This document provides an overview of nutrition in surgical patients. It discusses the basics of nutrition including caloric and protein requirements. The importance of nutrition for surgical patients is described along with the complications of malnutrition like infection and poor wound healing. Methods of nutritional assessment involving history, exams, and labs are outlined. Both enteral and parenteral nutrition are covered, including indications, contraindications, administration methods, and potential complications. The take home messages emphasize the importance of meeting caloric needs to avoid complications, using enteral nutrition when possible, and closely monitoring patients on nutrition support.
2. OUTLINE
1. Overview on Basics of Nutrition
2. Importance of Nutrition in Surgical Patient
3. Nutrition Assessment
4. Nutrition Support
ï± Enteral
ï± Parenteral
1. Take Home Message
3. BASICS OF NUTRITION
ï± Nutrition is the process of providing or obtaining the
foods necessary for health and growth.
ï± The general indications for nutritional support in
surgery are in the prevention and treatment of under
nutrition.
Clinical Nutrition (2003) 22(3): 235â239
4. ï± Normal functioning of human body requires a balance
between nutritional intake and metabolism
ï± Imbalances will manifest as nutritional deficiencies or
excess
5. NUTRITIONAL REQUIREMENTS
ï± Calories provided mainly by carbohydrate and fat
ï± Fat = 9 kcal/ g
ï± Carbohydrate = 4 kcal/ g
ï± Protein = 4 kcal/ g
ï± Daily caloric requirements: 30-35kcal/kg
ï± Metabolic stress associated with sepsis, trauma, surgery or ventilation lead to
increase energy requirement (35-40kcal/kg/day)
Medical Nutrition Therapy Guideline (2012)
6. MALNUTRITION
ï± Malnutrition :
ï§ condition that develops when the body does not get the right
amount of the vitamins, minerals and other nutrients it
needs to maintain healthy tissues and organ function.
ï± Can occur in people who are either undernourished or over-
nourished
Stratton RJ, Green CJ, Elias M. Disease-related malnutrition: an evidence-based approach to treatment. Oxon, UK: CABI
Publishing; 2003 (p. 3). Retrieved on 30th
December 2014, from http://espen.info/documents/ENGeneral.pdf
7. ESPEN Guidelines 2009
ï± Under nutrition:
ïŒ BMI <18kg/m2
ïŒ Weight loss >10-15% within 6 months
ïŒ Serum albumin <30g/L (with no evidence of hepatic or renal
dysfunction)
ïŒ <80% of ideal body weight
ï± Over nutrition:
ïŒ BMI >30kg/m2
ïŒ Body weight >20% from ideal body weight
8. BMI
Category BMI Range (kg/m)
Underweight <18.5
Normal 18.5 â 23.9
Overweight 24.0 â 26.9
Obese Class I 27.0 â 34.9
Obese Class II 35 â 40
Obese Class III > 40
9. COMPLICATION OF
MALNUTRITION
ï§ Wound infection
ï§Intra abdominal infection
ï§Sepsis
ï§ Pneumonia
ï§Gastro intestinal infection
ï§Urinary tract infection
ï§Catheter related infection
INFECTIOUS
ï§ Post operative bleeding
ï§Anastomosis leakage
ï§Impaired wound healing
ï§Gastrointestinal obstruction/
perforation
ï§Cardiac/renal/respiratory
dysfunction
ï§Multi organs failure
ïProlonged recovery period
ïIncreased need for nursing care
ïIncreased medical cost
ïProlonged hospital stay
NON INFECTIOUS
19. ENTERAL NUTRITION (EN)
ï± Delivery of nutrient into healthy and functioning GI tract
ï± Most preferred and more physiological
ï± Advantages
ïą Maintain gut mucosal integrity
ïą Maintain normal gut flora & pH
ïą Cheap & easily available
ïą Less complication
20. INDICATIONS &
CONTRAINDICATIONS
Indications Contraindications
âą Oral intake < 50% of required
need for the previous 7-10 days
âą Dysphagia or chewing problem
due to strokes, brain tumor, head
injuries
âą Major burns
âą Low output GIT fistulas (< 500
mls/day).
âą Mechanical obstruction of GIT
âą Prolonged ileus
âą Severe GI hemorrhage
âą Severe diarrhea
âą Intractable vomiting
âą High output GIT fistula
(>500ml/day)
âą Severe enterocolitis
25. EARLY EN VS DELAYED EN
ï± Initiate nutritional support ( by the enteral route if possible)
without delay:
ïEven in patients without obvious under nutrition, if it is
anticipated that the patient will be unable to eat for more
than 7 days
ïIn patients who cannot maintain oral intake above 60% of
recommended intake for more than 10 days.
