1. Surgical Nutrition

2. Outline Introduction Review of physiology Nutritional Assessment
Nutritional Support
Enteral
Parenteral
Conclusion

3. Introduction Surgical nutrition is important in
Well nourished and mildly malnourished patients who cannot take oral food for more than one week post operatively to avoid prolonged starvation.
Severely malnourished patients undergoing general surgery procedures.
All critically ill patients (Sepsis patients, Multiple Injury patients, Burn patients, etc).
Patients whom you predict cannot use their gut for prolonged period of time (Short gut syndrome, EC fistula, etc).

4. Critical issues Nutritional screening Nutritional assessment ABCD
Nutritional requirements
Nutritional support

5. Review of Physiology There are two broad classes of nutrients:
Those that provide energy
Carbohydrates, fats and proteins
Those that are incorporated in tissue synthesis
Proteins, vitamins, electrolytes, trace elements and water
Carbohydrates
30-60%
Stores depleted in 48hrs after starvation but within 24 hrs of stress
Proteins
Not stored; 2.5% daily turnover
2-4g/day is depleted in starvation but 30-50g/d after severe stress
Lipids
25-40% of total calories
Depleted in prolonged starvation and stress

6. The Cori cycle

7. ENERGY/NUTRIENT REQUIREMENT
Energy requirement is increased in catabolic state. Neonates/infants require about 3X energy requirements in adults.
The basal requirements are:
Energy J/kg
Proteins [g]
Carbohydrates [g]
Fat [g]
Water [ml] [45 -50]
Electrolytes
Vitamins

8. ESTIMATION OF ENERGY REQUIREMENT
Harris-Benedict equation estimates BEE at rest.
Men (13.7x weight) + (5x height) –(6.8 x age).
Women (9.6 x weight) + (1.7 x height) – (4.7 x age)
Most require kcal/kg/day.
Stress increases these values.
Requirements are increased by activity, surgery, trauma, fever, infection, burns, head injury, renal failure.
Decreased by sedation, paralysis, B blocker

9. Human catabolism Short term starvation Prolonged starvation
During the first hrs increased use of fat stores, and most tissues except RBCs, WBCs, and renal medulla oxidize lipid stores.
Brain has an obligate glucose requirement, over 3-5 days uses fatty acids for energy.
Reserves can maintain this demand for 12hrs but this can elongated by gluconeogenesis from lactate, glycerol and amino acids.
Prolonged starvation
Hepatic and renal gluconeogenesis drops
Brain cells use ketone bodies for energy.

10. Human catabolism [stress]
Protein
Proteolysis and synthesis [energy and acute phase reactant proteins by the liver]; negative nitrogen balance
Nitrogen loss:
5-8 gm/d normally
2-4 gm/d after several days of unstressed starvation
30-50 gm/d under severe stress (multiple trauma, sepsis, burns)
Lipids
Lipolysis
Carbohydrates
Glycogenolysis and gluconeogenesis
Insulin resistance
This response is stimulated by:
Hormones ACTH, GH, glucagon
Catecholamines
Cytokines associated with acute stress response

11. Nutritional assessment – ‘ABCD’
Anthropometric measurement
Length/ height; Weight/BMI; MUAC/skin fold thickness
Weight [<10%BW, <80% Ideal, 5% in 1month]
Biochemical findings
Serum protein [<30g/l]
FBC [PCV-anemia; Lymphocyte count <1500/mm3]
Immune competence [delayed hypersensitive reaction, antigen tests]
Clinical findings
History-weight loss, persistent nausea, anorexia, vomiting, diarrhoea, malaise, dysphagia
Signs: fluffy hair, pallor, skin rash, cheilosis, glossitis, neuropathy, dementia, muscle wasting, edema, Ascites
Dietary recall
How often, how much, how well
Indirect calorimetry
Oxygen consumption, determination of respiratory quotient
Measurement of nitrogen balance
Measurements of immunologic function

12. Nutritional requirement
Calculate total energy requirement [use equation]
Distribute thus:
Carbohydrates 50%
Fats 35%
Proteins 15%
Calculate nitrogen requirement -1.25g/kg BW
Trace elements
Electrolytes
Vitamins
Fluid 3L
Determine route
Enteral
Parenteral

13. Nutritional support Aims Routes
To provide energy, protein, trace elements and vitamins; To supply fluids and electrolytes
Routes
Enteral
Oro-enteric
Naso-enteric [NGT-NDT-NJT]
Needle catheter jejunostomy
Percutaneous endoscopic Gastrostomy/Jejunostomy
Parenteral
Peripheral /Central
Supplementary/Total
Temporary/permanent

