Nutrition is essential for surgery patients as surgical procedures and fasting can quickly lead to malnutrition. Patients with severe protein depletion are more likely to experience postoperative complications like pneumonia and infection. Nutritional status should be assessed through history, diet assessment, physical exam, and lab tests. Malnutrition is caused by reduced food intake, malabsorption, altered metabolism, and more. Nutritional requirements vary but are generally 25-30 calories/kg/day and 1.5-2 grams of protein/kg/day. Nutrition can be provided enterally through tubes or parenterally through IVs. Enteral nutrition is preferred over parenteral when possible.

1. Nutrition in surgery
Omer Hashmi

2. nutrition
Definition
The taking in and metabolism of
nutrients (food and other nourishing
material) by an organism so that life is
maintained and growth can take place.
Dorland’s Pocket Medical Dictionary

3. malnutrition
Definition
A disorder of nutrition or a wasting
condition resulting from energy and protein
deficiency, sometimes with vitamin and
trace element deficiency as well.
Dorland’s Pocket Medical Dictionary

5. Importance of nutrition in
surgery
1. Surgical procedures (and subsequent fasting)
after admission can cause these patients to go
into severe malnutrition quickly, often before
the treating team realizes it.
2. There is evidence that patient with severe
protein depletion have greater incidence of
postoperative complication such pneumonia,
wound infection, & prolonged hospital stay.

6. Assessment of nutritional status
1. History
2. Diet assessment.
3. Physical Examination.
4. Investigation

7. Malnutrition (history)
 Causes
 Reduced food intake
 anorexia
 fasting
 pain on swallowing,
 physical or mental impairment
 Malabsorption
 impaired digestion or absorption
 excess loss from gut
 Altered metabolism
 trauma
 burns
 sepsis
 surgery
 cancer cachexia
Not
appetizin
g food
weak and
anorexic
patient
increased
metabolic
demand
GI
obstruction
Cumulativ
e effects
of
repeated
periods of
fasting
Intestinal
failure

8. • Clinical nutritional history based on understanding of the
etiologies and pathophysiology of malnutrition.
• History of poor nutrient intake
• Anorexia
• Nausea
• Vomiting
• Early satiety
• Food preference
• Loss of body weight
• Weight loss of more than 10-15% during the past 6
months
EVALUATION OF
MALNUTRITION (HISTORY)

9.  Social & economic condition that may lead to poverty & malnutrition
 Inadequate income
 Homeless
 Drug abuse
 Chronic alcoholism
 Gastrointestinal symptoms
 Dysphagia
 Recurrent vomiting
 Chronic diarrhea
 Food intolerance
 Other chronic medical illnesses
 Disseminated cancer
 COPD
 Chronic inflammatory disease
EVALUATION OF MALNUTRITION
(HISTORY)

10. ASSESSING PATIENT FOR
MALNUTRITION
1. Clinical assessment:
 Lack of nutritional intake for 5 days or more.
 Clinical appearance – does the patient looked
malnourished?
 Unintentional weight loss for more than 10% from usual
body weight for previous 6 months. More than 20% is likely
to represent severe malnutrition.
 BMI less than 18.5.
 History of poor nutrient intake: anorexia, nausea, vomiting,
early satiety and food preference.

11. Physical examination anthropometry
Definition
• The science dealing with measurement of the size, weight and
proportions of human body
• It can assess level of energy reserves by estimate amount of
subcutaneous adipose stores.
• However it cannot identify specific nutrient deficiency
• Triceps skin fold thickness (mm)
 Mid arm circumference (cm) :
Mid-upper circumference (cm) – (π x triceps skin fold thickness)
(cm)

12. Papular keratitis
Bitot spot
Perifollicular
hemorrhage
Nasolabial seborrhea
Flaky paint of lower

13. EVALUATION OF MALNUTRITION
(LABORATORY INVESTIGATION)
To detect subclinical nutritional deficiencies
in patients
•Nitrogen Balance
•Serum Albumin
•Creatinine excretion
•Immunological Function assessment

14. Blood indices:
 Nitrogen balance
 Nitrogen balance provides an index of protein gain or loss:
6.25 protein gained is equivalent to 1 g nitrogen
 Can be assessed by measuring the difference between nitrogen
consumed (mouth, enteral tube or IV) and nitrogen excreted in the
urine, feces and other intestinal sources.
Nitrogen Intake – loss [90% urine, stool 5%, integument 5%]
or
[Protein intake (g)/6.25] – urinary urea (g) – 2(for stool & skin) –
2(non-urea nitrogen)

