1. Nutritional support is important for surgical patients to meet energy requirements, maintain core body temperature, enable tissue repair, and prevent or reverse catabolism caused by disease or injury. 2. The type and amount of nutritional support depends on the patient's pre-morbid state, age, duration of starvation, degree of insult, and likelihood of resuming normal intake. 3. Malnutrition can lead to complications including changes in the intestinal barrier and organ function, poor wound healing, immune dysfunction, and increased morbidity and mortality.

1. NUTRITION IN SURGICAL PATIENTS
Dr Vipin V Nair
Associate Professor Surgery & Plastic
Surgeon AFMC Pune

2. 2

17. NUTRITIONAL SUPPORT
FUNDAMENTAL GOALS
1. To meet the energy requirements for metabolic
processes.
2. To maintain normal core body temperature.
3. Substrate for tissue repair.
4. To prevent/reverse the catabolic effect of disease
or injury.

18. Pre‐operative nutrition and the elective surgical patient: why, how and what?
Anaesthesia, Volume: 74, Issue: S1, Pages: 27-35, First published: 02 January 2019,
DOI: (10.1111/anae.14506)

19. NUTRITIONAL SUPPORT
Requirement of nutritional support depends
on:-
Pre morbid state
Age and state of the patient
Duration of starvation
Degree of the insult
Likelihood of resuming normal intake within
a definite period

20. AIMS OF GOAL DIRECTED NUTRITIONAL
SUPPORT :
• To shorten the post-operative recovery
phase.
• To minimize the number of complications.

21. MALNUTRITION

22. • Changes in the intestinal barrier
• Reduction in GFR
• Alterations in the cardiac function
• Altered drug pharmacokinetics.
• Poor wound healing/anastomotic leak
• Loss of lean body mass
• Weak muscle strength (ventilation, pneumonia)
• Compromised immune defence (SSI, Sepsis, Shock)
• Impaired organ function
• Increased morbidity and mortality
• Longer hospital stay
• Progressive wasting
• Prolonged ventilator dependence

23. 23

24. Nutritional Requirement
Nutrients Normal In Surgical Patients
Calories 25 – 30 kcal/kg Upto 50 kcal/kg
Proteins 1g/kg Upto 3 g/kg pref 50%
to be administered
enterally
Carbohydrates 55-60% 70%
* Overzealous
administration of
glucose>5mg/kg/day
susceptibility to
infections

25. NUTRITIONAL REQUIREMENTS
• Protein requirements is in terms of nitrogen
Balance (NB)
NB= Protein intake Urine Urea nitrogen+4
6.25 0.8
• Target is to keep positive NB 2-4 g/day

26. Nutritional Risk Markers
1.Anthropometry :
-Weight for Height comparison
-Body Mass Index (<18 .5 )
-Triceps-skin fold (<14mm)
-Mid arm circumference (<12cm)
26

27. Nutritional Risk Markers
2.LAB PARAMETERS :
-Haemoglobin
-Albumin (< 3 g/dl)
-TIBC (< 200 ug/l)
-Total lymphocyte count (< 1500/cmm)
-Prothrombin Time
-Transferrin
-TBPA ( Thyroxine binding pre – albumin
-Retinol binding Protein

28. Principles for administration of
NUTRITION

30. Types of gastrostomy
Types
• Temporary
• Permanent
Approach
• Open
• Laparoscopic
Stamm
technique
Witzel
technique
Janeway
technique

31. Monitoring of Enteral Feeding

32. Complications of enteral nutrition
• Diarrhea
• Nausea and vomiting
• Constipation
• Aspiration pneumonitis
• Hyperglycemia
• Dyselectrolytemia

33. Contraindication to enteral nutrition

34. PARENTERAL NUTRITION

35. • Continuous infusion of hyperosmolar solution containing
carbohydrates, proteins, lipids and other necessary
nutrients through an in dwelling catheter inserted into
SVC
• PN should be considered if enteral nutrition cannot meet
the energy requirement (<50% of daily req) for more
than 7 -10 days
• Preoperative parenteral nutrition improves post-
operative outcome in patients with severe under nutrition
who cannot be adequately orally or enterally fed
Introduction

37. • Patients who are nutritionally depleted
• Unable to take nutrients via GI tract
• Patients who should not take nutrients by GI tract
because of an inherent risk or complicate
management of their current disease.
• Short gut syndrome
• Severely malnourished.

