SURGICAL NUTRITION

Michael L. Cheatham, MD, FACS, FCCM

Director, Surgical Intensive Care Unit
Orlando Regional Healthcare System
Orlando, Florida
The importance of appropriate nutritional support in the management of surgical patients has been
realized predominantly within the last decade. Only within that time period has the significant role of the
gastrointestinal tract in the prevention of bacterial translocation and maintenance of immune function
been noted. Enteral nutrition has been found to be superior to the more traditional parenteral nutrition
because of its ability to prevent intestinal mucosa atrophy and preserve barrier function. Nutrition is no
longer a simple matter of providing sufficient calories, but has advanced to the era of nutriceutical
therapy1 where cellular metabolism and immune response can be modulated via manipulation of the
nutrients provided to the patient.
Historically, disease was treated with starvation. R.J. Graves (of thyroid disease fame) was one of the
first physicians to advocate feeding the seriously ill patient. This was confirmed scientifically in the early
1900s when the occurrence of protein breakdown during illness was documented. The detrimental
effects of malnutrition on the critically ill patient are now well known:
DETRIMENTAL EFFECTS OF MALNUTRITION

Increased infectious morbidity

Prolonged hospital stay
Impaired immunological function
Impaired ventilatory drive
Weakened respiratory muscles

Prolonged ventilatory dependence

Impairment of visceral organ function
Decreased wound healing
Disruption of mucosal barrier
Increased mortality

As recently as the 1970's, however, the benefit of nutritional support was still debated. In the late
1970's and early 1980's, recognition of the effects of malnutrition and the theory that "more must be
better" led to the practice of providing patients with more calories than were needed (sometimes as high
as 4000-6000 kcal/day) in order to ensure adequate caloric supplies for healing. This theory is still
commonly used today and was the basis for the development of total parenteral nutrition or
hyperalimentation. Over the past decade, however, it has been recognized that there are few
advantages of overfeeding the surgical patient, and, in fact, there are numerous disadvantages and
potential hazards.
DISADVANTAGES OF OVERFEEDING

Carbohydrate Overfeeding
Hyperglycemia
Hypercarbia
Hypertriglyceridemia
Hyper- or hypokalemia
Hypophosphatemia
Hypomagnesemia
Hepatic steatosis / fatty liver
Azotemia
Respiratory insufficiency
Failure to wean from the ventilator
Immunosuppression
Increased susceptibility to infection

Lipid Overfeeding
Hyperlipidemia
Hypoxia
Increased infection rate
Higher postoperative mortality

Revised 5/30/01

As we enter the new millennium, the current theory on optimal nutritional support centers around three
goals:
1. To provide sufficient calories, protein, and fat to meet the cellular demands of the
patient while minimizing the detrimental effects of overfeeding
2. To maintain gut integrity and immune function
3. To prevent organ failure and sepsis
ESTIMATION OF ENERGY REQUIREMENTS
Appropriate feeding of the surgical patient begins with accurate assessment of the patients nutritional
requirements. Unfortunately, this is not a simple task and has been the subject of much debate. The
following are the commonly used methods for estimating energy requirements:
Body Weight Measurements
One of the earliest methods for estimating the degree of malnutrition was by measuring a patients weight
and comparing it with a calculated ideal body weight (IBW). Such methods are adequate for patients
who have chronic malnutrition and weight loss, but are not appropriate for the surgical patient population.
Surgical patients can have tremendous fluid shifts resulting in significant increases in measured body
weight that are not indicative of the patients actual nutritional status. Therefore, although a critically ill
surgical patients measured weight may significantly exceed the calculated IBW, the patient may actually
be in a state of severe malnutrition. Wound dressings, catheters, monitoring wires, and ventilator tubing
may similarly serve to confound attempts to accurately measure a patients weight.
Harris-Benedict Equation
The Harris-Benedict equation is perhaps the most commonly used method of estimating a patients
metabolic energy requirements. It calculates the estimated basal energy expenditure (BEE) in kcal/day
for a patient using the following equations:
Male:
Female:

