This document discusses malnutrition in surgical patients and provides guidelines on nutritional assessment and support. It notes that malnutrition is common in 30% of GI surgery patients and is often unrecognized. The aim is to identify at-risk patients and ensure their nutritional needs are met. It provides details on evaluating nutritional status, calculating calorie and protein requirements, and enteral and parenteral nutrition support options. The appropriate use of nutrition therapy is emphasized to prevent complications and support recovery from illness or surgery.

1. -Dr Jaymin Gupta
--Dr Snehal Dandge
-Guide:
-Dr Amol Wagh

2.  Malnutrition is common in about 30% of
surgical patients with Gastrointestinal disease
 Frequently unrecognised leading to lack of
appropriate support.
 Aim is to identify patients at risk of
malnutrition and to ensure that their
nutritional requirements are meet by the
most appropriate route and in a way that
minimises complications.

3.  Energy in starvation :
<12 hours: Food from last meal
12-24 hours: Glycogenolysis
>24 hours: Gluconeogenesis
48-72 hours: Lipid oxidation

5.  Another important adaptive response to
starvation is a significant reduction in the
resting energy expenditure, possibly
mediated by a decline in the conversion of
inactive T4 to active T3.
Despite these adaptive responses, there
remains an obligatory glucose requirement of
about 200 g per day even under conditions of
prolonged fasting.

7.  In contrast to simple starvation, patients with
trauma have impaired formation of Ketones
(LOSS OF ADAPTIVE KETOGENESIS).
 Breakdown of protein to synthesis glucose
(Gluconeogenesis) cannot be prevented by
the administration of glucose.

8.  BEE is 20 Kcal/kg/day
 In case of mild sepsis : 1.4 times
severe sepsis : 1.8 times
Severe Burns : 2 times
- Although it is generally accepted that metabolic
responses to trauma and sepsis is always
associated with “hypermetabolism” or
“hypercatabolism”, there is another school of
thought that these terms are ill defined and do
not indicate the need for very high energy
intakes.

9.  No evidence to show that the provision of
high energy intake is associated with
amelioration of the catabolic process.
 Permissive underfeeding in critically ill
surgical patients (Rising evidence).

10.  Trends are more important than a single
biochemical value.
 No single biochemical value that reliably
identifies malnutrition.

11.  Body weight- compared with usual(for individual)
or ideal
 UNINTENTIONAL weight loss of more than 10% of
a patient’s weight in the preceding 6 months
 BMI <15
 Skin fold thickness – Estimates body fat
 Mid arm circumference – Protein (Muscle stores)
All the aforementioned techniques impaired by the
presence of oedema.

12.  Fat stores - Skin fold thickness, Triceps fold
thickness
 Bioelectrical impedance analysis to estimate
intra and extracellular volumes.
 Research methods(expensive and impractical)
-in vivo neutron activation analysis
-Isotopic labelling studies

13.  Not a measure of nutritional status, particularly
in acute settings.
 Acute changes are often assessed by Pre-
albumin, Albumin and Transferrin.
 Better assessed by Pre-albumin (half life of 48
hours) rather than Albumin ( half life of 21 days).
 All these metrics are useful in pre-operative
evaluation of nutritional status; use of these
values for ongoing nutritional assessment in
hospitalised or critically ill patient is
controversial.

14.  Possibility of malnutrition should form part of
the workup of all patients.
 Malnutrition Universal Screening Tool (MUST);
a 5 step tool introduced by the British
Association of Parenteral and Enteral
nutrition.
 Identifies adults who are malnourished or at
risk of undernutrition.

16. 1.Resting Energy Expenditure/Basal energy
expenditure:
Harris Benedict Equation:
Male-66.5+(13.75x wt in kg)+(5x ht in cm)-(6.775 x age in
yrs)
Female-66.5+(9.6 x wt in kg)+(1.7x ht in cm)-(4-7 x age in yrs)
Calorie Requirement=REE x activity factor x Injury factor
2.Nitrogen balance:
Nitrogen balance= total nitrogen intake – total
nitrogen loss

17. • Nitrogen Loss= Total (Urine Urea Nitrogen) +
2gm/day (stool +skin)
• 24hrs Urine urea nitrogen= (Urine urea nitrogen) x
urine output (ml/day)
1000mg x 100ml
• 6.25gm of Proteins give 1 Gm of Nitrogen

18. Non Dibateic Patient :P:F:C=10:30:60
Diabteic Patient- P:F:C=20:30:50
OR Carbohydrates – 4kcal/day
Proteins -4kcal/Day
Fats- 9Kcal/day
Daily calorie Requirements of 70kg man
25-35 kcal/kg/day (aprrox. 30kcal/kg/day)
Total calorie requirement will be 70 x30=2100
Multiplied by stress factors in case of stress
Stress factors-
1.2- minor injury
1.5- head injury
1.6 – major injury
1.8 –Sepsis
2-burns

