Nutrition in the surgical patient

Malnutrition
• 50% of patients admitted to hospital are malnourished

• 25-30% become malnourished during hospital stay

• Malnutrition occurs due to decreased intake or

increased demand of nutrients(following trauma,
critical illness, sepsis, severe burns, major surgery)

Reilly et al, JPEN 1988 Jul-Aug;12(4):371-6

 Clinical Effects of malnutrition
Specific effects

• Wound dehiscence
• Poor healing
• Breakdown of surgical anastomosis
• Poor immune response to infection
 Clinical Effects of malnutrition
Non specific effects

• Central nervous system- apathy, drowsiness, inability to

clear secretions
• Loss of lean muscle mass- increased work of breathing,
ventilator dependency
• Sepsis-Multi Organ Dysfunction Syndrome (MODS)

Correia MI et al ,Clin Nutr 2003; 22:235-9 ,

Pichard C et al, Am J Clin Nutr 2004 ;79:613-18,
Amaral TF et al , Clin Nutr 2007;26:778-84
 Metabolic Effects of Surgery(Acute
Stress)
• Surgery – acute stress
• Stress response-catabolic state
• Cytokines released from injury site & Afferent nerve
signals to hypothalamus from injury site
• Release of cortisol, glucagon, Growth hormone
• Glycogenolysis & gluconeogenesis -Hyperglycaemia – state
of insulin resistance
• Lipolysis & protein breakdown
• Ketone body production supressed
• Loss of lean body mass

Sabiston text book of surgery- 20th ed pg-106

 Optimal nutrition
• Underfeeding in the setting of stress induced catabolism-
precipitous decline in nutritional status

• Overfeeding
hypercapnia
metabolic acidosis
hyperglycaemia
hypertriglyceridemia
hepatic dysfunction
azotaemia

Sabiston text book of surgery- 20th ed pg-107

 Nutritional assessment & monitoring
• MUST (Malnutrition Universal Screening Tool)

• NRS( Nutritional Risk Screening)- only tool shown to predict morbidity & mortality reliably in
acute care & GI surgery patients

• SGA (Subjective Global Assessment)

• Anthropometric measurements-IBW(Ideal Body Weight), BMI(Body Mass Index), skin fold

thickness.

• Oxygen consumption, determination of Respiratory Quotient(RQ)

• Body composition analysis- Dual energy X ray absorptiometry

• Biochemical measurements- Albumin, Transferrin, Prealbumin

Sabiston text book of surgery- 20th ed pg-107

 MUST (Malnutrition Universal
Screening Tool)

Malnutrition advisory group guidelines(MAG)- MAG—guidelines for Detection and Management

of Malnutrition,British Association for Parenteral and Enteral Nutrition, 2000, Redditch, UK
NRS( Nutritional Risk Screening)

Kondrup J et al, Clin Nutr 2003;23: 321-36

NRS( Nutritional Risk Screening)
 SGA (Subjective Global Assessment)

• SGA first described by Baker et al in 1982

• 2 components- history, physical examination
• Simple & easy- can be done by paramedical staff, Patient Generated
SGA also possible(PG-SGA)
• Patients classified in to 3 groups-
SGA grade A- well nourished
SGA grade B- moderately malnourished
SGA grade C- severely malnourished
• Components of SGA that affected rating mostly were muscle
wasting, loss of subcutaneous fat, and pattern of weight loss

Makhija et al, Nutrition in Clinical Practice / Vol. 23, No. 4, August 2008 405-9
Components of SGA
Modified SGA score –Indian
population
History Physical examination

Shirodkar et al, Indian J Gastroenterol

2005;24:246-250
 SGA in surgical patients
• Detsky et al studied 202 patients undergoing GI surgery
• SGA- B - 44 (21%), SGA- C – 19 (10%)
• Nutrition related complication rate -10%- wound infection, sepsis, death.
• Lowest complication rate in SGA class A & B –serum albumin level of >4
• Highest complication rate in SGA class C –serum albumin level of < 3
• Pham NV et all conducted prospective, cross-sectional study in surgical
patients in Vietnam
• determined rate of infectious complications -wound infections,
intraabdominal abscesses, anastomotic leakage.
• rate of complications higher in the SGA class C group (33.6%) compared
with those in class A (6%) and class B (11%)

