NUTRITION IN SURGERY

ISWARAN A/L AMPALAKAN

SURGICAL DEPARTMENT
MIRI GENERAL HOSPITAL
DEFINITIONS
 Nutrition
 The sum of the processes involved in taking in nutrients, assimilating them, and using them,
particularly for building sound bodies and promoting health
 Nutrient
 A food or biochemical substance used by the body that must be supplied in adequate amounts
from foods consumed
 There are 6 classes: water, proteins, carbohydrates, fats, minerals and vitamins
 Malnutrition
 Poor nourishment resulting from an inadequate or improper diet or from defect in metabolism
that prevents the body from using its food properly
 Enteral nutrition
 Food and liquid provided via tube feeding when a patient’s condition prevents oral intake
 Metabolism
 The sum of the physical and chemical processes by which living organized substance is built and
maintained (Anabolism), and by which large molecules are broken down into smaller molecules
to make energy available to the organism (Catabolism)
Dorland’s Medical Dictionary
NUTRIENTS
 Macronutrients
 Carbohydrate
 Main source of energy
 Made up of Carbon, Hydrogen and Oxygen
 Can be simple carbohydrate or complex carbohydrate
 Protein
 Molecules made up of Carbon, Hydrogen, Oxygen and Nitrogen
 One molecule is made up of smaller units called amino acid
 Fat
 Provide energy and dissolve certain vitamins
 One gram fat release twice as much energy as carbohydrate
 Saturated fat and unsaturated fats
 Water
 To maintain various functions

 Micronutrients
 Vitamins
 Minerals
Metabolism
Principle of Metabolic and Nutritional Care
 Surgery, like any injury elicits a series of reactions including release of cytokines and
inflammatory mediators  metabolic stress response (Systemic Inflammatory
Response Syndrome)
 The syndrome causes catabolism of glycogen, fat and protein with the release of
glucose, free fatty acids and amino acids
 These substrates are diverted from their normal purpose of maintaining peripheral
protein mass (muscle mass) to the task of healing and immune response
 The consequence of protein catabolism is the loss of muscle tissue, which is a
burden for functional recovery
 Metabolic stress response is necessary to achieve appropriate healing and
functional recovery
 Requires nutritional therapy, especially so if the patient is malnourished and the
stress/inflammatory response is prolonged
 Severe pre-existing inflammation and sepsis influence healing negatively
 Severely malnourished patients may exhibit an adynamic form of sepsis with
hypothermia, leukopenia, somnolence, impaired wound healing and pus production
 Avoidance of any nutritional therapy bears the risk of underfeeding
 Early oral feeding is the preferred mode of nutrition
 Nutritional status is a risk factor for post-operative complications

 Pre-operative serum albumin is a prognostic factor for complications after surgery, and
also associated with impaired nutritional status
 Considered to define surgical patients at severe nutritional risk by
 Weight loss >10-15% within 6 months
 BMI < 18.5kg/m2
 Pre-operative serum albumin <30g/l (with no evidence of hepatic or renal dysfunction)
 Nutrition Therapy
 Is the provision of nutrition/nutrients either orally, via enteral nutrition or parenteral
nutrition to prevent or treat malnutrition
 As a basic requirement, a systematic nutritional risk screening (NRS) has to be
considered in all patients on hospital admission
 The items of NRS comprise
 BMI < 20.5km/m2
 Weight loss >5% within 3 months
 Diminished food intake
 Severity of disease
 ESPEN criteria for malnutrition
i. BMI < 18.5kg/m2
ii. Combined : weight loss >10% or >5% over 3 months + reduced BMI or low Fat Free Mass Index
(FFMI)
 Reduced BMI is <20kg/m2 for patients younger than 70, <22kg/m2 for patients older than 70
 Low FFMI is <15 kg/m2 for females and <17kg/m2 for males
 Fat Free Mass Index  Body Mass Index

 Lean Weight = Weight x (1 - (body fat % / 100)

Nutritional Assesment

 HISTORY
 Presenting Complaint
 Vomiting, Dysphagia, Diarrhea
 Comorbidities
 Obesity, Malignancy
 Social and Dietary History
 Socio-economic background
 Intake & Amount
 Physical Examination
 Anthropometric Measurement
 Weight, Height and BMI
 Ideal Body Weight
 Skin fold thickness

 IBW (Men) 50kg + 2.3kg for each inch over 5 feet

 IBW (Women) 45.5kg + 2.3kg for each inch over 5 feet
Is pre-operative fasting necessary?

