1. Nutrition in
Surgery
Name: Nurzawani Binti Shamsudin
Matric No: 0918424

2. OUTLINE OF THE SEMINAR
• Definition
• Causes of inadequate intake
• Nutritional status, assessment,
& support
Introduction
• Introduction
• Indications
• Composition
• Complications
Enteral
nutrition
• Introduction
• Indications
• Composition
• Complications
Parenteral
nutrition

3. INTRODUCTION
1. Definition of nutrition & malnutrition
2. Causes of malnutrition
3. Objectives of nutritional support
4. Assessment of nutritional status
5. Estimating energy requirement
6. Estimating nutritional requirement.

4. NUTRITION
Definition
The taking in and metabolism of
nutrients (food and other nourishing
material) by an organism so that life is
maintained and growth can take place.
Dorland’s Pocket Medical Dictionary

5. MALNUTRITION
Definition
A disorder of nutrition or a wasting
condition resulting from energy and
protein deficiency, sometimes with
vitamin and trace element deficiency as
well.
Dorland’s Pocket Medical Dictionary

6. Malnutrition
 Causes
◦ Reduced food intake
 anorexia
 fasting
 pain on swallowing,
 physical or mental
impairment
◦ Malabsorption
 impaired digestion or
absorption
 excess loss from gut
◦ Altered metabolism
 trauma
 burns
 sepsis
 surgery
 cancer cachexia

7. IMPORTANCE OF
NUTRITION IN SURGERY
1. Surgical procedures (and subsequent fasting)
after admission can cause these patients to go
into severe malnutrition quickly, often before
the treating team realizes it.
2. There is evidence that patient with severe
protein depletion have greater incidence of
postoperative complication such pneumonia,
wound infection, & prolonged hospital stay.

8. Disease/surgery
Neuroendocrine stress response
Pro-inflammatory cytokine response
Metabolic change or/and reduced food
intake
Protein and energy loss
Slow recovery, poor wound healing, and
Increased infection

9. CAUSES OF INADEQUATE
INTAKE
Not
appetizing
food
weak and
anorexic
patient
increased
metabolic
demand
GI
obstruction
Cumulative
effects of
repeated
periods of
fasting
Intestinal
failure

10. OBJECTIVE OF
NUTRITIONAL SUPPORT
•Provide nutrition support consistent with patient’s medical
condition
•Prevent/ treat macronutrient and micronutrient deficiency
•Provide doses of nutrient compatible with existing
metabolism
•Avoid/ manage complications related to the technique of
nutrient delivery.
•Improve patient’s outcome such as those related to
morbidity
•To prevent and minimize the effect of catabolism

11. ASSESSMENT OF NUTRITIONAL
STATUS
Nutritional assessment
Depleted reserves
Muscle wasting, loss of
subcutaneous fat, albumin <
30 g/L, weight loss 10-15%.
Poor current intake
Anorexia/vomiting, poor
intake on food chart
NUTRITIONAL
SUPPORT
Likely clinical course
If not going to eat within next 5
days, if already malnourish and
at risk of further major
complication such as
abscess/fistula

12. ASSESSMENT OF
NUTRITIONAL STATUS
1. History
2. Diet assessment.
3. Physical Examination.
4. Investigation

13. ASSESSING PATIENT FOR
MALNUTRITION
1. Clinical assessment:
 Lack of nutritional intake for 5 days or more.
 Clinical appearance – does the patient
looked malnourished?
 Unintentional weight loss for more than 10%
from usual body weight for previous 6
months. More than 20% is likely to represent
severe malnutrition.
 BMI less than 18.5.
 History of poor nutrient intake: anorexia,
nausea, vomiting, early satiety and food
preference.

14. • Clinical nutritional history based on understanding of
the etiologies and pathophysiology of malnutrition.
• History of poor nutrient intake
• Anorexia
• Nausea
• Vomiting
• Early satiety
• Food preference
• Loss of body weight (see table)
• Weight loss of more than 10-15% during the past 6
months
EVALUATION OF
MALNUTRITION (HISTORY)

15. Percentage of weight loss and
impression
% weight loss Impression
5 Normal
10 -15 Risk
15 – 20 Malnutrition
20 – 30 Severe malnutrition
30 - 40 Incompatible

