1. NUTRITION IN
SURGERY
DR HITESH PATEL
Associate Professor
General Surgery Department
GMERS Medical college, Gotri, Vadodara.
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
3.
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
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
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,
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
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. Contraindication
s
• 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
35.
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
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
42.
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. Advantage
s
• 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
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
50. Intravenous Lipid
Emulsions
10% and
20%
Soybean or
Safflower
280 - 340
mOsm/l
• Concentration
s
• Parent oil
• Osmolarity
• 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. Complication
s
• 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
61. Prevention andTherapy
• 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. Overfeedin
g
• 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 caloriesin
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
68. TREATMEN
T
• 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
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. REFERENC
ES
• 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