ESPEN Guidelines on Enteral Nutrition 2006
26. PARENTERAL FEEDING
ï± BASIC OF PARENTERAL FEEDING
ï± INDICATIONS
ï± CONTRAINDICATIONS
ï± TYPES OF PARENTERAL NUTRITION
ï± CALORY REQUIREMENT
ï± COMPLICATIONS
ï± MONITORING PATIENT WITH PN
27. BASICS OF PARENTERAL
FEEDING
ï± Delivery of all nutritional requirements by IV route without
the use of GIT (bypass GIT)
ï± Sterile liquid chemical formula
ï± May be delivered via :
- Central line
- Peripheral line
28. INDICATIONS
ï± GIT Malfunction
OBSTRUCTED - Ca esophagus/stomach, stricture
FISTULATED - post op enterocutaneous fistula, high output fistulas
INFLAMMED - small bowel disease ex, crohnâs disease, acute severe pancreatitis
TOO SHORT - massive resection, short gut syndrome
ï± Pre operative : build up of malnourished patient
ï± Failure enteral feeding to meet caloric requirement
- major polytrauma, major burns
ï± Cancer : complication of chemotherapy, radiotherapy
ï± Newborns
- GIT anomalies, NEC
29. PRE OPERATIVE PN
Indicated in :
ï± Severely undernourished patients who cannot be adequately
enterally fed
Studies have shown that :
ï± Inadequate oral intake of >14 days = higher mortality
ï± 7-10 days of preoperative PN = improves postoperative outcome
in severe undernourished patient
ESPEN Guidelines of Parenteral Nutrition 2009
30. POST OPERATIVE PN
Indicated in:
ï± Undernourished patients = enteral nutrition is not feasible / not
tolerated
ï± Patients with postoperative complications
= 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.
ESPEN Guidelines of Parenteral Nutrition 2009
31. PN IS CONTRAINDICATED IN:PN IS CONTRAINDICATED IN:
ï± Functional and accessible GI tract
ï± Patient is taking orally
ï± Prognosis does not warrant aggressive nutrition support
(terminally ill patients)
ï± Risk exceeds benefit
ï± Patient expected to meet needs within 14 days
32. TYPES OF PARENTERAL
NUTRITION
Total Parenteral Nutrition Partial Parenteral Nutrition
Supplies all daily nutritional
requirement
Only part of the daily nutritional
requirements supplied,
supplementing oral intake ~ 50-70%
of patientâs energy needs
Central line Peripheral line
Long term support (>10 days) Short term support (10-14 days)
Hypertonic solutions with high
osmolarity
Formulation with low osmolarity
(< 900mOsm/L )
33. CALORY REQUIREMENT
Estimating energy requirement
( Harris- Benedict Equation)
ï± Men BMR =66.47 + 13.7 wt + 5.0 ht - 6.76 age
ï± Women BMR =65.5 + 9.56 wt + 1.85 ht - 4.68 age
Wt = weight in kg, ht = height in cm
BMR= Basal Metabolic Rate
ï± Total calorie need = BMR x Activity factor x Injury factor
for practical purpose: 30-35kcal/kg/day
35. MONITORING PATIENTS ON PN
Parameter Daily
Frequency
3x/week
Weekly
Glucose Initially â
Electrolytes,
FBC
Initially â
Phos, Mg, BUN,
Cr, Ca
Initially â
TG â
Fluid- I/O â
Temperature â
T. Bili, LFT Initially â
36. COMPLICATIONS OF PARENTERAL
NUTRITION
ï± Refeeding syndrome
ï± Expansion of extracellular volume, fluid overload
ï± Hyper/hypoglycemia
ï± Fluid or electrolyte abnormalities
ï± Catheter leak
ï± Air embolism
ï± Catheter related sepsis
Acute
37. COMPLICATIONS OF PARENTERAL
NUTRITION
Late
ï± Metabolic bone diseases : osteoporosis
ï± Hepatic complications : fatty liver, liver failure, hyperammonemia
ï± Gallbladder complications: cholestatic jaundice
ï± Venous thrombosis
ï± Catheter related sepsis
ï± Vitamin and traced element deficiency
38. REFEEDING SYNDROME
ï± Metabolic complication = in severely malnourished patients
ï± Potentially fatal condition - may be successfully managed
- prevented if detected early
Pathophysiology
ï± Metabolism shifts : catabolic -> anabolic state
ï± Insulin is released - triggering cellular uptake of K+, PO4, Mg
ï± Profound depletion those electrolyte extracelullarly
-hypo PO4, hypo Mg, hypo K+, hypo Ca ï multiorgan dysfunction
ï± PN initially delivered = maximum of 10 kcal/kg/day
= raised gradually to full needs within a week
39. Ways to wean off TPN
ï± PN may rapidly discontinued ï patient tolerating tube feeding
ï± Reduced PN volume by 1/2 for 1-2 H before discontinued it
ï minimize rebound hypoglycemia
ï± Enteral feeding initiated ï patientâs GIT function resume
ï± Initiation enteral feeding ï GIT function
ï minimal risk of aspiration
ï patient motivation.
