This document discusses nutrition in surgery and provides an overview of key topics including nutritional assessment, requirements, interventions, and complications. Nutritional assessment involves taking a history, physical exam including anthropometric measures, and lab tests to evaluate a patient's nutritional status. Enteral and parenteral nutrition routes are described. Enteral nutrition is preferred when possible as it supports gut health while parenteral nutrition is for cases of total gut failure. Complications of both enteral and parenteral nutrition are outlined. The goal of nutritional intervention is to identify and support patients at risk of malnutrition.

1. NUTRITION IN SURGERY
Dr Adewunmi Olayinka Lukman
General Surgery Unit II
UMTH

2. Outline
• Introduction
• Physiology
• Nutritional assessment
• Nutritional needs and requirements
• Nutritional intervention
• Conclusion
• References

3. Introduction
• Nutrition is the study of food in relation to the
physiological processes that depend on its absorption
by the body.
• Nutrient is a substance that is consumed as part of the
diet to provide a source of energy, material for growth
or their regulation e.g CHO, protein, fat, vitamins &
minerals

4. Introduction
• Malnutrition is common
• It occurs in about 30% of surgical patients with
gastrointestinal disease and in up to 60% of those in
whom hospital stay has been prolonged because of
postoperative complications

5. Physiology of Nutrition

6. Nutritional management of the surgical
patient
•Nutritional assessment
•Evaluation of nutritional status
•Calculation of nutritional
needs/requirements
•Nutritional intervention

7. Nutritional assessment
• The goal is to predict the patient at risk for complications due to
inadequate nutrition so that intervention can be undertaken.
• Assessment involves
• History
• Physical and Anthropometric Examination
• Laboratory Examination

8. Nutritional assessment
• Physical examination
• Body weight
• Anthropometric measures
1. Ideal body weight(IBW)
Men: 106 lb (48 kg) for the first k (152 cm) and 6 lb (2.7 kg) for
each inch (2.54 cm) over k.
Women: 100 lb (45 kg) for the first k (152 cm) and 5 lb (2.3 kg)
for each inch (2.54 cm) over 5 ft.

9. Nutritional assessment
• Body Mass Index(BMI)
weight(kg)/(height)² m²
• Mid arm circumference(MAC/MUAC)
Measure of muscle mass
Shakir strips

10. Nutritional assessment
• Waist circumference: F<88cm, M<102cm
• Hip circumference
• Fat fold thickness
Triceps
Biceps
supra-iliac
subscapular

11. Nutritional assessment
• Laboratory tests:
a. Serum albumin (<3.0g%; t½=14-20 days)
b. Serum prealbumin (<15mg%;t½=2-3 days)
c. Serum transferrin (<200mg%; t½=8-10 days)
d. Serum retinol-BP (t½ = 12 hrs)
• Immunological tests:
-Delayed cutaneous hypersensitivity.
-Total Lymphocyte Count = % L₀ x WBC/100.
-Complement levels.

12. Calculation of nutritional needs/requirements
• Age
• Metabolic rate
• Body protein reserves
• Caloric intake
• Nutritional status
• Disease state
• Stress associated with critical illness

13. Nutritional requirements
• Daily basal requirement per kg BW
-Energy: 125 – 146 kj/kg or 25-35 kcal/kg
-Protein: 0.7 – 1.0g/kg (4.1 kcal/g)
-CHO: 4.2 – 6.0g/kg (4.1 kcal/g or 3.4 kcal/kg from Dextrose)
-Fat: 1.5 – 2.0g/kg (9.3 kcal/g
-50% CHO; -35% fat; -15% protein.
-Water → 45 – 50 ml/kg (Tropics).
-Vitamins → RDAs.
-Trace minerals→ RDAs.

14. Caloric needs
• Basal Energy Expenditure (BEE)/BMR, using Harris-Benedict equation
• BEE (men)= 66.47+(13.75W)+(5H)−(6.755A)
• BEE (women)= 655.1+(9.56W)+(1.85H)−(4.68A)
• Age
• Weight
• Height

15. Caloric Needs
• Caloric needs in hospitalized patients:
→BEE x Injury Factor x Activity Factor
• Injury factors:
-Minor operation = 1.2 (20%↑)
-Skeletal Trauma = 1.35 (35%↑)
-Major sepsis = 1.6 (60%↑)
-Severe Burns = 2.10 (110%↑)
• Activity factors:
-1.2 if px is confined to bed
-1.3 if not confined to bed.

