Surgical Nutrition

Adequqte nutritional support is of paramount importance in the care of Surgical

patients. There will be suboptimal response to all therapeutic modalities in the
malnourished patients and complications - such as poor wound healing, impaired organ
function and compromised immunity may be observed. Thats the reason when adequate
nutritional support of the patient is not addressed, the clinical management become
complex and patient outcome may be compromised.

Specialized nutritional support whether enteral or parenteral, when used appropriately

can help to prevent the nutrition related morbidities in surgical patient .

Acute malnutrition also called Kwasiokar or acute hypo albuminemia , is defined as

starvation occuring during a catabolic stress such as surgery, infection, burn or trauma
and is a more aggressive nutritional insult than simple starvation for a brief period.
Chronic malnutrition also called marasmus which is characterized by growth retardation
and wasting of muscle and subcutaneous fat while maintaining apetite. Frequently these
two nutritional insult may be superimposed in surgical patient.

Patient should be considered malnourished or risk of developing malnutrition if they

have inadequate nutrition intake for 7 days or more or if they have a weight loss of 10%
or more of their preillness body weight.
Formula for determining wt loss : (usual wt – present wt.) % usual wt x100 ,
this formula is important to identify patient at nutritional risk and baseline assesment to
provide them with specialized nutritional support.

Two type of nutritional support :1- Enteral nutrition , preffered over , 2- parenteral
nutrition in any patient with a functional gut.
All critically ill patient and any elective surgery patient with an anticipation of 7 days
delay to resuming goal nutrition are candidate for Nutritional support.

Note : I think you guys should know this as well.

1- what is motto of surgical nutrition ? - If the guts work use it.

2- Normal daily requirement for adult - protein= 1gm/kg/day
Calories = 35kcal/kg/day.
3- How much is basal energy expenditure (BEE) increased or decreased in
Severe head injury = increased -1.7x
severe burn = increased – 2-3x
 what are the calorie contents and metabolic byproduct of : Fat =9kcal/g [Co2 + H20]
Protein= 4 kcal/g [ammonia]
Carbohydrate = 4lcal [ CO2 + H2o ]

What is the formula for conversion of nitrogen requirement/loss to

protein requrement/loss = nitrogen x6.25
= protein.

What is RQ ( respiratory Quotient ) : The ratio of CO2 produced to O2 consumption.

What is normal RQ = 0.8
What can be done to decrease RQ = More fat , less carbohydrate.

What dietary change can be made to decrease CO2 production in a patient in whom CO2
retention is a Concern = Decrease Carbohydrate Calories and increase Calories from fat.
What Lab test are used to monitor nutritional status = Blood levels of :
Decrease PREALBUMIN ( T1/2 = 2-3 days)- acute change determination.
Decrease Transferrin (T1/2 =8-9days.
Decrease Albumin (T1/2 = 14-20 days) - more chronic determination.
Total lymphocyte count < 1800 Anergy.
Decrease retinol binding protein ( T1/2 = 12 hour.)

Where Iron is absorbed? = Duodenum ( some in proximal jejunum).

Where is B12 absorbed = Terminal Ileum.
What are the surgical causes of vit B12 deficiency = Gastrectomy , excision of terminal
Ileum and blindloop syndrome.
Where the bile salt absorbed = Terminal Ileum.
Where are fat soluble vitamins are absorbed = Terminal Ileum.
Which vitamins are fat soluble = Viatmin ADEK ( KADE ) .
What are the signd of Fat soluble vitamins :
Vitamin A defeiciency = Poor wound healing.
Vitamin B12 / folate deficiency = Megaloblastic anemia.
Vitamin C deficiency = Poor Wound healing , Bleeding gum.
Vitamin K Deficiency = decrease in vitamin K-dependent clotting factor (Factor 2, 7
Bleeding and elevated PT. 9 & 10)
Chromium defeiciency = Diabetic state, esp. in patient with AODM.
Selenium Deficiency = Anergy.
Zinc deficiency = Poor wound healing, Alopecia, Dermatitis, Taste disorder.
Fatty deficiency = Dry , Flaky skin, Alopecia.
What vitamin increases pO absorption of Iron = PO Vitamin C ( ascorbic acid ) .
What vitamin lessens the deleterious effect of steriod on wound healing = Vitamin A.
 Common indication for TPN ( total parenteral nutrition ) = NPO more than 7days,
Enterocutaneous fistula.
Short bowel syndrome
Pancreatitis.

What are the possible Complication of TPN = Line infection.

Fatty infiltraion of the liver.
Eectrolyte/Glucose problem.
Pneumothorax during placement of
central line.
Loss of gut barrier ( mucosal barrier ).

What are the advantage of Enteral feeding = Keeps gut barrier healthy, thought to
lessen translocation of bacteria.
Not associate with complication of line
placement.
Associate with fever, electrolyte,
glucose problem.
What are the major Nutrient of gut = Glutamin.
What is refeeding syndrome = Decreased serum pottasium, Magnesium and phosphate,
after refeeding ( via TPN orenterally ) a starving patient.

What are the Vitamin K dependent Clotting factor = Factor 2,7,9,10 ( 2+7 =9,&then 10)
What is an elemental tube feed ? = Very low residue tube feed, in which almost all the
tube feed is absorbed.
Where is Calcium is absorbed ? = In Duodenum ( actively )
Jejunum ( passively ).
What is the major nutrient of the colon = Short chain fatty acid.
What must bind B12 for absoeption = Intrinsic factor from the gastric parietal cells.
How can serum serum bicarbonate be increased in patient on TPN = Increase Acetate
( which is metabolized into bicarbonate ).
What are “ Trophic “ tube feed = Very low rate of tube feed ( I,e approximately 10cc/hr)
is thought tokeep mucosa alive & healthy.
When should PO feeding be started after alaparotomy = after flatus or stool passed per
rectum ( usually postop day 3-5) .