This document discusses nutritional assessment and management in surgical patients. It begins with an outline of the topics to be covered, including nutritional assessment, requirements, interventions, and disease-specific nutrition. Various methods of nutritional assessment are described, such as clinical history, physical exam, laboratory tests, and calculations of energy expenditure. Enteral and parenteral nutrition are presented as interventions, with details on their indications, delivery methods, and complications. The goal of nutritional support is to meet metabolic needs in patients who cannot maintain adequate intake orally.

1. N U T R I T I O N A L A S S E S M E N T A N D
M A N A G E M E N T I N S U R G I C A L P A T I E N T S
B Y : D A W I T ( M D , G S R 1 )
M O D E R A T O R : D R . D A W I T T
( C O N S U L T A N T S U R G E O N )
J I M M A S P E C I A L I Z E D H O S P I T A L
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1

2. Outline
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 Introduction
 Nutritional assessment in surgical patients
 Nutritional requirments and interventions
 Nutrition in specific disease conditions
 Summary and recommendations

3. Objectives
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 To elaborate causes and consequences of
malnutrition in the surgical patient
 To clarify objective nutritional assessment methods
 To discuss on the different methods of providing
nutritional support and their complications

4. Introduction
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 Health is strongly influenced by nutritional
status
 Rates up to 50 percent in certain
populations
 1936=33% vs 3.5%(mortality)
 Identification
 Minimizes unwanted outcome in surgery

5. Consequence of malnutrition in surgical patients
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 Increase susceptibility to infection
 Poor wound healing
 Increase frequency of decubitus ulcer
 Over growth of bacteria in GIT
 Abnormal nutrient losses through the stool

6. Factors Affecting Nutritional Intake during
Illness
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Medications our role ????
Fear and Anxiety
Pain
Inappropriate
Diet Orders

7. ASSESSMENT OF NUTRITIONAL STATUS
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 The possibility of malnutrition should form part
of the work up of all patients
 A clinical assessment of nutritional status
involves:
 Focused Hx
 Focused P/E
 Focused Ixs

8. Nutritional ass’t…cont’d
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1. Clinical History
 History of poor nutrient intake
 Loss of body weight
 Social & economic condition that may lead
to poverty & malnutrition
 Gastrointestinal symptoms
 Other chronic medical illnesses

9. Nutritional ass’t…cont’d
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2. Physical Examination
 G/A
 V/S
 Anthropometry
 Body Mass Index

10. CONT’D
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BMI INTERPRETATION
<18.5 underweight
18.5-24.9 normal
25-29.9 Over wt
30-34.9 Obesity GI
35-39.9 Obesity GII
>/= 40 Extreme obesity GIII

11. HEENT
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Signs deficiencies
Alopecia, Easily plukablity PEM
Angular palebritis Vit B2
Bitot’s spots,conjuctival xerosis Vit A
Angular stomatitis Vit B2,6,12
Bleeding gum Vit C

12. Cont’d
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 Cardiovascular: Evidence of heart failure or high-
output state
 Neck: Thyromegaly
 Extremities: Edema, muscle wasting
 Skin: Ecchymoses, petechiae, pallor, pressure
ulcers, assessment of surgical wound healing and
signs of wound infection (if postoperative).
 Neurologic: Evidence of peripheral neuropathy,
reflexes, tetany, mental status

13. Nutritional ass’t…cont’d
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3. Laboratory Investiaton
 To detect subclinical nutritional deficiencies
• Nitrogen Balance
• Serum Albumin
• Creatinine excretion
• Immunological function assessment(TLS)

14. Nitrogen balance
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 Provides an index of protein gain/loss
1 g protein =6.25 g nitrogen
Nitrogen intake – loss{90%urine,intugumentary 5%,5%
stool}
overall protein status
effectiveness of a nutrition intervention
Serum albumin
 fall during acute stress b/c of
 Increase incirculating extravascular volume
 TNF alpha mediated inhibition of synthesis

15. Cont’d
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 Serum albumin
 most abundant
 liver
 = t1/2, 18-20 days
=2.2 g/dl marker of –ve catabolic state
Serum transferrin =t1/2, 8-9 days
 215–380 mg/dL
Serum prealbumin(transthyretin)=t1/2, 2-3
days. 19 to 43 mg/dL
Retinol binding protien

16. Creatinine excration
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 Metabolic product of skeletal muscle
 Produced constantly indirect proportion to skeletal
mass
 1g creatinine=18.5 fat free skeletal muscle
 CHI
 24-hour urine creatinine (mg)
 expected 24-hour urine creatinine (cm)

17. TOTAL ENERGY EXEDITURE
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 Definition
 BEE 60% of TEE
 Basal energy requirement is the function of the
individual's weight,height, age, gender, activity
level and the disease process

18. Basal energy expenditure (BEE)
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 Estimated using the Harris-Benedict equations:
 BEE(men)=66.47+13.75(W)+5(H)-6.67(A)
 BEE(women)=655.1+9.56(W)+1.85(H)-
4.68(A)
 where W = weight in kilograms; H = height in
centimeters; and A = age in years.

