2. Chairperson For Session
Associate Professor Dr. Mohiuddin Matabbar
Unit Chief, Unit VI
Department of Surgery, DMCH
Special Guest of Session
Associate Professor Dr. S. K. Paul
Associate Professor, Unit VI
Department of Surgery, DMCH
3. Nutrition
• Nutrition is the provision to obtain the essential
nutrients necessary to support life and health
• Nutrients are the substances that are not
synthesized in sufficient quantity in the body
and therefore must be supplied from diet
• Macronutrients: carbohydrates, fats, protein,
dietary fiber and water
• Micronutrients: vitamins, minerals and trace
elements
5. • Interpretation of BMI :
Methods of Nutritional Assessment
Surgical Risk by Serum Albumin Level :
6. Nutritional Requirements
• Adult Fluid Requirement :
– If kidney function is normal:
• 30-40 ml/kg/Day
– If kidney function is impaired :
• Previous day 24 hrs Urine Output + 500-700 ml
• Also consider other loss like NG, drain tube loss.
7. Calorie Requirement :
• Total Energy Exp. = Rest Energy Exp. x Stress
Factor x Activity Factor
• Rest Energy Expenditure
– Adults (18-65) 20-30 kcal/kg
– Elderly (65+) 25 kcal/kg
• Activity factors:
• Confined to bed 1.2
• Out of bed 1.3
Nutritional Requirements
Stress factors
• Major surgery 1.1-1.2
• Severe infection 1.4-1.8
• Skeletal trauma 1.2-1.4
• Burns 2.2
Pregnancy: Add 300 kcal/day
Lactation: Add 500 kcal/day
8. • Carbohydrate Requirement:
– 40-50 percent of total nutrition.
– Requirement 2g/kg/day
– 1 Gm dextrose = 3.4 kcals
– Generally, because glucose is an essential tissue
fuel, glucose and amino acids are provided
parenterally until the level of resting energy
expenditure is reached. Fats are added thereafter.
Nutritional Requirements
9. • Fat Requirement :
– 20-30 percent of nutrition
– 1 gram= 9kcal/g
– linoleic acid should constitute at least 2% and
linolenic acid at least 0.5% of daily caloric intake to
prevent essential fatty acid deficiency.
Nutritional Requirements
10. • Protein Requirement :
Nutritional Requirements
Burn injuries, open wounds, protein losing Enteropathy /
Nephropathy needs excess Protein intake to be dictated
by Nitrogen Balance.
11. • Nitrogen Balance :
Nitrogen Balance = N input - N output
• N input = (protein in g / 6.25) [1 Gm nitrogen = 6.25gm protein]
• N output = 24h urinary urea nitrogen + 24h urinary non-urea
nitrogen (20% of UUN) + non-urinary N losses (2gm/day)
• +4 to + 6: Net anabolism
• +1 to - 1: Homeostasis
• -2 to – 1: Net catabolism
Nutritional Requirements
16. Enteral Nutrition
• Refers to feeding via a tube placed into the gut
to deliver liquid formulas containing all
essential nutrients.
• Preferred route because of benefits derived
from maintaining the digestive, absorptive
and immunological barrier function of GIT.
19. Complications due to Enteral feeding
• Generally well tolerated with few complications
• Complications of enteral feeding include mainly
aspiration pneumonia and diarrhoea.
• Other complications may include :
– Refeeding syndrome
– Perforation of GIT with subsequent peritonitis
– Dehydration or overhydration
– Hypo or hyperglycemia
– Electrolyte Imbalance
21. Parenteral Nutrition
• Parenteral nutrition: process of supplying
nutrients via the intravenous route
– Total parenteral nutrition (TPN)
– Peripheral parenteral nutrition (PPN)
• TPN may reduce morbidity and mortality after
major surgery, severe burns, and head trauma,
especially in patients with sepsis.
• TPN is often used in hospital, long term care,
and sub-acute care, and infrequently is used in
the home care setting.
22. Venous access
• The infusion of hyperosmoler nutrient solution
requires a large bore, high flow vessel to
minimize vessel irritation and damage.
• The most common types of venous access line
include:
– Percutaneous non-tunnelled catheter
– PICC line (peripherally-inserted central venous
catheter)
– tunnelled central venous catheter (also called
Hickman line or Broviac or Groshong)
– Portacath (also called ‘implanted catheter’)
25. Calculating TPN For a Patient
• Calculate total kcal needs for patient per 24 hours
– These normally fall in the 20-30 kcal/kg range.
