Surgical nutrition

Surgical
Nutrition
(2020)
Surgical Club Red Sea University SC (RSU)

Prepared by
 DR. Rayan hashim 18
 Dr.khlood alhaj
 Dr.elhassan 19
 Dr.Aahd 19
 DR. Khlood mohamed osman 18
presented by
 DR. Amar yahia Ibrahim
 registrar of general surgery
SC (RSU) 6/7/2020

A majority of patients who come to service of
surgeon are either malnourished at the time of
presentation or develop a post operative problems
that affect their nutritional status , leading to higher
morbidity and mortality risk .

Metabolic considerations :
(1)physiological status :
Marinating a healthy nutritional status
requires adequate supplementation of :

1. Calories :
 obtained by carbohydrates or fats.
 this carbohydrates are digested into glucose which is
the only source for brain , RBC and adrenal medulla
cells .
2. Fats :
accepted as source of energy
3. Proteins :
for building of muscle and synthesis of enzymes and some
hormones .

Energy requirements
 One g carbohydrate provides about 4 kcal/g.
(Dextrose provides 3.4 Kcal)
 1 g fat provides about 9 KCal.
 protein 4 KCal for each g.
 An average adult needs 30--35 KCal/Kg/day

The Harris-Benedict equation
 estimates the basal energy expenditure (BEE) or
basic energy requirements at rest in kcal/day.
 Most patients at rest require 25–35 kcal/kg/day

Energy requirements are
increased by
 fever.
 infection.
 activity.
 burns.
 head injury.
 trauma.
 renal failure.
 surgery.

Energy requirements are
decreased by
 sedation.
 paralysis.
 β blockers.

Carbohydrates
 should generally account for 30%–60% of total
calories.
 Stored as glycogen in the liver (40%) and in
muscle (60%).
 he body stores 300–500 g of glycogen.

 These stores are depleted within 48 hours
during starvation.
 in as little as 12–24 hours in the stressed patient.

Proteins
 healthy individuals require 0.8–1.0 g
protein/kg/day.
 Stress increases these requirements:
 Mild stress: 1.0–1.2 g/kg/day.
 Moderate stress: 1.3–1.5 g/kg/day.
 Severe stress: 1.5–2.5 g/kg/day.

Nitrogen Balance
 is calculated by determining the difference
between net nitrogen intake and excretion.
 if the intake of nitrogen exceeds its amount
in urine , the body is said to be in a ( positive
nitrogen balance ) which is anabolic state in
which proteins are being formed .

 In negative nitrogen balance protein
catabolized and changed into glucose (
gluconeogenesis )
 Protein excreted in the urine can be measured
over 12–24 hours:
protein (g) = nitrogen (g) × 6.25.

Amino acids
 Essential amino acids cannot be produced by
the body, but nonessential amino acids can.
 at least 20% of their protein intake as essential
amino acids

Lipids:
 Lipids should provide 25%–40% of total calorie
requirements during nutritional supplementation.
 Fatty acids are a major fuel for the heart, liver,
and skeletal muscle.

 Liver oxidation of fatty acids forms ketone
bodies These ketone bodies are used by the
heart, skeletal muscle, and the brain
specifically during times of starvation.
 During the fed state, insulin stimulates
lipogenesis and fat storage and inhibits
lipolysis in adipocytes.

 During intravenous (IV) nutritional
supplementation a minimum of 3%–5% of the
total calories as fat is necessary to prevent
essential fatty acid deficiency.
 The essential fatty acids are linoleic and
linolenic acid.
 They act as precursors for prostaglandins and
eicosanoids.

Essential fatty acid deficiency
may result in
 dermatitis.
 ecchymoses.
 alopecia.
 anemia.
 edema.
 thrombocytopenia.
 respiratory distress.

 The manifestations of fatty acid deficiency may
occur within 4–6 weeks if nutritional support
does not include lipids

Other requirements:
 Vitamins:
 impaired wound healing may be a direct
result of deficiencies in vitamin A, vitamin
C, and the mineral zinc.
Minerals:
 Iron, Zinc, Iodine, Copper, Manganese
etc..

(2) Alterations During Abnormal
situation :
such as starvation or development of catabolic
state induced by:
stress
Trauma
surgery or
septic complication .

