The document discusses nutrition in surgery, outlining relevant physiology, basic nutrient requirements, causes of malnutrition, nutritional assessment techniques, energy requirements, indications for nutritional support, and methods of enteral and parenteral nutrition to correct deficiencies and support patients during and after surgery. Nutritional support can help reduce complications from malnutrition like impaired wound healing and increased risk of infection.

1. NUTRITION IN SURGERY
DR OLOFIN, K.E
Registral Asokoro District hospital FCT

2. OUTLINE
• INTRODUCTION
• RELEVANT PHYSIOLOGY
• BASIC NUTRIENTS & DAILY REQUIREMENTS
• CAUSES OF MALNUTRITION
• NUTRITIONAL ASSESSMENT
• ENERGY REQUIREMENTS
• INDICATIONS FOR NUTRITIONAL SUPPORT
• ENTERAL NUTRITION
• PARENTERAL NUTRITION
• FUTURE TRENDS
• CONCLUSION

3. INTRODUCTION
• A thorough understanding of nutritional therapy
is very important to the surgeon:
• Affects 30 – 50% of hospitalised pts
• Malnutrition produces :
»A reduction in lean muscle mass
»Alterations in respiratory mechanics,
»Impaired immune responses and
» Intestinal atrophy.
»Diminished wound healing
»Predisposition to infection
»Increased post-op Morbidity &
Mortality.

4. Definition
Determination of the nutritional status of
the surgical patient with the view to
correcting any deficiencies and the
provision of appropriate nutrients along
with route of delivery in accordance with
the pre-existing surgical condition or
resulting operative condition.

5. Intro: HISTORICAL PERSPECTIVE
• Robert Ellman(1938):Reported the first successful
administration of protein hydrolysate in humans.
• Helrick and Abelson (1944):Administration Fat
and Protein intravenously to support an infant
with intractable diarrhoea.
• Dudrick(1968) First realized total nutritional
support intravenously.

6. Relevant physiology
• METABOLIC RESPONSE TO STARVATION
- After 12hrs of not feeding,
• Plasma Insulin levels fall
• Glucagon rises
• Hepatic Glycogen is gradually converted into glucose
• With prolonged starvation, muscle glycogen is broken down
and converted into lactate, taken to the liver for conversion
to glucose(Cori cycle)
- After 24hrs
• Hepatic Gluconeogensis from amino acid precursors start
with loss of about 75g of skeletal muscle protein per day

7. Metabolic response to starvation
• About 100g of exogenous glucose is enough to
prevent muscle breakdown in simple fasting
• With Prolonged fasting,
• Fat stores are mobilized giving rise to Glycerol
and FFA
• Adaptive Ketogenesis occurs with the Liver
producing Ketone bodies from fatty acids and
after 2-3wks, the Brain adapts to using Ketone
bodies instead of glucose.

8. Basic Nutrients
• Carbohydrates
• Proteins
• Fats
• Vitamins
• Minerals
• Water

9. CAUSES OF INADEQUATE NUTRITION
Poor intake:
Poverty
Alcoholism
Anorexia:
Nervosa, Hyperemesis, Cancer, Sepsis, Liver disease
Git obstruction:
Benign stricture.
Neoplasm.
Colonic malignancy

10. CAUSES OF INADEQUATE NUTRITION
Inadequate absorption.
Motility disorders
Pseudo-obstruction
Major gastric resections
Short bowel syndrome
Excessive losses:
Git fistula
Malabsorptions states
Inflammatory bowel disease
Protein losing enteropathy
Excessive demand:
Hypercatabolic states:
Burns
Sepsis
Trauma
Surgical stress

11. NUTRITIONAL ASSESSMENT
• Process of identifying patients who are either
malnourished or at risk of malnutrition.
• Involves:
• History.
• Physical examination.
• Laboratory tests.
• Anthropometry
• Nutritional Screening.

12. HISTORY
– ALCOHOLISM
– AIDS
– ABSORPTION DISORDERS
– PAST SURGICAL HX.
• GASTRECTOMY
• ILEAL RESECTION
– HX OF RECENT WT LOSS.
– INFLAMMATORY BOWEL
DX.
– MALIGNANCY.
– DETAILED DIETARY HX.
– INTESTINAL OBST.
– PROLONGED
STARVATION.
– PSYCHIATRIC
DISORDERS—ANOREXIA
NERVOSA
– RECENT MAJOR
SURGERY, TRAUMA, OR
BURNS.
– SEVERE
CARDIOPULMONARY
DISEASE.