19. Cont’d
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 It will be adjusted in stress conditions
 Total calories=BEE X stress factor X activity factor
 Activity factor=1.2 in bed rest
=1.3 out of bed
conditions Kcal/kg/day Above BEE
Normal 25-30 1.1
Mild stress 25-30 1.2
Moderate stress 30 1.4
Sever stress 30-35 1.6
burns 35-40 2

20. ENERGY REQUIRMENT….cont’d
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 Rest Energy Expenditure
Adults (18-65)………………….. 20-30 kcal/kg
Elderly (65+)……………………. 25 kcal/kg
For burns Patients…………….. 30-35kcal/kg
 Other factors:
Pregnancy………………………..Add 300 kcal/day
Lactation………………………… Add 500 kcal/day
Obese or Super obese……… 15-20 kcal/kg

21. ENERGY REQUIRMENT….cont’d
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21Stress Factors
• Peritonitis……………………+ 15%
• soft tissue traum ………..+ 15%
• Fracture……………………..+ 20%
• fever (per oC rise)……….+ 13%
• Moderate infection………..+ 20%
• Severe infection ……………+ 40%
• <20% BSA Burns…………..+ 50%
• 20-40% BSA Burns…………+ 80%
• >40% BSA Burns……………+ 100%

22. NUTRITIONAL REQUIREMENTS…cont’d
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22FAT
 Requirement =3 g/kg/day
 30-40 percent of nutrition
 Liver can synthesize most fatty acids, but humans
lack the desaturase enzyme needed to produce n-3
and n-6 fatty acid series
 Therefore linoleic acid should constitute at least
2% and linolenic acid at least 0.5% of daily
caloric intake to prevent essential fatty acid
deficiency

23. NUTRITIONAL REQUIREMENTS…cont’d
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23CARBOHYDRATE
 40-50 percent of total nutrition
PROTEIN
 The basic requirement for nitrogen 0.10–0.15 g/kg
per day
 Additional protein burn injuries, open wounds,
protein losing Enteropathy / Nephropathy
 A lower protein intake may be necessary in patient
with chronic renal insufficiency who are not treated
by dialysis and certain patients with hepatic
encephalopathy

24. NUTRITIONAL REQUIREMENTS,
PROTEIN…cont’d
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Clinical condition requirement
normal 0.8
Metabolic stress (illness, injury) 1.0-1.5
Acute renal failure (undialyzed) 0.8-1.0
hemodialysis 1.2-1.4
Peritoneal dialysis 1.3-1.5

25. NUTRITIONAL INTERVATION
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 Goal
 To alter the course and outcome of
critical illness
 To supply the substrate necessary to meet
the metabolic needs of patients in who
adequate nourishment cannot be provided by
mouth

26. Indications for nutritional intervention
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 General indication
 pre existing nutritional deprivation
 Anticipated/actual inadequate energy
intake

27. Specific Indications for nutritional
intervention
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Inadequate intake for 5-7 days or anticipated
no intake for the same period
Serum albumin less than 3gm/dl
Weight loss of greater than 10% body wt in 6months.
Current wt less than 80% of the ideal wt
Anticipated severe insult to the body
Concurrent medical problem

28. ARTIFICIAL NUTRITIONAL SUPPORT
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 Nutritional support, via either enteral or parenteral
routes, is used in three main settings:
To provide adequate nutritional intake during
recuperative phase of illness or injury
to support the pts during systemic response to
inflammation, injury or infection during an extended
critical illness
pts with permanent loss of intestinal length or
function

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30. ENTERAL FEEDING
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 Delivery of nutrients into the gastrointestinal tract
 This can be achieved with
oral supplements (sip feeding) or
variety of tube-feeding techniques (NG, ND,NJ tubes)
Surgical techniques
 Percutaneous endoscopic gastrostomy (PEG)
 Surgical gastrostomy
 Percutaneous endoscopic Jejunostomy (PEJ)
 Surgical Jejunostomy
 A variety of nutrient formulations are available for
enteral feeding

31. ENTERAL FEEDING...cont’d
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 Long term feeding (>6 wk) usually requires
gastrostomy or jejunostomy tube
 Enteral feeding is often required in pts with
anorexia, impaired swallowing, or bowel disease
 Enteral formulas: standard (osmolality- 300) and
modified

