Surgical Nutrition

Brooke Sachs
Surgical Teaching
April 2018
Resources list plus with the help of lecture notes from Surgical Metabolism subject USYD 2015

 Born April 25 1906, died Sept 17 1991
 Wanted to be an artist but his parents did not approve
 Obtained a scholarship to the National Academy of
Design, training there while completing high school
 Went to Medical School to appease his parents – worked
at the peak of the Great Depression and struggled to
make money
 Went back to illustrating in order to make ends meet
 Wrote/illustrated over 200 pamphlets and 13 atlases
 According to Dr Michael DeBakey, Netter’s contribution
to our understanding of anatomy is the greatest
advancement since Vesalius in the 16th century
 Now has a medical school in Conneticut named after him

 Gain an understanding of surgical metabolism
 Understand how to optimise peri-operative nutrition in elective patients
 Understand how to optimise metabolic outcomes through nutrition in
emergency/non-elective patients
 Understand the different feeding methods and their relative risks, benefits and
uses in surgical patients
 Define and understand re-feeding syndrome

 Body builders
 Fitness fanatics
 Dieticians and nutritionists
 The Paleo Chef
 And so on and so on

 Elderly folk
 Post-trauma
 Cancer patients
 Liver disease patients
 Burns
 And so on, and so on

 37 M presents to hospital with severe epigastric pain  pancreatitis
 Diagnosed as severe, has SIRS then MODS response requiring ICU support
 Necrotising pancreatitis
 BMI 30, no recent weight loss or gain
 Doesn’t normally go to the doctor, no known background health conditions
 Normally eats meat, pies, doesn’t like fruit or vegetables
 Works as a truck driver, smokes 10 cigarettes/day for 20 years
 Normally drinks 1 carton of beer/week
 12 hours prior to presentation had pain start after celebrating his birthday by
drinking a bottle of whiskey

 70 F presented last night with small bowel obstruction and strangulation
requiring urgent laparotomy – 20cm bowel resected and re-anastomosed,
adhesiolysis
 Background previous open cholecystectomy, TAHBSO, AF on warfarin, PVD, HTN
 No recent weight loss, BMI 19
 Was well prior to the last 24h
 Previous smoker 50 pack years, quit 5 years ago, teetotaler, lives in assisted
living, normally walks with a 4ww but does her own grocery shopping, able to
complete ADLs
 What is your nutrition plan?

 Micronutrient deficiencies in the absence of macronutrient deficiency (enough
energy, not enough vitamins … all our patients who eat a lot of KFC)
 Macronutrient deficiency
 Pure starvation
 Relative protein deficiency
 Micro- and macronutrient deficiencies
 Often seen in the developing world
 Cachexia
 Cytokine mediated
 Cancer
 INADEQUATE NUTRITION CAN OCCUR IN PEOPLE EATING A NORMAL
DIET
 SURGICAL PATIENTS ARE IN A CATABOLIC STATE

 Sepsis, surgery, acute and chronic illness predispose individuals to metabolic
derangement
 This is driven by a pro-inflammatory state
 Can occur even when eating ”adequately”
 Can be worsened by anorexia promoted by illness
 Protein intake is the most important component of macronutrition in these patients
 This leads to:
 Loss of lean body mass (i.e. muscle)
 Structural and functional impairment (muscle wasting, organ impairment)
 Dysregulation of energy utilisation pathways
 Ineffective antioxidation  build up of toxins
 INCREASED COMPLICATIONS AND MORTALITY

 Detsky et al. JPEN 1987
 9% of moderately malnourished patients have major complications
 42% of severely malnourished patients have major complications
 Severely malnourished patients are four-times more likely to suffer post operative
complications than well-nourished patients
 Hypoalbuminaemia is associated with higher surgical morbidity and mortality
 Infectious complications are increased with malnutrition

 Our patients are septic, broken or inflammed
 Their endocrine systems are hyperactive (adrenal response, thyroid response)
 Surgery may resolve part of their inflammation, however the process of
performing surgery is extremely physiologically stressful
 Post-operative outcomes are impacted by
 Nutrition
 pre- and post-operative body composition
 Medications
 Post operative management

https://thoracickey.com/metabolism-in-surgical-patients/

 Desky et al
 Hx
 Weight change
 Dietary intake change
 GI symptoms
 Functional capacity
 Underlying disease and metabolic
demand
 Physical exam
 Loss of subcutaneous fat
 Muscle wasting
 Ankle oedema
 Sacreal oedema
 Ascites
 Also consider:
 Weight fluctuations – a patient who
lost 10% of their BW, then regained
3% is in a better position than
someone who lost 7% in the same time
frame
 Intention – someone intentionally
losing weight on a healthy diet is in a
better position than someone trying to
gain weight but losing it
 Previous surgeries/known background
GIT issues
 Medications