 Pre-operative fasting from midnight is unnecessary in most patients

 Patients undergoing surgery who are considered to have no specific risk of
aspiration, are allowed clear fluids until 2hours before anesthesia

 Clear fluids empties the stomach 60-90mins

 Exceptions are patients undergoing emergency surgery and those with
known delayed gastric emptying or gastro-oesophageal reflux
Metabolic preparation using carbohydrate
treatment
 Oral carbohydrates have been reported to improve post-operative well being
 In colorectal patients, the intake of hypo-osmolar carbohydrate rich drink has shown
t reduce post-operative insulin resistance
 Pre-operative intake of carbohydrate drink (CHO-Loading) with 800ml the night
before and 400ml before surgery does not increase risk of aspiration
 Fruit based lemonade may be considered as a safe alternative

 In order to avoid harm, CHO drink should not be given in patients with diabetes
 CHO drinks are unlikely to be of benefit in patients with Type I diabetes as they are
insulin deficient rather than insulin resistant

 For patients who cannot be fed enterally, an intravenous administration of 200g

glucose pre-operatively may be given
Is post-operative interruption of oral nutrition
intake necessary after surgery?
 Oral nutrition can be initiated in most cases immediately after surgery
 Early normal food on the first or second post-operative day does not cause
impairment of healing of anastomoses in the colon or rectum, and leads to
significantly shortened hospital length of stay
 The amount of initial oral intake should be adapted tot the state of gastrointestinal
function and to individual tolerance
When is nutritional therapy indicated?
 Inadequate oral intake for more than 14days is associated with higher mortality
 The general indication for nutritional support in the surgical patient is the
prevention and treatment of undernutrition
 The correction of undernutrition before surgery
 The maintenance of nutritional status after surgery
 The enteral route should always be preferred except for the following
contraindications
• Intestinal obstruction or ileus
• Severe shock
• Intestinal ischaemia
• High output fistula
• Severe intestinal haemorrhage
 If the energy and nutrient requirement cannot be met by oral and enteral
intake alone (<50%) caloric requirement) for more than 7 days, a combination
of enteral and parenteral nutrition is recommended
Which patients benefit from early post-operative
tube feeding?
 Early tube feeding (within 24hours) shall be initiated in patients where early oral nutrition
cannot be started, and in patients where oral intake will be inadequate (<50%) for more
than 7 days
 Special risk groups are
 Patients undergoing major head and neck or gastrointestinal surgery for cancer
 They often exhibit nutritional depletion before surgery
 Post-operatively, oral intake is delayed due to swelling, obstruction/impaired gastric emptying

 Patients with severe trauma including brain injury

 Immediate oral nutrition can be administered safely in patients with anastomoses after
partial and total gastrectomy
How should patients be tube fed after surgery?
 It is recommended to start tube feeding with a low flow rate (10-20ml/h) and to
increase carefully based on individual intestinal tolerance
 If long term tube feeding (>4weeks) is necessary (as in severe head injury),
placement of a percutaneous tube (percutaneous endoscopic gastrotomy – PEG) is
recommended
 More than 24
Within 12 hours 48-72 hours of
hours of
Metabolic of fasting
fasting
fasting

Response to
Starvation
Insulin level drops Lipolysis and
Gluconeogenesis
and Glucagon Adaptive
in liver
level increases Ketogenesis

Glycogenolysis &
Cori’s cycle
Metabolic Response in Trauma and Sepsis
 Increased counterregulatory hormone
 Increased energy requirement (15-20%)
 Increased nitrogen requirement
 Insulin resistance/stress induced hyperglycemia
 Preferential oxidation of lipid
 Increased gluconeogenesis/protein catabolism
 Loss of adaptive ketogenesis
 Fluid retention with hypoalbuminemia
Nutritional Support
 Enteral Nutrition
Oral Supplement
NG Feeding
Gastrostomy tube feeding
Jejunostomy tube feeding
 Parenteral Nutrition
Estimating Energy Requirement
 Simple Body Weight Calculation
 BEE (Kcal/day) = 25* x weight

