1.

Understand the daily

nutritional requirement of a
normal person
Kho Siew Jiuan

 Elements required
Macronutrients
Carbohydrate
fat and protein
Vitamins
trace elements
electrolytes and water
Total energy requirement: approximately 2030 kcal/kg per
day
(S. Wiliams, N. and J.K. Bulstrode, C. (2009). Bailey and Love's Short Practice
of Surgery 26th Edition.Scottish Medical Journal, 54(1), pp.263-265.)

 Carbohydrate:
Glucose requirement to meet the needs of central nervous system and
certain hematopoietic cells
The needs: 2-4 g/kg per day (a physiological maximum to the amount of
glucose that can be oxidised, which is approximately 4 mg/kg per minute)
Fat:
The unsaturated fatty acids, linoleic and linolenic acid (soybean and
sunflower oil emulsions), are considered essential because they cannot be
synthesised in vivo from non-dietary sources.
essential fatty acids (100200 g/week)
Protein:
basic requirement for nitrogen: 0.100.15 g/kg per day
(S. Wiliams, N. and J.K. Bulstrode, C. (2009). Bailey and Love's Short Practice
of Surgery 26th Edition.Scottish Medical Journal, 54(1), pp.263-265.)

National University Hospital of Singapore (June 2006)

 Water:
Water loss in a normal individual is approximately 2500
mL/day (urine =11.5 L, faeces =100 mL, sweating =600
mL and water vapour via breathing =400 mL).
Requirement: 2.5-3 L/ day
Electrolytes:
Na: around 100 mmol/day is lost in the urine and 40
mmol/day is lost in sweat, so required 12 mmol/kg per
day
K: 80 mmol/day of K is lost in the urine and a small
amount in the faeces, so required 0.51 mmol/kg per day
(Raftery, A., Delbridge, M. and Raftery, A. (2006).Surgery. 4th ed. Edinburgh:
Churchill Livingstone Elsevier, pp.178-187.)

LO2. Assess the nutritional status of

whether a preoperative or
postoperative surgical patient
Aiden Tan

Biochemical measurements
There is no single biochemical
measurement that reliably
identifies malnutrition.
Albumin is not a measure of
nutritional status.
Although a low serum albumin
level (<30 g/L) can indicate that
patient is more likely to be
malnourished.

British Association of Parenteral and Enteral Nutrition

introduced a malnutrition universal screening tool (MUST) to
identify adults who are malnourished or at risk of undernutrition

LO3 State the indications for the nutritional

supplement of a patient in a surgical ward
Lawrence Foo

General indication:
Any Patient who has sustained 5-7 days of inadequate
intake or who is anticipated to have no intake for this
period.

Preoperative
1. Starvation caused by poverty, dysphagia, vomiting,
diarrhea or self neglect
2. Failure of digestion as a result of pancreatic, biliary
duodenal or jejunal disease.
Postoperative
3.Ileus following surgery on the gastrointestinal tract
4.Major surgery
5.Bowel resection

4. Describe the types and methods

of nutritional supplement.
Meighalah Arumugam

Types and Methods of

Nutritional Supplement
Enteral

Parenteral

Delivery of nutrients into the

gastrointestinal tract.

Ryles tube

- Delivery of nutrients via the

intravenous route and without the use of
the gastrointestinal tract.
- Indicated when energy and protein
needs cannot be met by the enteral
administration, eg. massive resection of
the small intestine, intestinal fistula,
prolonged intestinal failure etc.

Percutaneous endoscopic
gastrostomy (PEG)

Peripheral (PPN)

Jejunostomy.

Central (TPN)

Sip-feeding

Sip-feeding
Prescribable oral nutritional supplements that are liquid nutrient formulations containing the complete
range of nutrients, which generally are administered by mouth to supplement or to provide the complete
nutritional requirements for an individual.

