nutritional management in surgical patient

1. NUTRITION
… and surgical patient
Dr. Md. Nazmus Sakib
Registrar
Surgery unit-I
MMCH.

2. INTRODUCTION
Malnutrition :
 Common but often unrecognized and patient do not get
appropriate treatment.
 Occurs about 30% of surgical patient with GIT diseases and
60% of prolonged hospital stay patient.
Aim of nutritional support:
To identify those patient at risk of malnutrition and to ensure
their proper nutritional support.

3. After short fasting (12 hours) most of the
food from GIT completely absorbed
Usages of liver glycogen(200 gm)
Usages of glycogen from muscle (500 gm)
De novo gluconeogenesis in liver from muscle catabolism
(75 gm/day)

4. Nutritional assessment
 Clinical technique- history, physical examination
 Body weight & antropometry- BMI, MUAC, skin fold
thickness
 Laboratory technique- serum albumin, lymphocyte
count, delayed hyper sensitivity

5. The MUST Tool (Malnutrition universal screening tool)
BMI (kg/m2)
0 = >20.0
1 = 18.5-20.0
2 = <18.5
Weight loss in 3-6 months
0 = <5%
1 = 5-10%
2= >10%
Acute diseases effect
Add a score of 2 if there has
been or is likely to be no or
very little nutritional intake for
>5 days
Overall risk of undernutrition
o 1 2 or more
low medium High

6. Causes of malnutrition in surgical patient:
 Decreased intake,
 Increased metabolic expenditure
 Altered nutrient use.
Fundamental goals of nutritional support:
 To meet the energy requirement for metabolic process
 To maintain a normal core body temperature
 For tissue repair

9. Energy requirement :
Normal person:
 20-30 kcal/kg/day
 Protein: 0.5-1 gm/kg/day
Surgical patient:
 35-40 kcal/kg/day
 Protein: 1-2 gm/kg/day

10. Daily nutritional requirement
Macronutrients:
 Carbohydrates 50%
 Fats 35%
 Proteins 15%
Micronutrients:
 Trace elements
 Electrolytes
 Vitamins

11. Fluid
 In adult : 30-40 ml/kg/day
 In children
Weight (kg) Water requirement
0-10 4 ml/kg/hr
10-20 40 ml/hr + 2 ml/kg/hr for each kg >10 kg
>20 60 ml/hr + 1 ml/kg/hr for each kg >20 kg

12. Some special circumstance
 In post operative patient vit-C requirement increases to 60-80
mg/day.
 Vit-B12 is indicated in patient undergone gastric surgery &
intestinal resection.
 Vit-A,D,E,K absorption is reduced in absence of bile.
 Sodium, potassium & phosphate are lost in significant amount is
diarrhoeal disease.
 In a jejunostomy patient average fluid loss is 4L/day.

13. ARTIFICIAL NUTRITIONAL SUPPORT
The indications for nutritional support :
 Any patient who has sustained 5–7 days of inadequate
intake
 Who is anticipated to have no intake for this period should
be considered for nutritional support.
The periods may be less in patients with pre-existing
malnutrition.

14. Routes artificial nutrition:
Enteral feeding Parenteral feeding

15. Enteral nutrition
The term ‘enteral feeding’ means delivery of nutrients into the
gastrointestinal tract. The alimentary tract should be used whenever
possible.
Types of enteral diet :
Polymeric diet
Monomeric/elemental diet
Diseases specific diet

16. Routes of enteral nutrition
 Oral route
 Sip feeding
 Tube- feeding techniques
 Naso-enteral tube- Nasogastric tube, Naso-
jejunal tube
 Gastrotomy- surgical/PEG
 Jejunostomy

17. Monitoring feeding regimes
• CBC, Urea and electrolytes, Blood glucose
• Temperature
• Body weight,
• Fluid Balance
Daily
• Urine and plasma osmolality
• Ca,Mg,Zn and phosphates
• plasma proteins, LFTs, Thiamine, ABG, Triglycerides
Weekly
• B12, Folate, Iron,
• Lactate,
• Trace elements
Fortnightly

18. Complications of enteral nutrition
Tube related
Gastrointestinal
Metabolic/biochemical
Infective

20. Parenteral nutrition
Total parenteral nutrition (TPN) is defined as the provision of
all nutritional requirements by means of the intravenous route and
without the use of the gastrointestinal tract.
Parenteral nutrition is indicated when
 Energy and protein needs cannot be met by the enteral
administration of these substrates.
Clinical indications- massive resection of the small intestine,
intestinal fistula, prolonged intestinal failure

21. Routes of parenteral nutrition
Peripheral
Conventional short cannula in wrist vein
Peripherally inserted central venous catheter
Central
Subclavian vein
Internal jugular vein
External jugular vein

22. Writing TPN prescriptions
 Determine total volume of formulation based on individual
patient fluid needs
 Determine amino acid (protein) content Adequate to meet
patient’s estimated needs
 Determine dextrose (carbohydrate) content ~70-80% of non-
protein calories or ~50% calorie needs

23. CONT…
 Determine lipid (fat) content ~20-30% non-protein calories
 Determine electrolyte needs
 Determine acid/base status based on chloride and CO2 levels
 Check to make sure desired formulation will fit in the total
volume indicated

24. Complications of parenteral nutrition
 Related to nutrient deficiency
 Related to over feeding
 Related to sepsis
 Related line

25. Advantages of enteral feeding over
TPN
 More physiological (liver not bypassed)
 Lesser cardiac work
 Safer and more efficient
 Better tolerated by the patient
 More economical

26. Refeeding Syndrome
Severe fluid and electrolyte shifts in malnourished patients
undergoing refeeding.
More common in parenteral nutrition(TPN)
Biochemical changes ↓ PO4
-2, ↓Calcium, ↓magnesium

27. CONT..
Feeding is discontinued for 4–5 hours overnight to allow gastric
pH to return to normal.

28. CONT…
Patients at risk
Severe malnutrition,
Anorexics
Prolonged periods of fasting
Alcohol dependency
Treatment involves matching intakes with requirements and
assiduously avoiding overfeeding.

29. CONT…
Calorie delivery should be increased slowly and vitamins
administered regularly.
Hypophosphataemia and hypomagnesaemia require
treatment.

30. TAKE HOME MESSAGE
Whenever the gut is
available for use, USE
IT!!!!

31. Parenteral nutrition should be reserved for the patients
in whom a clear contraindication to enteral nutrition is
present

32. In hospital the best way of optimizing
care is with multidisciplinary support team.
receive input from clinician, dietician,
nurse, chemical pathologist & microbiologist.

33. Thank you