Perioperative Nutrition

Prinnisa A Jonardi | 2006626544

STASE BEDAH DIGESTIF
BEDAH DASAR
2022
 Principles of metabolic and
nutritional care
• Compromised nutritional status is a risk factor for postoperative
complications
• Starvation during metabolic stress from injury differs from fasting under
physiological conditions
• Surgery itself leads to inflammation corresponding with the extent of
surgical trauma, leads to metabolic stress response.

• “Restitutio ad integrum” metabolic response is necessary. This requires

nutritional therapy especially when the patient is malnourished & the
stress response is prolonged.
Nutrition therapy

The success of surgery does not depend exclusively on technical surgical skills, but
also on metabolic interventional therapy

Define: The provision of nutrition or nutrients either orally or via enteral nutrition or
parenteral nutrition to prevent or treat malnutrition

Nutrition therapies are individualized and targeted nutrition care measures using
diet or medical nutrition therapy

In surgical patients: the indications for nutritional therapy are prevention and treatment
of catabolism and malnutrition
Type of nutrients

Carbohydrates
• Limited storage capacity
• Needed for brain and CNS
function (glucose)
• Yields 4.1  4 kcal/gram
• Recommended 45-65% total
daily calories intake

Ross, A. C., Caballero, B. H., Cousins, R. J., Tucker, K. L., & Ziegler, T. R. (2012). Modern nutrition in health and disease: Eleventh edition. Wolters Kluwer Health Adis (ESP).
Type of nutrients

• Major Endogenous fuel source

in healthy adults

Fat • Too small can lead to essential

fatty acid (linoleic acid)
deficiency and increased risk

s of infection
• Yields 9.3  9 kcal/gram
• Recommended 20-30% total
daily caloric intake

Ross, A. C., Caballero, B. H., Cousins, R. J., Tucker, K. L., & Ziegler, T. R. (2012). Modern nutrition in health and disease: Eleventh edition. Wolters Kluwer Health Adis (ESP).
Type of nutrients

• Needed to maintain anabolic

state (match catabolism)
• Adjust in patient with renal
Proteins and hepatic failure
• Yields 5.4  4 kcal/gram
• Recommended 10-35% total
daily caloric intake

Ross, A. C., Caballero, B. H., Cousins, R. J., Tucker, K. L., & Ziegler, T. R. (2012). Modern nutrition in health and disease: Eleventh edition. Wolters Kluwer Health Adis (ESP).
 Special consideration in surgery
Stress
• Injury or disease
• Surgery

Pre-hospital/pre-surgical nutrition

Nutrition history

Increased risk of malnutrition due to:

• Inadequate nutritional intake
• Surgical stress
• Subsequent increase in metabolic rate
• Extraordinary stressors (hypovolemia, bacteremia, medications)
• Wound healing
• Anabolic state, appropriate vitamins

Poor nutrition = poor outcomes

• For every gram deficit of untreated hypoalbuminemia there is ~30% increase in mortality

Weimann, A., Braga, M., Carli, F., Higashiguchi, T., Hübner, M., Klek, S., Laviano, A., Ljungqvist, O., Lobo, D. N., Martindale, R., Waitzberg, D. L., Bischoff, S. C., & Singer, P. (2017). ESPEN guideline: Clinical nutrition in
surgery. Clinical nutrition (Edinburgh, Scotland), 36(3), 623–650. https://doi.org/10.1016/j.clnu.2017.02.013
 Key aspects of perioperative care
Integration of nutrition into the overall management of the patient

Avoidance of long periods of preoperative fasting

Re-establishment of oral feeding as early as possible after surgery

Start of nutritional therapy early, as soon as a nutritional risk becomes apparent

Metabolic control e.g. of blood glucose

Reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function

Minimize time on paralytic agents for ventilator management in the postoperative period

Early mobilization to facilitate protein synthesis and muscle function.

