This document discusses nutritional management in surgical patients. It outlines the fundamental goals of nutritional support which are to meet energy requirements, maintain core body temperature, and allow for tissue repair. Early recovery after surgery protocols aim to avoid long pre-operative fasting, establish early oral feeding, integrate nutrition into overall patient care, and encourage early mobilization. Patients who require nutritional support include those who are already malnourished, at risk of malnutrition, unable to eat due to medical reasons, unable to eat enough due to conditions like burns or trauma, or unwilling to eat due to psychological reasons. Both enteral and parenteral nutrition routes are discussed, with enteral generally being preferred when possible due to improved outcomes. Guidelines for fluid, protein,

2. By
Dr Pirah Korai
Pg, SU-2
CMC LARKANA
Nutritional management
in surgical patients

3. OUTLINES
 Introduction
Fundamental goals of nutritional support
 ERAS Criteria
Who require nutritional support?
 Post operative complications
 Criteria of malnutrition
Daily fluid maintenance requirement
 Routes of administration of nutrition
 ASPEN Guidelines
 Enteral v/s parenteral
Principles of TPN
Standard regime and energy requirement

4. Nutrition
“THE BASIC DRUG”

6. Traumatized Man

8. Fundamental goals of Nutritional
support:

To meet the energy requirement for
metabolic processes

To maintain a normal core body
temperature

For tissue repair

9. ERAS Criteria
Avoidance of long periods of pre-operative fasting;
Re-establishment of oral feeding as early as possible after surgery;
Integration of nutrition into the overall management of the patient;
Reduction of factors which exacerbate stress-
related catabolism or impair gastrointestinal function;
Metabolic control, e.g. of blood glucose;
Early mobilisation

10. WHO REQUIRE NUTRITIONAL SUPPORT?

11. 11
A) Patients already with malnutrition
B) Patients at risk of malnutrition
WHO CANT EAT:
ESOPHAGEAL/GASTRIC OUTLET
OBSTRUCTION, HEAD & NECK
INJURY/SURGERY, SHOCK
WHO CANT EAT ENOUGH:
SEVERE BURNS, MAJOR
TRAUMA , SEPSIS
WHO WONT EAT:
ANOREXIA, DEPRESSION &
EATING DISORDERS
WHO SHOULD NOT EAT:
BOWEL
OBSTRUCTION/LEAKAGE, GI
FISTULAS, SEVERE
PANCREATITIS, IBD, RADIATION
ENTERITIS, PROLONGED ILEUS

12. 12
POST-OP COMPLICATIONS
• Impaired defenses
– decreased immunity
– decreased phagocytosis
– decreased chemotaxis
• Increased post-op infections
• Impaired wound healing
• Longer recovery period
• Prolonged hospital stay

13. 13
IMPAIRED NUTRITION
40%
60%
40% of hospitalized patients have an
impaired nutritional status

14. 14
33%
67%
33% of all gastrointestinal surgery patients are
malnourished
IMPAIRED NUTRITION

15. Criteria of Malnutrition
• O/H: Wt loss >10-15% within 6months
• BMI: <18.5 kg/m2
• Subjective global assessment: Grade C
• S-Albumin: <30g/L
(with no evidence of hepatic or renal dysfunction)

16. 1/3rd to 1/4th part of fluid to be provided by
Normal saline while rest through 5% Dextrose
Daily maintenance requirement:

17. Routesof ADMINISTRATIONOF NutritionS
--- Enteral
---Parenteral
---Combined

18. 18
ASPEN NUTRITION SUPPORT ALGORITHM
Functional GIT
Yes No
Enteral nutrition
Parenteral nutrition
Short term Long term/fluid
restriction
PPN Central PN
GI Function returns
No
GI Function
Standard
Nutrients
Speciality
Formulas
Normal Compromised
Adequate
progress to
oral feeding
Adequate progress to
more complex diet
and oral feedings as
tolerated
Inadequate PN
supplementation
Nutrient
tolerance
Progress to total enteral feedings Yes
Nutrition Assessment

20. 20

21. 21
Principles of TPN
• Used only when indicated
• All devices must be managed by staff trained in aseptic
• Cyclical feeds better than continuous infusion (Infusion over 10-18
hrs)
• Adequate adjustments in standard solutions as & when required
• Stop TPN when not needed
• Never discontinue at once ( Ramp down)
(Rate of infusion reduce to one half for 2 hrs, then half again for 2
hrs & then discontinue)
• Careful monitoring & watch for complications

23. 23
Parenteral nutrition
standard regimens
• Energy 30 kcal/kg/day (as energy and fat)
• Amino acids 1.5g/kg/day
• Electrolytes basal amounts
• Vitamins and trace elements basal amounts
Above are maintenance requirements. Additional fluid and electrolytes
may be required

24. Basic Energy Requirements:
-Esimated total caloric need of the patient : 25-
35kcal/kg/day
( so, 1800-2100 kcal/day for a 70-kg man)
-Generally 30% of calories should be via lipid (fat) and the
rest by glucose (carbohydrates)
-1.5 L of 20% dextrose contains 300g of Glucose and will
provide 1200kcal
0.5 L of 20% Lipid emulsion contains 100g of lipids and
will provide 900kcal.
-Thus , a combination will provide 2100kcal in 2L of fluids

25. Protein Requirement:
-Estimated daily requirement : 1-2g/kg/day
( so, 70g/day for a 70kg man)
-0.5 L of amino acid solution can thus complete
the usual nutritional requirement within
daily fluid allowance.

26. 26
Enteral vs Parenteral
Parenteral
‘guaranteed’ intake
‘never’ rejected
can be used with short gut or absent gut
function
Less nutritionally effective than EN
Hyperglycaemia
Electrolyte imbalance
Hyperlipidemia
Constant supervision
Needs long term CVC
Sterility and infection considerations
Costly
Enteral
Requires functional gut
can cause solute overload
Vomiting, Diarrhea
Can cause perforation(rarely)
Can be used to continue oral meds
More effective – on-line to portal system
Encourages gut motility
Normalises gut flora
Electrolyte imbalance unusual
Less supervision
Less infection
Cheap(er)

27. SUMMARY