16.  Social & economic condition that may lead to poverty &
malnutrition
◦ Inadequate income
◦ Homeless
◦ Drug abuse
◦ Chronic alcoholism
 Gastrointestinal symptoms
◦ Dysphagia
◦ Recurrent vomiting
◦ Chronic diarrhea
◦ Food intolerance
 Other chronic medical illnesses
◦ Disseminated cancer
◦ COPD
◦ Chronic inflammatory disease
EVALUATION OF MALNUTRITION
(HISTORY)

17. EVALUATION OF MALNUTRITION
(PHYSICAL EXAMINATION)
Findings Interpretation
General appearance
 Weight loss
 Decreased temporal & proximal extremity
muscle mass
 Decreased “pinch test”
Malnutrition < 90% of ideal weight
Decreased skeletal protein
Decreased body fat stores
Skin, nails, hair
Easily plucked hair
Spooning of nails
Protein
Iron

18. Findings Interpretation
Skin, nails, hair
Easy bruising, perifollicular hemorrhage
“Flaky paint” of the lower extremity
Coarse skin, papular keratitis “goose
bumps”
Peripheral edema
Vitamin C
Zink
Vitamin A
Protein
Eyes
Conjunctival pallor
Bitot spot
Opthalmoplegia
Anemia (non-specific)
Vitamin A
Thiamine

20. Papular keratitis
Bitot spot
Perifollicular
hemorrhage
Nasolabial seborrhea
Flaky paint of lower

21. PHYSICAL EXAMINATION
ANTHROPOMETRY
Definition
• The science dealing with measurement of the size,
weight and proportions of human body
• It can assess level of energy reserves by estimate
amount of subcutaneous adipose stores.
• However it cannot identify specific nutrient deficiency

22. Anthropometric assessment:
 Triceps skin fold thickness (mm)
 Mid arm circumference (cm) :
Mid-upper circumference (cm) – (π x triceps skin fold thickness)
(cm)
% standard men women interpretation
100 12.5 16.5 Adequate
50 6 8 Borderline
20 2.5 3 Severe
% standard men women interpretation
100 25.5 23 Adequate
80 20 18.5 Borderline
60 15 14 Depletion
40 10 9 Severe

23. Body Mass Index

24. EVALUATION OF MALNUTRITION
(LABORATORY INVESTIGATION)
To detect subclinical nutritional deficiencies
in patients
• Nitrogen Balance
• Serum Albumin
• Creatinine excretion
• Immunological Function assessment

25.  Nitrogen balance
◦ Nitrogen balance provides an index of protein gain or loss:
6.25 protein gained is equivalent to 1 g nitrogen
◦ Can be assessed by measuring the difference between nitrogen
consumed (mouth, enteral tube or IV) and nitrogen excreted in the
urine, feces and other intestinal sources.
◦ In most cases, total urine nitrogen can be calculated by dividing 24-h
urinary urea nitrogen by 0.85 & assuming approximately 2g/d for
nitrogen losses in feces & sweat.
Blood indices:
Nitrogen Intake – loss [90% urine, stool 5%, integument 5%]
or
[Protein intake (g)/6.25] – urinary urea (g) – 2(for stool & skin) –
2(non-urea nitrogen)

26.  Serum Albumin
◦ Serum albumin level falls during the acute stress of surgery,
sepsis or other acute inflammatory illness because of
 increased circulating extravascular volume
 TNF-α mediated inhibition of albumin synthesis
◦ The measurement of serum proteins, in particular albumin, is
often used as an index of malnutrition (<35g/L)
◦ Sensitive but non-specific.
◦ The half-life of albumin is 14 to 18 days.
◦ Prealbumin (half-life, 3 to 5 days) or transferrin (<200 mg/dL;
half-life, 7 days), have been proposed as more sensitive
indicators of rapid changes in nutritional status.
Blood indices

27.  Creatinine Excretion
◦ Creatinine is a metabolic product of skeletal muscle
creatine.
◦ It is produced constantly in an amount directly
proportional to skeletal muscle mass.
◦ With steady state a day-to-day renal function, each
gram of creatinine in the 24-h urine collection
represents 18.5g of fat free skeletal muscle.
◦ Measurement of creatinine in 24-h urine collection
can be used as a relative measure of this body
compartment.
Blood indices

28.  Immunological assessment
◦ Delayed cutaneous hypersensitivity or anergy, most
commonly tested by delayed reaction to skin recall
antigens, was widely used in early studies of nutritional
assessment and is a manifestation of cell-mediated
immunity
◦ Total Lymphocyte count is often <1000 /μL in PCM and
may accompany anergy to common skin test antigens.
◦ However, not all malnourished patients are at risk and the
defect is immunologic, not nutritional.
Blood indices

29. Adverse effect of protein or
calories depletion
 Impaired wound healing and higher rate of wound
breakdown.
 Impaired immune function and the ability to against
infection.
 Skeletal muscle mass is lost, reducing muscular
strength and general physical activity as well as
causing fatigue.
 Thoracic muscle mass depletion depresses
respiratory efficiency and increase risk of pneumonia.
 Albumin becomes depleted leading to generalized
edema.