13. Physical Examination
OVERALL APPEARANCE:
• Wasting/ stunting
• Skin
• Hair
• Eyes/sight
• Mouth: cheilosis, glossitis. Mucosal atrophy, dentition.
• Heart: chamber enlargement, murmurs
• Abdomen: liver ,abdominal mass, stomas, fistula.
• Rectum: stool colour, perineal fistula.
• Neurologic: neuropathies
• Extremities: muscle size and strength, pedal
oedema.

14. Laboratory Tests
• F.B.C: Total Lymphocyte Count
• E/U/CR.
• LFT: AST, ALT, ALP, Bilirubin, Albumin.
• Viseral Proteins: Prealbumin, Retinol Binding Protein,
Prothrombin
• Cutaneous Hypersensitivity tests

15. ANTHROPOMETRIC MEASUREMENTS:
• Science of assessing body size , wt, and proportions.
• Assess Somatic Proteins
• BED SIDE MEASUREMENTS:
• Height
• Weight (Admission weight is important)
• BMI = WT (kg)
HT2 (cm).

16. ANTHROPOMETRY contd…
• IDEAL BODY WT (in Kilograms)
Devine eqn; (M)50kg+2.3kg/every inch over 5ft
(F)45.5kg+2.3kg/every inch over 5ft
• MID HUMERAL CIRCUMFERENCE (MHC)
—somatic protein reserve.
• MID HUMERAL MUSCLE CIRCUMFERENCE
– accounts for subcutaneous tissue.
• TRICEPS SKIN FOLD THICKNESS.. estimates fat reserve
N.B : The results are compared with normal values for the patient’s age and gender.
• DUAL ENERGY X-RAY ABSORPTIOMETRY (DEXA).
• USED TO ASSESS VARIOUS BODY COMPARTMENTS- FAT, LEAN MUSCLE etc

17. SUBJECTIVE GLOBAL ASSESSMENT
• Only reproducible clinical method.
• Makes use of History & Physical Examination
• 5 FEATURES IN HX:
– WT LOSS PAST 6 MONTHS
– DIETARY INTAKE
– GI SYMPTOMS
– FUNCTIONAL STATUS OR ENERGY LEVEL
– METABOLIC DEMANDS
• 4 FEATURES IN PHYSICAL EXAMINATION:
• LOSS OF SUBCUT. FAT, OEDEMA, ASCITES AND MUSCLE WASTING.

18. Nutritional Indices

19. Staging of Malnutrition

20. Energy Requirements
TOTAL ENERGY EXPENDITURE(TEE):
Represents the caloric needs of the body under
certain patho-physiological stresses.
• BASAL ENERGY EXPENDITURE (BEE):
This is energy needed to maintain the heart, lung
as well as the synthesis of new chemical bonds &
for maintaining electrochemical gradient in cells.
-BEE can be measured via Indirect Calorimetry or
the Modified Harris-Benedict Equation.
TEE = BEE x Stress factor x Activity Factor

22. INDIRECT CALORIMETRY
• Most accurate method of measuring daily
caloric requirement.
• Using a metabolic chart is cumbersome and
expensive.
• Uses the Weir formula.
• R.E.E (Kcal/min) = [( 3.9 X VO2)+(1.1 X VCO2)]- (2.2x
UN)
Where :VCO2 = exhaled CO2 , V02 = O2 consumption,
UN=URINE NITROGEN.

23. Energy Requirements
ENERGY ABOVE BASAL NEEDS
• ELECTIVE OP -10%,
• TRAUMA- 10 -30% ,
• SEPSIS- 50-80%,
• BURNS- 100- 200%.
ACTIVITY FACTOR
Energy Exp. Of Activity
15-20% Of BEE Ambulatory.
10-15% Of BEE Bedridden.
5-10% Of BEE Ventilator

24. Daily Requirements: Carbohydrates
Carbohydrates
• Glucose : Yields 4.1kCal/g,
• Used as the primary fuel source.
• Average calories needed: 25-35 kcal/kg IBW.
• Final concentrations used in TPN range from
10 to 47%.
• Needed to stimulate insulin secretion; insulin
influences protein synthesis.

25. FATS
• Yields 9.2kCal/g.
• Represents 35% of basal energy requirement.
• Minimum requirements: Approx 4% of total
nonprotein calories OR 500 ml of 10% fat
emulsion 2-3 times/week OR 500 ml 20% once
weekly.
• Necessary to prevent essential fatty acid
deficiency.

