التغذية لمرضي الجراحة للزملاء المتقدمين لامتحانات اجنبية زي MRCS و للزملاء اللي منتقلين حديثا للعمل بالمملكة المتحدة او بينوو العمل فيها تابعونا علي الصفحة الجراح https://www.facebook.com/algarra7/ عنوان الفيديوعلى اليوتيوب https://youtu.be/PNe2e41pv_w

1. Surgical
Nutrition
Unwell Surgical Patient

2. Entral Feeding
• Oral
• NG
• NJ
• RIG
• Gastrostomy
• RIJ
• Jejunostomy
• RIG with jejunal extension
• Distal feeding

3. TPN
• Peripheral
• Central line
• Tunnelled line
• PICC

4. Assessment / MUST
• https://www.bapen.org.uk/screening-and-
must/must-calculator

5. Indications (NICE Guidance)
• Nutrition support should be considered in people who are malnourished,
as defined by any of the following:
• a body mass index (BMI) of less than 18.5 kg/m2
• unintentional weight loss greater than 10% within the last 3–6 months
• a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within
the last 3–6 months.
• Nutrition support should be considered in people at risk of malnutrition,
defined as those who have:
• eaten little or nothing for more than 5 days and/or are likely to eat little or nothing
for 5 days or longer
• a poor absorptive capacity and/or high nutrient losses and/or increased nutritional
needs from causes such as catabolism.

6. Requirements
• For people who are not severely ill or injured, nor at risk of refeeding
syndrome, the suggested nutritional prescription for total intake[7]
should provide all of the following:
• 25–35 kcal/kg/day total energy (including that derived from protein[9],[10])
• 0.8–1.5 g protein (0.13–0.24 g nitrogen)/kg/day
• 30–35 ml fluid/kg (with allowance for extra losses from drains and fistulae, for
example, and extra input from other sources – for example, intravenous
drugs)
• adequate electrolytes, minerals, micronutrients (allowing for any pre-existing
deficits, excessive losses or increased demands) and fibre if appropriate.

7. Refeeding
• Nutrition support should be cautiously introduced in seriously ill or
injured people requiring enteral tube feeding or parenteral nutrition.
It should be started at no more than 50% of the estimated target
energy and protein needs. It should be built up to meet full needs
over the first 24–48 hours according to metabolic and gastrointestinal
tolerance. Full requirements of fluid, electrolytes, vitamins and
minerals should be provided from the outset of feeding.
• People who have eaten little or nothing for more than 5 days should
have nutrition support introduced at no more than 50% of
requirements for the first 2 days, before increasing feed rates to meet
full needs if clinical and biochemical monitoring reveals no refeeding
problems.

8. Refeeding / Risk
• Patient has one or more of the following:
• BMI less than 16 kg/m2
• unintentional weight loss greater than 15% within the last 3–6 months
• little or no nutritional intake for more than 10 days
• low levels of potassium, phosphate or magnesium prior to feeding.
• Or patient has two or more of the following:
• BMI less than 18.5 kg/m2
• unintentional weight loss greater than 10% within the last 3–6 months
• little or no nutritional intake for more than 5 days
• a history of alcohol abuse or drugs including insulin, chemotherapy, antacids
or diuretics.

9. Monitoring
• https://www.nice.org.uk/guidance/cg32/resources/nutrition-support-
for-adults-oral-nutrition-support-enteral-tube-feeding-and-
parenteral-nutrition-pdf-975383198917

11. Albumin

12. Emergency laparotomy
• Adequate nutrition is vital for recovery from major surgery and it is recommended that
nutritional status be formally assessed both pre‐ and postoperatively. Where time allows,
the nutritional status of patients should be optimised pre‐operatively in discussion with a
dietician.
• Peri‐operative nutritional therapy is indicated in patients with malnutrition or those at
risk, such as patients not anticipated to be able to eat for > 5 days peri‐operatively, or
those not expected to be able to maintain > 50% of their recommended intake for
> 7 days. Although the enteral route is preferred, numerous indications for emergency
laparotomy are contraindications to enteral feeding. In these instances, parental feeding
is an alternative. It is common to site a multilumen central venous catheter during
surgery, and reserve one lumen for parenteral feeds only.
• Even if oral diet or feeding via the enteral route is possible, if energy and nutritional
requirements cannot be met (e.g. an intake < 50% of calorific requirement) for 7 days,
supplementation with parenteral nutrition is recommended. Where it is indicated,
parenteral nutrition should be administered as soon as possible.
• https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14514?fbclid=IwAR27X9LutnY7yM
Sp-kGVwmSLc23txBfFjbjzTCZ1-rq-7XgK3jMe68huBug
Pre‐optimisation of patients undergoing emergency
laparotomy: a review of best practice
T. Poulton D. Murray on behalf of the National Emergency
Laparotomy Audit (NELA) project team
First published: 02 January 2019

13. Surgical
Nutrition
Unwell Surgical Patient