Detsky AS et al, JPEN J Parenter Enteral Nutr. 1987;11:440-446

Pham NV et al, Clin Nutr. 2006;25:102-108
 Anthropometric measurements

• Ideal Body Weight(IBW)-

Men- 48 Kg for first 152 cm, 2.7Kg for each

additional 2.54 cm
Women- 45 Kg for first 152 cm, 2.3Kg for
each additional 2.54 cm
• outdated
 Anthropometric measurements
• Body Mass Index(BMI)-
Group BMI(Kg/m2)

Severely underweight <16.5

Underweight 16.5-18.4

Normal weight 18.5-24.9

Overweight 25-29.9

Obesity grade 1 30-34.9

Obesity grade 2 35-39.9

Obesity grade 3 ≥ 40

• In children BMI < 5th percentile- underweight, >95th

percentile overweight
 DEXA(Dual Energy X-ray
Absorptiometry)
• Measures body tissue composition – lean body mass, fat mass,
bone density
• Tissue density values- quantitative measurement of attenuation of
2 X-ray beams
• Maintaining skeletal muscle- lean body mass is principle objective
of nutritional support.
• Malnourished obese patients- although BMI will be high, lean body
mass will be low –Sarcopenic Obesity
• Surgical morbidity & mortality rates correlate more closely with
lean body mass than absolute weight based parameters(IBW/BMI)

Choban P et al, JPEN, J Parenter Enteral Nutr 37: 714-744

 Serum Albumin Level

• Elective surgery-preoperative albumin better prognostic indicator of

morbidity & mortality than anthropometric measurements
• Serum Albumin levels as indicator of nutritional status– acute phase
is limited
• Fluid shifts & increased capillary permeability – protein leakage –
falsely low values

Gibbs J et al, Arch Surg 134:36-42

Calculation of energy requirements
• Harris- Benedict equation for estimation of REE(Resting Energy Expenditure)
• Men- BMR= 66.5+(13.5xweight in Kg)+(5 x height in Cm)- (6.75x age in yrs)
• Women - BMR= 655+(9.5xweight in Kg)+(1.85 x height in Cm)- (4.67x age in
yrs)
• Stress factor – minor surgery – 1.1, major surgery – 1.2
• Activity factor-
confined to bed- 1.2
out of bed- 1.3
normal, healthy activity -1.5
1.1 for each degree rise of body temperature above 37 degree
• Simple & easier method-
25 to 30 kcals/kg/day for normal individuals
30 to 35 kcal/kg/day for patients moderate illness, injury, or malnutrition
35 to 40 kcals/kg/day for patients with critical illness or injury
Sabiston text book of surgery- 20th ed pg-110
 Nitrogen balance
• Nitrogen balance = nitrogen intake- nitrogen output
• Should be positive nitrogen balance if nutritional support is
adequate
• Nitrogen intake= total protein intake /6.25
• 24 hr UUN(g/day)= UUN(mg/dl) x UO(ml/day)x 1/1000(g/mg)
x 1/100 (dl/ml)
• Total nitrogen loss(g/day)= 24hr UUN(g/day) +(0.2 x 24 hr
UUN in gm/day) + 2 gm/day

Sabiston text book of surgery- 20th ed pg-110

 Criteria to initiate perioperative
nutritional support
• Past medical history- severe undernutrition, chronic disease

• Involuntary weight loss > 10-15% of usual body weight within 6

months or > 5% within 1 month

• Expected blood loss > 500ml during surgery

• Weight of 20% under IBW or BMI <18.5 Kg/m2

• Failure to thrive on paediatric growth & devolopment curves(< 5th

percentile )

Weimann et al, ESPEN guidelines on enteral nutrition. Clinical nutr 25:224-244, 2006
 Criteria to initiate perioperative
nutritional support
• Serum albumin <3 g/dl or transferrin <200 mg/dl in absence
of inflammatory state hepatic dysfunction or renal
dysfunction.

• Anticipate that patient unable to meet caloric requirements

within 7-10 days perioperatively.

• Catabolic disease(burns, trauma, sepsis, pancreatitis)

Weimann et al, ESPEN guidelines on enteral nutrition. Clinical nutr 25:224-

244, 2006
 Principles guiding routes of nutrition
• Use oral route , if there are no contraindications(C/I)
to oral feeding.

• Nutrition via enteral route, if patient not expected to

be on full oral diet within 7 days post surgery & no GI
tract C/I .

• Enteral nutrition C/I or not tolerated, use parenteral

route.
 Principles guiding routes of nutrition
• Administer at least 20% of calorie & protein
requirements enterally while reaching required goal with
additional parenteral nutrition(PN)

• Maintain PN until patient is able to tolerate 75% of

calories through enteral/oral route

• Maintain enteral nutrition until patient is able to tolerate

75% of calories through oral route.

