Role of nutrition and its importance for surgical patients

1. NUTRITION IN SURGICAL PATIENTS
MODERATER
Prof Surender Kumar (Ms)
Dr Kushagra Gaurav (Ms,mch)
Presented by:
Dr Ayushi Raj (JR2)
.

2. OVERVIEW
• MALNUTRITIION AND ITS IMPORTANCE
• METABOLIC RESPONSE TO STRESS,SEPSIS,SURGERY
• NUTRITIONAL ASSESSMENT
• CRITERIA
• HARRIS BENEDICT
• ESPEN GUIDELINE
• RECOMMENDATIONS
• INDICATIONS FOR NUTRITIONAL THERAPY
• METHODS OF FEEDING AND ROUTES
• COMPLICATIONS
• REFEEDING SYNDROME
• SUMMARY
O'Connell, P. R., McCaskie, A. W., & Sayers, R. D. (2023). Bailey & Love's short practice of surgery (27th ed.). CRC Press, Taylor &
Francis Group.

3. Why nutrition is important in
surgical patients?
1) Malnutrition is common in 30% of surgical patiets
with gastrointestinal diseases and 60% of them have
prolonged hospital stay due to post .operative
complications.
2) Impact of poor nutrition in surgical patients leads to
wound infection and delayed wound healing , sepsis,
pneumonia, post operative bleeding and anastomotic
site leak.
O'Connell, P. R., McCaskie, A. W., & Sayers, R. D. (2023). Bailey & Love's short practice of surgery (27th ed.). CRC Press,
Taylor & Francis Group.

4. Metabolic response to
starvation/stress/trauma
•Low insulin and high glucagon in first 12 hours
of starvation
•Glycogen stores are depleted and de novo
synthesis occurs from non carbohydrate source
gluconeogensis( in 24 hours)
•If starvation exceeds >24 hours breakdown of
fat stores occurs with increase in ketone bodies
O'Connell, P. R., McCaskie, A. W., & Sayers, R. D. (2023). Bailey & Love's short practice of surgery (27th ed.). CRC Press, Taylor &
Francis Group.

5. • Increase in regulatory hormones: adrenaline ,
nordrenaline, cortisol , growth hormone
• Increase in nitrogen requirements
• Insulin resistance and glucose intolerance
• Oxidation of lipids
• Protein catabolism
• Fluid retention with associated hypoalbuminemia
• Gluconeogenesis
O'Connell, P. R., McCaskie, A. W., & Sayers, R. D. (2023). Bailey & Love's short practice of surgery (27th ed.). CRC Press, Taylor &
Francis Group.

6. Effect of Metabolic response to
surgery on nutrition
• insulin resistance hyperglycemia
• Reduced activation of glut 4 transport protiens
leading to reduced glucose transport to
muscles.
• Muscle protein breakdown
• Combined hormonal and inflammatory
response causing acidosis,pain , immobility,
tissue damage and hypoxia
O'Connell, P. R., McCaskie, A. W., & Sayers, R. D. (2023). Bailey & Love's short practice of surgery (27th ed.). CRC Press, Taylor &
Francis Group.

7. NUTRITIONAL ASSESSMENT
• Nutritional assessment in critically ill patients is very difficult and
can be done by A,B,C,D:
• A: Anthropometric measurements
Mid arm circumference
Skin fold thickness
MAMC=MUAC(CM)-3.14 X TSF(CM)
BMI weight in kg/ height in m2
Body weight loss: >10% loss is considered significant in 3-6 months
O'Connell, P. R., McCaskie, A. W., & Sayers, R. D. (2023). Bailey & Love's short practice of surgery (27th ed.). CRC Press, Taylor &
Francis Group.

8. • B: BIOCHEMICAL TOOLS:
• albumin ( not a indcator of nutritional
assessment but for poor outcome in a critical
ill patient)
• pre-albumin ( better marker than albumin
due to short half life so early predictor for
acute nutritional changes)
O'Connell, P. R., McCaskie, A. W., & Sayers, R. D. (2023). Bailey & Love's short practice of surgery (27th ed.). CRC Press, Taylor &
Francis Group.

9. • CLINICAL ASSESSMENT:
General condition
Nutritional status
Loss of subcutaneous fat, edema , ascites
General and physical examination
O'Connell, P. R., McCaskie, A. W., & Sayers, R. D. (2023). Bailey & Love's short practice of surgery (27th ed.). CRC Press, Taylor &
Francis Group.

