By Dr. Abdulaziz Almusallam

1
Surgical Nutrition

• By Dr. Abdulaziz Almusallam
• Moderator Dr. Abhay Patwari .

2
Objectives

• Our talk will be about
• Introduction to nutrition
• Malnutrition
• Nutritional requirements
• Nutritional assessment
• Indications For nutritional support
• Routes and types of feeding

3

• Nutrition is an important category in the
  management of surgical patient.
• Those who suffer from trauma and sepsis or going
  for surgery, where the demands for energy is
  increased.
• Effective nutritional support requires
  appreciation that the metabolic and the
  nutritional needs of injured and septic patients
  differ from those of healthy individuals.

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Nutrition Support

• The aim of Nutritional Support is to identify the
  patients in need of the nutritional requirements
  and to ensure good support to minimize the risk
  of complications.

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Malnutrition

• The adverse effects were documented from as early
  as 1936.
• The incidence reaches 50 and is exacerbated by
  hospital stay.
• A suboptimal dietary intake for gt14 days is
  associated with a high morbidity and mortality.
• Nutrition screening, assessment and support must
  become an integral part of the multidisciplinary
  care of the surgical patient.
• High-risk patients, a referral should be made to
  a dietitian who will arrange the provision of
  nutrition support as indicated.
• If possible, especially in high-risk patients,
  surgery should be postponed until there is an
  improvement in the nutritional status.

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Malnutrition

• Impaired immune function
• infections
• Delayed wound healing
• Increased risk of postoperative complications
• Apathy, depression and neglect

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Malnutrition

• Muscle wasting and weakness which affects
• Respiratory function
• chest infections
• cardiac function
• heart failure
• mobility
• deep vein thrombosis
• pulmonary embolism
• pressure sores

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What is theNutritional requirements
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The principal requirements in nutritional regimen
are

• energy
• protein nitrogen
• vitamins, minerals, trace elements and water

10
Energy

• Carbohydrate and lipid are the main dietary
  sources of energy.
• Body needs app 30 kcal/kg/day .
• (it will be increased to up to 35 40
  kcal/kg/day in case of any metabolic stress).
• lipid can provide 1 g ? 9 kcal (H2O CO2) .
• CHO can provide 1 g ? 4 kcal (H2O CO2).

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Note
CHO is the fuel for glucose dependent tissue such
as
bone marrow.
Erythrocyte.
brain tissue.
Daily requirements of glucose 100 150 g will
suppress any glyconeogenesis and prevent ketosis.
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Protein nitrogen

• requirements are estimated at 0.8 1 gm/kg/day.
• healthy adult requires 1 gm of nitrogen / 150
  kcal/ day.
• nitrogen content of protein
• 6.25 g of protein contain 1 g of nitrogen.
• protein 1 g ? 4 kcal (ammonia).

13
Water

• Daily requirements are from 25 40 ml/kcal/day
  or 1 ml/kcal/day.
• Provided that we can add 300 ml for each degree
  (ºC) of rise in temperature.
• Fluid requirements Increased in
• Fever.
• Fistulas.
• Diarrhea.
• Decreased in
• Renal failure.
• Congestive heart failure.
• Cirrhotic ascites.

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Vitamins, minerals, trace elements

• Body needs them due to their function as
• Metabolic coenzymes (vit K ? factor 2,7,9,10).
• Co-function in wound healing (vit C, A).
• Antioxidant (vit C, E).

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Amino acid

• Glutamine
• Nitrogen carrier among organs.
• So it improves nitrogen balance.
• Fuel for lymphocyte and hepatocyte.
• Important for maintenance of small bowel mucosa.
• Deficiency may cause immune dysfunction.
• Supplementation 0.285 g/kg/day.
• Arginine
• Non essential amino acid. as glutamine.

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Omega 3 fatty acid

• Derived from fish oil.
• Polyunsaturated fatty acid.
• Anti-inflammatory.
• NB Omega 6 ratio between 36 differs in sepsis.
• Nucleotides
• structural units DNA and RNA. For immune system.