19. Proteins:1-1.5gm/kg/day
Every 100-150kcal should contain 1 gm of Nitrogen=6.25gm
proteins
Protein calories:
70x 1.5=105gm/day
Therefore, 105 x 4kcal/day= 420kcal/day
Lipids:
20% of 2100 = 420kcal
Therefore,
9kcal – 1gm; 420kcal =47gm
Remaining as carbohydrates
2100-420-420= 1260kcal
4kcal – 1gm
1260kcal- 370gm

20. 60gm egg = 6gm proteins

23. Each Deoxrange capsule contains 32.6gm elemental iron
And A to Z has folic acid,zinc along with vitamins

24.  Any Patient who has sustained 5 days
of inadequate intake or who is
anticipated to have no or inadequate
intake for this period should be
considered for nutritional support.
 Enteral nutrition:
- More physiological
- Cheap
- Maintains enterohepatic circulation
- Keeps the microvilli patent
- Prevents translocation of the gut
bacteria
Best route: Oral

25.  2-4 weeks
Good gastric emptying: Ryles tube (NG tube)
Poor gastric emptying: Nasojejunal tube
(Freccas)

26.  >4 weeks
Good gastric emptying: Feeding Gastrostomy
Poor gastric emptying: Feeding Jejunostomy

28.  Neurologic disorders including trauma and
disease
 Malignancy especially of the head and neck
 Burns
 Psychological disorders such as anorexia
nervosa
 Chemotherapy and radiation therapy
 Specific GIT disorders such as inflammatory
bowel disease and enterocutaneous fistulae

29.  Bolus feedings are reserved for patients with
gastrostomy feeding tubes.
 To reduce the risk of aspiration, the patient’s
head and body should be elevated to 30 to 45
degrees during feeding and for 1 to 2 hours after
each feeding.
 The feeding tube should be flushed with
approximately 30 ml of water after each use.
 Continuous infusion for nasojejunal,
gastrojejunal or jejunal tubes.

30.  Tube feedings:
Initially start with 20-30 ml/hour
Gradually increase as the patient can tolerate
more.
No feeds for 4-5 hours during the night (helps
to reduce aspiration rates, pneumonia)
Before every feed, first aspirate (to see if any
residual feed is left).
If >200 cc aspirate in 2 hours, feed is withheld.

32. Routes of
administration
Fine bore
naso-enteral
feeding tubes
Gastrostomy
Needle
catheter
jejunostomy

34. Enteral Formulae:
1.Standard Polymeric formula
2. Calorie dense formula
3.Immune enhancing formula
4. Fiber containing formula
5.High Protein /Bariatric formula
6.Elemental formula
7.Renal/Hepatic failure Formula

35.  Defined as provision of all nutritional
requirements by means of the intravenous
route and without the use of the
gastrointestinal tract.
 Indicated when energy and protein needs
cannot be met by the enteral administration
of these substrates.

36.  Primary therapy:
- Efficacy shown
i. Gastrointestinal cutaneous fistula
ii. Renal failure(acute tubular necrosis)
iii. Short bowel syndrome
iv. Acute burns
v. Hepatic failure(acute decompensation
superimposed on cirrhosis)
- Efficacy not shown
i. Crohn’s disease
ii. Anorexia nervosa

37.  Supportive therapy
- Efficacy shown
i. Acute radiation enteritis
ii. Acute chemotherapy toxicity
iii. Prolonged ileus
iv. Weight loss primarily to major surgery
- Efficacy not shown
i. Before cardiac surgery
ii. Prolonged respiratory support
iii. Large wound losses

38. Routes of parenteral nutrition
 Peripheral vein nutrition:
Employed short term intake
Limitations-
-Low concentration solution can only
be given
-Phlebitis if osmolarity exceeds 600
mOsm(10% glucose)
- Routine change of IV site is
necessary
 Central venous nutrition:
Requires insertion of a catheter into a
central vein
Full nutritional support for long term
can be given
PPN: Osmolarity less than
600mosml/L
TPN:
Osmolarity More than
950mOsml/L

39.  2000 kcal/day
 1L/2L
 Composition : Protein : Fat : Carbohydrate
20:30:50
TPN Solution
Parentral Nutrition:
Delivery of Nutrition in Elemental Form
Two compositions:
• 3 in 1-Available in Developing countries
(P:F:C = 10:20:70%)
• 2 in 1- Available in West (P:C=10-20%:70-
80%)

40. Components:
Carbohydrates: Variable concentration Dextrose
Maximum permissible Carbohydrate flow:5-7 mg/kg/hr
(Weight/Voulme of Carbohydrates – 25%)
Lipids:
Emulsion of Fish Oil and soya oil
Average dose: 500ml/week
Proteins:
In form of Essential amino acids
Normal daily requirement- 0.8 – 1 gm/kg/day
In stress – 1.5-2 gm/kg/day
In starvation- 2.5-3gm/kg/day
Calorie requirement- 30kcal/kg/day
(Atleast 20-30% should come from Proteins)