Weimann, A., Braga, M., Carli, F., Higashiguchi, T., Hübner, M., Klek, S., Laviano, A., Ljungqvist, O., Lobo, D. N., Martindale, R., Waitzberg, D. L., Bischoff, S. C., & Singer, P. (2017). ESPEN guideline: Clinical nutrition in
surgery. Clinical nutrition (Edinburgh, Scotland), 36(3), 623–650. https://doi.org/10.1016/j.clnu.2017.02.013
 Nutritional Support

Healthy male, 70 kg Surgery patient

• Caloric intake: Caloric intake:

• Mild stress (inpatient)
• 25-30 kcal/kg/day
• 25-30 kcal/kg/day
• Protein intake: • Moderate stress (ICU patient)
• 0.8-1 gram/kg/day (max 150gm/day) • 30-35 kcal/kg/day
• Severe stress (burn patient)
• Fluid intake • 30-40 kcal/kg/day
• 30 ml/kg/day • Protein intake:
• 1-2 gram/kg/day
• Fluid intake:
• INDIVIDUALIZED

Weimann, A., Braga, M., Carli, F., Higashiguchi, T., Hübner, M., Klek, S., Laviano, A., Ljungqvist, O., Lobo, D. N., Martindale, R., Waitzberg, D. L., Bischoff, S. C., & Singer, P. (2017). ESPEN guideline: Clinical nutrition in
surgery. Clinical nutrition (Edinburgh, Scotland), 36(3), 623–650. https://doi.org/10.1016/j.clnu.2017.02.013
Nutritional Support • Types of nutrinional support:
• Enteral
• Parenteral

Length of time a patient can remain

NPO after surgery without
complications is unknown, however
depends on:
• Severity of operative stress
• Patient’s preexisting nutritional status
• Nature and severity of illness

Carson J, Al-Mousawi A, Rodriguez NA, Finnerty CC, Herndon DN. Metabolism in Surgical Patients. In: Sabiston’s Textbook of Surgery. 20th ed. 2016.
Enteral Nutrition
What is Enteral Nutrition?
• Enteral Nutrition
• Also called "tube feeding”, enteral nutrition is a liquid mixture of all the needed nutrients.
• Consistency is sometimes like a milkshake.
• It is given through a tube in the stomach or small intestine.
• If oral feeding is not possible, or an extended NPO period is anticipated, an access devise for
enteral feeding should be inserted at the time of surgery.
• Mucosal exposure to feeds
• Stimulates enteric blood flow, maintains barrier function by preserving tight junction integrity
• Bacterial fermentation: support the normal flora
• Gut motility: minimize ileus
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

• Malnourished patient expected to eat within

5-7 days
• Severe acute pancreatitis
• High output enteric fistula distal to feeding
tube
• Inability to gain access to GI tract
• Intractable vomiting or diarrhea
• Aggressive therapy not warranted
• Expected need less than 5-7 days if
malnourished or 7-9 days if normally
nourished

Carson J, Al-Mousawi A, Rodriguez NA, Finnerty CC, Herndon DN. Metabolism in Surgical Patients. In: Sabiston’s Textbook of Surgery. 20th ed. 2016.
 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

Carson J, Al-Mousawi A, Rodriguez NA, Finnerty CC, Herndon DN. Metabolism in Surgical
Patients. In: Sabiston’s Textbook of Surgery. 20th ed. 2016
Carson J, Al-Mousawi A, Rodriguez NA, Finnerty CC, Herndon DN. Metabolism in Surgical Patients. In: Sabiston’s Textbook of Surgery. 20th ed. 2016.
 Gastric vs. Small Bowel Access
• Indications to consider small bowel access/post-pyloric feeding:
• Gastroparesis/gastric ileus
• Recent gastrectomy surgery
• Upper GI tract condition (carcinoma, stricture, fistula)
• High risk of bronchial aspiration
• Significant gastroesophageal reflux
• Pancreatitis
• Ileus
• Proximal enteric fistula or obstruction

Carson J, Al-Mousawi A, Rodriguez NA, Finnerty CC, Herndon DN. Metabolism in Surgical Patients. In: Sabiston’s Textbook of Surgery. 20th ed. 2016.
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
• Whole protein nitrogen source, for use in patients with normal or near normal GI function
• Monomeric or elemental
• Predigested nutrients; most have a low-fat content or high % of MCT; for use in patients with
severely impaired GI function
• Disease specific
• 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
Jenis Nutrisi Enteral di RSCM
Jenis Nutrisi Enteral di RSCM
 Enteral Nutrition Prescription Guidelines

