1. Nutrition in Surgical Patient
General Surgery
Nutrition in Surgical Patient
Dr. Ziad H. Delemi
B.D.S, F.I.B.M.S (M.F.)
Mosul university- College of dentistry-oral & maxillofacial surgery department

2. Malnutrition
Causes:
-Pre-operative: starvation(self neglect, poverty, dysphagia)failure of proper digestion.
-Post-traumatic:
-Hypercatabolic:sever sepsis, burn
Mosul university- College of dentistry-oral & maxillofacial surgery department

3. Effects of Malnutrition
Poor wound healing (dehiscence).
Delay callus formation.
Coagulation disorder.
Impaired drug metabolism in the liver.
Depress immunity.
Decrease tolerance to radiotherapy & chemotherapy.
Sever mental apathy.
Mosul university- College of dentistry-oral & maxillofacial surgery department

4. Indication of nutrition
Pre-operative nutritional problems.
Post operative complications(ileus more than 4days, sepsis).
Intestinal fistula.
Massive bowel resection.
Management of malabsorption.
Anorexia nervosa.
Mosul university- College of dentistry-oral & maxillofacial surgery department

5. Indication of nutrition
Intractable vomiting.
Maxillofacial trauma.
Multiple trauma.
Malignant disease.
Burn.
Renal failure, liver disease.
Mosul university- College of dentistry-oral & maxillofacial surgery department

6. Assessment of the nutritional status of the patient
A- characteristic appearance: lean & hungry, apathic, superimposed hectic flush around sunken cheeks & pinched nose.
B- physical examination:
Skin: rash, hyperkeratosis, nail deformity.
Eyes: keratoconjectivitis, night blindness.
Mouth: chelosis, glossitis, mucosal atrophy.
Hair: recent loss.
CNS: peripheral neuropathy, psychiatric problems.
Mosul university- College of dentistry-oral & maxillofacial surgery department

7. Assessment of the nutritional status of the patient
C- special test:
Body weight, body mass index wt/height².
Upper arm circumference indicated if <23 cm ♀ or 25 cm in ♂.
Triceps skin fold thickness, min. 13 mm ♀, 10 mm ♂
Serum Albumin not less than 35 g/L
Lymphocyte count <1500 /mm³
Candida skin test
N2 – balance studies.

8. Nutritional requirement
1- calories(energy):provided by CHO & fat. healthy adult at rest need 1500 – 2000 nonproteinous calories /day.
2- N2: min. for +ve N2 balance 40 gm of protein & ↑in Hypercatabolic state.
3- H2O: ml/day.
4- electrolytes: N+ 100mmol/dl, K+ 60mmol/dl, Ca++ 20 mmol/dl, Mg+ 30 mmol/dl, Cl- 100mmol/dl
Mosul university- College of dentistry-oral & maxillofacial surgery department

9. Nutritional requirement
5- vitamins: water soluble vit. C& B, vit. C 70 mg/day & vit. B12 500µg /week IM.
Fat soluble vit. A 6000 IU /week, K 8mg/week IM, E 10 mg/day ,D 5 µg/day.
Vit. A&C affect Wound healing
Vit. D Rickets, osteomalacia
Vit. E Anemia, ataxia, nystagmus, edema, myopathy.
Thiamine Encephalopathy
Vit. B6 neuropathy…
6- minerals: iron 50 µmol/day, zinc 50 µmol/day, copper 15 µmol/day, iodine 5µmol/day.

10. Constituents of TPN CHO: Dextrose 20%, 50%, 70%.
Fat : Intralipid 10-20%.
Protein: Vamine, Freamine, Nephramine, Hepatomine .
Water 1500cc/day.
Electrolytes K+, Na+, Cl-, Ph-, Ca++
Vitamins
Trace elements: Mg, Fe, Zn, …
Albumin: 60 gm/day.
Insulin: to keep blood glucose mg/dl.
Heparin: 1000 U/L protect central line & for lipolysis
Mosul university- College of dentistry-oral & maxillofacial surgery department

11. Methods of Nutrition A- Enteral:
1- mouth: if there is no contraindication (?) start with liquid then semisolid then solid.
2- NG tube: used for regular gastric aspiration& for feeding of liquid diet.
3- tube enterostomy: used if NG tube is not possible & if more than 4 weeks enteral feeding is indicated, types ( Gastrostomy, Jejunostomy).
Mosul university- College of dentistry-oral & maxillofacial surgery department

12. Methods of Nutrition B- parenteral nutrition:
By IV feeding, it indicated when enteral feeding is not possible or not enough.
Routes of administration:
1- central venous line: usually hyperosmolar solution administered directly in to central vein, so they are rapidly diluted by fast flow of blood to avoid thrombosis & thrombophlebitis, example Hickman catheter.
Mosul university- College of dentistry-oral & maxillofacial surgery department

13. Methods of Nutrition 2- peripheral venous line:
Lower osmolarity solutions may be administered through peripheral veins, usually changed 3-4 days due to infusion thrombophlebitis.
Mosul university- College of dentistry-oral & maxillofacial surgery department

14. Methods of Nutrition

15. Complications of TPN 1- malposition of catheter tip.
2- infection specially septicemia.
3- essential fatty acid deficiency.
4- hypophosphatemia.
5- jaundice.
6- metabolic acidosis.
7- metabolic & electrolytes disturbances.
Mosul university- College of dentistry-oral & maxillofacial surgery department