2. AIMS OF DISCUSSION
INTRODUCTION
GOAL OF NUTRITIONAL SUPPORT
MALNUTRITION
NUTRITIONAL ASSESSMENT
ESTIMATION OF ENERGY NEEDS
NUTRITION ADMINISTRATION
FORMULA FOR EN AND PN
TAKE HOME MESSAGES
3. INTRODUCTION
Nutrition is the process of providing or obtaining the foods necessary
for health and growth.
The general indications for nutritional support in surgery are in the
prevention and treatment of under nutrition.
Dietary nutrition supplies carbohydrates, lipids and proteins that drive
cellular metabolism.
4. Cont…
Chemical processes that maintain cellular viability consist of catabolic
(breakdown) and anabolic (synthesis) reactions. Catabolism produces
energy, whereas anabolism requires energy.
Feeding drives synthesis and storage, whereas starvation promotes the
mobilization of energy.
Normal functioning of human body requires a balance between
nutritional intake and metabolism
6. GOAL OF NUTRITIONAL SUPPORT
Identify those patients at risk of malnutrition.
Prevent or reverse the catabolic effect of disease or injury
To meet the energy requirements of metabolic process
To maintain a normal core body temperature
To provide substrates for adequate tissue repair
7. Metabolic Response to Starvation
Low plasma Insulin and high plasma Glucagon
Hepatic Glycogenolysis and Gluconeogenesis
Protein catabolism
Lipolysis
Adaptive ketogenesis
Reduction in resting energy expenditure ( from 25-30 kcal/kg/day to
15-20 kcal/kg/day.
8. Metabolic response to Trauma and Sepsis
Increased counter regulatory hormones like Adrenaline,
Noradrenaline, Cortisol, Glucagon and GH.
Increased energy requirement up to 40kcal/kg/day
Increased Nitrogen requirements
Preferential oxidation of lipids
Increased Gluconeogenesis and protein catabolism
Fluid retention and associated hypoalbunaemia.
9. Who will need nutritional support?
Well nourished and mildly malnourished patients who cannot take oral
food for more than one week post operatively to avoid prolonged
starvation.
Severely malnourished patients undergoing general surgery
procedures.
All critically ill patients (Sepsis patients, Multiple Injury patients,
Burn patients, etc.)
Patients whom you predict cannot use their gut for prolonged period
of time (Short gut syndrome, EC fistula, etc.)
10. When to Start?
Preoperatively in severely malnourished patient undergoing a major
surgical operation.
Immediately postoperatively in severely malnourished patients.
Immediately after major trauma, sepsis, major burns.
Normal or mildly malnourished patient who is unable to eat on his
own by 7 days after surgery.
11. NUTRITIONAL REQUIREMENT
Calories provided mainly by carbohydrate and fat
- Fat = 9 kcal/ g
- Carbohydrate = 4 kcal/ g
- Protein = 4 kcal/ g
Daily caloric requirements: 30-35kcal/kg /day.
Metabolic stress associated with sepsis, trauma, surgery or ventilation
lead to increase energy requirement (35-40kcal/kg/day)
12. MALNUTRITION
Condition that develops when the body does not get the right amount
of the calorie, vitamins, minerals and other nutrients it needs to
maintain healthy tissues and organ function.
Can occur in people who are either undernourished or over-
nourished.
Occurs in about 30% of surgical patient with GI disease and in up to
60% of those in whom hospital stay has been prolonged because of
post op complications.
13. Impact of poor nutrition in surgical patients
Wound infection
Sepsis
Pneumonia
Post operative bleeding
Anastomotic leak
All these results in prolonged recovery period, prolonged hospital stay
and nursing care finally increase the medical cost.
14. Nutrition in emergency surgical patients
In emergency surgical patients who are malnourished, operative
procedure must be done as early as possible as life saving procedure.
There is window of opportunity within first 24 to 72 hours following
a surgery, in which starting enteral feeding is associated with
preserving gut integrity as well as diminishing the activation of
inflammatory cytokines.
When patient can not tolerate oral/enteral feeding for >7 days then
parenteral nutrition should be started mainly TPN, Human Albumin,
Amino acid, Lipid emulsion.
15. ESPEN GUIDELINE
Under nutrition:
- BMI <18.5 kg/m2.
- Weight loss >10-15% within 6 months.
- Serum albumin <30g/L (with no evidence of hepatic or renal
dysfunction).
- <80% of ideal body weight
Over nutrition:
- BMI >30kg/m2
.