BEE = 66 + (13.7)(weight in kg) + (5)(height in cm) - (6.8)(age)

BEE = 665 + (9.6)(weight in kg) + (1.8)(height in cm) - (4.7)(age)

The resting energy expenditure (REE) is considered to estimate a patients true metabolic energy
requirements after accounting for activity and the stress of injury and can be calculated using the BEE as:
REE = BEE * activity factor * injury factor
Injury factor
minor surgery
trauma
sepsis
burns

Activity factor
bed rest
1.2
ambulatory1.3

1.2
1.35
1.6
2.1

The Harris-Benedict equation was derived from the energy requirements of healthy volunteers and is
therefore not directly applicable to critically ill patients. While the BEE tends to underestimate the true
metabolic requirements of the surgical patient, the REE commonly overestimates energy requirements.
Nutritional therapy based on these measurements alone will therefore likely lead to overfeeding. The
Harris-Benedict equation is, however, frequently used as an initial estimate of a patients energy
requirements in order to begin nutritional support.

Revised 5/30/01

Indirect Calorimetry
A more accurate albeit more costly and labor intensive method of measuring a patients resting energy
expenditure is indirect calorimetry or a metabolic cart. By measuring a patients oxygen consumption
(VO2) and carbon dioxide production (VCO2), an accurate calculation of the patients resting energy
requirements can be made. This accuracy is increased if the patient is receiving mechanical ventilation
(as the inspired and expired gases can more easily be obtained), but is decreased if the patient is
receiving high inspired oxygen fractions or has a high minute ventilation. Indirect calorimetry is useful in
evaluating the patients true metabolic energy expenditure and is frequently performed weekly to ensure
that appropriate levels of nutritional support are being provided.
Clinically, the current literature suggests that the energy requirements of most surgical patients can be
met by providing carbohydrate and fat calories totaling 25-30 kcal/kg/day in an optimal ratio of 70%
carbohydrate calories to 30% fat calories. Specific patient populations may require modifications of these
guidelines. Burn patients, for example, may require as much as 40-45 kcal/kg/day in order to meet their
greatly increased metabolic requirements. Patients receiving mechanical ventilation may require less
carbohydrate calories in order to decrease carbon dioxide production and minute ventilation. On
average, carbohydrate administration should not exceed 4 mg/kg/min. Carbohydrate administered in
excess of this rate is not oxidized, but rather stored as lipid resulting in hepatic steatosis as well as the
other complications associated with carbohydrate overfeeding. In fact, current research suggests that
optimal nutritional support may be possible by delivering as little as 80% of a patients calculated energy
requirements.
ESTIMATION OF PROTEIN REQUIREMENTS
Once hepatic stores of glycogen have been depleted (occurring within the first 24 hours), muscle protein
is utilized predominantly as the primary source for energy substrates. This catabolism results in
increased excretion of nitrogenous waste via the gastrointestinal tract and kidneys. Surgical patients,
because of the stress of their injury and wounds, are inherently catabolic requiring increased protein
administration to prevent further protein breakdown. These patients also have increased energy and
protein requirements to provide for wound healing as well as the need to replace protein which is lost
from wounds and fistulae. Estimation of protein requirements must therefore take these increased losses
into account. The following are the commonly used methods for estimating protein requirements:
Calorie to nitrogen ratio
A simple method for estimating protein needs based on caloric requirements is the calorie to nitrogen
ratio. A ratio of 150 carbohydrate calories to 1 gram of nitrogen is commonly utilized to determine protein
administration. The calorie to nitrogen ratio may not, however, account for the increased protein needs of
surgical patients resulting in inadequate protein administration.
Nitrogen balance
Calculation of a patients nitrogen balance can be used as an indicator of whether sufficient nutrition is
being supplied to prevent further breakdown of muscle protein. A patient who is in positive nitrogen
balance excretes less nitrogen than they consume and is incorporating nitrogen into newly formed
protein (i.e. muscle). A patient who is in negative nitrogen balance excretes more nitrogen than they
consume and is continuing to use muscle protein as an energy source. The goal of nutritional support is
positive nitrogen balance.
Nitrogen Balance =