 Estimated Kcal/kg/day required (range from 20-35)

 Harris Benedict Equation

 BEE (men) : 66.47 + 13.75(W) + 5(H) – 6.76 (A)

 BEE (women) : 65.51 + 9.56 (W) + 1.85 (H) – 4.68 (A)
 W = Weight in kilograms
 H = Height in centimeters
 A = Age in years
 Any adult with a burn >15% (10%in children) of TBSA has an increased nutritional
requirement.

How to calculate
 Protein requirement (Davies formula):
 Adult: 1gm protein / kg + 3gm protein / % burn
 Child: 3gm protein / kg + 1 gm protein / % burn

 Energy requirement (Sutherland formula):

 Adult: 20 kcal / kg + 70 cal / % burn
 Child: 60 kcal / kg + 35 cal / % burn
Total Energy Expenditure (TEE)
 TEE (kcal/day) = BEE x stress/activity factor
 Enteral Feeding
 The gastrointestinal tract is always the preferred route of support, i.e., "If the gut works, use it“
 Potential benefits of enteral nutrition over PN include:

 Physiologic
 Nutrients are metabolized and utilized more effectively via the enteral than the parenteral route.
 The gut and liver process enteral nutrients before their release into systemic circulation.
 The gut and liver help maintain the homeostasis of the amino acid pool as well as the skeletal muscle tissue.

 Immunologic
 Gut integrity is maintained by enteral nutrients through the prevention of bacterial translocation from the gut,
sytemic sepsis, and potential increased risk of multiple organ failure.
 Lack of GI stimulation may promote bacterial translocation from the gut without concurrent enteral nutrition.
 Provision of early enteral nutrition may minimize risk of gut related sepsis.
 Safety (avoid complications related to intravenous access):
 Catheter sepsis
 Pneumothorax
 Catheter embolism
 Arterial laceration
 Cost
 Cost of EN formula is less than PN.
 Cost of equipment and personnel for preparation and administration is less.
Tube feeding technique
I. Continuous Feeding Method I
 Start at 20-40mls/hour continuously, aspirate 4hourly
 If the aspirate <300ml, return all aspirate.
 Increase rate by 20ml/h every cycle until meets the caloric need
 If aspirate >300ml, return 300ml aspirate to the patient and reduce rate by 50%
 If there is no evidence of bowel obstruction, administer prokinetic agent
 Once aspirate <300ml, continue increase rate

II. Continuous Feeding Method 2

 Start at 25mls/h for 4 hours followed by 2 hours rest
 Aspirate just prior to next cycle
 If aspirate <300mls, increase rate by 25mls/h per cycle
 If aspirate >300mls, reduce rate by 50%
III. Intermittent Bolus Feeding
 Start with 50mls every 3 hours, aspirate before every feed
 If the aspirate <300ml, return all aspirate and increase rate by 20ml/h every cycle until meets
the caloric need
 If the aspirate >300mls return 300ml aspirate to patient and reduce by 50mls per feed
 If there is no evidence of bowel obstruction, administer prokinetic agent
 Once further aspirate <300mls, feeding may be increased 50mls after every 2 feed
 If aspirate continue to be >300mls, consider continuous feeding

 NG Tube is appropriate commonly, but if required for more than 1week, fine bore
feeding tube is preferred
 Causes fewer gastric/esophageal erosion
 Fine bore feeding tube is made of soft polyurethane or silicone elastomer
Feeding Regime
Method Criteria Advantage

Continuous • Start from 20-50ml/h • Reduces abdominal

• Increase 10-25ml/h every 8-12h cramping, aspiration,
till desired volume achieved diarrhea, gastric
distention, nausea,
vomiting

Intermittent/Bolus • Start with 50ml every 3-4h • Approximates meal

• Increase 50ml every 8-12h as pattern
tolerated • Easy to administer
Calorie requirement
 During the acute and initial phase of critical illness
 Provide non protein calories at 20-25kcal/kg/day