- Body weight >20% from ideal body weight
16. Malnutrition Universal Screening Tool (MUST)
Parameter Range Score
1. BMI: >20kg/m2 0
18.5-20kg/m2 1
<18.5kg/m2 2
2. Wt. loss in 3-6 mon. <5% 0
5-10% 1
>10% 2
3. No nutritional intake for 2
>5 days
17. Interpretation of MUST Tool
SCORE 0: Low risk of undernutrition, needs only routine clinical care with
treatment of underlying conditions, repeat screening every week in hospital, every
month in care homes, every year for special (old age) groups in community.
SCORE 1: Medium risk of undernutrition, document intake for 3 days in hospital or
care homes, repeat screening from <1 month to >6 months with dietary advice.
SCORE 2 OR MORE: High risk for undernutrition, refer to dietician or implement
local policies, need food and food fortification and supplements in hospital, care
homes or community.
18. BMI
Underweight - <18.5kg/m
2
Normal - 18.5 – 24.9kg/m
2
Overweight - 25.0 – 29.9kg/m
2
Obese Class I - 30.0 – 34.9kg/m
2
Obese Class II - 35.0 – 39.9kg/m
2
Obese Class III - ≥ 40kg/m
2
20. HISTORY
Enquiries about presenting complaints like Vomiting, Diarrhoea and
Dysphagia.
Specific enquiries pertinent to nutritional status include recent history
of Weight fluctuation with attention as to the timing and intent.
Enquiries about co-morbidities like Obesity, Malignancy, IBD.
Social & Dietary History.
22. Laboratory Tests
CBC – Haemoglobin (HCMC anaemia), Total Leucocytes count
LFT – Serum albumin
Serum Transferrin
Serum Prealbumin
Others
- Nitrogen balance – for adequacy of protein intake.
- Electrolytes/Creatinine
23. ESTIMATION OF ENERGY NEEDS
Indirect calorimetry:-
• Remains the gold standard in measuring energy expenditure in the
clinical setting.
• Measures CO2 production and O2 consumption during rest and
exercise at steady-state to calculate total energy expenditure (TEE).
• Indirect calorimetry allows for gas analysis and calculation of RQ.
• RQ is 1.0, 0.7 and 0.8 for glucose, fat and protein respectively.
• RQ higher than 1.0 suggests over feeding and lipogenesis.
24. Basal energy expenditure (BEE):-
Can be predicted by using the Harris-Benedict equation (in kilocalories per
day).
For men equals
66.5 + [13.7 × weight (kg)] + [5 × height (cm)] – [6.8 × age (years)].
For women equals
655 + [9.6 × weight (kg)] + [1.8 × height (cm)] – [4.7 × age (years)].
25. Total Energy Expenditure(TEE):-
TEE = BEE x Activity Factor x Stress Factor x Thermal Factor
ACTIVITY FACTOR:
Bed rest – 1.2
Mobile – 1.3
THERMAL FACTOR:
380c – 1.1, 390c – 1.2, 400c – 1.3, 410c – 1.4
26. STRESS FACTOR:
Starvation - 0.8
Postoperative – 1 to 1.05
Cancer – 1.1 to 1.45
Sepsis – 1.25 to 1.55
Multiple Trauma – 1.25 to 1.55
Burn – 1.5 to 1.7
27. Estimates of Protein Requirements:
Non stressed patients should receive 0.8 to1.2 g/kg/day of protein.
Critically ill generally require 1.2 to 1.5 g/kg/day
Burn, septic, and obese patients may require 1.5 to 2 g/kg/day.
29. PRINCIPLES GUIDING NUTRITION
Use the oral route if the GI tract is fully functional and there are no
other contraindications to oral feeding.
Initiate nutrition via the enteral route if the patient is not expected to
be on a full oral diet within 7 days post surgery and there are no GI
tract contraindications
If the enteral route is contraindicated or not tolerated, use the
parenteral route within 24 to 48 hours in patients who are not
expected to be able to tolerate full enteral nutrition (EN) within 7
days.
30. Administer at least 20% of the caloric and protein requirements
enterally while reaching the required goal with additional Parenteral
nutrition .
Maintain PN until the patient is able to tolerate 75% of calories
through the enteral route and EN until the patient is able to tolerate
75% of calories via the oral route
34. ORAL ROUTE
Oral administration of nutrition is the preferred route since it is the
most physiologic and the least invasive.
Mental Alertness and Orientation Patients who have altered
mentation are at increased risk for aspiration and should not begin an
oral nutrition regimen.
Intact Chewing/Swallowing Mechanism Patients who have had a
stroke or undergone pharyngeal surgery may have difficulty
swallowing. They may be candidates for modified oral diets.
35. NUTRITION IN POST OPERATIVE PATIENTS
Oral/ enteral route is preferred in post operative patients unless
contraindicated.