– Burn patients will require more depending on burned
surface area.
– The hospital nutrition support team will be able to give
advice on kcal needs for burn or other special needs
patients.
• Next, figure protein requirements
– These are usually 0.8-2.0 g/kg/actual or dry body weight.
– Some diseases such as acute renal failure without dialysis
and hepatic encephalopathy may require 0.5-0.6
g/kg/body weight.
• Special amino acids preparations are sometimes available for
these patients. Check with the hospital pharmacy.
26. Calculating TPN For a Patient
• Times the grams of protein by 4 kcal per gram to
get the number of kcal provided by protein.
• Subtract protein kcal from total kcal required by
patient.
• Decide number of kcal to be provided by lipid.
– This can be up to 60% of non-protein kcal.
– Normal is 30-50%.
– Minimum is 5% of total kcal.
– Maximum is 1g/kg per day.
– 20% lipids will supply 2 kcal per ml.
– 10% lipids will supply 1.1 kcal per ml.
– Order per directions on hospital form.
27. • Subtract lipid kcal from non-protein kcal
• The remaining kcal will be given as dextrose.
– Divide kcal needed by 3.4 to calculate grams of dextrose.
– Order as grams per day or as % of total volume
depending on form.
– Up to 80% of total kcal can be given as dextrose in
stressed patients.
– Minimum requirement is 100g/day.
– Maximum rate of oxidation is 5 mg/kg body weight/min.
– Most ICU patients are not to be fed at the maximum rate
in order to lessen the stress of metabolism.
– Patients with Diabetes Mellitus or glucose intolerance, or
those with pulmonary disease that results in excess CO2
production, need special consideration.
Calculating TPN For a Patient
28. • Solutions with osmolarity greater than 900
mOsm/liter will require central venous access.
• Routine hospital parenteral forms include
options for standard or modified electrolytes,
vitamins, minerals, and certain compatible
medications.
Calculating TPN For a Patient
29. • Using the example of a 70-kg person, one first
calculates the overall caloric goal and the
proportion contributed by protein, usually as
follows:
Calculating TPN For a Patient (example)
30. Calculating TPN For a Patient (example)
Calorie/Protein Yields
• 1 gm protein = 4 kcals
• 1 gm fat = 9 kcals
• 1 gm dextr. = 3.4 kcals
• 1 gm nitrogen =
6.25gm protein
31. • Enteral Feed preperations :
– Normal : 1Kcal/ml
– Renal preperation : 2 Kcal/ml
– Diabetic Preperation : Low GI
• Prescibe procedure
Practical Considerations and formulations
32. Practical Considerations and formulations
• Carbohydrate :
– 1L 5% DA = 50 gm glucose
– 1L 10% DA = 100 gm glucose
– 1L 25% DA = 250 gm glucose
• FAT :
– 1L 10% Fatisol = 100 gm fat
• Protein :
– 1L of 5% AA + D sorbitol + elctrolyte = 7.7gm N = 48.1 gm
– 1L of 7% AA + 10% DA + electrolyte = 10.7gm N = 68 gm
34. Complications of TPN
• Mechanical Complication:
– Air embolism
– Pneumothorax
– haemothorax
– Cardiac tamponade
– Injuries to arteries and
veins
– Injury to thoracic duct
– Brachial plexus injury
35. Metabolic Complications:
• Early or nutrient related
– hyperglycemia
– hypoglycemia
– hyperlipidemia
– refeeding syndrome
• late or related to long term administration
– Hepatic dysfunction, Steatosis, steatohepatitis, lipidosis,
cholestasis, cirrhosis
– biliary complications: acalculous cholecystitis, Gb sludge, stone
– Metabolic bone disease: osteomalaacia, osteopenia
– Fluid overload
– Hypo/hypernatremia, Hypercalcemia, Hypo/hyperkalemia
Complications of TPN
36. • To Avoid Metabolic Complications:
Complications of TPN
37. • Infection :
– Catheter related sepsis is most common life threatening
complication
– Causes: staph epidermidis and staph aureus,
enterococcus, candida, E coli, psuedomonas, klebsiella
etc in immunocompromised pts
• Contraindications for lipids include:
• Hyperlipidemia
• Severe liver disease
• coagulopathy
• acute pancreatitis with hyperlipidemia
• severe pulmonary disease
• Thrombocytopenia
Complications of TPN