14. Indications for nutritional support
This should consider the following:
The patient's premorbid state (healthy or otherwise)
Poor nutritional status (current oral intake meeting <50% of total energy needs)
Significant weight loss (initial body weight less than usual body weight by 10% or more or a decrease in inpatient weight by more than 10% of the admission weight
The duration of starvation (>7 days' inanition)

15. Indications for nutritional support
An anticipated duration of artificial nutrition (particularly total parenteral nutrition [TPN]) of longer than 7 days
The degree of the anticipated insult, surgical or otherwise
A serum albumin value less than 3.0 g/dL measured in the absence of an inflammatory state
A transferrin level of less than 200 mg/dL
Anergy to injected antigens

16. Nutrition in surgery: routes

17. Enteral Advantages Options Routes Complications
Cheap, more physiological, more efficacious in traumatized and burns patient
Options
Blenderised
Chemically defined
Special purpose formulation
Modular
Routes
Oro-enteral
Nasoenteral
Needle Catheter Jejunostomy
Percutaneous endoscopic gastrostomy/jejunostomy PEG/PEJ
Complications
Tube –displacement, dislodge, blockage; bowel perforation, reflux and aspiration pneumonia
Feed-high osmolar feed cause severe diarrhoea

18. Indications for enteral feeding
PEM with inadequate oral intake
Dysphagia except for fluids
Prolonged return to normal dietary intake after trauma/ surgery
Inflammatory Bowel Disease (IBD)
Distal, low output enterocutaneous fistulas
To enhance adaptation after massive enterectomy

19. Contraindications Mesenteric ischemia Small Bowel obstruction Sepsis
Pancreatitis
Fistula proximal small intestinal
SBS
Severe diarrhoea

20. Complications of enteral feeding
Pneumothorax
Oesophageal stricture, perforation
Fatal arrhythmias
Relating to the feeding regimen
Feed intolerance (diarrhoea, vomiting)
Hyperglycaemia
Enteric infection
Relating to the feeding tube
Malposition
Dislodgement / migration
Aspiration, sinusitis
Peritonitis
Fistula formation
Intestinal obstruction
Tube fracture/ blockage
Oesophageal and gastric mucosal erosions

21. Parenteral Sources Formulations Carbohydrate-based Fat-based
Intralipid 10%
Intralipid 20%
Vamin 9 glucose
Synthamin 14

22. Indications
When nutritional support is appropriate but effective enteral nutrition is not possible
Proximal intestinal fistula
IBD (especially in the perioperative period)
Massive intestinal resection (<100cm of small bowel remains)
Ileus
Severe pancreatitis
Acute burns
Hepatic failure (acute decompensation on cirrhosis

23. Standard TPN Standard Glucose 250g 4200J Protein 500ml 4200J
Amino acids 14g
Na 100mmol
K 100mmol
Cl 191mmol
Mg 19mmol
Folic acid
Water

24. TPN Access Protocol Peripheral Central ‘Daily dose method’
Calculate energy required
Calculate VOLUME requirements/24h.
Determine PROTEIN requirements g/kg/d.
Calculate daily CALORIES kcal/kg/d.
Determine % to be given as protein, CHO, fats.
Add electrolytes, trace elements.
Co-administer Lipids to prevent fatty acid deficiency.

25. Monitoring
Daily Clinical evaluation, input-output chart, weight, urinalysis, blood glucose
48-hrly EUC, blood pH, Clotting profile
Weekly LFTs, Serum Ca, FBC

26. TPN Advantages Successful outcome Improved survival Wound healing
Resistance to infection
Immunity is improved
Synthesis of blood elements RBC, plasma proteins
Successful outcome
GI fistula
Bowel failure
Burns
Persistent ileus
Pancreatic pseudocyst/ascites/fistulae

27. Advantages of TPN
Can be used for longer periods with hyperosmolar fluids at larger volumes
Survival rate is improved and morbidity reduced.
Weight loss and tissue breakdown are minimized
Wound healing is enhanced
Resistance to infection and general immunity are improved
Formation of RBCs and plasma proteins is maintained

28. Complications of TPN Procedure Feed Needle malposition Air embolism
Fat embolism
CCF
Pulmonary embolism
Septicaemia
Feed
Acute reactions to fats and amino acids
Hyperosmolarity-related complications
Metabolic acidosis
Hyperglycemia
Rebound hypoglycemia
Anaemia
Zinc deficiency
Jaundice
Altered biochemical profile
Refeeding syndrome

29. Conclusion
Nutritional supplementation reduces the risk of complications if given to severely malnourished patients undergoing major surgical procedures and in patients with severe sepsis, trauma and burns.
One of the most important therapeutic modalities of the 20th century has been nutritional support, in particular, IV feeding.
The ability to intervene in and correct nutritional deprivation states that cause significant mortality in patients is germane hence it should not counted as a luxury.