1. For 4th year medical student
Surgical Nutrition
For 4th year medical student

2. Surgical nutrition Starvation Response to injury
Nutritional assessment
Nutritional requirement and planning
Formula and route
Monitoring

3. Nutrition Storages Obligate glycolytic cells
Carbohydrate: glycogen (liver and muscles)
Protein: muscles, enzyme
Fat
Obligate glycolytic cells
neurons
leukocytes
erythrocytes
renal medullae

4. Starvation Short-term fasting (<5 days) Principal sources of fuel
Muscle protein and body fat
fat being the most abundant source of energy
Glycogen storages in liver : muscle
75 to 100 : 200 to 250 g
Muscle-deficiency in glucose-6-phosphatase
Hepatic glycogen stores ; rapidly and preferentially depleted, which results in a fall of serum glucose concentration within hours (<16 hours)

5. Short-term fasting

6. Starvation Prolonged starvation Decrease systemic proteolysis
Adaptation by vital organs (e.g., myocardium, brain, renal cortex, and skeletal muscle)
Using ketone bodies as their principal fuel source
compensated starvation

7. Prolonged starvation

8. Response to injury Neuroendocrine and immunologic responses Ebb phase
sympathetic activation and catecholamine release -> increase in energy expenditure
Ebb phase
Flow phase
Catabolic phase: hypermetabolism, negative nitrogen balance
Anabolic phase: positive nitrogen balance, increase weight
Recovery phase

9. Response to injury

10. Estimation of Energy Requirements
Nutritional assessment
Pertinent information:
Age, sex
BMI
presence of weight loss: 5% in 1 month, 10% in 6 months
chronic illnesses
dietary habits
Physical examination:
assess loss of muscle and adipose tissues
organ dysfunction
changes in skin, hair, or neuromuscular function

11. Estimation of Energy Requirements
Nutritional assessment
Anthropometric data
triceps or subscapular skin fold thickness
mid-arm muscle circumference
Biochemical determinations
creatinine excretion
albumin level (half-life days)
prealbumin level
total lymphocyte count
transferrin level

12. Estimation of Energy Requirements
BMI = weight (kg) / hight2 (metre)
BMI weight status
< 18.5
Underweight
20-25
Normal
Overweight
>30
Obese
>40
Very obese
Total lymphocyte count = WBC x %lymphocyte

13. Estimation of Energy Requirements
A fundamental goal of nutritional support
to meet the energy requirements for essential metabolic processes and tissue repair
Caloric requirement
indirect calorimetry (oxygen consumption and carbondioxide production)
serum markers (e.g., prealbumin level)
urinary nitrogen excretion
Failure to provide adequate nonprotein energy sources will lead to consumption of lean tissue stores.

14. Estimation of Energy Requirements
Basal energy expenditure (BEE)
BEE (men) = (W) (H) – 6.76 (A) kcal/d
BEE (women) = (W) (H) – 4.68 (A) kcal/d
W = weight in kilograms
H = height in centimeters
A = age in years
BEE = kcal x Wt.

15. Estimation of Energy Requirements
Total energy expenditure (TEE)
TEE=(BEE x AF x SF) + FF+GF
Activity factors
Bed ridden
Respirator support
Limited activity on bed
1.2
Normal activity
1.3

16. Estimation of Energy Requirements
Stress factors
Major surgery
1.2
Peritonitis, multiple trauma
Major sepsis
1.3
Cancer
Severe thermal burn
Fever factors
Plus13%ofBEE/1C(>37.0C)
Growth factors
Moderate degree previous malnutrition
add 5% of BEE
Severe degree previous malnutrition
add 10-15% of BEE
3500 excessive kcal/wk (500 kcal/day)
1 lb weight gain

17. Estimation of Energy Requirements
Adjustment of carbohydrate: protein: fat ratio
Carbohydrate %
4 kcal/gm, dextrose = 3.4 kcal/gm
Protein %
4 kcal/gm
Fat %
9 kcal/gm
Adequate carbohydrate intake
Insulin secretion
Inhibit proteolysis
Glucose 150 gm/day->protein-sparing effect

18. Estimation of Energy Requirements
Protein requirement
Normal condition
Protein gm/kg/d
Stress
Increase protein requirement (up to 2 gm/kg/d)
Non-protein calorie : nitrogen ratio (kcal : gram Nitrogen) :1 :1
1 gm Nitrogen = 6.25 gm protein