Total protein intake (grams)

--------------------------------------6.25

(UUN + 4 grams)

Revised 5/30/01

where

6.25 = 6.25 grams of protein per gram of nitrogen

UUN = urine urea nitrogen
= grams of nitrogen excreted in the urine over a 24 hour period of time
4
= 4 grams of nitrogen lost each day as insensible
losses via the skin and gastrointestinal tract

As with any equation that attempts to estimate a physiologic parameter, nitrogen balance is only a crude
estimate. It is not valid in the presence of burns, fistulae, wounds with high protein output, or renal
failure. Nitrogen balance measurements are also time consuming as they require a 24 hour urine
collection for measurement of UUN (although some recent work as suggested that accurate
measurements may be obtained with only an 8 hour urine collection).
Because of the inaccuracy associated with determination of protein requirements, the current
recommendations are that an estimate of 1.5 grams of protein/kg/day should be used in calculating
protein administration for surgical patients. For comparison, a healthy person requires approximately 0.8
grams of protein/kg/day. Administration of more than 1.5 grams/kg/day exceeds the bodys ability to
incorporate protein and does little to restore nitrogen balance. The exception to this is the burn patient
who is losing large quantities of protein through their burn wounds. These patients may require protein
administration of up to 2-2.5 grams/kg/day.
THE ROLE OF LIPIDS IN NUTRITION
Intravenous lipid emulsions are commonly used in the administration of intravenous parenteral nutrition
as a compact source of calories. They are especially useful when meeting caloric needs would require
carbohydrate administration rates in excess of 4 mg/kg/min (resulting in lipogenesis) or would result in
hyperglycemia or hypercarbia. Diabetics and patients on steroids who are already hyperglycemic may
also benefit from having more calories supplied as lipid. Lipid administration is not without side-effects
however. Administration of lipid at rates of greater than 3 grams/kg/day has been associated with
cholestasis. Lipids have also been implicated as a cause of decreased humoral and cell-mediated
immune function. The type of lipid used may play a significant role as the omega-3 fatty acids have
recently been suggested to improve immune response.
In the critically ill surgical patient, carbohydrate prevents protein catabolism and restores nitrogen balance
more effectively than does lipid when adequate amounts of protein are provided. Thus, the majority of
the current literature suggests a carbohydrate to lipid ratio of approximately 70:30 with at least 3% of
the lipids as essential fatty acids.
WHO SHOULD BE FED?
Debate continues as to which patient populations are most likely to benefit from nutritional support and
which forms of nutrition are most appropriate. In general, however, most authors agree that there are
four clear indications for nutritional support:
1.
2.
3.
4.

Malnourished patients
Critically ill trauma, burn, or septic patients
Normally nourished patients who have had no oral intake for 5-7 days
Normally nourished patients who will be unable to eat for at least 10 days

Exogenous nutritional support may be indicated for patients with mild to moderate nutritional deficits,
patients who are unable to take adequate oral intake, and for prophylaxis against the development of
malnutrition. Nutritional support is not indicated for routine pre-operative or post-operative patients who
are expected to be able to eat adequately post-procedure.

