This document discusses nutrition support in surgery patients. It begins by outlining the aims of nutrition support to identify and meet the nutritional needs of at-risk patients. It then covers metabolic responses to starvation, increased energy and nutrient requirements in trauma/sepsis patients, methods of nutritional assessment, and factors that warrant nutrition support. The document provides details on enteral and parenteral nutrition support, including formulas, delivery methods, monitoring, and complications. It also addresses special considerations for burns patients and those with short bowel syndrome.

1. NUTRITION IN SURGERY
DR PRAJWAL
MODERATOR: DR ELROY

2. •Aim of nutrition support is to identify
patients at risk for malnutrition and to
meet their nutritional requirements
•Malnutrition has high risk of
complications plus mortality

4. Metabolic response to starvation
• Within 12 hours of fasting…
• Insulin level and Glucagon level
• Glycogenolysis (liver glycogen to glucose)
• Cori’s cycle
• > 24 hours… Gluconeogenesis in liver
• 48 – 72hrs : Lipolysis and Adaptive Ketogenesis

5. In trauma/ sepsis..
• Increased counterregulatory hormones
• Increased energy requirement( 15- 25% more)
• Increased nitrogen requirement
• Insulin resistance / stress induced hyperglycemia
• Preferential oxidation of lipids
• Increased gluconeogenesis / protein catabolism
• Loss of adaptive ketogenesis
• Fluid retention with hypoalbuminemia

6. Energy requirements
One g carbohydrate provides about 3.4 KCal,
whereas 1 g fat provides about 9 KCal.
Protein 4 KCal for each g.
An average adult needs 30--35 KCal/Kg/day

7. Nutritional Assessment
• Dietary History and History of weight loss
• Physical Examination:
• General appearance( emaciated, apathetic look)
• Assessment of body fat stores (Skin fold examination
over biceps and triceps, subscapular region)
• Assessment of protein stores (Muscle bellies of biceps,
triceps, supra and infraspinatus)
• Assessment of metabolic stress (indirect calorimetry ,
temp, wbc count, pulse, positive blood culture, abscess)
• Physiological fn – poor wound healing, early fatiguability,
grip strength, resp muscle fn test

8. • Body weight and Anthropomentry
• Laboratory tests: Serum albumin levels, Lymphocyte
count, Skin hypersensitivity tests
• THE MUST TOOL BMI, WT LOSS IN 3-6
MTHS, ACUTE DISEASE.

9. Nutrition support given to..
Past medical history
Involuntary loss
Blood loss >500ml
BMI < 18.5 kg/m2
Serum albumin <3 or transferrin <200mg/dl
Failure to thrive
Severe burns, trauma, sepsis, pancreatitis
NPO > 7 days

10. Nutritional Support
• Enteral
• Parenteral
• Daily requirement:
• Water 30- 70 ml/kg
• Calories 50 – 70 kcal/kg
• Protein 1.5- 2.0 gm/kg
• Sodium 0.9 – 1.2, Potassium 0.7-0.9 mmol/kg

12. Enteral nutrition
• Oral supplements
• N/G tube feeding
• Gastrostomy tube feeding
Per-cutaneous
Open surgical / Laparoscopy
• Jejunostomy tube feeding
Laparoscopy/open surgery

13. Sip feeding
• Sip feeds provide 200 kcal and 2 g protein per
200ml carton
• Given in patients whose appetite is impaired
• Oral diet started at regular intervals , more
frequently. Progressive shift from oral liquid to
soft and normal diet ideally be one between 2-3
days

14. Tube feeding techniques
• NG TUBE , FINE BORE TUBE INSERTION
• 20-30ML administered per hr initially , gradually
increased within 2-3 days, feeding discontinued
for 4-5 hours overnight
• Aspiration is performed on regular basis, if
aspirate is more than 200ml per 2 hours, stop
feeding temporarily

15. Fine Bore Tube insertion
• Nasogastric tube is appropriate commonly but if
required for more than a week, then fine bore
feeding tube is preferred
• Fine bore feeding tube is made of soft
polyurethane or silicone elastomer (internal
diameter 3mm)
• It causes few gastric / esophageal erosions

16. Gastrostomy
• Stamm (sero-lined) – temporary
• Janeway (mucous-lined) – permanent

21. PER CUTANEOUS
ENDOSCOPIC GASTROSTOMY
• 2 methods of PEG
• Ponsky pull technique
• Push through technique
(Sacks-Vine)