Early post operative enteral feeding decreases the incidence of
infectious complication and maintain mucosal barrier function.
However, in patients who can not tolerate enteral feeds or they are
contraindicated, the parenteral route is used.
36. DIET SELECTION
Transitional diets minimize digestive stimulation and colonic
residue while providing more calories than IV fluids alone in patients
recovering from postoperative ileus.
Clear liquids provide fluids mostly in the form of sugar and water.
For short-term use after an acute illness or surgery (GI procedure).
Regular diet represents an unrestricted regimen that includes various
foods designed to meet all caloric, protein, and elemental needs.
37. ENTERAL NUTRITION (EN)
Delivery of nutrient into healthy and functioning GI tract.
Most preferred when oral route is contraindicated.
Advantages are:-
1. Maintain gut mucosal integrity
2. Maintain normal gut flora & pH
3. Cheap & easily available
4. Less complication
38. Indications of EN
Oral intake < 50% of required in the previous 7-10 days.
Dysphagia or chewing problem due to strokes, brain tumor, head
injuries.
Major burns.
Low output GIT fistulas (< 500 ml/day).
39. Contraindication of EN
Mechanical obstruction of GIT.
Prolonged ileus
Severe GI haemorrhage
Severe diarrhoea
Intractable vomiting
High output GIT fistula (>500ml/day)
Severe enterocolitis
41. Patient must be haemodynamically stable before starting enteral
nutrition
The contraindications of enteral nutrition as stated earlier must be
ruled out.
The choice of route must be made, the least invasive ones are
preferred
42. NASOENTERIC:
Head end of the bed raised to 35 degrees.
20-30 ml/hr are administered initially and gradually increased.
Residual volumes should be checked 1 hour after meal and it should
not exceed 50ml/hr.
Signs of intolerance should be monitored and rate and osmolarity
adjusted accordingly.
43. GASTROSTOMY
Placement of a tube through the abdominal wall directly into the stomach.
Stamm Gastrostomy (sero-lined) – temporary
Janeway Gastrostomy (mucous-lined) – permanent
45. PER CUTANEOUS ENDOSCOPIC GASTROSTOMY
2 methods of PEG:-
Ponsky pull technique
Push through technique (Sacks-Vine)
48. ENTERAL FORMULA
1. LOW RESIDUE ISOTONIC FORMULAS:
Calorie density of 1 kcal/ml
Non protein-calorie : nitrogen ratio =150:1
No fibre, no bulk, no residue
Cheap, first line for stable GI tract
49. Cont…
2. ISOTONIC FORMULA WITH FIBER :
Soluble and insoluble fiber
Stimulate pancreatic lipase activity
Degradation into short chain fatty acids
50. Cont…
3. IMMUNE ENHANCING FORMULAS:
Glutamine, arginine, omega-3 fatty acids, nucleotides, beta carotene
4. CALORIE DENSE FORMULA: 2kcal/ml
5. HIGH PROTEIN FORMULA
51. Cont…
6.ELEMENTAL FORMULA:
Pre-digested nutrients.
Adv: Ease of absorption in gut impairment, pancreatitis.
Disadv: Poor in fat, vitamin, trace elements.
High osmolarity, high cost.
7. SPECIAL FORMULAS:
Renal/Pulmonary/Hepatic failure patients
52. Complication of EN
TUBE RELATED:-
- Malposition of tube
- Displacement of tube
- Blockage of tube
- Break/Leakage
- Aspiration
54. Cont…
METABOLIC/BIOCHEMICAL:-
- Electrolyte imbalance
- Vitamin, Mineral, Trace element deficiency
REFEEDING SYNDROME:-
- After prolonged fasting period
- Leads to sudden rise in insulin and electrolyte abnormalities resp,
hepatic and renal dysfunction
- Rate of feeding should be slow at starting
55. PARENTERAL NUTRITION
Delivery of all nutritional requirements by IV route without the use of
GIT (bypass GIT).
Sterile liquid chemical formula are used.
May be delivered via :
- Central line
- Peripheral line
The high cost and complications has limited its use.
56. INDICATIONS OF TPN
GIT Malfunction
1. OBSTRUCTED: Carcinoma oesophagus/stomach, stricture
2. FISTULATED: Post op entero-cutaneous fistula, high output fistulas
3. INFLAMMED: Crohn’s disease, acute severe pancreatitis
4. TOO SHORT: Massive resection, short gut syndrome.
Pre operative : Build up of malnourished patient
57. Cont…
Failure of enteral feeding to meet caloric requirement:- Major
polytrauma, major burns.