19. Estimation of Energy Requirements
Polyunsaturated fatty acids
Long chainfatty acids (long chain triglycerides : LCT)
Hydrolyzed by bile salt and pancreatic lipase
Monoglyceride and free fatty acid
Medium-chain fatty acids (medium chain triglycerides : MCT)
Directly absorbed by enterocyte
For fat mulabsorption (intestinal mucosa damage, bile salt deficiency), obstructive jaundice

20. Estimation of Energy Requirements
Nitrogen balance
= nitrogen intake-nitrogen loss
= Total protein intake (grams)/ (UUN + 4 grams)
UUN = grams of nitrogen excreted in the urine over a 24 hour
4 = 4 grams of nitrogen lost each day as “insensible losses” via the skin and gastrointestinal tract

21. Formula and route Enteral nutrition Advantages easily administered
well tolerated
promotion of gut mucosal growth and development
maintain the barrier function of the gastrointestinal tract
supporting the body’s mucosal immune system
better nutrient use
fewer metabolic disturbances such as hyperglycemia, cholestasis, and fatty infiltration of the liver
less expensive
fewer infectious complications

22. Formula and route Enteral nutrition Contraindication Bowel obstruction
Intractable N/V
Severe short gut
Upper GI tract or high output fistula
Severe acute pancreatitis

23. Formula and route Parenteral nutrition Peripheral parenteral nutrition
Limit osmolarity
12.5% glucose
Short term
Total parenteral nutrition
Central vein

25. Monitoring Initial monitoring Daily: BW and intake-output
Blood sugar, urine sugar, electrolyte
Daily: BW and intake-output
Weekly: Blood sugar, BUN, Cr, Electrolyte, Live function test, Trace element, Urine urea nitrogen

26. Complication Refeeding syndrome
Chronic malnutrition, prolong fasting
-Decrease insulin
-Increase glucagon and cortisol
-Glycogenolysis
-Gluconeogenesis
-Protein catabolism
-Depletion of electrolytes, protein, fat, mineral and vitamins
Refeeding
Insulin secretion
Protein and glycogen synthesis
Increase glucose, Mg, PO, K uptake
-Hypophosphatemia
-Hypokalemia
-Hypomagnesaemia
-Thiamine deficiency
-Sodium and water retention

27. Complication High risk patient Severe malnutrition
Glucose base formula
Electrolyte abnormality

28. Complication Prevention Correct electrolyte abnormality Slow feeding
Avoid over feeding

29. Question
64 year-old male, CA mid esophagus with cachexia and aspiration pneumonia
Nutritional risk status
Severe malnutrition with systemic infection
Nutritional assessment
Healthy BW 70kg, current BW 56 kg, Height 156 cm, moderate dehydration, moderate loss of muscle mass, physical signs of essential fatty acid deficiency, anular stomatitis
Hct 35%, N 88%, L11% Eo1%
BUN 20 mg/dl, Cr1.5 mg/dl
Na 132 mEq/L, K 2.8 mEq/L, Cl 102 mEq/L, CO2 28 mEq/L
Albumin 3.4 mg/dl, globulin 4.0 mg/dl
Urine spec , urine ketone +

30. Question Planning for primary disease Nutritional planning
Radiation
Nutritional planning
Route: GI function?
Esophageal stent +/-NG tube
Nutritional requirement
Total energy requirement: 30x70= 2100 kcal/d
Protein requirement: 1.5 x70= 105 g/d, 105/6.25=16.8 g N2
420 kcal/d
Non Protein calories = =1680 kcal
NPC:N = 1680/16.8 = 100:1
Carbohydrate 50%

31. Question Nutritional requirement Carbohydrate: 50% Fat Water Potassium
2100/2= 1050 kcal/d
Fat
2100-( )= 630 kcal
Water
1ml/kcal/d = 2,100 ml
Holliday -Sagar
Potassium
Every 1 mEq/L ↓K below 3.5 mEq/L = total body potassium deficit of mEq
=0.7, 70 mEq
Elixir KCl 15 ml= 20 mEq, 52.5 ml
Every 1 mEq/L ↓K below 3.5 mEq/L = total body potassium deficit of mEq
K3-3.5 : แก้ 1-2 mEq/kg, K2.5-3 แก้ 2-3mEq/kg

32. Question Formula and route Monitoring
Generic feeding formula, step feeding
Goal: 5-7 days
Add water: 1 kcal/ml
Add multivitamins syr.
Monitoring
Calories count: goal?
NG feeding
BW OD
Electrolyte, BUN, Cr, BS, PO, Mg
Nitrogen balance, prealbumin
Current condition: change caloric requirement

33. Thank you