41. CELIMINE
(500ml)

42. CELIPID
-Soyabean oil
emulsion for infusion
20%
- 250ml
- Each 1000ml has
200gm of Purified
soyabean oil
- Nowadays, Fish oil
emulsion is used

43. NUTRIFLEX

44.  TPN provides calories, proteins, essential fatty acids
along with electrolytes, vitamins and trace elements
 Concentrated Dextrose 70% is used. 1g provides 3.4
kcal/g.
 1gm of fat provides 9kcal/g and is available in 10% and
20% emulsions containing 1.1kcal/ml or 2kcal/ml
respectively
500cc of 10% fat emulsion=550 kcal
500cc of 20% fat emulsion=1000kcal
Essential fatty acid deficiency can be prevented by giving
500cc of 10% emulsion 2-3 times a week

45.  Crystalline amino acids
500cc of 5.5% AA- 4.63g N or 28.9g of protein
500cc of 10% AA- 8.4g N or 52.5g of protein
 Electrolytes are administered with the fluids or can be added
separately
 Trace elements
 0.5mg of Manganese
 1mg of Copper
 4mg of Zinc
 10 microgm Chromium
 Vitamins are added in IV fluids and Vit K is administered
intramuscularly weekly

46. TPN for 50 kg man:
Daily calorie requirement
18-65yrs:20-30kcal/kg
>65yrs :35kcal/kg
Burns:30-35kcal/kg
Let’s take 25kcal/kg for him:
Total requirement: 25 x 50= 1250kcal/day
Multiplying factor for protein requirement
1.2 for sedentary
1.4 for moderately active
1.8 for heavy physical activity
Let’s say his protein requirement is 1.4x 50=70gm/day
Celemin has 10.09gm/100ml
So 1 pint celemin (500ml) gives 50.45gm/day
But to give him exact amount of proteins, we should give 693.75ml/day
Or we can say 100ml of 10% celemin gives 10gm protein, so we need 700ml
approximately for 70gm protein.

47. Lipids
Provide 20% of total calorie requirement:
20/100 x 1250=250kcal
Celipid 250ml
(2000kcal/1000ml)gives 500kcal
So we can give him one celipid every alternate day.
Carbohydrates should give 60% of daily calorie requirement
Dextrose requirement:1250-(250+250)=750kcal
Each gram of Dextrose provides 3.4kcal
So 750kcal will be provided by 221gm
We will have to give 315ml of 70% dextrose everyday
(100ml dextrose contains 70gm)
So 50kg man should get
700ml of Celimin daily, 250ml of Celipid every alternate day,315ml of 70%
dextrose daily

48. Total Daily requirement=700+250+315=1365ml
Kabiven of 1540ml Pack in ward gives combination of all three in 1310kcal.
He needs 1469ml from it for 1250kcal/day
Nutriflex omega special 625ml Pack gives 740kcal of all three combinations
,1056ml to be given for 1250kcal

51.  Small bowel motility is three times slower in
Ileum than in the jejunum (More time for
absorption; critical in conservation of fluid
and electrolytes)
 Ileum – ONLY site for Vitamin B12 and Bile
salt absorption
 Short bowel – 100 cm without IC Junction /
60 cm + IC Junction

52.  Short Bowel – Net absorbers vs Net secretors
 Hypotonic fluid (water, tea, juices) – NOT
encouraged for net secretors

53.  Severe fluid and electrolyte shifts in
malnourished patients undergoing refeeding.
 Parenteral > Enteral
 Predisposing factors: Alcoholics, Severe
malabsorptive states, anorexics, thiamine
deficiency, prolonged fasting.

54.  Sudden shift of catabolic to anabolic state
leading to:
- Hypokalaemia
- Hypophosphataemia
- Hypomagnesemia
Predisposing to fatal Cardiac arrhthymias.

55.  To prevent; commence feeds at 10
Kcal/kg/day with slow increases over 4 to 7
days.

56.  EC Fistula: TPN except distal bowel fistula or
low output
 Transplant – calorie of 30-35 Kcl/kg and 1.3
to 1.5 g/kg/day
 IBD
- High protein, low fat and low carb diet
- Avoid meat and alcohol

57.  Pancreatitis: low fat, low carb, high protein
 Severe burns: High protein, high carb and low
fat (to offset hypermetabolism)
 Renal failure: Low quantity, low protein, high
carb
 Respiratory failure: Low carb (RQ<1)

58.  To recap;
Daily weight monitoring of a patient on TPN (
>1 kg/day gain suggestive of Fluid overload)
LFT/BUN – Once weekly
Serum Electrolytes – Every 3 days

59.  Surgery (“sterile inflammatory response”)
impacts both innate and adaptive immunity
 Provision of immune modulating nutrients
lowers infectious risk
 Amino Acids (Glutamine, Arginine)
 Lipids ( Omega 3 PUFA)
 Micronutrients ( Vitamin C, Selenium )