Revised 5/30/01

WHEN TO FEED PATIENTS

Most of the current literature supports feeding surgical patients within the first 24-48 hours post-injury in
order to support wound healing, organ function, and immune status. The benefit of enteral nutrition
begun early far surpasses that of nutrition initiated later. "Bowel rest" is associated with disruption of the
mucosal barrier and greater infectious morbidity. Early nutrient administration decreases the incidence of
sepsis, diminishes gut translocation, and improves wound healing. Enteral feeding also appears to be
better tolerated if begun early and may help prevent ileus development.
The degree to which patients are fed is determined by the time period following injury. Patients do not
necessarily need to immediately receive 100% of their energy requirements. In the first 3 days postinjury, a priority should be placed on providing adequate water, glucose, sodium, potassium, vitamins,
and minerals. By the first 3-7 days post-injury, patients should be receiving at least 50% of their energy
requirements, preferably enterally. By the 7th day post-injury, patients should be receiving 100% of their
energy requirements. It should be kept in mind that in patients who were nutritionally depleted before
their injury, adequate nutrition should be instituted as soon as possible as these patients are already
catabolic.
ENTERAL VERSUS PARENTERAL NUTRITION
Although long the subject of debate and controversy, significant data now exists to support the use of
enteral nutrition over total parenteral nutrition (TPN) in the care of the critically ill surgical patient. Every
attempt should be made to feed patients enterally if the gastrointestinal tract is functional. This may be
accomplished orally; via nasogastric or nasoduodenal (Dobhoff-type) tubes; via gastrostomy; or via
jejunostomy. Energy substrates delivered enterally are better utilized by the body than if administered
parenterally. Enteral feedings prevent intestinal mucosa atrophy, maintain immune response, preserve
normal gut flora, improve nitrogen balance, improve wound healing, and decrease bacterial translocation
with subsequent multiple system organ failure. Their use is also associated with a decreased incidence
of hyperglycemia, fewer pneumonias, fewer intra-abdominal abscesses, decreased length of stay in the
intensive care unit, fewer ventilator days, decreased incidence of catheter related sepsis, and decreased
hospital charges.
While more than 90% of surgical patients can tolerate enteral feeding postoperatively, not all patients
may be capable of receiving their total caloric requirements enterally. Some patients may develop
diarrhea, especially if institution of enteral support has been delayed and gut mucosal atrophy has been
allowed to occur. Malabsorption and enterocutaneous fistulas may also prevent total enteral support. In
such patients, the benefits of enteral feeding may be realized if only 25-40% of their total caloric needs
are delivered by this route. The remaining energy requirements can be delivered parenterally. In
patients who require parenteral nutrition, every attempt should be made to increase the percentage of
nutritional support delivered enterally so that parenteral nutrition can be discontinued and invasive
catheters removed. Several recently published prospective randomized trials and meta-analyses have
failed to show any significant benefit and an increased rate of complications with the use of parenteral
nutrition in the support of post-operative and critically injured patients raising doubt as to the benefit of
parenterally administered nutrition.
CALCULATION OF A PATIENTS ENERGY AND PROTEIN REQUIREMENTS
The following are examples of the calculation of caloric energy and protein requirements for a typical 60
year old, 70 kg, 180 cm surgical patient who has undergone a small bowel resection. In the first example,
we will assume that he is capable of tolerating enteral nutrition. In the second example, we will assume
that he has a prolonged ileus and must receive his nutritional support parenterally.

Revised 5/30/01

Calculation of Enteral Feeding Rates

To determine the appropriate feeding rate, we must first calculate the patients metabolic energy
requirements. Using the Harris-Benedict equation we obtain the following BEE and REE:
BEE = 66 + (13.7)(70) + (5)(180) - (6.8)(70) = 1449 kcal/day
REE = 1449 kcal/day * 1.2 * 1.35 = 2347 kcal/day
For comparison, calculation of the energy requirements using 30 kcal/kg/day yields 2100 kcal/day which
is in-between the BEE and REE estimates. To determine protein requirements, we will use 1.5
gm/kg/day yielding an estimated protein requirement of 105 gm/day.
There are many enteral nutrition or tube feed formulas on the market. Different formulas are available
at each hospital. A sample of a typical hospital nutrition formulary is illustrated below. From this list, we
can choose the formula that will best provide our patients nutritional requirements.

