Nutrition in

Surgical Patients
By MRITTIKA GANGULY

What?
Carbohydrate
Lipid
Protein
Trace elements
Vitamins

Who?
Malnourished (>10% lean body mass)
Incapable of eating (>10 days)

MALNUTRITTION
Malnutrition is common among

surgical patients e.g.---major

abdominal surgery
Malnutrition associated with:
High infection rate
Increased hosp. stay
Increased morbidity and
mortality
4

The goals of nutrition support:

To minimize protein breakdown
Preserve lean body mass
Promote protein synthesis
Optimize immune responses.

When?
Preoperative?
Early?
Late?
---after initial resuscitation following injury or

surgery

How?
Parenteral
Enteral
Total
Partial

Issues
Metabolic response to injury
Cytokines, inflammation, hormones
Biology of substrates
Enteral vs. Parenteral

EBB PHASE
Typically, the ebb phase of the stress
response occurs within the first 12 to 48
hours.
It is characterised by catabolism. It is
driven largely by release of cytokines and
hormones.

The Ebb Phase

Hypometabolic
Hypothermic
Hypoinsulinemic
Hypoperfusion

Hypercortisolism
Hyperglucagonemia
Hyperglycemia
Hypercatecholemia

The patient warms up,cardiac

output increases and the
surgical team relaxes
The Flow Phase
Cuthbertson. Lancet 1:233, 1942

The Flow Phase

Hypermetabolic
Hyperthermic
Catabolic

Hyperinsulinism
Hypercortisolism
Hyperglucagonemia
High cardiac output

Nutritional Assessment
Body weight
Body mass index
creatinine height index
Serum proteins:albumin, prealbumin,

transferrin
Immune competence: lymphocytes, DH
Nitrogen balance

Nutritional Requirements
25 cal/kg/day
carbohydrate ~70%
Lipid 15-30%
Protein 1.5-2.0g/kg/day. Not for calories
Additional 50% to 100% for stress as in ICU

patients

Protein requirements
Normal: 0.8-1 g/kg/d protein (up to 60-

70g/d).
Moderate depletion/ stress: 1-1.5 g/kg/d.
Severe: 1.5-2.
Calculate grams of nitrogen = grams of
protein/ d/ 6.25.
Nitrogen-to-calorie ratio is usually 1gN to
every 150 kcal (1:150).
Need less protein with renal failure before
dialysis and hepatic encephalopathy.
Multiple trauma/ burn/ sepsis --> 30-50 non
protein and 1.5-3 protein.
Stress factor ~ 1 gm/kg/24hr
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Nutritional Goals
Nitrogen balance
Preserve or restore visceral protein
Reduce morbidity
Reduce mortality
Reduce hospital stay

Malnutrition is common in surgical

patients.
Pre operative
Postoperative
More then 20% loss of average
body wt. is associated with high
morbidity & mortality.

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Nutrition Intervention

Modes of administration

20

Modes of administration

Enteral nutrition

Simple Home made Diet

Commercial formulae
Care
Hygiene
Timing frequency
Tolerance
Oral cavity /tube care

21

Blenderized vs
Commercial feed

What is parenteral nutrition?

Parenteral Nutrition
also called "total parenteral nutrition," "TPN," or
"hyperalimentation."
It is a special liquid mixture given into the blood via a
catheter in a vein.
The mixture contains all the protein, carbohydrates, fat,
vitamins, minerals, and other nutrients needed.

Indications for Parenteral Nutrition Support

Malnourished patient expected to be unable to eat > 5-7

days AND enteral nutrition is contraindicated

Patient failed enteral nutrition trial with appropriate tube
placement (post-pyloric)
Enteral nutrition is contraindicated or severe GI
dysfunction is present
Paralytic ileus, mesenteric ischemia, small bowel

obstruction, enteric fistula distal to enteral access sites

Benefits of Enteral Nutrition

Over Parenteral Nutrition
Cost
Tube feeding cost ~ $10-20 per day
TPN costs up to $1000 or more per day!

Maintains integrity of the gut

Tube feeding preserves intestinal function; it is more physiologic
TPN may be associated with gut atrophy

Less infection
Enteral feedingvery small risk of infection and may

prevent bacterial translocation across the gut wall

TPNhigh risk/incidence of infection and sepsis

Refeeding Syndrome
the metabolic and physiologic consequences of

depletion, repletion, compartmental shifts, and

interrelationships of phosphorus, potassium, and
magnesium
Severe drop in serum electrolyte levels resulting from
intracellular electrolyte movement when energy is
provided after a period of starvation (usually > 7-10
days)
Physiologic and metabolic sequelae may include:
EKG changes, hypotension, arrhythmia, cardiac arrest
Weakness, paralysis
Respiratory depression
Ketoacidosis / metabolic acidosis

Refeeding
Syndrome
(continued)
Prevention and Therapy
Correct electrolyte abnormalities before starting nutrition

support
Continue to monitor serum electrolytes after nutrition support
begins and replete aggressively
Initiate nutrition support at low rate/concentration (~ 50%
of estimated needs) and advance to goal slowly in patients
who are at high risk

Consequences of Over-feeding
Risks associated with over-feeding:
Hyperglycemia
Hepatic dysfunction from fatty infiltration
Respiratory acidosis from increased CO2 production
Difficulty weaning from the ventilator

Risks associated with under-feeding:

Depressed ventilatory drive
Decreased respiratory muscle function
Impaired immune function
Increased infection

Complete & Balanced Nutrition

Ideal balance of protein, fat and carbohydrate
Best quality protein

Soluble fiber FOS

28 Essential vitamins & minerals

Oral and tube feed

Lactose and Gluten free

Objective
To investigate changes in nutritional status and
the influence of oral supplements on nutritional
status, morbidity, and quality of life in
postoperative surgical patients

Study design & method

prospective, randomised, controlled trial
Patients 18 - 80 years admitted to hospital for elective

gastrointestinal or vascular surgery

Study design & method

Patients were assessed on admission to hospital and

again on initiation of the oral diet postoperatively

Entry was determined by the presence of malnutrition

defined by anthropometric criteria on admission or on

resumption of the oral diet by the eighth postoperative
day, and/or a weight loss of 5% or more from admission
until oral intake was resumed by the eighth
postoperative day

Exclusion
patients who required parenteral nutrition
pregnant or lactating
Patients with terminal diseases and those with decompensated liver or renal

disease.

Nutritional assessment
Height
Weight
BMI
Mid arm circumference
Tricep skin fold

Criteria for malnutrition

BMI< 20Kg/m2
TSF & MAMC < 15th percentile and/ or weight loss>

5% from admission to hospital to the point of

inclusion
BMI < 18 and < 16Kg/m2, and anthropometry below

5th percentile moderate & severe malnutrition

BMI > 25Kg/m2 - Overweight

Incidence of wound and

chest infection

Results
Patients in the control group lost a maximum mean (SD) of

5.96 (4.21) kg in weight over a period of eight weeks while

patients in group TG lost less weight overall (maximum
mean (SD) 3.40 (0.89) kg (p<0.001) occurring at four
weeks and progressively regained weight from week 4)
Anthropometry, grip strength, and QOL were similarly

significantly different between groups (p<0.001)

Fewer patients in the treatment group (7/52) required

antibiotic prescriptions compared with the control group

(15/49)

THANK YOU