38. • Patient not expected to feed in 7 days.
- Prolonged ileus or intestinal obstruction
- Entero-cutaneous fistulas
- Pancreatitis
- Major Bowel surgery
Esophageal replacement
Gastric or colon surgery
Whipple’s procedure

39. WHEN TO START
• Pre-op in severely malnourished patient
undergoing a major surgical operation.
• Immediately Post-op in severely malnourished
patient.
• Immediately after major trauma, sepsis, burns
• Mildly malnourished unable to eat after 07
days of surgery

40. ASSESSMENT OF NUTRITION
• Goal-directed
• Repeated assessment of response to feeding
• Underfeeding
• Overfeeding is detrimental,
Hypercapnia
Metabolic acidosis,
Hyperglycemia,
Hypertriglyceridemia,
Hepatic dysfunction
Azotemia

41. Methods of Nutritional Assessment

42. Ideal Body Weight

43. Lean Body Mass

45. Serum Albumin Level
• Useful in detecting and quantifying
malnutrition
Requires significant energy stores for synthesis
Inhibited by inflammation
Long half-life of approximately 20 days
• Preoperative albumin levels less than 3 g/dL
: increased morbidity

46. Serum Albumin(contd)
• Poor indicator of nutritional
status in acute phase.
• False hypoproteinemia
(fluid shifts and increased
capillary permeability ->
protein leakage from the
intravascular compartment,
-> hemodilution).

47. Surgical Risk By Serum Albumin Level

48. Indication of PN
1. Short bowel syndrome secondary to massive small
bowel resection.
2. High output enterocutaneous fistula (>500ml/d)
3. Prolonged paralytic ileus
4. Multiple injuries, blunt or open abdominal trauma
5. Malabsorption
6. Functional gastrointestinal disorder
7. Granulomatous colitis, ulcerative colitis, Tuberculous
Enteritis
8. Malignancy
9. Failure to provide adequate calories by enteral tube
feeding

49. PATIENT SELECTION
CRITERIA TO INITIATE NUTRITION
SUPPORT PRESENT
FULLY/ PARTIALLY DYSFUNCTIONAL GI
TRACT

50. Components
• Primary - Carbohydrate
- Protein
- lipid
• Others - Electrolytes (except iron)
- Multivitamins
- Trace elements
- Medications

51. FORMULATIONS
• Single Component Formulae e.g. lipid emulsions,
dextrose solutions
• Two-in-one Solutions:
– Dextrose + amino acids
• Three-in-one Solutions:
– Dextrose + Amino Acids + Lipid Emulsion

54. Calculation of Nutritional
Requirement
Calculate calorie and protein requirement
Calculate calories from protein content
Remaining calories to be given are distributed b/w
dextrose and lipids (max 20%)
Or
Lipid emulsions can be infused periodically as single
components

55. SAMPLE CALCULATION
Avg 70 kg patient
• Total calories required- 30x70=2100 kcal/day
• Proteins required – 1.5 g x 70= 105 g/day
• Calories from amino acids – 105 x 4 =420 kcal
• Remaining: 2100-420= 1680 kcal
• Calories from lipids (20%) – 420 kcal
• 420 kcal/9 kcal/gm= 47 g lipids/day
• Remaining calories :2100 - (420+420)=1260
• 1260 kcal/3.4 kcal/gm= 370 gm
dextrose/day

56. SPECIFIC GUIDELINES - CARBS
• 20-70 % hypertonic dextrose – to be given in CVC,
cause thrombophlebitis in peripheral veins
• 1gm of dextrose– 3.4kcal
• Contraindicated in
– Alcohol withdrawal/ delirium tremens
– Suspected intracranial He
Infusion rates to be cautiously monitored to avoid hyperglycemia and
hypercapnia during weaning-off
Glucose infused @ 1-4 mg/kg/min has muscle sparing effect

