haemo/ pneumothorax,
Brachial plexus injury, air embolism, sepsis

Metabolic: Hyperglycemia, hypoglycemia,

Hypertriglyceridemia, fluid &
electrolyte disturbance, Hyperosmolar
syndrome, steatohepatitis,
Refeeding and overfeeding syndromes

Others:
Cirrhosis, acalcular cholecystitis,
Gallstone, osteomalacia