surgical nutrition

1. SURGICAL
NUTRITION
MODERATOR- Dr Chandraman Prajapati
Prepared By- Dr Lalit K Shah
Resident General Surgery

2. Content
• Metabolic respone to fasting and stress
• Nutritional assessment
• Routes of surgical nutrition
• Advantages and disadvantages of different routes

3. Metabolic response to starvation
• Low plasma insulin , High plasma glucagon
• Hepatic glycogenolysis , Protein catabolism
• Hepatic gluconeogenesis , Lipolysis
• Adaptive ketogenesis
• Reduction in resting energy expenditure( from
approximately 25-30kcal/kg per day to 15-20kcal/kg per
day)

6. Metabolic response to trauma and sepsis
• Increased counter regulatory hormones
• Increased Energy requirements(upto 40kcal/kg per day)
• Insulin resistance and glucose intolerance
• Preferential oxidation of lipids
• Increased gluconeogenesis and protein catabolism
• Loss of adaptive ketogenesis
• Fluid retention and associated hypoalbuminaemia

9. NUTRITIONAL ASSESMENT
• Clinical history
• Laboratory Techniques :albumin
• Body Weight and Anthropometry
• Imaging :dual energy x ray absorptiometry
• Measurement of immunological function

11. Imaging
• DEXA scan monitors long term nutritional progress
• Measures changes in Body tissue composition
• Lean Body Mass, Fat Mass And Bone Density

12. Criteria to initiate perioperative nutritional support

15. ROUTES
• Oral
• Enteral
• Parenteral

16. Oral Feeding
• Conscious patient with intact appetite and swallowing
function
• Indicator of compromised swallowing function include :
Neurological impairement(cognitive or oral motor)
Coughing or Choking with feeds
Symptoms indicating a possible aspiration associated
pathology(recuurent pneumonia)

18. ENTERAL ACCESS FOR FEEDING
• Delivery of nutrients directly into GIT
• Advantages
-more physiological
-maintains the integrity of GIT
-reduces translocation of bacteria from GIT
-reduces the levels of proinflammatory cytokines

19. Early initiation of Enteral feeding
• Early (24 to 48 hrs)institution of enteral feed after major
surgery minimizes
Risk of Undernutrition
Can abate hyper metabolic response seen after surgery
• Intake within first week should be atleast 60% to 70% of
the total estimated energy requirement as per
assessment

23. Complications of enteral nutrition
● Tube-related
Malposition
Displacement
Blockage
Leakage
Erosion of skin and mucosa
● Gastrointestinal
Diarrhea
Constipation
Nausea, vomiting
Abdominal cramps
Aspiration

24. Continued Complications
● Metabolic/biochemical
Electrolyte disorders
Vitamin, mineral, trace element deficiencies
● Infective
Exogenous (handling contamination)
Endogenous (patient)

25. Contraindications To Enteral nutrition
• Diarrhea refractory to medical management
• Paralytic ileus or small bowel obstruction
• Intractable vomiting
• Severe shock ,hemodynamically instability
• GI hemorrhage, Severe short bowel
• Severe GI malabsorption ,
• Inability to gain access to GI tract

26. Parenteral Nutrition
• Development of PN in the 1960s
• A major advance in surgical care
• Allow nutrion in and survival of patient with nonfunctioning
GI system
• IV infusion of nutrition in Elemental form ,bypassing
digestion
• Long term Hyperosmolar –TPN
• Short term lower osmolar solution -PPN

27. • Routes of delivery
1. Peripheral(PPN-Peripheral parenteral nutrition)
-short term nutrition upto 2 weeks
-Advantages: avoid complications of central venous administration
-Disadvantages: limited by development of thrombophlebitis
1. Central(TPN-Total parenteral nutrition)
-central vein preferred(subclavian>internal jugular>femoral)

29. Ordering parenteral Nutrition

30. 1. For TPN formulated without lipid (two-in-one solution)
Total kilocalories = 2100 k cal
Calories from amino acids 105g× 4k/cal= 420 kcal
Remaining calories 2100 – 420= 1680 kcal
Then make up the difference with dextrose: 1680kcal/( 3 .4 kcal /g) =494 g dextrose
Remember
Amino acid(1 g amino acid 4 kcal)
Dextrose(1 g dextrose 3.4 kcal)
Lipid(1 g fat 9 kcal)
Total kilocalories (25 to 35kcal/kg/day ) 30 kcal/kg/day × 70 kg =2100 kcal
Protein 1.5 g/kg/day = 1.5g /kg /day ×70kg =105g protein

31. For TPN formulated with lipid (three-in-one solution):
Total kilocalories = 2100 kcal
Provide 20% of the total calories as lipid:
Lipid = 2100 kcal× 0.2 = 420 kcal
420kcal / 9 kcal g = 47 g lipid
Calories from amino acids: 105g ×4 kcal =420kcal
Remaining calories: 2100 – 420- 420=1260 kcal
Then make up the difference with dextrose: 1260/ 3. 4 = 370 g
dextrose

32. Final volume (for three-in-one, maximally concentrated):
Amino acids stock solution g mL ( 10 % means 10g per 100ml) = 105g= 1050 ml
Dextrose stock solution g mL ( 70% means 70g per 100ml ) = 370g= 528ml
Lipids stock solution g mL ( 20% means 20g per 100ml ) = 47g = 235ml
Total volume= 1830mL /day

34. Complications of parenteral nutrition
● Related to nutrient deficiency
Hypoglycaemia/hypocalcaemia/ hypophosphataemia/
hypomagnesaemia (refeeding syndrome)
Chronic deficiency syndromes (essential fatty acids, zinc, mineral and
trace elements)
● Related to overfeeding
Excess Glucose :
hyperglycaemia
hyperosmolar dehydration
hepatic steatosis
increased sympathetic activity,
fluid retention
electrolyte abnormalities

35. ●Excess fat:
Hypercholesterolaemia
Hypertriglyceridaemia,
Hypersensitivity reactions
● Related to sepsis
Catheter-related sepsis
● Related to line
On insertion:
Pneumothorax,damage to adjacent artery, air
embolism, thoracic duct damage, cardiac
perforation or tamponade, pleural effusion
Long-term use: occlusion, venous thrombosis

36. Nutritional support of the surgical patient
Nutritional support before and after surgery are critical for
increasing the likelihood of positive outcomes.
1. Optimizing preoperative nutrition
2. Safe initiation of postoperative nutrition
3. Gastrointestinal anastomosis
4. Hemodynamic instability/vasopressor infusion

39. REFRENCES
• BAILEY AND LOVE 27th Edition
• SABISTON , Text Book Of Surgery 21th Edition
• SCHWARTZ,principles of surgery 11th Edition

40. THANK YOU