30. Adverse effect cont.
 Small bowel mucosa atrophy reduces its ability to absorb
nutrient and may lead to bacterial translocation into
bloodstream because loss of mucosal integrity.
 Impaired mental function leads to apathy, depression and
low morale.
 Post operative complication rates are higher.
 Prolonged recovery times and longer hospital stay.

31. ASSESSMENT OF
NUTRITIONAL REQUIREMENT
 Energy and protein requirement vary depending on
weight, body composition, clinical status, mobility and
dietary intake.
 Few patients require more than 2500 kcal/day.
Additional calories are unlikely to be used effectively
and may constitute a metabolic stress.
 Refeeding the chronically starved patient must be
cautious because of the dangers of hypokalemia and
hypophosphatem.ia
uncomplicated Complicated/stresse
d
Energy (kcal/kg/day) 25 30 – 35
Protein (g/kg/day) 1.0 1.3 – 1.5

33. REFERENCES
 Garden’s Principles & Practice of
Surgery, 5th edition.
 Burkitt’s Essential Surgery, 4th edition.
 Medical Nutrition Therapy Guidelines
for nutrition support in critically ill adult
by Ministry of Health, Malaysia

34. Metabolic Response to
Starvation
 After 12 hours of not feeding
 Plasma insulin level falls
 Glucagon rises
 Hepatic glycogen is gradually converted into
glucose
 With prolong starvation, muscle glycogen is
broken down and converted into lactate
which is taken to the liver and converted to
glucose
 After 24 hours
 Hepatic gluconeogenesis from amino acids
precursors start with loss of about 75g of
skeletal muslce protein per day.

35. Metabolisms in starvation and
stressed state
Muscle
Protein
75g
Fat stores
Tryglicerides
Amino acid
Glycerol
Fatty acid
Liver
Glycogen
75g
gluconeogenesis
Oxidation
Fatty acid
Glucose
180g
brain
RBC
WBC
Neurons
Kidney
muscle
Lactate +pyruvate
Ketone Heart
Kidneys
muscle
Fig :Metabolism during fasting (<5 days)

36. Muscle
Protein
250g
Fat stores
Tryglicerides
Amino acid
Glycerol
Fatty acid
KIDNEY
gluconeogenesis
Gluconeogenesis
LIVER
oxidation
Fatty acid
Glucose
360g
Wound
RBC
WBC
Nerve
Muscle
Kidney
Lactate
+pyruvate
Ketone
Heart
Kidney
MuscleFig: Fuel utilization following trauma
In Acute injury, significant alteration in substrate utilization. There is enhanced nitrogen
loss indicative of protein catabolism.

37. ENERGY REQUIREMENT
oBEE (men) = 66.47 + 13.75 (weight) + 5.0 (height) – 6.76 (age) x
(activity factor) x (injury factor) kcal/day
oBEE (women) = 655.1 + 9.56 (weight) + 1.85 (height) – 4.68 (age)
x (activity factor) x (injury factor) kcal/day
BEE = Basal Energy Expenditure = quantity of energy
required to satisfy the requirements of the body at rest
oEquation adjusted for type of surgical stress
oSuitable for estimating energy requirement in >80% of patients
oProvision of 30kcal/kg/day will adequately meet energy
requirement ( reduce risk of overfeeding)
oActivity factor
伉 confined to bed :1.2
伉 out of bed :1.3
oInjury Factor
伉 minor operation :1.20
伉 skeletal trauma :1.35
伉 Major sepsis :1.60
伉 severe thermal burn :1.5

38. •Estimation of energy and protein
requirement:
Uncomplicated Complicated
Energy 30 34 – 40
(kcal/kg/day)
Protein 1.0 1.3 – 2
(g/kg/day)
•24-hour urinary urea excretion
• Common method for assessing protein
requirement