anesthesiology

1. Supplemental Parenteral
Nutrition Role During
Pre and Postoperative
Bambang Pujo Semedi
Dept. of Anesthesiology and Reanimation
Faculty of Medicine Universitas Airlangga – Dr. Soetomo Academic Hospital
SURABAYA

2. Introduction
• Malnutrition in patients undergoing surgery is
common1.
• Malnutrition is commonly seen in surgical patients with
an underlying illness such as malignancy, chronic organ
failure, and inflammatory bowel disease.
• The incidence of malnutrition in surgical patients
has been reported to range from 23–33% depending
on type of surgery and nutrition assessment tool
used 2,3.
1. Abunnaja, S.; Cuviello, A.; Sanchez, J.A. Enteral and parenteral nutrition in the perioperative period: State of the art. Nutrients
2013, 5, 608–623, doi:10.3390/nu5020608.
2. Ozkalkanli, M.Y.; Ozkalkanli, D.T.; Katircioglu, K.; Savaci, S. Comparison of tools for nutrition assessment and screening for
predicting the development of complications in orthopedic surgery. Nutr. Clin. Pract. Off. Publ. Am. Soc. Parenter. Enter. Nutr.
2009, 24, 274–280, doi:10.1177/0884533609332087.
3. Thomas, M.N.; Kufeldt, J.; Kisser, U.; Hornung, H.M.; Hoffmann, J.; Andraschko, M.; Werner, J.; Rittler, P. Effects of malnutrition on
complication rates, length of hospital stay, and revenue in elective surgical patients in the G-DRG-system. Nutrition 2016, 32, 249–
254, doi:10.1016/j.nut.2015.08.021.

3. …Introduction
The catabolic impact of surgery  negatively impact
nutrition status
1. Traynor, C.; Hall, G.M. Endocrine and metabolic changes during surgery: Anaesthetic implications. Br. J. Anaesth. 1981, 53,
153–160, doi:10.1093/bja/53.2.153.
2. Yeh, D.D.; Fuentes, E.; Quraishi, S.A.; Cropano, C.; Kaafarani, H.; Lee, J.; King, D.R.; DeMoya, M.; Fagenholz, P.; Butler, K.; et
al. Adequate Nutrition May Get You Home: Effect of Caloric/Protein Deficits on the Discharge Destination of Critically Ill
Surgical Patients. JPEN J. Parenter. Enter. Nutr. 2016, 40, 37–44, doi:10.1177/0148607115585142.
Surgery, like any injury
1. affect immune function
2. increase loss of muscle mass
3. exacerbate malnutrition
Optimizing nutritional status preoperatively is crucial
Stress hormones
(e.g., cortisol, catecholamines,
and glucagon)
Inflammatory cytokines
(e.g., TNF alpha, IL 1 and 6).
Inflammation
Metabolic stress

4. Effects of (Surgical) Trauma on
Homeostasis of The Organism
(Surgical) trauma is
accompanied by a
negative nitrogen
balance
Nitrogen balance is
more negative than
during pure fasting

5. Hypermetabolic Response

6. Identification of malnutrition in major
surgery is important…
• Careful preoperative nutritional assessment should include
1. a determination of the level of stress
2. an evaluation of the status of the GI tract,
3. the development of specific plans for securing enteral access.
• Patients already demonstrating compromise of nutritional
status should be considered for a minimum of 7 to 10 days
of nutritional repletion prior to surgery.
• Widespread use of total parenteral nutrition (TPN) in
unselected patients is unwarranted and may actually
worsen outcomes.
• TPN should be reserved for preoperative nutritional
support only in severely malnourished patients in whom
the GI tract is unavailable.