10. Criteria to start nutritional support
• Involuntary loss of > 10-15% of usual body
weight with 3-6 months
• BMI <18.5/kg/sq.m
• Serum albumin <3g/dl or
transferrin<200mg/dl in abscence of any
inflammatory state
• Catabolic process like burns,
polytrauma,sepsis
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

11. THE HARRIS BENEDICT EQUATION
• To calculate BMR/BEE:
• MALES: (10 X WEIGHT IN KG)+(6.25X HEIGHT IN CM)-(5
X AGE IN YEARS)+5
• FEMALES: (10 X WEGHT IN KG) + (6.25 X HEIGHT IN CM)
– ( 5 X AGE IN YEARS)-161
• In normal people BEE=1(20 kcal/day)
• Mild to moderate sepsis=1.4
• Severe sepsis =1.8
• Severe burns = 2 times
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

12. ESPEN GUIDELINES
• Early oral feeding is the preferred mode of nutrition
for surgical patients .
• Malnutrition and underfeeding are risk factors for
post operative complications
• Reduce perioperative stress and improve outcomes
• Pre habilitation : aims at including nutrition ,
physical exercise and stress reducing component
(preoperative) to decrease LOS and post operative
complications
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

13. ESPEN RECOMMENDATIONS
• PREOPERATIVE:
 Patients undergoing surgery with no risk of
aspiration shall drink clear fluids until 2hrs before
anesthesia and solids shall be allowed until 6 hours
before anesthesia.
 To inpact postoperative insulin resistance and LOS
preoperative carbohydrate treatment 2 hrs before
surgery can be considered
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

14. POSTOPERATIVE
 Early oral nutrition intake shall be continued after surgery.
 To take oral intake according to individual tolerance and also
according to the type of surgery involved eg: oral intake better
tolerated in patients of laparoscopic moreover than open colic
surgery
 Early oral/ enteral nutrition on POD-1 or POD-2 does not
cause imparement of healing and leading to reduced LOS
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

15. Indications in nutritional therapy
• Assess nutritional status before and after surgery as
preoperative fasting of more than 14 days has high
morbidity and mortality.
• Nutritional therapy is indicated if patient is
anticipated to unable to eat for than 5 days
• If nutritional therapy cannot be met by enteral
nutrition and oral for > 7 days, combination of
enteral and parenteral is recommended
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

16. • For parenteral nutrition all in one (three
chamber bag ) is preferred instead of multi
bottle system
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

17. • Severe nutritional risk according to espen
atleast with one following criteria:
Weight loss >10-15% within 6 months
BMI<18.5 kg/m2
Nutritional risk screening > 5
Serum albumin <30 g/l
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

18. ROUTES & METHODS OF FEEDING
ORAL
ENTERAL
PARAENTERAL
COMBINATIONS
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th
ed.). CRC Press, Taylor &amp; Francis Group.

20. ENTERAL ROUTE
• Indication: when oral intake is inadequate for
>3 days
Contraindications:
• Circulatory shck
• Mechanical bowel obstruction
• Intestinal ischemia
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

21. Enteral vs Parenteral
• More physiological
• Less costly
• Retains the hepatic function
• Maintains gut mucosa
• Prevention of bacteria from transcolation into
blood stream
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

22. O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

23. Complications of enteral feeding
 Occlusion /dislocation/malposition/leakage
 Reflux of gastric contents into the airway
 Nausea , abdominal cramps
 Bloating
 osmotic diarrhea
 Overfeeding
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

24. Parenteral feeding
INDICATION:
• GI FAILURE
• HIGH OUTPUT FECAL FISTULA
• INITIAL PHASE OF ACUTE SEVERE PANCREATITIS
ROUTES:
o Peripheral ( increased risk of thrombophlebitis)
o Central (subclavian>>ijv)
o PICC (less common)
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

25. O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

26. Reefeding syndrome
• Large amount of tpn is given in chronically
malnourished patient
• Anabolic shift state
• Metabolic changes:
• Hypocalcemia
• Hypophosphatemia
• Hypomagnesemia
• Hyponatremia
• hypokalemia
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

27. TAKE HOME MESSAGE
• Prehabilitation- this aims at reducing metabolic risks to
reduce perioperative stress and improve outcomes.
• Sacropenia is associated with increased risk of
postoperative major and total complications in patients
undergoing surgery
• It aims for a trimodial approach including nutrition ,
physical exercise and stress reducing compenent .
• Preoprative nutrition to decrease postoperative
infectious and non infectious complications
• Preoperative nutritional supplementation decreases
post operative complications and length of stay in
hospital
O'Connell, P. R., McCaskie, A. W., &amp; Sayers, R. D. (2023). Bailey &amp; Love's short practice of surgery (27th ed.). CRC Press, Taylor &amp;
Francis Group.

28. • THANK YOU!