32. ENTERAL FEEDING....CONT’D
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Why Preferable?
 Physiologic & matabolic benefits
 Immunologic function
 Cost benefits
 Safety benefits
Fewer infectious complicationsa
 44% reduction in infectious complications
Less hyperglycemia → neutrophil inhibition

33. Contraindications
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Short bowel syndrome
Bowel obstruction
GI bleeding
Protracted vomiting & diarrhea
Fistulas, Ileus
GI ischemia
Gastroparesis, GOO
Repeated aspiration(reflux)

34. Complications
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Tube related
 malposition
Blockage
Aspiration
Local complication
 mainly aspiration pneumonia and diarrhoea

35. Delivery Methods
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35 Sip feeding
Commercially available supplementary sip feeds are
used in patients who can drink but whose appetites
are impaired
 Nasogastric tube
less expensive, easier to secure and maintain
Diabetics and patients with severe head injuries
may have profound gastroparesis

36. Contraindications to NGT
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 delayed gastric emptying Gastric residuals of
200 mL or more in a 4- to 6-hour period
 gastric outlet obstruction
 a history of repeated aspiration due to
reflux
 inability to protect the airway (a relative
contraindication to gastric feeding)

37. Delivery Methods….cont’d
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37 Post pyloric access via
a duodenal or jejunal nasoenteric tube is preferred
when gastric feedings are not tolerated and/or when
patients are at risk for aspiration
Gastrostomy
 The placement of a tube through the abdominal wall
directly into the stomach if patients require enteral
nutrition for prolonged periods (4–6 weeks)
 Surgical vs PEG

38. Delivery method….cont’d
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38 Jejunostomy
 Jejunal feeding has become increasingly popular
 uses:
 associated with a reduction in aspiration
 enhanced tolerance of enteral nutrition
 in patients with severe pancreatitis
 The only absolute contraindication is distal
intestinal obstruction.

39. Feeding Tolerance
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39 Pts will tolerate
If GI output’s ˂600ml/d
Isotonic formula of 30ml/hr administered
 Poor tolerance
Vomiting & severe abdominal cramp
Gastric residuum >50% over past 4hrs
Increased abdominal distension
Worsening diarrhea
 NB: Parenteral nutrition if any of the above

40. Enteral Formulas
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 Low-Residue Isotonic Formulas
 Isotonic Formulas with Fiber
 Immune-Enhancing Formulas
 Calorie-Dense Formulas
 High-Protein Formulas
 Elemental Formulas

41. low-residue isotonic formulas
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 Most low-residue isotonic formulas provide a caloric
density of 1.0 kcal/Ml
 standard or first-line formulas for stable patients
with an intact gastrointestinal tract
Elemental Formulas
 predigested nutrients and provide proteins in the
form of small peptides
 ease of absorption
 malabsorption, gut impairment, and pancreatitis

42. Parenteral nutrition
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Definition
considered
7-10 days
enteral feeding is not feasible

43. Parenteral nutrition....cont’d
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TYPES
 Peripheral parenteral nutrition (PPN)
osmolarity 1,000 mOsm (approximately 12%
dextrose solution) to avoid phlebitis
 large volumes (>2,500 mL) are needed
Temporary (<2weeks)
solutions that contain more than 3%
aminoacid and 5% glucose are poorly
tolerated peripherally
Generally intended as supplement to oral
feeding and is not optimal for critically ill pts

44. Parenteral nutrition, PPN....cont’d
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45. Parenteral nutrition, types....cont’d
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 Total/central parenteral nutrition
(TPN/CPN)
provides complete nutritional support
The solution, volume of administration, and
additives are individualized based on an
assessment of the nutritional requirements
Catheters placed into the central venous system
terminate in the vena cava
catheter inserted via
 subclavian or
 internal/external jugular vein

46. Parenteral nutrition, TPN....cont’d
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46TYPES OF TPN FORMULATIONS
 TPN formulation without lipid (2-in-1
solution)
Calories from amino acids--- 20 to 25%
Calories from dextrose------- 75-80%
 TPN formulation with lipid ( 3-in-1 solution)
calories from amino acids----- 20 to 25%
calories from lipids------------- 20%
calories from dextrose--------- 55 to 60 %

47. Parenteral nutrition, TPN....cont’d
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 Special solutions
 Additives
Electrolytes should be adjusted daily
If the serum bicarbonate is low, the solution should
contain more acetate
The calcium:phosphate ratio must be monitored to
prevent salt precipitation

