1. NUTRITIONAL SUPPORT IN SURGICAL PATIENTS
M K ALAM MS ; FRCS
Professor of Surgery

2. 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

3. ADEQUATE DIET IS NECESSARY TO MAINATAIN NORMAL BODY COMPOSITION AND ORGAN FUNCTIONS

4. Definition
Nutritional support is an adjuvant therapy used to support the surgical patients until they are able to sustain themselves with adequate spontaneous nutrition by mouth.

5. Malnutrition Common in hospitalized patients.
Up to 50% may have moderate malnutrition.
Increases morbidity and mortality.
Damaging effects on activity level & appearance.
Damaging effects on psychological status.
Prolongs hospital stay

6. ENDOGENOUS ENERGY STORES CARBOHYDRATE - GLYCOGEN
Just enough to last one day
Liver- 400 kcal
Muscle kcal -- not readily available
Essential for: RBC, WBC, bone marrow, eye , renal medulla & peripheral nerves
Brain- normally uses glucose but switches to fat in starvation.
1 Gm. = 4 kcal

7. 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

8. 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

9. SIMPLE
STARVATION
↓ energy expenditure
↑ use of fat for fuel
↑ lipolysis
↓ nitrogen loss
↓ glucose use by brain*
* RBC, WBC, renal medulla,
neurons, muscles & intestinal mucosa supply maintained
POST-SURGERY STARVATION ↑ hormonal stimulation ↑ cellular activity ↑ metabolic rate ↑ energy expenditure ↑ gluconeogenesis ↑ protein breakdown ↑ nitrogen loss ↑Lipolysis

10. 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

11. Which patient requires nutritional support?
MAIN CONSIDERATIONS
Which patient requires nutritional support?
Select the appropriate substrate.
Obtain and maintain access for delivery.

12. Severely malnourished due to disease
WHICH PATIENT?
Severely malnourished due to disease
Become malnourished due to surgical therapy
Insufficient intake for more than 5-7 days
Unable to resume dietary intake within 5-7 days

13. 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 )
Mid arm muscle circumference <60% ( M 25.5 cm, F 23 cm )
Triceps skin fold <60% ( M 12.5mm, F 16.5mm )

14. 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

15. 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

16. ASSESSMENT OF NUTRITIONAL REQUIREMENTS
Optimal nutrition should provide adequate requirements of :
Calories- Carbohydrate & fat
Protein
Water
Electrolytes
Trace elements
Vitamins

17. Energy requirements in adults
Energy : Uncomplicated patients Kcal/ kg/ day
Complicated/ stressed pts Kcal/kg/day
Energy source : Carbohydrates %
Lipids 20 %

18. Carbohydrates: Predominant form used- dextrose
Optimal 4-5mg/kg/min.
Lipids: 20% of total calories
Lipid emulsion mixed with other element “3 in 1”

19. Protein
Uncomplicated patients 1 g / kg/ day
Complicated/ stressed pts g / kg/ day

20. Electrolytes:*
Sodium mEq / kg /day
Potassium mEq/ kg/ day
Calcium mEq/ kg/ day
Magnesium mEq /kg /day
* adjusted daily
Trace elements
Vitamins

21. 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

22. 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

24. 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

26. Feeding gastrostomy

27. Jejunostomy feeding

28. 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.

29. Advantages of enteral feeding
Simplicity
Greater availability
Lower cost
Well tolerated
Maintains gut integrity
Fewer complications

30. Contraindications to enteral feeding
Intestinal obstruction
Paralytic ileus
High output entero-cutaneous fistula
Short bowel syndrome
Severe acute pancreatitis
Malabsorption

31. 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

32. Total parenteral nutrition- TPN
Delivering predigested nutrients via hyperosmolar
solution into venous system
TPN or CVN ( central venous nutrition ) : Subclavian / Internal jugular,
Catheter tip in SVC
Most commonly used
PVN ( peripheral venous nutrition ) or PPN: Solution of lower calorie, lower dextrose and higher lipid Suitable for 7-10 days feeding

33. TPN vs PPN
Given to patient who can tolerate some oral feeding but cannot ingest adequate amount of food.
Administered through peripheral veins
Two types of solutions used- lipid emulsions or amino acid- dextrose solutions
Extended period of intensive nutritional support.
Administered through central venous catheter.
Solution contains high concentration of protein and dextrose

34. TPN

35. Sever malnutrition ( unable to take orally )
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 )

36. 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

37. Long term nutritional support Majority have malignancy
Home TPN
Long term nutritional support
Majority have malignancy
Special catheter- e.g. Hickman
Subclavian vein through subcutaneous tunnel
Support system

38. 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

39. THANK YOU !