26. FATS
• EFA(linoleic and linolenic) are needed for
membrane structure and prostaglandin
synthesis.
• Symptoms of deficiency:
Hair loss, thrombocytopenia, poor wound
healing, dermatitis, hepatomegaly with fatty
liver, low PG levels, bone changes and poor
wound healing.

27. PROTEINS
• 4 kcal/g. 6.25 g protein=1 g of nitrogen)
• (Av 35-40g/d).
• Normal status, no stress: 0.65 to 1.1 g/kg/day.
x2-3 in hyper catabolic states.
• Should be given with energy source at
8400kJ/2000kCal: 13g N (150:1).
• Include essential amino acids.

28. Vitamins
• Involved in metabolism, protein synthesis,
immune function, etc.
• Most effective when given orally.
• Lost in increased amount in urine of patients
with trauma, burns and sepsis.
• Fat soluble: A, D, E, K.
• Water Soluble; B1, B2, B6, B12, Niacin,Biotin,
Panthothenic acid(B3), C.

29. Trace Elements
• Involved in metabolism, immunology, wound
healing
• Iron- Heme, Cytochrome, Metalloenzyme
cofactor.
• Zinc(5mg/d)-Metalloenzyme cofactor in CHO,
Prot, fat + Nucleic acid metab., Vit A transport
and lymphocyte function.
• Trauma patients lose massive amount in urine.

30. Trace Elements
• Cu(1.5mg/d).-Metalloenzyme cofactor;
cytochrome oxidase, dopamine hydroxylase,
lysyl hydroxylase etc.
• Others-Chromium(0.02mg/d),
Selenium(100microgm), Mn(0.5mg), Mb, I, F.

31. Daily Requirements

32. Indications for Nutritional Support
• Any patient with inadequate intake per-oral for 3-
4 days.
• Patients who cannot eat
• Patients who cannot eat enough (hypercatabolic
states)
• Patients who will not eat. (Anorexia, Malignancy)
• Patients who should not eat eg short bowel symdrome,
major bowel surgeries( oesophagial replacement, whipple”s
procedure), Inflammatory bowel disease, Radiation enteritis,
Gastroschisis, Intestinal atresia, Intussusception, NEC,

33. ROUTE OF NUTRITION
• ENTERAL
• PARENTERAL

34. ENTERAL NUTRITION
• Nutritional support using the gastrointestinal tract
• Preferable when practicable
• Advantages
– Prevents intestinal mucosal atrophy
– Supports gut-associated immunological shield
– Attenuates the hypermetabolic response of the injury and
surgery
– Cheaper than TPN and has fewer complications
– Reduced post-operative mortality

35. Enteral Nutrition
INDICATIONS
• PEM with Inadequate Oral
intake in previous 5-7days
• Normal Nutritional status
but <50% intake in
preceding 10 days
• Distal, low output EC Fistula
• To enhance adaptation after
massive enterectomy
(+TPN)
• Severe Dysphagia
• Major Trauma
• Major Full Thickness Burns
CONTRA-INDICATIONS
• Intestinal Failure
• Prolonged Small Bowel Ileus
• Complete Small Bowel
Obstruction
• Proximal small bowel fistula
• Intrinsic Small Bowel
pathology eg Crohns dx,
Radiation Enteritis

36. Methods of Enteral Nutrition
• Oral Route( eg Sip Feeding)
• Tube Feeding techniques(Access)
(i)Nasoenteric Tube feeding
» Nasogastric
» Orogastric
» Nasoduodenal/Nasojejunal
(ii) Tube Enterostomies
» Surgical Gastrostomy/ Jejunostomy
» Percutaneous Endoscopic Gastrostomy
» Percutaneous Endoscopic Jejunostomy

37. Nasogastric Tube feeding
• Requires intact gag
reflex, normal gastric
motility/gastric outlet.
• Adv: Low cost, easy
placement, easy
removal
• D/adv: Increased risk of
aspiration/tube
dislodgement.
• Convert to
Percutaneous if needed
for >30days.