 During recovery phase

 Provide non protein calories at 25-30kcal/kg/day
 Use Ideal Body Weight
 For underweight patients, use Actual Body Weight
 Enteral Formula Categories
General Purpose (Polymeric) • Used in patients with normal digestion and
 Eg: Ensure absorbtion
• Contain intact protein
• Provide 1-2kcal/ml
• Lactose free
• 30-40gm protein/L
• Low viscosity ( 300-500 mOsm/kg)
Defined/hydrolyzed (Monomeric) • In patients with compromised GI (hydrolyzed to
 Also known as elemental formula/peptide based improve digestion)
 Eg: Peptamen • Provide 1-2kcal/ml
• Lactose free
• 30-45gm protein/L

Semielemental • In patients with limited GI function

 Also known as free amino acid formula • Contain free amino acid, minimal fat and minimal
residue
• Hyperosmolar and low viscosity
• Provide 1kcal/ml
• 40gm protein/L
 Cont
Disease Specific • Designed for specific organ dysfunction or
 Eg: Glucerna, Nepro metabolic disorder

Rehydration • For patient requiring optimal ratio of simple

carbohydrate to electrolyte for purpose of
maximizing fluid and electrolyte absorbtion

Modular • Formula providing protein, fat or carbohydrate as

single nutrient to alter the nutrient composition of
commercial formula/food
Indication and Contraindication
INDICATION CONTRAINDICATION

• Oral intake <50% of required need • Mechanical Obstruction of Git

for previous 7-10 days

• Dysphagia or chewing problem • Prolonged Ileus

due to stroke, tumor, head injuries

• Major Burn • Severe GI Hemorrhage

• Severe Diarrhea

• Intractable vomiting

• Severe enterocolitis
Complications (Mechanical)
1. Aspiration

 Pulmonary aspiration is an extremely serious complication of enteral feeding and

can be life-threatening in malnourished patients.
 Symptoms include dyspnea, tachypnea, wheezing, rales, tachycardia, agitation,
and cyanosis.
 Aspiration of small amounts of formula may not cause immediate symptoms, but a
fever later may suggest aspiration pneumonia.
 Risk Factors of Aspiration:
 Decreased level of consciousness
 Diminished gag reflex
 Neurologic injury
 GI reflux
 Supine position
 Large gastric residuals
2. Tube Malposition
 Complications may arise during the placement of a feeding tube or simply from the
presence of one
 Feeding tube placement can cause bleeding, tracheal or parenchymal
perforation, and GI tract perforation
 Presence of the feeding tube itself may cause upper and lower airway
complications, such as aggravation of esophageal varices, etc
3. Tube Clogging
 Tube clogging is more likely with intact protein products and viscous products.
 Most clogs can be prevented by routine flushing of the feeding tube.
 The recommended first line method to unclog a tube is to instill warm water using
slight manual pressure.
 If this fails, a pancrelipase and sodium bicarbonate solution may be instilled in order
to "digest" the clog.
Complications (Metabolic)
Problem Cause Treatment
Hyponatremia Overhydration Change formula
Restrict fluid
Hypernatremia Inadequate fluid intake Increase free water
Dehydration Diarrhea Evaluate cause of diarrhea
Inadequate fluid intake Increase free water
Hyperglycemia Too much calories Evaluate caloric intake
Lack of adequate insulin Adjust insulin
Hypokalemia Refeeding syndrome Evaluate cause of diarrhea
Diarrhea Replace K
Hyperkalemia Excess K intake Change formula
Renal insuffiency
Parenteral Nutrition

 Infusion of a nutrient hyperosmolar solution (< 900 mosm/l)

containing carbohydrates, protein, fat and other essential nutrients
through an IV route
 Components are elemental or pre-digested form
 Protein as amino acid
 CHO as dextrose
 Fat as lipid emulsion
Composition of Formula
 Standard Parenteral Dextrose Solution
 5% - 70% concentration
 3.4KCal/gm
 Intravenous Lipid Emulsion
 Concentration : 10% and 20%
 Parent oil : Soybean or Saffflower
 Caloric content : 10% (1.1 Kcal/ml) ; 20% (2.0Kcal/ml)
 Parenteral Amino Acid Solutions
 Hypertonic solutions
 Contains essential and non-essential Amino Acid
 Variable amount of electrolyte
Designing Parenteral Nutrition Formula