7. • Deterioration of nutritional status in the critically
ill patient undergoing major surgery is associated
with:
• reduced systemic immunity
• exaggerated stress response
• organ system dysfunction
• poor wound healing
• delayed functional recovery
• Predictors of poor surgical outcome :
• weight loss (> 10%)
• hypoalbuminemia (serum albumin level < 2.5 g/dL)
• other purported signs of protein calorie malnutrition

8. A compromise in nutritional status pre-
operatively may increase complications in
the later stage…
• Prospective study evaluated four markers in non-cancer
patients preoperatively, including :
1. percent ideal body weight
2. percent weight loss
3. serum albumin level
4. arm muscle circumference
• Comparing with patients in whom all markers were normal,
patients with at least one abnormality of these markers had
a significant increase in :
• the incidence of overall complications (48% vs 23%, p , 0.05),
• major complications (31% vs 9%, p , 0.05),
• length of stay (29 vs 14 days, p , 0.05)
Warnold I, Lundholm K. Clinical significance of preoperative nutritional status in 215 noncancer patients.
Ann Surg 1984; 199:299 –305

9. How long can a normal
individual tolerate starvation?
• Theoretically, normal individual can be starved
without adverse effects ranges from as long as
12 to 14 days to as little as 72 hours
• ..but the stress and hypermetabolism of critical
illness and major surgery shorten this time
period to 5 to 7 days.
• Patients already demonstrating compromise of
nutritional status will be at risk of major
complication-related malnutrition.

10. • Population : patients undergoing elective surgery
involving resection of a portion of the upper GI tract
• Result :
• Patients with weight loss alone (> 10%) faired no worse
than control subjects without weight loss.
• However, patients with > 10% weight loss with some
evidence of physiologic impairment sustained a
significantly higher incidence of major complications
(primarily septic)
*Physiologic impairment in this study defined by abnormal :
1. serum protein levels
2. maximal inspiratory pressure
3. hand grip dynanometry
4. body composition
Windsor JA, Hill GL. Weight loss with
physiologic impairment—a basic indicator of
surgical risk. Ann Surg 1988; 207:290 –296
Weight loss and physiologic impairment are
predictors of postoperative complications

11. There are four questions to
answer in nutrition therapy...
Nutrition
What?
Who?
How?
When?

12. “FLOW”
Hypermetabolism
Catabolism
“EBB”
shock and
hypoperfusion
Time
Time course varies by stress: classically 6-7 days
Peak
amplitude
influenced by
type of
stressor
Cuthbertson DP, The Disturbance of metabolism produced by bony and non bony injury, with notes on certain abnormal conditions of bone, Biochem J. 1930;24:1244-1263.
Cuthbertson D, Tilstone WJ. Metabolism during the Postinjury period. Adv Clin Chem. 1969; 12:1-55
Stress Response Curve
12-24 hours Weeks
“RECOVERY”
Anabolism
Trauma,
Major
surgery
Start low..go slow

13. Clinical Nutrition 42 (2023) 1671-1689

14. Clinical Nutrition 42 (2023) 1671-1689
1. Every critically ill patient staying for more than
48 hours in the ICU should be considered at risk
for malnutrition. (S1, strong consensus, 96%)
2. Medical nutrition therapy shall be considered
for all patients staying in the ICU, mainly for
more than 48 hours.(R1, Grade GPP, strong
consensus 100%)

15. What does newest guideline recommend for parenteral
nutrition in critically ill patients?

16. Clinical Nutrition 42 (2023) 1671-1689
• Early and progressive PN can be provided instead of no
nutrition in case of contraindications for EN in severely
malnourished patients.
(R7, Grade 0, strong consensus, 95%)
• In patients who do not tolerate full dose EN during the
first week in the ICU, the safety and benefits of initiating
PN should be weighed on a case-by-case basis.
(R20, Grade GPP, strong consensus, 96%)
• In case of contraindications to oral and EN, PN should be
implemented within three to seven days.
(R6, Grade B, consensus 89%)
• PN should not be started until all reasonable strategies
to improve EN tolerance have been attempted.
(R 21, updated, Grade GPP, consensus, 100%)

17. Clinical Nutrition 42 (2023) 1671-1689
Parenteral
Nutrition (PN)
Early
Parenteral
Nutrition
Early
Enteral
Nutrition

18. Early
Parenteral
Nutrition
Screening and
Assessment
Malnutrition
confirmed ?
Contraindication
for EN ?
Oral nutrition
possible ?
Early Enteral
Nutrition
Clinical Nutrition 42 (2023) 1671-1689
Early or Delayed
Medical Nutrition
Clinical Nutrition in ICU