48. Parenteral nutrition, TPN....cont’d
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 Medications:
Albumin, H2-receptor antagonists, heparin, iron,
dextran, insulin, and metoclopramide can be
administered in TPN solutions
However, not all medications are compatible with
3-in-1 admixtures
Regular insulin should initially be administered
subcutaneously according to a sliding scale
After a stable insulin requirement has been
established, insulin can be administered in the TPN
solution, generally at two thirds of the daily
subcutaneous insulin dose

49. Parenteral nutrition, TPN....cont’d
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TPN- macronutrient solutions
 Crystalline Aas containing 40-50% essential and 50-
60% non essential Aas are used to provide protein
needs
rich in branched chain for hepatic encephalopathy
rich in essential Aas for renal insufficiency pts
 Glucose in IV solutions is hydrated
While there is no absolute requirement of glucose in
most pts, providing >150g glucose/d maximizes
protein balance
 Lipid emulsions are available as 10% (1.1kcal/ml) or
20% (2 kcal/ml) solutions and provide energy as well
as source of essential fatty acids
 Rate of infusion should not exceed 1 kcal/kg/h

50. INDICATIONS
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 Entero-cutaneous
fistula
 Renal failure (ATN)
 Short bowel syndrome
 Severe burns
 Hepatic failure
 Crohn’s disease
 Anorexia nervosa
 Acute radiation
enteritis
 Acute chemotherapy
toxicity
 Prolonged ileus
 Weight loss preliminary
to major surgery
50
Parenteral nutrition, TPN....cont’d

51. Parenteral nutrition, TPN....cont’d
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51ADMINISTRATION OF TPN
Introduction of TPN should be gradual
E.g, approximately 1,000 kcal is provided the first
day
If there is metabolic stability (i.e.normoglycemia),
this is increased to the caloric goal over 1 to 2
days
 Continuous vs cyclic administration

52. ADVANTAGES DISADVANTAGES
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Bed side technique
Avoids complications of
central venous catheter
Avoid multiple venous
cannulations
Hypertonic solutions can
be given
Trained personnel is
needed
Line blockage
Mal position
Phlebitis
Line sepsis
thrombosis
52
Parenteral nutrition....cont’d
PICC line

53. 12/21/2015
53

54. ADVANTAGES DISADVANTAGES
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Central access needed
Multiple lumen can be
used in acute emergency
Hypertonic solutions can
be given
Can be placed for more
than 6 weeks
Inserted in theatre
Increase infection rate
Multiple complications
54
Parenteral nutrition....cont’d
Central Catheter(Non Tunneled)

55. ADVANTAGES DISADVANTAGES
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Convenient exit site
Long lasting than
non tunnels
Hypertonic solutions
can be given
Removal needs
surgical dissection
Catheter related
sepsis
Other complications
55
Parenteral nutrition....cont’d
Central Catheter(Tunneled)

56. Parenteral nutrition....cont’d
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Discontinuation of TPN
 When the patient can satisfy 75% of his or her
caloric and protein needs with oral intake or enteral
feeding
 To discontinue TPN, the infusion rate should be
halfed for 1 hour, halved again the next hour, and
then discontinued
 Tapering in this manner prevents rebound
hypoglycemia from hyperinsulinemia
 It is not necessary to taper the rate if the patient
demonstrates glycemic stability

57. comparison
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Enteral Parenteral
Cost $10-20 per day $100 or more per day
Gut Preserves intestinal
function
May be associated with
gut atrophy
Infection Very small risk of
infection
High risk/incidence of
infection and sepsis

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59. Burns
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 Extensive burns double or tripple REE &
urinary nitrogen losses
 Increase in metabolic demand is proportional to
ungrafted body surface
 Other interations ?
 Enteral feeding is preferred when tolerated
 Start within 6-12hrs postburn to reduce hyper
metabolism & improve survival

60. Burns.... Cont’d
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 Require 40kcal/TBSA in addition to the
maintenance
 Increased Pr⁻ requirement frm the normal
 0.8g/kg/d to 2.5g/kg/d
 During the hyper metabolic phase of burn injury
(0–14 days), the ability to metabolize fat is
restricted
diet that derives calories primarily from
carbohydrate is preferable

61. NUTRITION REQUIREMENTS IN HEAD
INJURY
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 Energy requirement calculation
 2 wks after HI
120% to 250% above their basal energy expenditure
Enteral administration is preferred for acute
neurological patients.
Nutrition therapy should start early: within 24
to 48 hours of admission to the intensive care unit.