 Occurs when a patient has been under-nourished or not nourished at all for a
period of time, then switched suddenly to adequate/excess calories
 Precipitates an insulin surge
 Metabolic rate increases, therefore the O2 consumption and CO2 production
increase
 Insulin stimulates shift of phosphate, potassium and magnesium from serum into
cells, resulting in electrolyte imbalances
 The whole-body stores of these electrolytes are likely to already be low
 Critically low serum levels can precipitate cardiac/neuromuscular compromise
leading to arrhythmias, CHF, acute respiratory failure and death
 Thiamine deficiency contributes to adverse outcomes

 Take baseline EUC, CMP, lipid studies
 Repeat these at least BD for the first few days in most patients at risk
 Involve a dietician in management
 Replace electrolytes, aiming for K>4, Mg >1, Phosphate >1
 Add thiamine and multivitamin to the diet/IV administration
 Slowly increase calories to the patient’s calculated requirements

 Oral
 Water
 Clear fluids
 Free fluids
 Light diet
 Full diet
 NGT/OGT/NDT/ODT/NJT/OJT/PEG (percutaneous endoscopic gastrostomy)/PEJ
 Enteral feed formula
 TPN/parenteral nutrition
 Central for long term feeds
 Peripheral for short term feeds
 Both can be supplementary to any of the above options

 Clear fluid diets – about 400-500 kcal/day
 Free fluids – 900-1000kcal/day
 Energy requirements are 25-35 kcal/kg/day
 With 1.5g/kg/day ideal body weight of protein
 Protein: Fat: Glucose ratio 20:30:50% of daily calories

 Our GIT is designed for digestion and absorption
 Enteral feeds promote immunocompetence and maintenance of the integrity of
tissues
 Non-utilisation of the GIT leads to complications in critical care and geriatric
patients, even when for short periods
 It is cost effective compared to TPN, and does not have the risk of line sepsis

 To avoid periods of starvation within 24-72 h with oral/enteral feeds will be
INSUFFICIENT to achieve adequate intake in moderate-severely malnourished
patients
 When unable to use the GIT
 Intestinal obstruction
 Short bowel/intestinal failure/malabsorption
 High output enterocutaneous fistula(e)
 Non-functioning GIT
 Ischaemic bowel
 Severe shock with impaired splanchnic perfusion
 ESPEN Guidelines on Parenteral Nutrition

 http://espen.info/documents/Acutepancreatitis.pdf
 Mild to moderate pancreatitis
 No evidence that enteral vs paerenteral has a beneficial effect
 Nutritional therapy to be considered if refeding is delayed
 Usually fast for 2-5 days, treat cause, replace fluids and electrolytes, analgese, then
commence oral feeds from day 3-7) with a carbohydrate-rich, moderate-protein,
moderate-fat diet prior to normal diet
 Severe pancreatitis
 Essential to have nutritional support
 Parenteral vs enteral based on patient tolerance. ENTERAL FEEDS should be
attempted in all patients  some patients will require a combination
 Some authorities suggest early jejunal feeds, some suggest parental with small enteral
based on tolerance
 IV lipids safe with hypertriglyceridaemia is avoided
 Feeds of any kind reduce the hypercatabolic state seen in severe pancreatitis

 It is helpful to give epidural analgesia peri-operatively to decrease opioid
requirements, reduce effects on peristalsis, and improve post-operative cognitive
functions
 Anaesthetic guidelines have changed in many centres to allow clear fluids until 2h
pre-op (though not in this lady’s case) – pre operative glucose reduces insulin
resistance
 Aim would be to commence enteral feeds within hours of completing surgery
 NG/NJ vs oral dependent on patient status post operatively
 Oral is preferable – decreased length of stay associated with consuming orally vs having
a tube
 Consideration of TPN only if patient is not expected to meet >50% of required caloric
intake within 7 days of operation

 Surgical nutrition is complicated
 It’s not something you do on your own – involve the dietician, the patient and the
nursing staff
 It’s easy to make a big difference with small tweaks, even in the absence of allied
health input
 Always think about the little things you can do to optimise your patients
 Good peri-operative nutrition reduces cost and complications acutely as well as
improving survival at 5 years in oncological surgeries
 Educate
 Educate
 Educate

Surgical Nutrition