Malnutrition in surgical patients
causes :
(a) starvation:
1- social causes as poverty and neglected elderly
. 2- Dysphagia ( carcinoma of esophagus )
3- loss of appetite ( carcinoma of the stomach )
4- repeated vomiting ( pyloric stenosis )

5- malabsorption ( extensive inflammatory bowel
disease )
6- Extended postoperative restriction of oral
intake (prolonged pralytic ileus )

Metabolic response to starvation
• Within 12 hours of fasting
• Insulin level decrease and Glucagon level
increase
• Glycogenolysis (liver glycogen to glucose)
Cori’s cycle

• > 24 hours
Gluconeogenesis in liver
• 48 – 72hrs :
Lipolysis and Adaptive Ketogenesis

 The major hormones that play an active role in
metabolism in the presence of stress or sepsis
include:
 adrenocorticotropic hormone (ACTH).
 cortisol.
 catecholamines.
 glucagon.

 Hyperglycemia is present during stress
secondary to:
a relatively low insulin level
peripheral insulin resistance.

Insulin secretion may be inhibited
by:
 catecholamines.
 sympathetic nervous system activation.
 somatostatin.
 Catecholamines and cortisol
 also contribute to a relative resistance of
peripheral tissues to the effects of insulin.

Liver glycogenolysis and
gluconeogenesis are stimulated by:
 catecholamines.
 cortisol.
 glucagon.

The glucose produced from these
processes is essential for certain
tissues, including:
 red blood cells.
 white blood cells.
 the renal medulla.
 neural tissue.
 wound tissue.

(b) Hyper catabolism :
1- Major trauma and burn
2- Major surgical procedures
3- Sever acute pancreatitis
4- Major sepsis ( peritonitis and septicemia)

In trauma/ sepsis:
• Increased counterregulatory hormones
• Increased energy requirement( 15- 25% more)
• Increased nitrogen requirement
• Insulin resistance / stress induced hyperglycemia

• peripheral oxidation of lipids
• Increased gluconeogenesis / protein catabolism
• Loss of adaptive ketogenesis
• Fluid retention with hypoalbuminemia

Effect of malnutrition on the
outcome of surgery :
1- Impairment of wound healing
2- Suppression of immune response
3- A sense of mental and physical exhaustion
4- Reduced tolerance to radiotherapy and
chemotherapy

Diagnosis (Nutritional Assessment) :
 Dietary History
 Physical Examination:
 Laboratory tests:
Surgical Club Red See University SC (RSU)

Dietary History
1. Weight loss
 More than 10% unintentional weight loss in a
3-6 month period is significant.
 A 5% unintentional weight loss in 1 month is
also significant.

Other suggestive findings in the history include:
 anorexia.
 persistent nausea.
 vomiting.
 diarrhea.
 generalized malaise

Physical Examination:
 loss of subcutaneous fat.
 muscle wasting.
 edema.
 ascites (late finding).

Anthropometric measures :
* Recent unintentional weight loss of 10 %
* Body mass index
* Mid-arm circumference
* Triceps skin fold

(Body mass index BMI)
 (BMI) is weight in kilogram divided by
height in metres squared

Mid-arm circumference

 The colors on the tape correspond to the
following results:[6]
 Children:
 Green: 135 mm or above (normal)
 Yellow: 125 mm to 134 mm (at risk)
 Orange: 110 mm to 124 mm
(moderate malnutrition)
 Red: less than 110 mm (severe
malnutrition)

 Adults:
 Acute malnutrition (women): less than 24
centimeter (9.4 in) (240 mm)
 Acute malnutrition (men): less than 25
centimeter (9.8 in) (250 mm)

Triceps skin fold

Signs suggestive of specific
nutrient deficiencies include
 skin rash.
 pallor.
 cheilosis.
 glossitis.
 gingival lesions.
 hepatomegaly.
 neuropathy.
 dementia.

 serum albumin
 transferrin
 prealbumin,
 retinol-binding protein
 nitrogen balance
Laboratory :
serum proteins

Energy expenditure
 measured by the Respiratory Quotient (RQ).
 RQ = Carbon di oxide production
(VCO2)/oxygéna consomption (VO2)
 These values are used to estimate the
adequacy of nutritional support.

 An RQ value of 1.0 is consistent with
predominant glucose utilization. Of 0.7 and 0.8
is consistent with fat and protein utilization,
respectively
 higher than 1.0 suggest the presence of
lipogenesis or overfeeding.