62. CONT’D
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 Enteral formulas: Complete and isotonic
formulas should be initially chosen.
 Start with 30ml/hr
 Check G.residue Q 4hr ,stop if >125ml
 Increase by 15-25ml Q 12-24hr as tolerated until
desired rate is achieved
 The Brain Trauma Foundation recommends
that total nutritional support should be achieved
within 7 days of the injury
 Prokinetic drugs???

63. Acute pancreatitis
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 The DX of pancreatitis often mandates strict bowel
rest for extended periods of time
 Patients with three or fewer Ranson criteria should
be treated with: fluid replacement, nasogastric
suction, and bowel rest for at least a week before
considering parenteral nutrition
Most of these patients can resume an oral diet and
do not benefit from TPN
 Those with more than three Ranson criteria should
receive nutritional support

64. Ranson’s Criteria
Surg Gynecol Obstet 138:69, 1974
 Hct decreases > 10%
 Calcium falls to < 8.0 mg%
 Base deficit > 4 mEq/L
 BUN increases > 5 mg%
 PaO2 is < 60 mmHg
If > 3 are present within 48 hours of admission,
60% die

65. Cont’d
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 If severe, initiate early nutrition support (within 72
hours)
 jejunal feeding is superior to TPN

66. Summary of Ideal Feeding Solutions in
Acute Pancreatitis
 Parenteral: Crystalline amino acids, hypertonic
glucose solutions (IV fat emulsions tolerated)
 Enteral: Low fat, elemental, hypertonic
solutions given into jejunum

67. Nitrogen and Fat Needs
in Pancreatitis
 Nitrogen: 1.0 – 2.0 gm/kg/d
Nitrogen balance study is helpful
 Fat: Fat well tolerated IV and to limited degree in
jejunum, no oral fat should be given

68. Renal-Failure Formulas
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 The primary benefits of renal formulas are the lower
fluid volume and concentrations of potassium,
phosphorus, and magnesium needed to meet daily
calorie requirements.
 This type of formulation almost exclusively contains
essential amino acids
 Has a high nonprotein-calorie:nitrogen ratio;
however, it does not contain trace elements or
vitamins.

69. Pulmonary-Failure Formulas
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 In pulmonary-failure formulas, fat content is usually
increased to 50% of the total calories, with a
corresponding reduction in carbohydrate content.
 The goal is to reduce carbon dioxide production and
alleviate ventilation burden for failing lungs.

70. cancer
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 over two-thirds of patients with cancer develop
malnutrition
 Malnutrition associated death in 20–40% of these
patients
 Rx can worsen preexisting malnutrition
 REE increases by 20-30% in some malignancies
 Lactic acidosis from high anaerobic metabolism in
neoplastic tissue
 Neoplastic tissues act as nitrogen traps
 Cancer cachexia manifests as: progressive involuntary
weight loss, fatigue, anemia, wasting, and tissue
depletion
 It may occur at any stage of the disease

71. Cancer….cont’d
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71
 Nutrition support has become an essential adjunct
in caring for the cancer patient
 Nutritional supplementation in cancer patients may
reduce :
 infectious complications
 perioperative morbidity
 But convincing evidence of improvement in overall
survival is lacking
 Ample evidence that nutritional supplementation
stimulate tumor growth

72. Short bowel syndrome
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 SB ˂ 200cm or ˂ 150cm with ileocecal valve
 Minimum SB length required to become
independent of TPN is 120cms
 Inadequate intestinal absorptive surface leads to
malabsorption, excessive water loss, electrolyte
derangements and malnutrition
 Usually need temporal parenteral nutrition
 Supplement TPN with oral intake
 Frequent small meals, avoiding hyperosmolar
foods, Restricting fat intake and limiting
consumption of high oxalate foods

73. SBS.... Cont'd
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73 Adaptation to short gut occurs over time, and initial
management should be directed at
avoiding electrolyte imbalance and dehydration
providing daily caloric requirements through TPN
 Uniquely formulated diets containing glutamine and
human growth hormone have shown promise for
accelerating intestinal adaptation
Adaptation - Increase in villous height
- Luminal diameter
- Mucosal thickness

74. summary
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 The gut should always be the preferred route
for nutrient administration
 Subjects receiving intravenous feedings and bowel
rest had significantly exaggerated response to injury
 During parentral nutrition close monitoring of;
Serum Na, K on alternative days has
LFT, triglycerides weekly to be
Renal parameters biweekly remembered

75. REFERENCES
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 Uptodate 20.1
 Bailey & Loves short practice of surgery,
25th and 26th edn.
 Schwartz's principles of surgery,9th and 10th edn.
 Medscape general surgery
 Nutrition therapy and pathophysiology ,Marcia
nelms
 ACS, Principles & Practice of Surgery, 6th edn.
 Greenberg 6th edt

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