15. Blood indices
 Serum Albumin
 Serum albumin level falls during the acute stress of surgery,
sepsis or other acute inflammatory illness because of
 increased circulating extravascular volume
 TNF-α mediated inhibition of albumin synthesis
 The measurement of serum proteins, in particular albumin, is
often used as an index of malnutrition (<35g/L)
 Sensitive but non-specific.
 The half-life of albumin is 14 to 18 days.
 Prealbumin (half-life, 3 to 5 days) or transferrin (<200 mg/dL;
half-life, 7 days), have been proposed as more sensitive
indicators of rapid changes in nutritional status.

16. Blood indices
 Creatinine Excretion
 It is produced constantly in an amount directly
proportional to skeletal muscle mass.
 With steady state a day-to-day renal function, each
gram of creatinine in the 24-h urine collection
represents 18.5g of fat free skeletal muscle.
 Measurement of creatinine in 24-h urine collection can
be used as a relative measure of this body
compartment.
 Immunological assessment
 Total Lymphocyte count is often <1000 /μL in PCM and
may accompany anergy to common skin test antigens.

18. ASSESSMENT OF NUTRITIONAL
REQUIREMENT
 Energy and protein requirement vary depending on
weight, body composition, clinical status, mobility and
dietary intake.
 Few patients require more than 2500 kcal/day. Additional
calories are unlikely to be used effectively and may
constitute a metabolic stress.
 Refeeding the chronically starved patient must be
cautious because of the dangers of hypokalemia and
hypophosphatem.ia
Daily energy
requirement
uncomplicated Complicated/stresse
d
Energy (kcal/kg/day) 25 30 – 35
Protein (g/kg/day) 1.0 1.3 – 1.5

19. Caloric requirements
• 25-30 cal/kg/day
• carbohydrate ~70%
• Lipid 15-30%
• Protein 1.5-2.0g/kg/day. Not for calories
• Additional 50% to 100% for stress as in
ICU patients

20. What to give

21. How to give (Routes of administration)
Enteral
NGT
Gastrostomy
Jejunostomy
PEG (percutaneous endoscopic gastrostomy) in
prolonged periods
Trans-gastric jejunostomy
Parenteral
 Central
 peripheral
Combination

22. Enteral vs parenteral
General Surgery
 Laparotomy
Enteral better than parenteral (Level I evidence)
 Ulcerative Colitis and CD after resection
Enteral better than parenteral (Level I evidence)
 Liver transplantation
Enteral = Parenteral (Wicks 1994 Level I evidence)
 Acute pancreatitis
Gastric and duodenal feeding- ↑ complication (Ragins
1973)
TPN, jejunal feeding  (Stabile 1984, Bodoky 1991)
Jejunal feeding = TPN (McClave 1997 Level I evidence)
Jejunal feeding better than TPN (Windsor 1998 Level I evidence)

23. Parenteral nutrition
As Primary Therapy:
 TPN influence the disease process:
1. GIT fistula (high output)
2. Renal failure (ATN)
3. Short Bowel Syndrome
4. Acute Burn (severe trauma)
5. Hepatic failure
6. With normal bowel length but with
malabsorption syndrome due to SPRUE,
enzymatic or pancreatic insufficiency,
Ulcerative colitis, regional enteritis
7. Anorexia nervosa

24. Parenteral nutrition distribution

25. Take home message
 I will assess the patient (history,phy exam, labs)
 I will always memorize that
 TOTAL CAL REQUIREMENT PER KG PER DAY IS
 BEEx INJURY FACTORx ACTIVITY FACTOR
 In normal individual its 25-30kcal/kg/day
 After I have decided total caloric requirement in 24 hrs ,I will get
through my caloric chart and with reference to food I will prepare
diet chart for my patient

26. Thank u for having
me…

27. REFERENCES
 Garden’s Principles & Practice of Surgery, 5th edition.
 Burkitt’s Essential Surgery, 4th edition.
 Medical Nutrition Therapy Guidelines for nutrition support in
critically ill adult by Ministry of Health, Malaysia
 Bailey and loves 26th edition