Gastric feeding Small bowel feeding

Continuous feeding:
Continuous feeding only; do not bolus due to risk
• Start at rate 30 mL/hour
of dumping syndrome:
• Advance in increments of 20 mL q 8 hours to goal
• Start at rate 20 mL/hour
• Check gastric residuals q 4 hours
• Advance in increments of 20 mL q 8 hours to goal
Bolus feeding:
• Do not check gastric residuals
• Start with 120 mL bolus
• Increase by 60 mL q bolus to goal volume
• Typical bolus frequency every 3-8 hours

Weimann, A., Braga, M., Carli, F., Higashiguchi, T., Hübner, M., Klek, S., Laviano, A., Ljungqvist, O., Lobo, D. N., Martindale, R., Waitzberg, D. L., Bischoff, S. C., & Singer, P. (2017). ESPEN guideline: Clinical nutrition in
surgery. Clinical nutrition (Edinburgh, Scotland), 36(3), 623–650. https://doi.org/10.1016/j.clnu.2017.02.013
Complications of
Enteral Nutrition
Parenteral Nutrition
 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

Weimann, A., Braga, M., Carli, F., Higashiguchi, T., Hübner, M., Klek, S., Laviano, A., Ljungqvist, O., Lobo, D. N., Martindale, R., Waitzberg, D. L., Bischoff, S. C., & Singer, P. (2017). ESPEN guideline: Clinical nutrition in
surgery. Clinical nutrition (Edinburgh, Scotland), 36(3), 623–650. https://doi.org/10.1016/j.clnu.2017.02.013
Indications for Parenteral Nutrition
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)

Paralytic ileus, mesenteric ischemia, small

Enteral nutrition is contraindicated, or
bowel obstruction, enteric fistula distal to
severe GI dysfunction is present enteral access sites
 TPN vs PPN
• TPN (Total Parenteral Nutrition) • PPN (Peripheral Parenteral Nutrition)
• High glucose concentration (15%-25% • Similar nutrient components as TPN, but
final dextrose concentration) lower concentration (5%-10% final
• Provides a hyperosmolar formulation dextrose concentration)
(1300-1800 mOsm/L) • Osmolarity <900 mOsm/L (maximum
• Must be delivered into a large-diameter tolerated by a peripheral vein)
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

Weimann, A., Braga, M., Carli, F., Higashiguchi, T., Hübner, M., Klek, S., Laviano, A., Ljungqvist, O., Lobo, D. N., Martindale, R., Waitzberg, D. L., Bischoff, S. C., & Singer, P. (2017). ESPEN guideline: Clinical nutrition in
surgery. Clinical nutrition (Edinburgh, Scotland), 36(3), 623–650. https://doi.org/10.1016/j.clnu.2017.02.013
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)

Carson J, Al-Mousawi A, Rodriguez NA, Finnerty CC, Herndon DN. Metabolism in Surgical Patients. In: Sabiston’s Textbook of Surgery. 20th ed. 2016.
Complications of Parenteral Nutrition

Carson J, Al-Mousawi A, Rodriguez NA, Finnerty CC, Herndon DN. Metabolism in Surgical Patients. In: Sabiston’s Textbook of Surgery. 20th ed. 2016.
Jenis Nutrisi Parenteral RSCM
Nutrition Screening

33
 Basic Data Requirement
• Body mass Index • Severe weight loss

1. < 18,5 underweight

1. >5% in 1 month
2. 18,5-24,9 Normal
2. <7,5% in 3 month
3. 25-29,9 overweight
3. >10% in 6 month
4. 30+ Obese
• Mid arm circumference

1. Male : <17,6 cm

2. Female : <17,1 cm
Diagnose Malnutrition
 Pengukuran Albumin

ALBUMIN
• Synthesized in and catabolized by the liver
• Pro: often ranked as the strongest predictor of surgical outcomes –
inverse relationship between postoperative morbidity and mortality
compared with preoperative serum albumin levels
• Con: lack of specificity due to long half-life (approximately 20 days)
• Normal range: 3.5-5 g/dL