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Electrolytes
Electrolyte requirements Usual adult range Infants/children
Sodium 60 to 200 mEq/day 2 to 4 mEq/kg/day
Potassium 60 to 200 mEq/day 2 to 4 mEq/kg/day
Magnesium 8 to 40 mEq/day 0.25 to 0.5 mEq/kg/day
Calcium 10 to 30 mEq/day 0.5 to 3 mEq/kg/day
Phosphorus 10 to 40 mMol/day 0.5 to 2 mMol/kg/day
Chloride As needed to maintain acid-base balance Same as adults
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Vitamins

• Naturally derived from food.
• Dose 5 ml by weekly subQ or IM injections.

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Trace elements( addamel injection )
Daily trace mineral requirements Adults Peds lt 5 years Peds 5 - 12 years
Copper 300 to 500 mcg 20 mcg/kg 200 to 500 mcg
Manganese 60 to 100 mcg 2 to 10 mcg/kg 50 to 100 mcg
Zinc 2.5 to 5 mg 0.1 mg/kg 2 to 5 mg
Chromium 10 to 15 mcg 0.14 to 0.2 mcg/kg 5 to 15 mcg
Selenium 60 mcg 2 to 3 mcg/kg 30 to 40 mcg
Molybdenum As needed 0.25 mcg/kg As needed
Iodine As needed 1 mcg/kg As needed
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Nutrition Assessement

• Difficult in practice as there is no gold
  standard for all Patients.

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What to Assess

• Clinical assessment
• Anthropometric assessment
• Blood indices

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Clinical assessment

• Weight loss
• Useful if no dehydration or odema present
• 10 mild malnutrition
• 30 severe malnutrition
• Body mass index
• (Calculated as weight /height in m2)
• Food intake appetite
• Fever
• Rx

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Anthropometric assessment

• Triceps skin fold thickness
• minimum is 10 mm in male and
• 13 mm in the female.
• Mid arm circumference
• lt 25 cm male or
• lt 23 cm female
• Hand grip strength

24
Blood indices

• Reduced
• serum albumin
• Normal gt 3.5 g/dl
• prealbumin or transferrin
• Lymphocyte count
• If lt 1500/ mm3, it indicates an impaired cellular
  defense mechanism

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• No index of nutritional assessment shown to be
  superior to clinical assessment

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THE MUST TOOL
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Indications for nutritional support

• 1.Diminished food intake in
• Preoperative malnutrition
• Coma
• Postoperative ileus lasting for gt 4 days

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Indications for nutritional support

• 2.Diminished digestion and absorption, eg
• Pyloric stenosis
• Pancreatic disease
• Biliary disease
• Malabsorption syndrome
• Short bowel syndrome
• Radiation enteritis
• Ulcerative colitis
• Duodenal fistula

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Indications for nutritional support

• 3.Chronic disease, eg
• Chronic cardiac, hepatic or renal disease
• Malignant disease
• 4.Hypercatabolic states
• Polytrauma
• Burn
• Sepsis

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Things to remember

• Use gastrointestinal tract if available
• Prolonged post-operative starvation is not
  required
• Early enteral nutrition reduced post-operative
  morbidity

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Routes of feeding

• Enteral Nutrition
• Fine-bore nasogastric tube
• Nasojejunal tube
• Open surgical gastrostomy or jejunostomy
• Percutaneous endoscopic gastrostomy (PEG)
• Parenteral Nutrition
• Internal jugular or ..
• Subclavian vein
• PICC (peripheral inserted central catheter PICC)

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Enteral Nutrition

• Benefits
• More physiologic
• Less complications
• Gut mucosa preserved
• No bacterial translocation
• Cheaper

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Enteral feeding

• Complications
• Diarrhoea
• Aspiration pneumonia
• Leakage around tubes
• Blockage of tubes
• Migration of tubes