23. Peg procedure

24. Jejunostomy tube
• Witzel (Open) - permanent
• Button jejunostomy
• Roue-en-y (rarely used)
• Endoscopic

28. Button jejunostomy

29. Complications
• Tube related:
• Malposition
• Displacement
• Blockage / Leakage / Breakage
• Erosion of skin / mucosa
• Gastrointestinal:
• Diarrhoea
• Bloating, Nausea, Vomiting
• Abdominal cramps, Aspiration
• Constipation

30. • Metabolic:
• Electrolyte disorder
• Vitamin, Mineral, Trace element deficiency
• Drug interactions
• Infection:
• Aspiration:
• Overloading
• Supine position/ unconscious

31. • Solute overloading :
• diarrhea, dehydration, electrolyte imbalance
(hypokalemia, hypomagnesemia), hyperglycemia
(hyperosmolar, nonketotic coma)
• Rarely perforation

32. Advantages of enteral feeds
• Preserves gut integrity
• Decreases likelihood of bacterial translocation
• Preserves immunologic function of gut
• Increased compliance with intake
• Costs less than parenteral nutrition
• Intake easily/accurately monitored

33. Contraindications
• Intractable vomiting/ diarrhoea
• Paralytic ileus
• GI Obstruction
• Diffuse peritonitis
• Severe GI haemorrhage, GI malabsorption
• Short bowel syndrome(<100cm)
• Severe shock
• Distal high output fistula

34. Formula selection
BASED ON…
 Functional status of GI tract
 Physical characteristics of formula (osmolality, fiber
content, caloric density, viscosity)
 Macronutrient ratios
 Digestion and absorption capability of patient
 Specific metabolic needs
 Contribution of the feeding to fluid and electrolyte needs
or restriction
 Cost effectiveness

36. Rate and Method of Delivery
• Bolus—300 to 400 ml rapid delivery via
syringe several times daily
• Intermittent─300 to 400 ml, 20 to 30
minutes, several times/day via gravity drip
or syringe
• Cyclic—via pump usually at night
• Continuous—via gravity drip or infusion
pump

37. Enteral Nutrition Monitoring

38. Parental nutrition
• DEFINITION
• Defined as infusion of a nutrient hyperosmolar solution
containing carbohydrates, proteins, fat, and other
essential nutrients through an intravenous route
delivered via an indwelling intravenous catheter.
• Components are in elemental or “pre-digested” form
• Protein as amino acids
• CHO as dextrose
• Fat as lipid emulsion
• Electrolytes, vitamins and minerals

39. Peripheral parenteral nutrition
• To provide calories for <2 weeks
• Low dextrose conc (5-10%), aminoacid conc with
concentrated lipid(20%)
• Osmolarity< 900mosm/l
• Delivered into peripheral vein

40. Total parenteral nutrition
• High dextrose conc(50-70%)
• Aminoacids(8.5-10%)
• Osmolarity of 1000-1900mosm/l
• Catheter used : Polyurathrene or Silicon rubber

41. Sites for insertion
• 1) Short term central access – Infraclavicular
approach to subclavian vein
• 2) Long term central access – Tunneled catheter
into subclavian or internal jugular vein
• 3) Percutaneous inserted central catheter –
Catheter inserted into vein in antecubital area of
the arm and threaded into subclavian vein and
tip placed in sup vena cava

43. Delivering systems:
• 1) Multiple Bottle system: More flexible, requires proper
monitoring
Risk of improper mixing present
• 2) Three in one system: For long term cyclic or home
therapy

44. Duration of delivery
• Continous – Slow continous infusion,
Provides nutrition throughout the day
• Cyclic – Over period of 8 – 12 hours
(typical at night)

45. Advantages
• Provides nutrients when less than
2 to 3 feet of small intestine remains
• Allows nutrition support when GI
intolerance prevents oral or enteral
support

46. Estimating Energy
Requirements
• Harris-Benedict equations:
• BEE (men) = 66.47 + 13.75 (W) + 5.0 (H) - 6.76 (A)
kcall/d
• BEE (women) = 65.51 + 9.56 (W) + 1.85 (H) - 4.68 (A)
kcall/d
• where W = weight in kilograms,
• H = height in centimeters, and
• A = age in years.