Weimann, A., Braga, M., Carli, F., Higashiguchi, T., Hübner, M., Klek, S., Laviano, A., Ljungqvist, O., Lobo, D. N., Martindale, R., Waitzberg, D. L., Bischoff, S. C., & Singer, P. (2017). ESPEN guideline: Clinical nutrition in
surgery. Clinical nutrition (Edinburgh, Scotland), 36(3), 623–650. https://doi.org/10.1016/j.clnu.2017.02.013
 Pengukuran Albumin

Preoperative albumin levels have been found to be a better

prognostic indicator of morbidity and mortality than
anthropometric measurements

Preoperative albumin levels < 3 g/dL are independently

associated with an increased risk of developing serious
complications within 30 days of surgery, including sepsis, acute
renal failure, coma, failure to wean from ventilation, cardiac
arrest, pneumonia, and wound infection
 Screening Tools Recommended by
ESPEN 
Hospital: Nutritional
Community:
Risk Screening (NRS),
Malnutrition Universal
Malnutrition Screening
Screening tool (MUST) 
tool (MST) 

Elderly: Mini Validated in GI surgery :

Nutritional Assessment Subjective Global
(MNA) Assesment (SGA)
Malnutrition Universal
Screening Tool (MUST)
Nutritional Risk Screening (NRS)
Malnutrition Screening Tool (MST)
Mini Nutritional Assessment (MNA)
 Mini Nutritional
Assessment (MNA)
Malnutrition Indicator Score:
• 17 to 23.5 points
 at risk of malnutrition
• <17 points
 malnourished
Subjective Global
Assesment (SGA)
Perhitungan Kebutuhan
Kalori
Langkah Penentuan Diet dan Cairan
Tentukan kebutuhan cairan dan kebutuhan kalori

Tentukan diet
• Rute : Oral/Enteral/Parenteral
• Prinsip : GUT PRESERVATION (Selama bisa menggunakan usus, pilihan adalah oral/enteral)
• Konsistensi/Formula : Diet Cair/Lunak/Padat
• Bila dilakukan reseksi anastomosis usus, maka diharapkan usus mulai menyatu dalam 3-5 hari, yakin tidak ada
leakage dalam 7 hari. Awalnya dengan clear fluid mulai hari ke 3. Naikan bertahap diet cair/ASI setiap hari
sesuai dengan toleransi pasien (10-20cc/kgBB terbagi dalam 6-8x pemberian)
• Jumlah Kalori
• Kalori total, jumlah protein (dalam gram)
• Tambahan protein dalam kondisi luka bakar atau trauma berat (misal tambahan ekstra putih telur)
Langkah Penentuan Diet dan Cairan
3. Tentukan Cairan
a. Tentukan jumlah cairan yang perlu diberikan IV
Contoh penulisan diet :
(jumlah kebutuhan total cairan dikurangi yang
• Diet lunak per oral 1500 kkal, protein 50 gram
masuk per oral)
• Diet cair per NGT 6 x 20 cc
b. Tentukan jenis cairan sesuai dengan : • Diet cair dengan menggunakan susu formula
• Kebutuhan total cairan • Kalori susu formula : 100 cc susu formula = 100
• Jumlah kalori yang perlu diberikan parenteral kkal
• Kebutuhan elektrolit • Nothing per oral (NPO) atau puasa
4. Monitoring Toleransi Makanan
a. Muntah
b. Bising usus (bukan buang angin)
c. Nilai produksi NGT
Langkah Penentuan Diet dan Cairan
Kalori Total
• Masing-masing jumlah kalori dari protein (gram) serta
￮ kebutuhan kalori non-protein (karbohidrat dan lemak)

Kalori Protein
• Kebutuhan protein : 0.8 – 1.5 g/kg/hari (~ 1g/kg/hari)
• 1 g protein = 4.1 kkal

Kalori Non-Protein
• Kalori non-protein = total kalori – kalori protein
• *Pada praktiknya kalori non-protein = total kalori
• 60 % dari kalori non protein = kalori dari karbohidrat
• 40% dari kalori non protein = kalori dari lipid
Prinsip Pemberian Kalori Parenteral
1. Perhatikan Osmolaritas :
• Jika <900 mOsm  boleh akses perifer
• Jika >900 mOsm  akses sentral

