RATIONAL FOR NUTRITIONAL
depletion has been
demonstrated to be
determinant of the
support leads to
surgery patients are at
risk of nutritional
intake, surgical stress
& increased metabolic
and reduced length
of hospital stay.
ALL THE NUTRITIONAL NEEDS COULD NOT BE MET BY NATURAL FOODS RIGHT AFTER
▪ Increase to 30-40 kcals/kg
▪ Patient on ventilator usually require less calories ~20-25 kcal/kg
▪ Increase to 1-1.8 grams/kg
POST-OPERATIVE NUTRITION REQUIREMENTS
METHODS OF NUTRITIONAL SUPPORT
▪ Use gastrointestinal tract if available
▪ Prolonged post-operative starvation is probably not required
▪ Early enteral nutrition reduced post-operative morbidity
An alternate means of providing nutrients to people who cannot eat any or
▪ Enteral Nutrition usually can begin post operatively as
soon as the patient is haemodynamically stable.
Preferably it should start within 24 hours after surgery
and no later than 48 hours.
▪ As long as there is no significant abdominal distension,
or flatus enteral feeding is not contraindicated.
ORAL NUTRITION SUPPLEMENT
▪ Patients who are malnourished either at the time of, or
shortly following, major abdominal or vascular surgery have
a more rapid recovery of nutritional status, physical function
and quality of life, if given nutritional advice and prescribed
routine oral supplements in the immediate postoperative
period and following two months.
(Postoperative management in adults, A practical guide to postoperative care for clinical staff. Scottish Intercollegiate Guidelines Net work. Aug 2014)
ADVANTAGES OF EARLY ENTERAL FEEDS IN
POST OPERATIVE PATIENTS
▪ Enteral feeding reverses mucosal atrophy induced by starvation and it
increases anastomotic collagen deposition and strength.
▪ Enteral feeding helps in wound healing.
▪ Early Enteral feeding reduces septic morbidity after abdominal
trauma and pancreatitis.
▪ Early Enteral feeding helps to increase the strength of the tissues.
GASTROINTESTINAL DYSFUNCTION IN ICU
IT OCCURS FREQUENTLY IN CRITICALLY ILL PATIENTS AND IS
ASSOCIATED WITH ADVERSE OUTCOMES
Difficulty for ICU patient to maintain adequate nutrition is that patients commonly
have gastrointestinal dysfunction caused mainly by failing intestinal motility plus
due to Fecal lost.
-The diarrhea frequently observed in ICU may be ascribed to several causes,
including the use of drugs or laxatives.
-Absorption of both energy and all macronutrients is significantly less in patients if
fecal output exceeds 350 g/day.
▪ Although semi-elemental formulas cost more than polymeric formulas they are still widely used because
they are believed to be better absorbed, less allergenic, better tolerated.
▪ Semi elemental diet is designed for use in patients suffering from maldigestion and malabsorption.
▪ They contain dipeptides, tripeptides and some free amino acids as nitrogen source and variable doses of
fat in the form of long chain triglycerides and MCTs, carbohydrates, minerals, vitamins and trace
▪ Therefore, it is recommend that enteral support with a peptide-based diet is safe and extremely useful in
the catabolic, critically ill patient or in patients with significant gastrointestinal malabsorption associated
with a protein-losing enteropathy.
1. Brinson, R R; A reappraisal of the peptide-based enteral formulas: clinical applications. Nutr Clin-Pract. 1989 Dec; 4(6): 211-7
Semi elemental diet
• Critical illness or malnutrition affects the Gut nutrient intake and barrier function
• Gut permeability increases - higher risk of potential Bacterial translocation and Sepsis
Maintains Gut Integrity
▪ Gastrointestinal (GI) intolerance symptoms are the limiting factor to enteral alimentation in the
immediate postoperative period.
▪ Study has been conducted to postulate semi elemental diet might be better absorbed and better
tolerated so as to avoid the need for TPN, to the patients undergoing major abdominal surgery.
▪ Feeding begun 6 hr postoperatively at 25 ml/hr and increased by 25 ml/hr at 12-hr intervals up to
the rate providing 1.5 times the calculated REE (via jejunostomy &TPN regimen).
▪ Although overall mean daily calorie and nitrogen intakes were lower for the enteral than for the
TPN group, the enteral group was nevertheless in positive caloric and nitrogen balance, and
maintained similar serum albumin, prealbumin, and plasma transferrin levels.
GI tolerance to enteral feeding was excellent during the first three postoperative days, allowing the
progression of the feeding rate to 99% of goal.
Hamaoui E, Lefkowitz R;Enteral nutrition in the early postoperative period: a new semi-elemental formula versus total parenteral nutrition. JPEN J Parenter Enteral Nutr. 1990 Sep-Oct;14(5):501-7.
▪ Average daily cost of supplies was more than double in TPN in comparison with EN
▪ Conclusion: enteral feeding using this formula is well tolerated and cost-effective in
the immediate postoperative period.
Hamaoui E, Lefkowitz R;Enteral nutrition in the early postoperative period: a new semi-elemental formula
versus total parenteral nutrition. JPEN J Parenter Enteral Nutr. 1990 Sep-Oct;14(5):501-7.
STUDY OF PEPTIDE DIET IN LIVER TRANSPLANT
▪ Peptide-based enteral formula diet as started around 14 days after liver transplantation
- End-stage liver disease score in the experimental group was significantly lower than that in the control
- Elevation of enzymes in the liver function tests such as alanine aminotransferase and total bilirubin, and
C-reactive protein in the experimental group had significantly improved, and became almost normal
- These findings suggest that administration of whey-
hydrolyzed peptide attenuates the post-transplant liver
dysfunction and may avoid an unnecessary liver biopsy.
Arakawa Y, Shimada M, Effects of a whey peptide-based enteral formula diet on liver dysfunction following living donor liver
transplantation. Surg Today. 2014 Jan;44(1):44-9.