 Total Kilocalories (25-35 kcal/kg/day)

 30kcal/kg/day x 70kg = 2100kcal/day

 Protein (1.5gm/kg/day)
 1.5kgm/kg/day x 70 = 105gm/day
 2 in 1 system 3 in 1 system

 Total calories required = 2100kcal  Total calories required = 2100kcal

 Calories from Amino Acid :  20% of lipid : 2100 x .02 = 420kcal,

105gm x 4kcal/g = 420 kcal 9kcal/g = 47gm lipid

Difference : 2100 – 420 = 1680kcal  Calories from Amino Acid: 105gm x

4kcal/g = 420 kcal
 Dextrose provide 3.4kcal/g
Difference : 2100 – 420 – 420 = 1260
1680 x 3.4 = 494g of dextrose
 Dextrose provide 3.4kcal/h
1260 x 3.4 = 370gm of dextrose
 Fluid Volume = (amount of substance / conc. of substance) x 100

 Amino Acid (10%) : 105 g  1050ml

 Dextrose (70%) : 370g  528ml
 Lipid (20%) : 47g  235ml

 Final Volume : 1813ml/day

Complications (Mechanical)
 Mechanical complications are primarily related to the initial placement of a
central venous catheter
 Improper placement may cause pneumothorax, vascular injury with hemothorax,
brachial plexus injury or cardiac arrhythmia.
 Venous thrombosis may occur after central venous access is established.
 Signs include distended neck veins and swelling of the face and ipsilateral arm.
 The risk of venous thrombosis is greater if patients are dehydrated, have had prolonged
bed rest, have venous stasis, have sepsis, or have hypercoagulation.
 Additional risk factors include morbid obesity, smoking, or ongoing estrogen therapy.
 Infection
 The infusion apparatus from container to catheter tip may prove a source for the
introduction of bacterial or fungal organisms
 The operator inserting the venous catheter, the pharmacist compounding the solution, or
the care-giver hanging the bag or changing the site dressing may be the source of
contamination
 The primary preventive measures include
 Adhering to strict aseptic procedure while establishing access
 Prohibiting the use of the TPN line for other purposes
 Changing the dressing routinely while wearing a mask and gloves
 Extending the application of antimicrobial solution at least 1 inch beyond the final dressing.
 Placing a sterile sponge over the catheter, then placing an occlusive dressing.
 Inspecting the site for tenderness, erythema, edema, loose sutures, or drainage.
 Changing the TPN intravenous tubing every 48 hours.
Complications (Metabolic)
 Early Complication
 Occur early in the process of feeding and may be anticipated
 Avoided by careful monitoring and appropriate adjustment of intake
 Late complications
 Less predictable
 May be caused by
 An exacerbation of preexisting abnormalities
 Unpredictable long-term requirements
 Inadequate solution composition
 Failure to monitor adequately.
Early Complications Late Complications

Volume overload Essential fatty acid deficiency

Hyperglycemia Trace mineral deficiency

Refeeding syndrome Vitamin deficiency

Hypokalemia Metabolic bone disease

Hypophosphatemia Hepatic steatosis

Hypomagnesemia Hepatic cholestasis

 Refeeding Syndrome
 The metabolic and physiologic consequences of depletion, repletion, compartmental
shift and inter-relationship of phosphate, potassium and magnesium
 Severe drop in serum electrolyte level resulting from intracellular electrolyte movement
when energy is provided after a period of starvation
 Metabolic shift : catabolic  anabolic state
 Insulin is released , triggering cellular uptake of K+, PO4, Mg

 Hypophosphatemia
 Hyperglycemia
 Fluid retention
 ECG changes, cardiac arrest, arrhythmia
 Hypotension, weakness, paralysis
 Respiratory distress
 Ketoacidosis/metabolic acidosis
Prevention and Therapy

 Correct electrolyte imbalance before starting nutrition support

 Continue to monitor serum electrolytes after nutrition support begins
 Initiate nutrition support at low rate/concentration (50% of estimated need)
and advance to goal slowly