16. Effect of Malnutrition
• Impaired wound healing
• Altered immune responses
• Accelerated catabolism
• Increased organ dysfunction
• Delayed recovery and
• Increased morbidity and mortality

17. Nutritional Intervention
• The aim of nutritional support is to identify those
patients at risk of malnutrition and to ensure that
their nutritional requirements are met by the most
appropriate route and in a way that minimizes
complications.
• Enteral
• Parenteral

18. Enteral route
• Nutritional support using the gastrointestinal tract
• Advantages
• Prevents intestinal mucosal atrophy
• Supports gut-associated immunological shield
• Attenuates the hyper metabolic response the injury and surgery
• Cheaper than TPN and has fewer complications
• Reduced post-operative mortality

19. Enteral route
• Direct
• Tube feeding (<4weeks)
Naso gastic
Naso duodenal
Naso jejunal

20. Enteral route
• Stoma feeding (>4weeks)
Gastrostomy
Jejunostomy

21. Complication of enteral feeding
Tube related
• Malposition
• Displacement
• Blockage
• Breakage/leakage
• Local complications (erosions of
skin/mucosa
GIT
• Aspiration
• Diarrhea
• Bloating
• Abdominal cramps
• Constipation
• Nausea/vomiting

22. Complication of enteral feeding
Biochemical
• Electrolyte disorder
• Vitamin, mineral and trace
elements deficiency
• Drug interaction
Infection
• Endogenous
• Exogenous

23. Parenteral nutrition
•Parenteral nutrition is defined as the provision of
all nutritional requirements by means of the
intravenous route and without the use of the
gastrointestinal tract.

24. Parenteral nutrition: indications
• Total gut failure
• Poor delivery
GIT fistula
Short bowel syndrome
Acute radiation enteritis
• Types: Total
Partial

25. Parenteral nutrition planning
• TPN team.
• Estimate fluid, energy & N₂ needs daily based on weight.
Harris –Benedict equation
1.5g/kg/d of amino acids in critically ill.
Total kcal of 25kcal/kg/d.
• Energy sources:
CHO as dextrose (3.4 kcal/kg)
Fat as long/medium-chain TG (9.3 kcal/kg)

26. Parenteral nutrition planning
• Protein source:
Essential & non-essential amino acid
• TPN solutions:
3-in-1 mixture (70% dex; 20% lipid; 10% a.a)
Non-lipid 2-in-1 mixture.
Special solutions.
• Additives:
Electrolytes
Medications.

27. Parenteral nutrition
• Route of administration
Peripheral line or PICC
Adv: Easy insertion
Convenient for patient/health personnel
Disadv: Thrombophlebitis
short duration (7-14days)

28. Parenteral nutrition
• Central line: IJV, SCV, IVC
Adv: good delivery
Long duration
Disadv: Inconvenient
Expertise

29. Parenteral nutrition
• Infusion protocol
• Daily dose method
• Delivery by infusion pump
• Daily clinical exam – I/O, Wt, urine urea, electrolytes and osmolality
• Serum E/U, Blood PH, clotting studies every 48hrs
• Blood glucose daily, urine glucose twice daily
• LFT, serum calcium, FBC weekly.

30. Complication of Parenteral nutrition
• Related to Cannula
Pneumothorax
Damage to adjacent artery
Air embolism
Thoracic duct damage
Cardiac perforation
Tamponade
Pleural effusion
Hydromediastinum

31. Complication of Parenteral nutrition
• Related to Nutrient deficiency
Hypoglycemia
hypokalemia
Hyponatremia
Hypomagnesemia
Hypophosphatemia

32. Complication of Parenteral nutrition: related
to excessive feeding
GLUCOSE AMINO ACIDS FATS
Hyperglycemia Metabolic acidosis hypercholesterolemia
Hyperosmolar dehydration hypercalcemia hypertriglyceridaemia
hepatic steatosis Aminoacidemia Lipoprotein X
Hypercapnea Uraemia Hypersensitivity reaction
Increased sympathetic activity

33. Complication of Parenteral nutrition
• Related to sepsis
Catheter-related sepsis
Systemic sepsis

34. Conclusion
• Nutrition in surgery is key to the management of surgical patient
• All patients who have sustained or who are likely to sustain 7 days of
inadequate oral intake should be considered for nutritional support
• It is imperative that nutrition-related morbidity is kept to a minimum

35. References
• Bailey and Love: Short practice of surgery, 25th edition
• Sabiston’s Textbook of surgery, 19th edition

36. •THANK YOU FOR YOUR
ATTENTION