47. TEE = REE X ACTIVITY FACTOR X DISEASE FACTOR X
THERMAL FACTOR
AF = 1.2 BED REST, 1.3 MOBILE
DF = 1.2 G.SURGERY, 1.3 SEPSIS, 1.6 MULTIORGAN
FAILURE, 1.7 – 30-50 %BURNS, 1.8 = 50-70%
BURNS, 2 = 70-90% BURNS
TF = 1.1 = 38, 1.2 = 39, 1.3 = 40, 1.4 = 41

48. • SIMPLE BODY WEIGHT CALCULATION
• REE(KCAL /DAY) = 25 X WEIGHT
• INDIRECT CALORIMETRY
• REE + (3.9XVO2) + (1.1X VCO2)- 61

49. Composition of formulas
• STANDARD PARENTERAL DEXTROSE SOLUTION:
5 TO 70% CONCENTRATION, 3.4KCAL/GM
Cannot be used in patient under severe stress
Disadvantages : essential fatty acid deficiency
fatty liver

50. Intravenous Lipid Emulsions
• Concentrations 10% and 20%
• Parent oil Soybean or Safflower
• Osmolarity 280 - 340 mOsm/l
• Caloric content 10% = 1.1 kcal/ml
20% = 2.0 kcal/ml
Isotonic, Suitable for peripheral infusion, patient
under stress, Provide essential fatty acids and
Reduces the incidence of fatty liver

51. Parenteral Amino Acid Solutions
• Hypertonic solutions
• Contain essential and non-essential AA
• Variable amounts of electrolytes
• Concentrations depend on final volume

52. Amino acid solution
• Cheaper than albumin, readily used for protein
manufacture
• No risk of transmission of infection
Branched amino acid – beneficial in patients with liver
disease
Glutamine enriched amino acids – improve survival in
stressed & sick patients.
Arginine improves immune function.
Enriched with essential amino acids – beneficial in
patients with renal failure

53. Designing parenteral nutrition
formula
• Total kilocalories (25-35 kcal/kg/day)
30 kcal/kg/day x 70 kg
= 2100 kcal
• Protein (1.5gm/kg/day)
1.5kcal/kg/day x 70kg
• = 105gm protein

54. 2 in 1 solution
• 60 -70% dextrose, 10 to 20% amino acids
• Total kilocalories – 2100 kcal
• Calories for amino acids – 105gmx 4 kcal/gm =
420 kcal
• The difference 2100 – 420 = 1680kcal
• Dextrose 3.4kcal/gm so, 1680 x 3.4 = 494g
dextrose

55. 3 in 1 solution
• Includes 10 to 30% lipid emulsion
• Total kilocalories =2100kcal
• 20% of lipid , i.e 2100 x 0.2 = 420kcal
• 9kcal/gm = 47 gm lipid
• Calories from aminoacid 105gmx 4 kcal/gm = 420 kcal
• Remaining calories = 2100- 420- 420 = 1260kcal
• 1260 kcal (3.4kcal/gm) = 370gm dextrose

56. • Fluid volume = amount of substance/ conc. of
substance x 100
• Final volume is
• Amino acid (10%) = 105gm = 1050 ml
• Dextrose (70%) = 370 gm = 528ml
• Lipids(20%) = 47gm = 235ml
• So total 1813ml/day

57. Complications
• First 48 hours:
• MECHANICAL – MALPOSITION,
HEMOTHORAX,PNEUMOTHORAX, AIR
EMBOLISM, BLOOD LOSS, PUNCTURE OF
SUBCLAVIAN ARTERY
• METABOLIC- FLUID OVERLOAD,
HYPERGLYCEMIA,HYPOPHOSPHATEMIA,
HYPOKALEMIA, HYPOMAGNESEMIA, REFEEDING
SYNDROME

58. First two weeks
• MECHANICAL: CATHETER DISPLACEMENT,
CATHETER THROMBOSIS, CATHETER OCCLUSION
• METABOLIC: HYPERGLYCEMIA COMA, ACID BASE
IMBALANCE, ELECTROLYTE IMBALANCE
• INFECTION: CATHETER SITE INFECTION