2. Hitung Kebutuhan Kalori

• Hitung berapa gram kebutuhan protein, lipid, dan karbohidrat
• Penuhi kebutuhan protein dan lipid, baru karbohidrat dengan mencocokkan sediaan
• Protein 4,1 kkal/g ~ 4 kkal/g
• Lipid 9,4 kkal/g ~ 9 kkal/g
• Karbohidrat 4,1 kkal/g ~ 4 kkal/g
Kebutuhan Energi (KE)
Kebutuhan Energi Basal (KEB) – Harris Benedict
• Pria = 66 + (13,7 + BB kg) + (5,0 x TB cm) - (6,8 x U
thn)
• Wanita = 65 + (9,6 x BB kg) + (1,85 x TB cm) - (4,7 x
U thn)

Kebutuhan maintenance = 30 kkal x BB (ideal atau

aktual) *BB yang lebih kecil
Kebutuhan Energi (KE)
• *BB ideal :
 Pasien bedah: KEB x stress factor
• Usia < 40 th : (TB - 100) x 0,9
 Bedah minor: 1,1 x KEB
• Usia ≥ 40 th : TB - 100
 Bedah mayor elektif: 1,2 x KEB
• *BB aktual :
 Skeletal trauma dan head injury: 1,35 x KEB
• Pria : (LLA x BBI)/26,3
dan 1,6 x KEB
• Wanita : (LLAxBBI)/25,7
 Perhitungan Cairan
1. Tentukan jumlah cairan yang perlu diberikan Jumlah Total Cairan
IV • Dewasa: 40 cc/kg/hari
a. Hitung total cairan yang diperlukan • Anak :
b. Hitung total cairan yang dapat masuk per oral/enteral • 100 cc/kgBB/hari untuk 10 kg pertama
c. Hitung jumlah cairan yang perlu diberikan IV (total –
• 50 cc/kgBB/hari untuk 10 kg kedua
oral/enteral)
• 20 cc/kgBB/hari untuk sisanya

2. Tentukan jenis cairan sesuai dengan:

a. Kebutuhan cairan yang perlu diberikan IV Elektrolit
b. Jumlah kalori yang perlu diberikan parenteral (kalori • Na : 2-4 meq/kgBB/hari
total-kalori yang dapat masuk per oral) • K : 1-2 meq/kgBB/hari
c. Kebutuhan elektrolit
Kasus
• Pasien laki-laki, 54 tahun,
dengan Kolangitis akut
moderate (tokyo guideline gr
II). Ikterus obstruksi ec
stenosis CBD distal, Multiple
limfadenopati paraaorta curiga
Limfoma post ERCP POD 5
pro laparoskopi diagnostic
Kasus
• Pasien laki-laki, 54 tahun,
dengan Kolangitis akut
moderate (tokyo guideline gr
II). Ikterus obstruksi ec
stenosis CBD distal, Multiple
limfadenopati paraaorta curiga
Limfoma post ERCP POD 5
pro laparoskopi diagnostic
PERHITUNGAN KALORI
TN.SUKA
BB aktual: 40 kg
BB ideal: 46-63
TB: 159 cm
IMT: 15,9

BB ideal: 159-100 = 59 kg

• Kebutuhan]pasien ini:
• Kalori: 40x30= 1200 kcal • *Diet pasien Tn.Suka (plan 2)*
• Protein: 1 mg x 40 x 4 = 160kcal • 1.MC:6X150=900kcal
• Sisa kalori: 1040 • Protein: 10gr/260ccx150ccx6pemberianx4kcal= 138 kcal
• Karbohidrat: 70%x1040=728 kcal • Karbo: 40gr/260ccx150ccx6pemberianx4kcal= 553 kcal
• Lemak: 30%x1040= 312kcal • Lemak: 7gr/260ccx150x6pemberianx9kcal= 218 kcal