38. Nasoduodenal/Nasojejunal tube
feeding
Indications:
• High aspiration risk,delayed gastric emptying,
gastroparesis, gastric dysfunction due to trauma
or surgery .
Adv: Beneficial for lower incidence of nosocomial
pneumonia.
DisAdv: Requires endoscopy or fluoroscopy for
placement, increased risk of tube
migration/dislodgement

39. Surgical Gastrostomy
Indications
• Normal gastric functions
and no esophageal reflux,
or when nasal route is
unavailable
• Adv: Optimal patient
comfort; can be placed
via endoscopy,
laparoscopy, or
fluoroscopy
• DisAdv: Increased risk of
aspiration/fistula after
tube removed, stoma
care required, potential
for tube
dislodgement.
Jane-way
Gastrostomy

40. Surgical Gastrostomy
PEGSTAMM’S Gastrostomy

41. Surgical Jejunostomy
• Indications: Impaired gastric motility,
GERD/aspiration potential,
gastric dysfunction due to surgery/trauma
• Adv: Decreased aspiration risk; can be placed
via endoscopy, fluoroscopy, or laparoscopy
• D/Adv: Potential for volvulus/intraperitoneal
leakage

42. Surgical Jejunostomy
WITZEL
JEJUNOSTOMY
LARGE BORE NEEDLE
Needle Jejunostomy

43. Percutaneous Endoscopic Gastrostomy
Indications: Impaired swallowing, oropharyngeal or
esophageal obstruction, major facial trauma
Used for debilitated patients needing caloric
supplementation, hydration or frequent medicine
dosing
Contraindications include ascites, sepsis, bleeding
tendency, peritoneal dialysis, significant gastroparesis.

44. Enteral Feeds
1. POLYMERIC COMMERCIAL FORMULAS:
- Blenderized diet.
- Nutritionally complete commercial preparations.
ENSURE (HYPEROSMOLAR), OSMOLITE ,JEVITY (ISOTONIC).
2. CHEMICALLY DEFINED FORMULAS:
- commonly called ELEMENTAL DIETS
- pre-digested and readily absorbable
- a.a +tg+ simple sugars.
- expensive, unpalatable, can cause bloating, diarrhoea, cramping.
eg : Vivonex, Neutramel
3. MODULAR FORMULATIONS: (protein, fat and CHO composed to
suit the individuals requirement) – supplemental diet
4. SPECIAL FORMULAR FOR SPECIFIC CLINICAL CONDITIONS:
Renal, hepatic , pulmonary, immune deficiency.
EXAMPLES: PROMOD, MICROLIPID

45. Feeding Regimen
• Patients feeding through the stomach should
get Isotonic feeds at 30ml/hr and this can be
increased daily by 30ml/hr
• Nasoduodenal/Nasojejunal feeds should be
300mOsm/kg in concentration and delivered
at an initial rate of 30ml/hr via a peristaltic
pump
• Monitor feeding using a Checklist.

46. Monitoring Enteral feeds
• Confirm tube location via X-rays before feeding
• Elevate head of bed to 45o for gastric feeds
• Check gastric residuum 4hrly. Withhold feeds
temporarily if residuum is >50% of ordered
volume.
• Check for Abdominal distension
• Check frequency, consistency & volume of Stool
output.
• Weigh patient on alternate days, record on a
graph

47. Monitoring cont…
• Daily intake /output recordings.
• Chart volume of formula given separate from
water or other oral intake
• Change administration tubing and cleanse
feeding bag dly.
• Irrigate feeding tube with 20mls of water after
use
• Weekly FBC, Serum Iron, Serum Magnesium
• Weekly 24hr Urine collection for Urea
Nitrogen assessment

48. Complications of Enteral feeding
Gastrointestinal: diarrhea(commonest);
constipation; nausea and vomiting
Mechanical: blocked tube; tube migration; reflux
aspiration (most feared complication)
Metabolic: hyper/hypoglycemia; Hyper/hypoNa+;
hyper/hypoK+; dehydration/overhydration;
hypophosphatemia

49. Parenteral Nutrition
• Refers to delivery of nutrients through the
intravenous route.
Types:
• PERIPHERAL PN
• CENTRAL PN
• TOTAL PN
• SUPPLEMENTAL
• HOME
• HOSPITAL

50. INDICATIONS FOR PN:
1. DIMINISHED INTAKE
(i) GIT BLOCKED ANATOMICALLY
 Stricture, malignancies,
 Achalasia, intestinal obstruction
 GOO
(ii) GIT FUNCTIONALLY BLOCKED
• Ileus: peritonitis,exomphalos,gastrochisis
• Post-0p: GIT, maxillofacial, oesophageal
• Gi irradiation, cytotoxic chemotherapy.
• Anorexia nervosa
• Hyperemesis gravidarum

51. INDICATIONS cont…
2. DIMINISHED ABSORPTION FROM THE INTESTINE
 Short bowel syndrome, fistula of GI, malabsorpton
states
 GI inflammation
3. Increased requirement:
 Burns, severe trauma, severe sepsis ,tetanus.