19. Early Parenteral Nutrition (PN)
Early and progressive PN can be
provided instead of no nutrition in
case of contraindications for EN in
severely malnourished patients.
(R7, Grade 0, strong consensus, 95%)
In patients who do not tolerate
full dose EN during the first week
in the ICU, the safety and
benefits of initiating PN should be
weighed on a case-by-case
basis.
(R20, Grade GPP, strong consensus,
96%)
Early Erenteral Nutrition (EN)
Clinical Nutrition 42 (2023) 1671-1689
Early Medical Nutrition (EN/PN)

20. Delayed Medical Nutrition (EN/PN)
PN partial
if possible
Clinical Nutrition 42 (2023) 1671-1689

21. Other substrates
Glucose/
Carbohydrates
Lipids
Glutamine (GLN) Fish oil (omega-3) Micronutrients
Clinical Nutrition 42 (2023) 1671-1689

22. Lipid
• The administration of intravenous lipid emulsions
should be generally a part of PN.
(R24, Grade GPP, strong consensus, 100%)
• Intravenous lipid (including non-nutritional lipid
sources) should not exceed 1.5 g lipids/kg/d and
should be adapted to individual tolerance.
(R25, Grade GPP, strong consensus, 100%)
• Parenteral lipid emulsions enriched with EPA plus
DHA (Fish oil dose 0.1-0.2 g/kg/d) can be provided
in patients receiving PN.
(R33, updated, Grade 0, strong consensus, 100%)

23. Asesmen status nutrisi menjadi
kunci utama untuk mengidentifikasi
malnutrisi
• Berdasarkan kriteria The Global Leadership
Initiative on Malnutrition (GLIM), seorang pasien
didiagnosis malnutrisi bila sekurangnya memiliki
satu kriteria fenotipik dan satu kriteria etiologis.
• Asupan nutrisi dapat dinilai secara cepat dan
mudah dengan metode semi- kuantitatif :
1. skala analog antara 0 dan 10/10 atau
2. porsi yang dikonsumsi (0, 1⁄4, 1⁄2, 1), seperti yang
dilakukan dalam Survey Nutrition Day

26. General principles of nutrition intervention
Parenteral Nutrition
Jankowski et al. World Journal of Surgical Oncology (2018) 16:94

27. Role Peripheral Parenteral Nutrition
(PPN) in Major Gastrointestinal Surgery
• Patients undergoing major gastrointestinal surgery may be
in particular need of nutritional therapy due to potential
pre-existing disease-related malnutrition and the impact of
surgical procedures.
• Perioperative parenteral nutrition, i.e., delivery of balanced
quantities of amino acids, glucose, lipids, and
micronutrients intravenously (i.v), may be required when a
patient's nutritional needs cannot be met by oral or enteral
routes.
• Peripheral parenteral nutrition (PPN), delivered via a
peripheral catheter, is aligned with the Enhanced Recovery
After Surgery (ERAS) concept of minimally invasive
interventions where possible.
Clinical Nutrition ESPEN 43 (2021) 16-24

28. Who is the candidate for PPN ?
7 days post surgery
for a bridging period
to prevent malnutrition in the
1st month after surgery
• 10 days before surgery
• inpatient and/or outpatient PPN delivery

29. Expert considerations for PPN use
M. Senkal, L. Bonavina, B. Reith et al. (2021)

30. Route of Nutrition Therapy

31. Indication of peripheral and central nutrition

32. What is the choice ?
Clinimix N9G15E
Lipid 20% (mL) 100 250
Nitrogen (g) 4,55 4,55
Glukose (g) 75 75
Lipid (g) 20 50
Total calorie (Cal) 610 910
Non caloric protein (Cal) 500 800
Glucose : Lipid ratio 60 : 40 38 : 62
Caloric : Nitrogen ratio 105 200
Osmolarity 792 730
Volume 1100 1250
Lipid 20%
Glucose + Protein

33. Take home message
• The patient's nutritional status strongly affects the
postoperative outcome, especially after major
gastrointestinal surgery.
• Recognising preoperative malnutrition is crucial so that
nutrition therapy can be carried out early.
• Although enteral nutrition is still a first-line nutrition
therapy, under certain conditions, parenteral nutrition
remains necessary.
• Parenteral nutrition can be given before or after major
surgery, depending on the patient's problems.
• Peripheral parenteral nutrition is an alternative to
interventional nutrition because it is more non-invasive
and can reduce the risk of complications.