• *Diet pasien Tn.Suka (plan 1):* • 2.Bubur sumsuk cup kecil 1x (Kalori 100, karbo: 20mg, protein: 4mg, lemak: 5
• 1.Bubur sumsum (kalori 275, karbo: 52 mg, protein: 4 mg, lemak: 5 mg) mg)
• Kalori 3x275 = 825 kcal • Energi: 100 kcal
• Karbo 52x4x3 kcal = 624 kcal • Karbo: 20x4x1 = 80kcal
• protein 4x4x3 = 48 kcal • Protein: 4x4x1= 16 kcal
• lemak 5x9x3= 135 kcal • Lemak 5x9x1=45kcal

• 2.MC: 1200-825 =  375 kcal • 2.Bfluid: 1200-900-100=200kcal

• Susu = 1 kcal/cc • Energi: 210 kcal
• MC: 3x150 • Karbo: 37.5x4= 160 kcal
• Protein: 10gr/260ccx150ccx3pemberianx4kcal= 69 kcal • Protein 15x4= 60kcal
• Karbo: 40gr/260ccx150ccx3pemberianx4kcal= 276 kcal • Lemak: 0x
• Lemak: 7gr/260ccx150x3pemberianx9kcal= 109 kcal
Kasus
• S: Sudah tidak sesak napas, pasien diet bubur toleransi baik tidak habis karena kurang selera, mual tidak ada, muntah tidak ada, BAK biasa, BAB 1x kemarin konsistensi padat
warna kecokelatan , flatus ada  

• O: Compos mentis, hemodinamik stabil

Abdomen
I: tampak distensi
A: bising usus positif
P: Lemas, nyeri tekan tidak ada, hepar lien tidak teraba
P:Shifting dullness positif

• A: Kolangitis akut moderate (tokyo guideline gr II)

Ikterus obstruksi ec stenosis CBD distal
Multiple limfadenopati paraaorta curiga Limfoma
Efusi pleura susp metastasis
DM tipe 2  

• P: Tindakan bila bilirubin < 10

Diet lunak (1200 kcal)
-bubur sumsum 3x1 cup besar
-MC 3x150 cc
Cefoperazone sulbactam 2x1 gr i.v (H5)
Levofloxacin 1x750 mg (H5)
Regulasi gula darah sesuai TS IPD  
Referensi
• Carson J, Al-Mousawi A, Rodriguez NA, Finnerty CC, Herndon DN. Metabolism in Surgical Patients. In:
Sabiston’s Textbook of Surgery. 20th ed. 2016.
• Lobo, D. N., Gianotti, L., Adiamah, A., Barazzoni, R., Deutz, N., Dhatariya, K., Greenhaff, P. L., Hiesmayr, M., Hjort
Jakobsen, D., Klek, S., Krznaric, Z., Ljungqvist, O., McMillan, D. C., Rollins, K. E., Panisic Sekeljic, M., Skipworth, R.,
Stanga, Z., Stockley, A., Stockley, R., & Weimann, A. (2020). Perioperative nutrition: Recommendations from the ESPEN
expert group. Clinical nutrition (Edinburgh, Scotland), 39(11), 3211–3227. https://doi.org/10.1016/j.clnu.2020.03.038
• Ross, A. C., Caballero, B. H., Cousins, R. J., Tucker, K. L., & Ziegler, T. R. (2012). Modern nutrition in health and
disease: Eleventh edition. Wolters Kluwer Health Adis (ESP).
• Unger, N., & Holzgrabe, U. (2018). Stability and assessment of amino acids in parenteral nutrition solutions. Journal of
pharmaceutical and biomedical analysis, 147, 125–139. https://doi.org/10.1016/j.jpba.2017.07.064
• Weimann, A., Braga, M., Carli, F., Higashiguchi, T., Hübner, M., Klek, S., Laviano, A., Ljungqvist, O., Lobo, D. N.,
Martindale, R., Waitzberg, D. L., Bischoff, S. C., & Singer, P. (2017). ESPEN guideline: Clinical nutrition in
surgery. Clinical nutrition (Edinburgh, Scotland), 36(3), 623–650. https://doi.org/10.1016/j.clnu.2017.02.013
• Zhou, X., Wu, X., Deng, B., & Huang, L. (2020). Comparative Survey on Nutrition Risk and Nutrition Support Among
Hospitalized General Surgery Patients Over a 7-Year Period. JPEN. Journal of parenteral and enteral nutrition, 44(8),
1468–1474. https://doi.org/10.1002/jpen.1784