TYPICAL HOSPITAL NUTRITION FORMULARY

Isotonic
Conc
Fiber
Elemental Formulas
Formula Formula Formula
Osmolite Two Cal Ultracal Vivonex Vital HN Reabilan
HN
TEN
HN
kcal/mL
1.06
2.0
1.06
1.0
1.0
1.0
Prot. g/L
37
84
44
38
42
57
CHO g/L
145
220
123
206
185
158
Fat g/L
38.5
91
45
3
10.8
51.9
mOsm
300
690
310
630
500
490
Na mg/L
640
1306
930
460
566
997
K mEq/L
26
62.6
41
20
35.8
42.3
Mg mg/L
212
422
340
200
267
330
Phos mg/L
530
1052
850
500
667
497
NCP:N
153:1
125:1
128:1
149:1
125:1
125:1
ratio

High
Low CHO
Oral Supplements
Nitrogen
Osmolite Pulmocare Ensure Ensure Ensure
HN
II
Plus Pudding
1.06
1.5
1.06
1.5
250
44
63
37
55
7
141
106
145
200
34
36.8
92
37
53
10
300
490
470
690
930
1310
845
1050
240
40.3
44.4
40
48
8
304
423
211
282
68
758
1057
528
705
200
125:1
125:1
153:1 146:1
198:1

Of these formulas, Osmolite HN is a commonly used, relatively inexpensive enteral formula which is
appropriate for surgical patients as it has a high protein content. Using Osmolite HN as our choice, we
calculate the patients requirements in mL/hr as:
Caloric Goal

= 2100 kcal/day
= 2100 kcal/day 1.06 kcal/mL = 1981 mL/day or 83 mL/hr

Protein Administration

= 1.981 L/day x 44 gm protein/L = 87 gm protein/day

Since this rate does not provide enough protein to meet the patients calculated requirements (105 gm
protein/day), we can either increase the tube feeding rate or provide another source of protein. If we
increase the tube feeding rate, we run the risk of overfeeding as we would have to deliver 2.4 L/day (105
gm 44 gm/L) of Osmolite HN to provide the 105 gm of protein. This would mean that we would be
delivering 2530 kcal/day (2400 mL/day x 1.06 kcal/mL), which far exceeds the patients caloric needs.
The other option is to use a different source of protein. Some enteral formulas are available with very
high protein contents. Another option is to use Promod, a protein powder (48 gm of protein per scoop)
that can be added to tube feeds to increase their protein content. If we use Promod to provide the extra
18 gm of protein (105 gm - 87 gm) we need to meet our goal, our final nutrition requirements would be:

Revised 5/30/01

Osmolite HN at 83 mL/day with 1/3 scoop of Promod added to each liter

providing 2100 kcal/day and ~105 gm of protein/day (actually 103 gm, but it is
difficult to measure 0.375 scoops)
For comparison, if we only had the standard low protein Osmolite available, we would have to deliver 2.8
L/day to supply enough protein (resulting in over 3000 kcal/day!) or we would have to add 2/3 of a scoop
of Promod to provide an extra 32 gm of protein.
There are special enteral formulas available for special patient situations. Patients who are on
hemodialysis or have congestive heart failure and cannot tolerate large volumes of fluid may benefit from
formulas such as Two Cal HN, which is concentrated. Patients who have short gut syndrome and do
not have enough absorptive area to tolerate normal tube feeds may need an elemental formula. These
formulas consist of small carbohydrates and mono- and di-peptides that are easily absorbed by diffusion
and do not need a large mucosal surface area. From reviewing the sample formulary, it is clear that
formulas have different electrolyte concentrations as well which may be useful in the patient who needs
chronic electrolyte replacement.
CALCULATION OF TOTAL PARENTERAL NUTRITION RATES
Calculation of Total Parenteral Nutrition (TPN) administration rates are similar to those for enteral
nutrition. There are fewer TPN formulas on the market because TPN can be modified more easily than
can prepackaged enteral formulas. There are four basic TPN formulas:
Typical Parenteral Nutrition Formulas
Amino Acids
(gm protein/L)
Dextrose
(kcal/L)

Standard
4.25%
(42.5)
25%
(850)

High Nitrogen
7%
(70)
21%
(714)

Concentrated
5%
(50)
35%
(1190)

Peripheral
5%
(50)
10%
(340)