Immune Functions :
 Total lymphocytic count
 Delayed type hypersensitivity
 reaction

Nutritional Supplementation:
 offered to both malnourished and hyper
catabolic patients
 Natural route is by oral intake ( should be
attempted whenever possible )

 If natural route is not possible then a tube
inserted in the proximal GIT tract ( enteral
nutrition ).
 or catheter in the venous system ( parenteral
nutrition ) is done

 All patients in whom an illness or operative
procedure may delay oral intake for at least 7–10
days require nutrition supplementation.
 Normally nourished patients undergoing surgical
procedures where oral intake will be delayed for
fewer than 7 days generally do not require
nutritional support beyond fluid and electrolyte
administration with dextrose.

Enteral Nutrition
 use of GIT for nutritional support is better than
parenteral nutrition better control
 the enteral route is indicated in all patients
with an intact, functional gastrointestinal (GI)
tract.

indication :
 indicated in patients in whom oral intake is
inadequate or impossible
 Unconscious patients
 severe dysphagia
 Head and neck surgery
 Burns
 Critically ill patients who have adequate intestinal
function be supplemental or total feeding in any
case

Potential benefits include:
 prevention of intestinal mucosal atrophy.
 preservation of intrinsic gut immune function.
 inhibition of stress-associated increases in
intestinal permeability.
 decreased infection rate in critically ill
patients fed enterally than when TPN used.

Route of administration :
1. oro-enteric
2. nasoenteric routes: used for short-term and
intermediate-term nutritional support.
3. direct enteric routes
gastrostomy
jejunostomy.

Administration regimens and
formula :
 - the administration of nutrients through the
stomach is easier than jejunostomy for the
former liquid diets generally well tolerated
 - the jejunum is highly sensitive , and feed
should be started with isotonic , sterile formula
at a slow rate

contraindications to enteral
feeding include:
 mesenteric ischemia.
 bowel obstruction.
 intra-abdominal sepsis.
 necrotizing pancreatitis.
 high-output GI fistula.
 short bowel syndrome

Complication :
1- Mechanical complications include :
 pharyngeal and esophageal mucosal
irritation and ulceration
 Obstruction of the feeding tube lumen
 Tube displacement

2- Gastrointestinal complication include
 Nausea , pulmonary aspiration
 Vomiting , distention
 Colics , diarrhea

3- Metabolic complication include :
 glucose intolerance
 electrolyte imbalance
 nutrients excesses or deficiencies

Parenteral Nutrition : (TPN )
 the feeding nutrients are supplied an
intravenous delivery system
 is indicated when the GI tract is unavailable
or nonfunctional

Indication :
 massive bowel resection
 radiation enteritis
 sever inflammatory bowel disease
 prolonged paralytic ileus
 high output intestinal fistula
 moderate to sever pancreatitis

 preoperative administration of TPN to the
severely debilitated patient for 10-14 days
reduce postoperative mortality

Route of administration :
 Via central venous catheter insert
percutaneous through either subclavian or
the internal jugular vein.

administration regimens and
formula
 Daily requirements are estimated according to
body weight
 protein administrated as L-amino acids solution

 solutions also contain sodium , potassium ,
phosphate , magnesium , vitamins , trace
elements and glucose
 Fat emulsion are produced from soya oil “
intra lipid , in 10% and 20% concentration give
twice weekly

 when using amino acid carbohydrate solution ,
it should be administered in gradually increasing
deal with carbohydrate
 over 3-4 days , this allows for development of
tolerance , increasing of insulin required to

Monitoring :
 by measuring the body weight daily , fluid
intake and output , blood count , blood urea ,
serum Na ,K and Cl , urine and blood sugar
and nitrogen .
 Weekly estimation of plasma protein , serum
Ca ,Mg , phosphate , LFT and blood
coagulation studies and any manifestation of
sepsis

Complication :
 1- Nutritional and metabolic
 2- Catheter “ misplacement ,injury to artery , veins ,
venous thrombosis , most serous sepsis
 3- Failure of gut barrier
 In patient who had massive small intestinal resection “ short
bowel” can provided with TPN at home

STEPS IN NUTRITION SUPPORT
Assessment of Nutrition
Resuscitation
Fluid & electrolytes derangements
Nutritional Requirements
Caloric goal – start with 10-15kcal/kg/d
and increased slowly up to 30-
35kcal/kg/day

Routes & Methods of Feeding
Oral, enteral, parenteral or combinations
Monitoring
Adequacy, complications

Referances
 General Surgery (Board Review Series) 1st Edition
 SRB's Manual of Surgery, 3rd Edition
 Schwartz's Principles of Surgery, 11th Edition
 Bailey & Love's Short Practice of Surgery, 27th Edition
 Alkaaser Alainy

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