40. COMBINATIONS OF ENTERAL AND PARENTERAL
FEEDING
ï± >60% of energy needs cannot be met via the enteral
route, e.g. in high output enterocutaneous ïŹstulae
ï± partly obstructing benign or malignant gastrointestinal
lesions which do not allow enteral feeding.
ESPEN Guidelines of Parenteral Nutrition 2009
41. ENTERAL NUTRITION VS PARENTERAL
NUTRITION
Studies have shown that:
ï± There are no significant differences in mortality rate
ï± There are no significant differences regarding length of hospital
stay.
ESPEN Guidelines on Enteral Nutrition 2006
Enteral feeding Parenteral feeding
Lower risk infection Higher risk infection
Decreased cost Increased cost
Lower incidence
hyperglycemia
Higher incidence
hyperglycemia
42. TAKE HOME MESSAGES
1. Malnutrition leads to prolong stay, prolong recovery period and
increased medical cost
2. Normal caloric requirement = 30-35kcal/kg/day
Metabolic stress =35-40kcal/kg/day
3. Use enteral feeding unless contraindicated
4. Low osmolarity PN (<900mOsm/L) given via peripheral line
5. In high risk patient to develop re feeding syndrome, we should
start with low calories
6. Parameters that required daily monitoring are glucose,
electrolytes, FBC, I/0 and temperature
43. REFERENCES
1. Bailey & Loveâs Short Practice of Surgery 25th
edition
2. Espen Congress Istanbul (2006), retrieved on 5/1/12 from
http://www.espen.org/presfile/Meier.pdf
3. ESPEN Guidelines on Enteral/Parentral Nutrition: Surgery 2006 & 2009
edition
4. Nutritional support in surgical patient by Richard J. E. Skipworth.
Kenneth C. H. Fearhon
5. Nutrition Journal homepage
6. En. Chong, Dietician HTAA
7. Miss Han, TPN Pharmacist
8. TPN Tutorial (www.rxkinetics.com/tpntutorial)
Hinweis der Redaktion
The general indications for nutritional support
in surgery are in the prevention and treatment of
undernutrition, i.e. the correction of undernutrition
before surgery and the maintenance of
nutritional status after surgery, when periods of
prolonged fasting and/or severe catabolism are
expected. might suggest that malnourished patients were those
with decreased inmunocompetence.
30-35=20-30% from fat
The stress of surgery or trauma increases protein and energy requirement by creating a hypermetabolic and catabolic state
Se albumin: half life 18-20 d, low levels are markers of negative catabolic state and a predictor of poor outcome, levels r low in surgery, hepatic and renal disease, critical ill
Se tranferrin: half life 8-9d, reflects protein status over last 2-4 weeks, also reflects iron status therefore low value reflects low protein status in setting of normal iron
Nitrogen balance:
Mantains GIT mucosal integrity ( physical and immunity barrier) - reduces bacterial translocation
It includes oral
nutritional supplements (ONS) as well as tube
feeding via nasogastric, nasoenteral or percutaneous
tubes.
The main purpose using fibercontaining
formulae is feeding the gut to maintain
gut physiology, improving gastrointestinal tolerance
(e.g. prevention of diarrhoea and constipation)
and for glycaemic and lipid control.
(PN should be used when GIT is not functioning and in patients who cannot adequately enteral fed)-
If abrupt discontinuation of TPN cannot be avoided, 10% dextrose solution may be administered for a few hours and then discontinued