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Enteral Feeding

• What to be given in feeds ?
• Blenderised feeds
• Commercially prepared feeds
• Polymeric
• eg Isocal, Ensure, Jevity
• Monomeric / elemental
• eg Vivonex

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Enteral feeding

• NG tube
• When to use
• Short term lt 30 days
• Intact gag reflex
• Normal gastric function
• Low risk of aspiration
• Benefits
• Easy tube placement
• Surgery not required
• Easy to check gastric residuals
• Accomodates bolus or intermittent infusions

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Enteral feeding

• Naso-jejunal tube
• When to use
• Compromised gastric function
• Early enteral feeding
• Benefits
• May decrease aspiration risk
• Surgery not required
• Problems
• Transpyloric placement may be difficult
• Frequent dislodgement
• Tube malposition common

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Enteral feeding

• Gastrostomy Tube
• long term gt 30 days
• bolus, intermittent or continuous feedings
• meal times

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Enteral feeding

• PEG tube
• Allows gastric decompression simultaneous
• JT feeding

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Paranteral Nutrition

• GI tract is not functioning well enough to meet
  nutritional needs of patient so nutrients put in
  bloodstream intravenously.
• examples
• Small bowel resection
• Bowel obstruction (small or large)
• Large output fistula below enteral feeding site

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Paranteral nutrition

• Allows greater caloric intake
• BUT
• Is more expensive
• Has more complications
• Needs more technical expertise

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Paranteral Nutrition

• Indications
• Intestinal failure
• Temporary eg prolonged ileus post op
• Permanent eg small bowl ressection
• Indication for home parenteral nutrition .

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Parenteral Nutrition

• Contra-Indication ( not absolute )
• Need to be corrected before starting parenteral
  nutrition .
• Heart Disease
• Shock
• Blood dyscrasias
• Chronic liver disease
• Disorders of fat metabolism
• Uncontrolled DM

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Parenteral nutrition

• Complications
• Associated with placement of a central line
• Arterial injury
• Nerve injury (vagus nerve / sympathetic plexus)
• Pneumothorax OR Haemothorax
• Thoracic duct injury
• Cardiac arrhythmias
• Cardiac tamponade Air embolism
• Cerebrovascular injury

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Paranteral

• Metabolic Complications
• Hyperosmolar states
• Hypo / hypernatraemia
• Calcium and magnesium disorders
• Fatty acid deficiency
• Hyperammonaemia
• Hyperglycaemia / reactive hypoglycaemia
• Acidosis Zinc / Copper / Chromium deficiency
• Cholestatic liver profile 
• Sepsis

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Two main forms of parenteral nutrition

• Peripheral Parenteral Nutrition
• Central (Total) Parenteral Nutrition
• Both differ in

• composition of feed
• primary caloric source
• potential complications
• method of administration

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Centeral Paranteral Nutrition

• Route of administration
• Should be a central great vein
• Avoid peripheral vein thrombosis by the irritant
  hypertonic solution .
• Traditionally achieved by subclavian vein
  cannulation .
• Silicone-rubber catheters
• Introduced via cephalic vein
• Can be left for as long as possible

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Peripheral Parenteral feeding

• If short term feeding ( lt 2 weeks) .
• possible by using
• PICC
• short cannula at wrist veins
• PPN
• cannot use more than D10
• Cannulas to be switched from hand to hand
• Every 24-48 hours

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Parenteral Nutrition

• Solutions
• Composition
• Carbohydrates
• Glucose , fructose , sorbitol .
• Fats
• Amino acids
• Na, K , PO4 , Ca , Mg .
• Others ( added whenever indicated )
• Minerals
• Vitamins
• Trace Elements

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Paranteral nutrition

• Preparations
• Vamin 9 Glucose
• Synthamin 14
• Aminoplex
• Intralipid 20

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Parenteral feeding dosage
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Thank you