57. SPECIFIC GUIDELINES - LIPIDS
• Dense source of calories – helpful when glycemic
control is an issue
• 1gm of lipid – 9kcal
• In critically ill – controversial benefit, altered fatty
acid metabolism may predispose to ill effects of
lipid infusion
Immunosuppression in acute phase
Modulation of inflammatory response
Adverse clinical outcomes/ increased hospital
stay
Prolonged mechanical ventilation and
increased susceptibility to infection

58. SPECIFIC GUIDELINES - LIPIDS
• Soybean oil (omega-6-FA linoleic acid) – pro-inflammatory
potential, cause decreased levels of available anti-oxidants in
plasma lipoproteins
• Fish oils (omega-3-fatty acids) – protective against
inflammatory conditions and results in reduced infective
complications, shortened hospital stay
• Prolonged PN –min of 500ml lipid emulsion every 2 weekly.

59. SPECIFIC GUIDELINES - PROTEINS
• 0.8g/kg/day in healthy adults
• 1.5 to 2 g /kg/day in fasted surgical patients
• 3 gm/kg/day in severe trauma
• Nitrogen to calorie ratio required in surgical patients
– 1:150
• Chronic renal/ hepatic failure – low protein diets

60. SPECIFIC GUIDELINES – Electrolytes
DAILY REQUIREMENT-
• 1-2 mEq/kg of Na and K
• 10-15 mEq of calcium
• 8-20 mEq of Mg
• 20-40 mmol of phosphorus
 Additional K+, Mg2+, PO4
3- required in previously
malnourished/ rapid anabolic state
 Renal Impairment – restriction of electrolyte content

61. Trace Elements
MINERAL FUNCTION DEFICIENCY
Copper Formation of RBCs, absorption of
iron, synthesis and release of
proteins and enzymes
Microcytic hypochromic anemia,
leukopenia neutropenia, delayed
wound healing
Iron Oxygen transportation, electron
transport
Microcytic hypochromic anemia ,
pallor fatigue
Selenium Antioxidant Impaired cellular immunity
Cardiomyopathy
Manganese Cofactor of many enzymes,
necessary for glycemic control,
thyroid function
Impaired metabolism of
carbohydrate and lipid ,impaired
protein synthesis ,Wt loss
Zinc Essential co-factor of many
enzymes , DNA replication,
immune function, Collagen
formation
Impaired wound healing,
impaired immune function

62. ROUTE SELECTION
Peripheral Parenteral
Nutrition (PPN)
– Peripheral vein
– Short-term support (<2
wks)
– Under 900 mOsm,
higher causes
thrombophlebitis
Central /Total Parental
Nutrition
– Larger, central veins-
subclavian, IJV
–Tunneled catheter ,PICC
–Long-term support
–Infusion of hyperosmolar
(>1500mOsm/L)

63. ROUTES
PICC LINE
BASILIC/MEDIAN CUBITAL/CEPHALIC
CENTRAL VENOUS LINE
SUBCLAVIAN/JUGULAR
CENTRAL VENOUS LINE

64. COMPLICATIONS OF PN
Mechanical
• Pneumothorax
• Arterial puncture,
• Hemothorax ,
• Thrombosis and PTE
Infection : Catheter related sepsis
Hepatobilliary complications :
• Cholelithiasis
• Hepatic steatosis

65. Monitoring nutrition support
• Monitor vitals
• Body wt, total intake and out put daily
• Serum electrolytes 1-2 days till values are stable then
weekly
• Serum glucose 4-6 hrly untill stable then weekly
• Serum TG
• Care of catheter site

66. PARENTERAL NUTRITION FORM

67. CONCLUSION
• Optimization of nutritional level is important for
a favorable clinical outcome of surgical patients
• Feeds should be customized as per specific
patient requirement
• Overfeeding/ underfeeding – deleterious effects
• Crucial role in prevention/ reversal of catabolic
effects of trauma/ surgery
• Constant clinical and biochemical monitoring to
look for complications of PN

68. THANK YOU