Cancer : complication of chemotherapy, radiotherapy
Newborns:
- GIT anomalies
- NEC
58. PRE OPERATIVE PN
Indicated in :
-Severely undernourished patients who cannot be adequately enterally fed.
-In cancer cachexia patients who are planned for operative procedure.
Studies have shown that :
- Inadequate oral intake of >14 days => higher mortality
- 7-10 days of preoperative PN => improves postoperative outcome in severe
undernourished patient.
59. POST OPERATIVE PN
Indicated in:
Undernourished patients and enteral nutrition is not feasible / not tolerated
Patients with postoperative complications with impairing gastrointestinal
function => unable to receive and absorb adequate amounts of oral/enteral
feeding for at least 7 days
Post operative PN is life saving in patients with prolonged gastrointestinal
failure.
60. Advantages of TPN
Can be used for longer periods with hyperosmolar fluids at larger
volumes
Survival rate is improved and morbidity reduced.
Weight loss and tissue breakdown are minimized
Wound healing is enhanced
Resistance to infection and general immunity are improved
Formation of RBCs and plasma proteins is maintained
61. Total Parenteral Nutrition Partial Parenteral Nutrition
Central line Peripheral line
Supplies all daily nutritional requirement Only part of the daily nutritional
requirements supplied, supplementing oral
intake ~ 50-70% of patient’s energy needs
Long term support (>10 days) Short term support (10-14 days)
Hypertonic solutions with high osmolarity
(1000-1900mOsm/L)
Formulation with low osmolarity (< 900
mOsm/L )
62. FORMULA FOR PN
2 in 1 solution : 60-70% dextrose, 10-20% amino acids (Nutriflex
Peri, Nutriflex Plus).
3 in 1 solution : In addition it has 10-30% lipid emulsions
(NuTRIflex Lipid Peri, NuTRIflex Lipid Plus, Kabiven).
In addition – sterile water, electrolyte, mineral and vitamins.
64. COMPLICATIONS OF PARENTERAL NUTRITION
ACUTE:-
Refeeding syndrome
Hyper/ hypoglycaemia
Fluid or electrolyte abnormalities
Catheter leak
Air embolism
Catheter related sepsis
65. LATE:-
Metabolic bone diseases : osteoporosis
Hepatic complications : fatty liver, liver failure, hyperammonemia
Gallbladder complications: cholestatic jaundice
Venous thrombosis
Catheter related sepsis
Vitamin and traced element deficiency
66. REFEEDING SYNDROME
Characterised by severe fluid and electrolyte shift in malnourished
patients undergoing refeeding.
More common with parenteral nutrition.
Results in Hypophosphataemia, Hypocalcaemia, Hypomagnesaemia.
These can results in altered myocardial function, arrhythmia,
deteriorating respiratory function, liver function, seizure, confusion,
coma, tetany, death.
High risk patients are alcohol dependent and severe malnutrition.
T/t – Avoiding overfeeding, vit administration, correction of electrolyte.
67. IMMUNO NUTRITION
Nutrients affecting the immune system
Recognised: arginine, glutamine, omega-3 fatty acids, nucleotides
Potential : vit C and E, selenium copper zinc, taurine, branched chain
amino acids, n acetyl-cysteine.
68. IMPACT ON OUTCOME
For well nourished or mildly malnourished general surgery patients,
peri-operative nutritional support did not improve outcome and
actually is associated with increased septic complications after
surgery.
For severely malnourished patients before a major surgical
procedure, peri-operative nutritional support reduced postoperative
complications (wound complications, prolonged hospital stay, ICU
days, use of hospital resources) by about 10%, without significant
increase in infectious complications.
69. TAKE HOME MESSAGES
Malnutrition leads to prolong stay, prolong recovery period and increased
medical cost
Normal caloric requirement = 30-35kcal/kg/day, Metabolic stress = 35-
40kcal/kg/day
Use enteral feeding unless contraindicated
Low osmolarity PN (<900mOsm/L) given via peripheral line
In high risk patient to develop re feeding syndrome, we should start with low
calories
Parameters that required daily monitoring are glucose, electrolytes, I/0 and
temperature
70. REFERRENCES
Williams, Norman S., P. Ronan O’Connell, and Andrew McCaskie.
Bailey & Love’s Short Practice of Surgery, 27th Edition: The
Collector’s Edition. CRC Press, 2018.
Townsend, Courtney M., R. Daniel Beauchamp, B. Mark Evers, and
Kenneth L. Mattox. Sabiston Textbook of Surgery E-Book. Elsevier
Health Sciences, 2016.
ESPEN Guidelines on Enteral/Parenteral Nutrition: Surgery 2012
edition