If our patient has a small bowel ileus and cannot tolerate enteral nutrition, we will need to provide him
with parenteral nutrition. His metabolic energy requirements will be the same: 2100 kcal/day and 105 gm
protein/day.
Peripheral TPN is rarely used in the surgical patient population. To achieve adequate nutrient delivery
with peripheral TPN requires very large volumes of TPN. Peripheral TPN cannot be as concentrated as
the other centrally administered formulas because it is administered via peripheral veins which
thrombose with high osmotic fluids. The only role for peripheral TPN is in patients who cannot have a
central line placed or patients on home TPN who cannot care for a central line. Most surgeons are very
comfortable with placement of central lines and therefore prefer central TPN.
To calculate TPN administration rates, we must first choose an appropriate formula. Since our patient
has recently undergone an operation and therefore has increased protein requirements, we will elect to
use the high nitrogen or stress TPN formula. We will also use lipids to provide some of his caloric
support. Lipids provide 2 kcal/mL. Using the high nitrogen formula, therefore, and a carbohydrate to lipid
ratio of 70:30, we calculate his administration requirements as:

Revised 5/30/01

Caloric Goal

= 2100 kcal/day
= (2100 (0.7) carbohydrate calories + 2100(0.3) lipid calories)/day
= (1470 carbohydrate calories + 630 lipid calories)/day
= (1470 714 kcal/L TPN + 630 2 kcal/mL lipid)/day
= (2058 mL TPN + 315 mL lipid)/day
= 86 mL TPN/hr + 13 mL lipid/hr

Protein
= 2.06 L TPN/day x 70 gm protein/L TPN = 144 gm protein/day
Administration
Thus, the above TPN and lipid administration rates will provide both the patients caloric and protein
requirements. For comparison, we will perform the same calculations for the standard TPN formula
which has more dextrose, but less protein.
Caloric Goal

= 2100 kcal/day
= (2100 (0.7) carbohydrate calories + 2100(0.3) lipid calories)/day
= (1470 carbohydrate calories + 630 lipid calories)/day
= (1470 850 kcal/L TPN + 630 2 kcal/mL lipid)/day
= (1729 mL TPN + 315 mL lipid)/day
= 72 mL TPN/hr + 13 mL lipid/hr

Protein
= 1.73 L TPN/day x 70 gm protein/L TPN = 121 gm protein/day
Administration
Using the standard formula, we will be able to decrease the TPN rate, but at the expense of delivering
less protein. In this patient we will still be able to provide his protein requirements. This is not always the
case, however, and the majority of surgical patients will require the high nitrogen formula in order to
achieve positive nitrogen balance. If, for example, we obtain a 24 hour UUN measurement on our patient
after a week of parenteral nutrition and find that his nitrogen balance is -6 (i.e. he is still losing more
protein than he is taking in), we will need to increase his protein administration further. Attempting to do
so with standard TPN will likely lead to carbohydrate overfeeding which will not occur with the high
nitrogen formula.
In addition to specifying a TPN and lipid administration rate, with parenteral nutrition we also have the
option of modifying the electrolyte concentrations to treat electrolyte imbalances, adding vitamin
supplements, or adding other medications to the TPN solution. Common additive medications include
insulin (for treating hyperglycemia induced by the dextrose content of TPN) and H2 blockers. Placing
such medications in the TPN solution itself decreases administration costs and nursing time.
SUGGESTED READING
1.
2.
3.
4.

Zaloga GP. Frontiers in critical care nutrition. New Horizons 1994; 2:121.
DeBiasse MA, Wilmore DW. What is optimal nutritional support? New Horizons 1994; 2:122-130.
Minard G, Kudsk KA. Is early feeding beneficial? How early is early? New Horizons 1994; 2:156-163.
Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral
nutrition in surgical patients. NEJM 1991; 325:525-532.
5. Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, McL.Booth FV, et al. Early enteral feeding,
compared with parenteral reduces postoperative septic complications: the results of a meta-analysis.
Ann Surg 1992; 216: 172-183.
6. Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major
abdominal trauma- reduced septic morbidity. J Trauma 1989; 29: 916-922.
7. Heyland DK. Nutritional support in the critically ill patient. Surg Clin N Am 1998; 423-440.

Revised 5/30/01