NUTRITION IN

SURGERY

Afifah Jaafar
 OVERVIEW
• Malnourishment and nutrition
• Estimating requirements
• Enteral nutrition
• Parenteral nutrition
 WHY THIS TOPIC?
• Over 25% of hospital inpatients may
be malnourished
• Good nutrition is the foundation of
good“Malnutrition
health is a broad term commonly used
as an alternative to undernutrition but
technically it also refers to overnutrition.
People are malnourished if their diet does not
provide adequate calories and protein for
growth and maintenance or they are unable to
fully utilize the food they eat due to illness
(undernutrition). They are also malnourished if
they consume too many calories
(overnutrition).”
UNICEF
WHY MALNOURISHED?
IDENTIFYING MALNOURISHED
PATIENT
• HISTORY: recent wt loss,
reduced intake, diet change,
N+V, diarrhoea, pain
• EXAMINATION: hydration
state, evidence of
malnutrition, BMI,
anthropometric indices eg mid
arm circumference, skin fold
measures, grip strength
• Ix: Albumin
 PREVENTION
• Identify those at risk
• Uninterrupted meals
• Appetising food
• Refer to dietician early
 POOR NUTRITION
• Delayed wound healing
• Muscle weakness
• Increased tendency to infection
 ENERGY REQUIREMENTS
• Provided by carbohydrate and fats, also protein
in starvation
– 1g carbohydrate = 4 kCal
– 1g fat = 10 kCal
– 1g protein = 4 kCal
• Fundamental goal of nutrition support:
– Energy requirements for metabolic process
– Substrate requirements for protein synthesis
 ENERGY REQUIREMENTS
• Target energy: 25-30 kCal/kg/day
• Following trauma or sepsis, energy
substrates demand are increased
• Some equations are available eg
harris Benedict
Condition kCal/kg/da Adjustment Grams of Non protein
y above BEE protein/kg/da calories:
y nitrogen

Normal/ 25-30 1.1 1.0 150:1

moderate
malnutrition

Mild stress 25-30 1.2 1.2 150:1

Moderate stress 30 1.4 1.5 120:1

Severe stress 30-35 1.6 2.0 90-120:1

Sepsis 35-40 2.0 2.5 90-100:1

SUBSTRATE REQUIREMENTS
• To prevent use of protein as energy
source
• Appropriate non protein
calorie:nitrogen ratio is 150:1
• 1g N = 6.25g protein
 PRACTICALLY…
• A patient weighing 50kg
Condition kCal/kg/day Adjustment Grams of Non protein
above BEE protein/kg/day calories:
nitrogen
Normal/
moderate 25-30 1.1 1.0 150:1
malnutrition
• Energy requirement = 30 x 5
~ 1500 kCal/day
• Carbohydrate requirement = 1500/4 = 385g CHO
• Appropriate ratio = 150:1 = 1500:10
• Protein requirement = 10g N x 6.25
= 62.5g protein
 PRACTICALLY…
• A patient weighing 50kg
Condition kCal/kg/day Adjustment Grams of Non protein
above BEE protein/kg/day calories:
nitrogen
Normal/
moderate 25-30 1.1 1.0 150:1
malnutrition

• Protein requirement = 50g/day

= 50/6.25 = 8g N
• Appropriate ratio = 150:1 = 1200:8
At least 1200 kCal non protein should be provided
• Energy requirement = 30 x 5 x 1.1
= 1650 kCal/day
• Carbohydrate requirement = 1500/4 = 385g CHO
 ACCESS OF NUTRITION

Enteral

vs

Parenteral
 ENTERAL NUTRITION (EN)
• Nutrition given into GI
tract
• Preferred over PN
based on reduced cost
and associated risks of
IV route
• Reduces intestinal
mucosal atrophy
STUDIES ON ENTERAL
NUTRITION
 ENTERAL FORMULAS
• Factors determining types used:
– Functional status: pt with intact GI tract
will tolerate complex solution
– Extent of organ dysfunction
– Nutrient needs to restore optimal
function and healing
– Cost of specific products
 Osmolality of Selected Liquids/
Medications
Liquid or Drug mOsm/kg
EN formulas 250 to 710
Milk 275
Sodas 695
Juices ~990
Ice Cream 1150
Acetominophen elixir 5400
Diphenoxylate suspension 8800
Chloral hydrate 4400
Metoclopromide 8350
 Osmolality
• Isotonic formula = osmolality ~300 mOsm
• Body attempts to restore the 280 – 300 mOsm
• Enteral feedings range from < 300 – 700
mOsm/kg
• Formulas with high osmolality may cause shift of
water into intestinal space = rapid transit,
diarrhea
• Medications tend to be hypertonic; may need to
be diluted to decrease hypertonicity when given
via tube
• Low residue isotonic formulas
• 1 kCal/mL
• Low residue isotonic formulas
• 1 kCal/mL
Access options Comments

NG tube Short term use; aspiration risks; nasopharyngeal trauma;

frequent dislodgement
Nasoduodenal/ Short term use; lower aspiration risks; placement
nasojejunal challenge
PEG tube Endoscopy skills required; may be used for gastric
decompression or bolus feeds; aspiration risks; long
term; complicated by site leaks
Surgical Requires GA and small laparotomy
gastrostomy
Fluoroscopic Blind placement using needle and T-prongs to anchor to
gastrostomy stomach
PEG-jejunal tube PEG placement 1st then fluoroscopic conversion

Direct PEJ Direct endoscopic placement with enteroscope;

placement challenges; greater risks of injury
Surgical Commonly applied during laparotomy
jejunostomy
Fluoroscopic Difficult approach; not commonly done
jejunostomy
 Functioning GI tract? Consider PN
YE
S
Start feeding at 20-40
mls/H

Aspirate 4 hourly

•Return 200 mls

Aspirate > 200 mls
aspirate to patient
NO •Exclude bowel
obstruction
Return aspirate to patient, •Administer
increase by 20 mls after 3 prokinetic agent
cycles •Reduce rate by
Aspirate 4 hourly 50%
Consider small
bowel feeding,
Increased rate to meet
elemental feeding,
caloric needs
supplemental PN
 GUIDELINES FOR SUCCESS
• Use fine bore (9 Fr) NG feeding when
possible
• Check position
• Build up feeds gradually
• Weigh weekly, check bld glucose and
plasma electrolytes
• Treat underlying conditions vigorously
 PARENTERAL NUTRITION
• Bypasses the GI tract
• Direct into
bloodstream
• To deliver complete
nutritional
requirements or as a
supplement to
enteral feeding
• Central line
• Hickman line
• Peripheral line

INDICATIONS: When use of enteral

feeding is not possible or inadequate
 COMPLICATIONS
• Infection
– Sterile technique during line insertion & feeding
connection
– Stop the feed, remove and reinsert CVL
• Villous atrophy
– Gut wall more permeable to bacterial flora
– Use enteral feeding where possible
• Electrolyte imbalance
– Proper monitoring
• Hyperglycaemia
– Close d-scan monitoring
– May need temporary insulin administration
 GUIDELINES FOR SUCCESS
• Meticulous sterility
• If infection is suspected, remove line and
culture its tip
• Do not use the line for uses other than
nutrition
• Monitoring: FBC, BUSE/Creat/RBS/Ca/PO4
daily until stable then 3x/wk, LFT and
lipid 3x/wk until stable then wkly
• Do not rush
• Treat underlying conditions vigorously