52. Methods of Delivery
PERIPHERAL PN:
• SAFER
• SUPPLEMENTAL NUTRITION FOR < 14 DAYS
• FORMULATIONS:
• GLUCOSE 5-10%
• AA---2-5%
• FAT—10-30%
• OSMOLALITY:600-1000mOsm/kg – the higher the
osmlality, the more the risk of phlebitis
• DELIVERED IN A VEIN WITH A FLOW 10-50ml/min

53. Methods of Delivery
CENTRAL PN:
• Usually for TPN
• Rarely supplemental
• ACCESS:
• SUBCLAVIAN
• INT. JUGULAR
• FEMORAL RARELY
• TEFLON OR SILASTIC COATED CATHETERS
– BROVIAC OR HICKMAN TYPE.

54. Composition of TPN
– FLUID 3L: 3 LITRE BAG DELIVERY SYSTEM
– AMINO ACID
• 45% ESSENTIAL
• 20% BRANCHED CHAIN—LEUCINE,ISOLEUCIN,VALINE
• 12% AROMATIC– PHENYLALA,TYR,TRYPTOPHAN
• OTHERS
– CALORIES GLUCOSE 50%-70%,FAT 20-30%
– ELECTROLYTES
– TRACE ELEMENTS
– VITAMINS
– MISCELLANEOUS-HEPARIN, INSULIN etc.
• ADMINISTRATION:Gradual, @1000Kcal/day, Increase by
500ml/day until goal is achieved (via an infusion pump).

55. Initiating PN…
• TPN team (surgeon, nutritionist,endoscopist,
physician, e.t.c )
• The parenteral nutrition solution is prepared in
the Pharmacy under sterile conditions.
• 3L ethyl vinyl acetate bag for infusion at the
desired rate through a volumetric infusion pump.
• Weigh the patient.
• Calculate the fluid requirement for next 24 hour.
• Calculate the energy and nitrogen requirement

56. Initiating PN…
Carbohydrates calories:
Glucose, Fructose, Sorbitol, Xylitol, Glycerol.
Lipid calories
Intralipid (soyabean oil), Liposyn (sunflower oil)
NITROGEN SOURCE
• Composed of crystalline amino acids
(essential and non-essential) solutions.
• Vamin 9® [9g/l],
• Vamin 14® [14g/l]
• Vamin 18® [18g/l])
• Synthetic aminosol
• Pernutrin

57. Initiating PN…
TRACE ELEMENTS / VITAMINS
• Additrace® which contains iron, zinc,
manganese, copper, chromium, selenium,
molybdenum, fluoride and iodide but not
calcium, magnesium or phosphate.
• Parentrovite A and B
• Water soluble vitamins are available as
commercial preparations
– Water Soluble Solivito®, fat soluble Vitlipid®.
• Fluid and Electrolytes: As required

58. Monitoring of TPN
• DAILY.
• WT, FLUID BALANCE, FBC, E/U/Cr untill stable.
• GLUCOSE (6-12hrly initially)
• ACIDBASE STATUS
• 3 times Weekly:
• CAL, MG, PHOSPHATE, PLASMA PROTEINS
• LFT, COAGULATION SCREEN
• FORTHNIGHT-2WK
• B12, FOLATE, IRON, LACTATE, TG, TRACE ELEMENTS.

59. Complications of PN

60. REFEEDING SYNDROME
• It is seen in moderate to severely
malnourished patients who are suddenly over
fed.
• Patient develops hypophosphatemia,
hypocalcemia,hypomagnesemia
,hyperglycemia
• The clinical presentation is that of respiratory
failure

61. Future Trends
• Immunomodulation:
• Nutritional support with immune-modulating nutrients have
been shown to enhance immunity and wound healing and
reduce infection.
• They are started days before surgery before major surgery and
continued postoperatively.
• Examples are, glutamine , ornithine-αketo-glutarate, arginine,
omega 3 fatty acids and nucleosides
• Small bowel transplantation.

63. Conclusion
• Malnutrition continues to be a major problem
in hospitalized patients .
• Nutritional Support Available > 2decades
• Need to improve safety, reduce cost and make
it easier to administer.
• Advances in nutrition & nutritional
pharmacology will contribute to improvement
in dx outcome that have today significant
mortality.

64. • THANKS FOR LISTENING!!!

65. References
• Principles and practice of Surgery(Badoe)
• Bailey and love’s short practice of surgery
• Parenteral nutrition- Janice Hovasi Cox et al
• Schwartz’s Principles of Surgery