59. 1 – 2 Months
• MECHANICAL: TEAR OF CATHETER, CATHETER
THROMBOSIS, BLOOD LOSS, AIR EMBOLISM
• METABOLIC: ESSENTIAL ATTY ACID DEFICIENCY,
VITAMIN OR TRACE ELEMENT DEFICIENCY,
METABOLIC BONE DISEASE, LIVER DISEASES
• INFECTION: TUNNEL INFECTION, SEPSIS

60. Refeeding Syndrome
• Hypophosphatemia
• Hyperglycemia
• Fluid retention
• Cardiac arrest
• ECG changes, hypotension, arrhythmia, cardiac
arrest
• Weakness, paralysis
• Respiratory depression
• Ketoacidosis / metabolic acidosis

61. Prevention and Therapy
• Correct electrolyte abnormalities before
starting nutrition support
• Continue to monitor serum electrolytes after
nutrition support begins and replete
aggressively
• Initiate nutrition support at low
rate/concentration (50% of estimated
needs) and advance to goal slowly in
patients who are at high risk

62. Overfeeding
• Overfeeding usually results from
overestimation of caloric needs
• Clinically, increased oxygen consumption,
increased CO2 production, suppression of
leukocyte function, and increased infectious
risks
• Hyperglycemia
• Hepatic dysfunction from fatty infiltration
• Respiratory acidosis from increased CO2
production
• Difficulty weaning from the ventilator

63. Monitor
• No single criteria
• Chest Xray to check for placement
• Clinical monitoring – Vital signs – 4 hrly
• Weight (daily)
• Site care and dressing change
• I/o charting

64. • GRBS MONITORING 3 TIMES A DAY
• Daily Electrolytes (Na+, K+, Cl-)
Glucose
Acid-base status, BUN
• 2 times/week
Ca+, P, Mg
LFT, S.CREAT, ALBUMIN
• Hb,TC, INR weekly
• Urine checked for glycosuria daily

65. Special considerations
• Burns
• >30 PERCENT OF TBSA - SEVERE
• Provide extra 20 to 30% extra calories
• Early feeds and enteral feeds
• Anabolic agents (Recomb hgf, beta
blockers)
• Analgesics, Anxiolytics

66. Estimation of calories in
BURNS
Harris benedict :
Men : BEE = 66.5 +(13.75X W) + (5XH) – (6.76 X A)
Female: BEE +65.5 +(9.65 X W) + (1.85X H) – (4.68xA)
Multiply by stress factor of 1.2 – 2.0
Curreri:
16 – 59 yr: Calories = (25x w) +(40 x %bsab)
>60 yrs : Calories = (20x w) + (65x %bsab)

67. Short Bowel syndrome
• Massive resection of small bowel.
• Symptoms are severe if > 75 % small bowel resected
• If ileocaecal removed
• If remaining bowel is diseased with impaired absorption
• Decrease in intestinal surface area, decrease in intestinal
transit time, decrease in intestinal absorption
• Gastric acid hypersecretion
• D Lactic acidosis
• Nephrolithiasis

68. TREATMENT
• Immediate Post op period: Adequate replacement of IV
fluid, electrolytes with zinc and H2 receptor antagonists
• Bowel adaptation period: Enteral feeding started as
soon as possible once stool output is less than
1000ml/day. Glutamine and medium chain triglycerides
to maintain mucosal healing
• Long term treatment: Small and frequent oral feeds
started, in intact colon diet rich in complex carbohydrates
are given.
If terminal ileum resected, vitamin b12 given monthly and
in patients with d lactic acidosis – carbohydrate diet is
reduced

69. Gastrointestinal fistula
• Diversion of intestinal contents commonly
to skin
• Common causes: Crohns, Bowel injury,
Bowel surgery, Radiation injury
• High output fistulas: >500ml fluid loss

70. REFERENCES
• BAILEY AND LOVE 26 TH EDITION
• SABSITON 17TH EDITION
• S.DAS OPERATIVE SURGERY 5 TH EDITION
• PYE’S SURGICAL HANDICRAFT
• NUTRITION SUPPORT THEORY AND THERAPEUTICS- SCOTT A
SHIKORA, GEORGE L.BLAKBURN
• PRACTICAL GUIDELINES ON FLUID THERAPY 2ND EDITION
SANJAY PANDYA
• MEDSCAPE ONLINE RESOURCES