Ryles tube (NG tube)

A narrow bore tube passed into the stomach via the nose. It is used for short- or medium-term nutritional
support, and also for aspiration of stomach contents.

Contraindications
Skull fractures
Severe facial fractures
Obstructed esophagus
Esophageal varices
Confirmation of position
Auscultation while injecting air
Testing pH of aspirate
Observation for bubbles when placed
in water
X-ray

Percutaneous endoscopic gastrostomy

(PEG) / jejunostomy
Endoscopic medical procedure in which a tube is passed into a patient's stomach through the
abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate.

Indication
Stroke, cerebral palsy, brain injury
Anatomical (eg. Cleft lip and palate during the process of
correction)
Radiation therapy for tumors in head & neck

Contraindication
Inability to perform an OGDS
Uncorrected coagulopathy
Peritonitis
Untreatable massive ascites
Bowel obstruction (unless the PEG is sited
to provide drainage)

Parenteral supplement
Feeding a person intravenously, bypassing the usual process of eating and digestion. The
person receives nutritional formulae that contain nutrients such as glucose, amino acids, lipids
and added vitamins and dietary minerals
Ideally each patient is assessed individually by a team consisting of specialised doctors,
nurses, clinical pharmacists and Registered Dietitians evaluate the patient's individual data
and decide what formula to use and at what infusion rate.

5. Calculate the necessary

nutritional requirement based
on specific surgical condition
Yek Chu Jie

 For most patients, an approximation based on weight and

clinical status is sufficient
Energy
Daily Energy Expenditure of a stable patient is ~ 2030
kcal/kg/day or 1 kcal/kg per hour
hospitalized patients energy demands from activity are
minimal, so total energy requirement~ 13001800
kcal/day

 Estimated Caloric Needs of Various Neurosurgical

Patients
Initial protein requirements following head injury have been
estimated at 1.5 2.5 g/kg IBW/day
The Traumatic Brain Injury Foundation Guidelines suggest that
15% of calories should be given as protein

6. Discuss the pros and cons of enteral and parenteral nutrition

Alice Ng

Enteral Nutrition
Pro

Cons

independent risk factor for VAP (microaspiration,

decreased with post-pyloric feeding)
sinusitis (N/G)
misplacement into trachea aspiration
perforation of oesophagus, pharynx, stomach or
bowel
PEG use associated with high 30 day mortality
(site infection abdominal wall infection, bowel
obstruction)
diarrhoea
metabolic derangement: electrolytes,
hyperglycaemia, re-feeding syndrome
intolerance: vomiting, excessive aspirates (200500mL), abdominal distension, constipation or
diarrhea
Labor-intensive assessment, administration, tube
patency and site care, monitoring.

cheaper
simpler
stimulates intestinal blood flow
maintain GI mucosal barrier (prevents bacterial
translocation and portal endotoxaemia)
reduced gut associated lymphatoid system
(GALT) becomes a source of activated cells
and proinflammatory stimulants
prevents disuse atrophy
reduces septic complications compared with TPN
avoids CVL complications
avoids TPN induced immunsuppression (lipid
load)
improves healing
improved weaning and recovery
reduced muscle catabolism

Pro

Parenteral nutritionCon

Ease of administration
no delay in caloric intake
does not rely of gastric/intestinal function so
provide nutrition in setting of mucositis
Easier correction of fluid and electrolyte inbalance
Allow nutrition support when GI intolerance
prevent oral or enteral support

High financial cost

catheter related: sepsis, occlusion, thrombosis
hyperglycaemia
Hypercholesterolaemia
use fat emulsions with low phospholipid to
TG ratio
stop fat infusion
use IV heparin to increase plasma lipolytic
activity,
use insulin to increase lipase activity in
adipose tissue
refeeding syndrome
Hepatic dysfunction
may develop steatosis, cholecystitis
hyperchloraemic metabolic acidosis
amino acids have a high Cl- content
promote enterocyte atryophy l/t loss of gut barrier
function