Surgical Nutrition

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Surgical Nutrition

• What not to do.

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Feed by the wrong route
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Feed by the wrong route

• Nasogastric

• Parenteral

SURGERY
Stroke Crohns disease not eating enough
Diet Oral supplements Nasojejunal PEG/jejunostomy
Peripheral PN More than one....
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Feed by the wrong route

• enteral

• parenteral

• Physiological
• Simple
• May prevent bacterial translocation
• Complications less
• Cheap

• Misses the portal circulation
• Complex
• Complications line, sepsis, LFTs etc
• Expensive

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Feed by the wrong route
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Feed by the wrong route

• enteral

• parenteral

• Physiological
• Simple
• May prevent bacterial translocation
• Complications less
• Cheap

• Misses the portal circulation
• Complex
• Complications line, sepsis, LFTs etc
• Expensive

Nasojejunal?
Standard bags?
PEG?
In good hands?
Aspiration? Diarrhoea?
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Feed by the wrong route
Avoid PN if the gut works
Consider nasojejunal feeds large gastric
aspirates oesophageal pathology
Avoid EN if the gut is leaking
Active intra-abdominal sepsis Recent fistula
formation
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Feed too much
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Feed too much..

• 85 year old female
• 36Kg 5ft
• stroke

• 25 year old male
• 110kg 6ft 2ins
• Multiple injuries

Calculate nutritional requirements Remember
stress and activity factors Consider the aim of
nutritional support
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Feed too much
Systemic inflammatory response produces negative
nitrogen and energy balance
Elective surgery study
Low serum albumin is due to inflammation, not
malnutrition
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Feed too much

• Complications of excess feeding
• Hyperglycaemia
• Sepsis
• Fatty liver
• Abnormal LFTs

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..or not at all
Nutritional screening for all?
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Produce complications
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Produce complications

• Enteral
• NG tube misplacement
• Aspiration of feed
• Vomiting
• Diarrhoea
• Infection
• Peritonitis from PEG insertion
• Endoscopy complications
• PEG leakage
• Tube blockage
• Inadvertent removal

• Parenteral
• Pneumothorax
• Cardiac tamponade
• Mediastinal haematoma
• Line misplacement
• Line infection
• Fluid overload
• Line blockage
• Inadvertent removal
• Central venous thrombosis
• Pulmonary embolism
• Jaundice

Metabolic abnormalities Refeeding syndrome
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Produce complications

• Enteral
• NG tube misplacement
• Aspiration of feed
• Vomiting
• Diarrhoea
• Infection
• Peritonitis from PEG insertion
• Endoscopy complications
• PEG leakage
• Tube blockage
• Inadvertent removal

• Parenteral
• Pneumothorax
• Cardiac tamponade
• Mediastinal haematoma
• Line misplacement
• Line infection
• Fluid overload
• Line blockage
• Inadvertent removal
• Central venous thrombosis
• Pulmonary embolism
• Jaundice

Metabolic abnormalities Refeeding syndrome
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Produce complications

• NG tube misplacement

• Aspirate from tube
• Test with pH paper
• CXR if doubtful
• Consider whether tube has moved every time feed
  commences

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Produce complications

• Diarrhoea
• usually antibiotics
• send cultures
• anti-diarrhoeals
• change feed
• beware faecal collectors
• is absorption adequate?

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Produce complications

• PEG leakage
• ?obstructed
• ?ileus
• ?abscess
• ?flange

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Produce complications

• Inadvertent tube removal
• Nasal bridle
• PEG

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Produce complications

• Line infection
• Dedicated line
• Nursing care
• Avoid doctors!

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Produce complications

• Jaundice
• Usually more than one cause
• Intra-abdominal sepsis
• Line sepsis
• Too many calories
• Antibiotics
• Biliary obstruction
• Too much fat (long term)
• Underlying liver disease

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What not to do.

• Feed by the wrong route
• Feed too much
• or not at all
• Produce complications