1. Presenter : Dr.Asif Mian Ansari
DNB Resident
Dept. of General surgery
Max super speciality Hospital,
Mohali, Punjab
2. Requirements increased during stress
A well-nourished patient usually tolerates major surgery
better than a severely malnourished patient
Malnutrition complicates surgical outcomes
Surgical patient decreased intake, increased metabolic
expenditure
Wound healing is an anabolic state, requires high amount of
nutrients
3. For men:
BMR= 66.5 + (13.75 x Wt in kg) + (5.003 x Ht in cm) – (6.775 x age in years)
For women:
BMR= 655.1 + (9.536 xWt in kg) + (1.850 x Ht in cm) – (4.676 x age in years)
Stress increases BMR stress factor is multiplied as following:
Minor surgery : 1.1
Major surgery : 1.2
Skeletal trauma : 1.35
Head injury : 1.6
6. Clinical history
Anthropometric measurements:
IBW, BMI, Lean body mass, skinfold thicknes
Oxygen consumption, determination of respiratory quotient
Body composition analysis: Dual-energy x-ray absorptiometry
Biochemical measurements:Albumin, transferrin, prealbumin
Measurement of nitrogen balance
Measurements of immunologic function
7.
8.
9. Severe nutritional risk expected with at least one of the
following:
Past medical history: Severe under-nutrition, chronic disease
Involuntary loss >10%-15% of usual body weight within 6 mo or >5%
within 1 mo
Expected blood loss >500 mL during surgery
Weight 20% less than IBW or BMI <18.5 kg/m2
Failure to thrive on pediatric growth and development curves (<5th
percentile
10. Serum albumin <3.0 g/dL or transferrin <200 mg/dL in the absence
of an inflammatory state, hepatic dysfunction, or renal dysfunction
Anticipate that patient will be unable to meet caloric requirements
within 7-10 days perioperatively
Catabolic disease :
▪ Significant burns or trauma
▪ Sepsis
▪ Pancreatitis
15. Preoperative nutritive therapy :
Patient’s level of malnutrition
Nutritional options available to the patient preoperatively. e.g. E or
PN
Likelihood of response to preoperative nutrition
Relative risk of delaying the particular surgery
16. Enteral >>>>>Parenteral
oral route if the GI tract is fully functional & no other
contraindications
Patients who do not have any absolute contraindication to EN
and who are expected to be unable to take adequate nutrition
orally within 24-48 hours, initiate direct EN as soon as possible
17. If the enteral route is contraindicated:
InitiateTPN within 24-48 hours in all critically ill or injured patients who
are not expected to be able to tolerate significant EN within 48-72 hours
InitiateTPN within 24-48 hours in all patients (regardless of injury or
illness severity) who are not expected to be able to tolerate significant EN
within 3-4 days
Consider initiating supplemental PN in any critically ill or injured patient
who can tolerate only limited enteral feeding and who is not expected to
tolerate sufficient enteral feeds to meet 60%-80% of projected protein-
caloric needs within 48-72 hours
18. Administer at least 20% of the caloric and protein
requirements enterally while reaching the required goal with
additional PN
Maintain PN until the patient is able to tolerate 75% of
calories through the enteral route, and maintain EN until the
patient is able to tolerate 75% of calories via the oral route
19. Clear liquids when signs of bowel function returns
Clear liquid diets supply fluid and electrolytes and little
stimulation of the GI tract
Patients must have adequate swallowing functions
Advance diet to full liquids followed by solid foods, depending
on patient’s tolerance
Consider the patient’s disease state (e.g. diabetes)
If oral not possible enteral (tube) feeding
20. Maintains GIT integrity and positive effect on immunity of
small intestine
Enhanced utilization of nutrients
More efficient plasma insulin response
Easy and safety of administration
Less cost thanTPN
Mechanical, infectious and metabolic complications less
severe than withTPN
23. Standard formulas are sterile & nutritionally complete
Specialty formulations may be more efficiently absorbed in
patients with short gut syndrome, severe trauma, burn, injury,
and chronic malabsorptive diarrhea
Immune-enhancing formulas are enriched with arginine,
glutamine, nucleotides, and omega-3 fatty acids
25. Nutrients provided intravenously
Components of a PN mixture include:
Protein (Amino Acids) , carboydrates (dextrose) , Fats (Long-chain
fatty acids), sterile water, electrolytes, vitamins and trace minerals
Used in nutritionally compromised patients
Used when enteral nutrition is contra-indicated
Is either primary or supportive therapy
Before receiving PN, patients should be hemodynamically
stable and able to tolerate the fluid volume and nutrient
content
26. Malnourished patient expected to be unable to eat > 5-7 days
Patient failed enteral nutrition trial with appropriate tube
placement
Enteral nutrition is contraindicated or severe GI dysfunction
Paralytic ileus, mesenteric ischemia, small bowel obstruction, enteric
fistula distal to enteral access sites
27. TPN
High glucose concentration (15%-25%
final dextrose concentration)
Provides a hyperosmolar formulation
(1300-1800 mOsm/L)
Must be delivered into a large-
diameter vein
PPN
Similar nutrient components asTPN,
but lower glucose concentration (5%-
10% final dextrose concentration)
Osmolarity < 900 mOsm/L (maximum
tolerated by a peripheral vein)
May be delivered into a peripheral
vein
Because of lower concentration, large
fluid volumes are needed to provide a
comparable calorie and protein dose
asTPN
28.
29. IV formulations or emulsions of nutrients that are
administered in an elemental form
Available in wide range of concentrations, including 10% to
70% dextrose, 5.2% to 20% amino acids, and 10% to 30% lipid
emulsions
Two-in-one formulation- glucose + amino acids (daily)
Three-in-one formulation- glucose + amino acids + lipids (once
or twice weekly)
PN formulations can include medications such as insulin
30. Total kcal = 30 x 70 kg=2100 kcal/day
Total protein req = 1.5 x 70 = 105 g/day
If three-in-one formulation is given then:
20% calories should be provided by fat
20 % of 2100 k cal = 420 kcal
lipid req = 420 / 9 = 47 g of lipids
Kcal by amino acids = 105 x 4 = 420 k cal
Remaining k cal = 2100 – 420 – 420 = 1260
Req of dextrose = 1260 / 3.4 = 370 g dextrose
31. Final volumes maximally (stock )concentrated:
Amino acids (10% stock solution) = 105 g = 1050 mL
Dextrose (70% stock solution) = 370 g = 528 mL
Lipids (20% stock solution) = 47 g = 235 mL
Total volume = 1813 mL day
32. Catheter related
Central vein thrombosis, catheter embolism, haemo-pneumo thorax,
haemopericardium, air-embolism, tracheal puncture, arterial laceration, brachial
plexus injury
Infections
Catheter Blockage
Metabolic :
Hyperglycaemia, electrolyte and acid base abnormalities, trace element and
vitamin deficiencies.
Hypo/hyper glycaemia
Hepatic function changes:
Cholestasis, elevated liver enzymes and hepatomegaly
GI changes: Atrophy of intestinal mucosa
33. OVER FEEDING
Hyperglycemia
Hepatic dysfunction from fatty
infiltration
Respiratory acidosis from increased
CO2 production
Difficulty weaning from the ventilator
Fluid overload
UNDER FEEDING
Depressed ventilatory drive
Decreased respiratory muscle
function
Impaired immune function
Increased infection
Weight loss and malnutrition