Sabiston text book of surgery- 20th ed pg-111

 ENTERAL NUTRITION
ROUTES OF ADMINISTRATION :
• < 4 weeks= Nasogastric(NG)/Nasoduodenal / Nasojejunal (NJ)
• > 4 weeks= Gastrostomy /Jejunostomy-percutaneous,
surgically
• NG & NJ feeding a/w comparable rates of pneumonia-
protective effect of pyloric sphincter.
• Large multicentre trial, W/H enteral feeds if NG output is >
500 ml compared to 200 ml previously.
• No difference in the incidence of pneumonia, time n
ventilator, length of ICU stay.
Davies AR et al, Crit Care Med 40:2342-48
Montejo JC et al, The REGANE study, Intensive Care Med, 36:1386-93
 Advantages of enteral nutrition
• Delivery of nutrients
• Stimulates enteric blood flow, increases mucosal mass.
• Increased brush border enzyme synthesis, villous height.
• Maintains barrier function by preserving tight junction integrity –
prevents bacterial translocation
• Induce Production & release of mucosal immunoglobulins
• Polysaccharides fermented- support normal bacterial flora, FFA-
fuel for colonocyte.
• Increases gut motility- decrease ileus

Alverdy JC et al, Surgery 104:185-190

Groos S et al, J Submicrosc Cytol Pathol 28:61-74
Boelens PG et al – Ann Surg 259:649-55
 Enteral nutrition

Gastric feeding Jejunal feeding

Solution used Hypertonic or isotonic isotonic

Infusion rate Bolus/continious Continious

Initiation of infusion 25-30 ml/hr

Increments 25-30 ml/hr daily

Intolerance Vomiting Distension, diarrhoea,

colic, reflux to NGT
 Enteral formulas
Low residue isotonic formulas:
• Calorie density of 1 kcal/ml
• Non protein-calorie: nitrogen ratio =150:1
• No fibre, no bulk, no residue
• Cheap, first line for stable gastrointestinal tract
Elemental formula:
• pre-digested nutrients,
• Advantages: ease of absorption in gut impairment, pancreatitis
• Disadvantages: poor in fat, vitamin, trace elements , High
osmolarity, high cost
Immune enhancing formulas:
• Glutamine, arginine, omega-3 fatty acids, nucleotides, beta
carotene
 Monitoring schedule for enteral
feeding
Parameters Acute patient Stable patient

Electrolytes Daily 1-2x/week

Complete blood count Daily 1-2x/week

Glucose level 3x/day, more often if 3x/day, less often if good

poorly controlled control
Creatinine & urea levels Daily Weekly/twice weekly

Nitrogen balance Daily 2-3 x/week

Input & output Daily 2-3x/week

Body weight daily 2-3x/week

Urine output Hourly Every 4 hours

 Complications of enteral feeding
Local problems: epistaxis, sinusitis, nasal necrosis

Mechanical problems: tube malpositioning, dislodgement

Solute overload: Diarrhoea, dehydration, electrolyte

disturbance, hyperglycaemia.

Sabiston text book of surgery- 20th ed pg-118

Complications of enteral feeding
Complications of enteral feeding
 REFEEDING SYNDROME
• Definition- fatal shifts in fluids and electrolytes that occur in
malnourished patients receiving artificial refeeding (enteral or
parenteral)

• Incidence-34 % devolop hypophosphatemia after starting refeeding

• Features
Hypophosphatemia – hallmark
Other features- hyponatremia, hypokalaemia, hypomagnesaemia ,
thiamine deficiency

Hisham M et al, BMJ, 2008 Jun 28; 336(7659): 1495–1498

 How does refeeding syndrome
develop?

• Prolonged fasting
• BMR decreased by 20-25%, body switches
from using carbohydrates to fat & proteins as
main source of energy
• Intracellular minerals depleted(Po4, Mg, K),
although serum concentrations are
maintained- intracellular compartment shrinks
& renal excretion decreases
 How does refeeding syndrome
develop?
• Refeeding started ---> glucose becomes available
for body---> insulin secretion ---> Anabolism --->
requires Po4, Mg, K, thiamine- cofactor(shifted
intracellularly)
• Hyperglycaemia following refeeding ---> osmotic
diuresis, dehydration, metabolic acidosis, lactic
acidosis, hypercapnoea, respiratory failure,
difficult to wean from ventillator
• Due to lipogenesis- fatty liver
 National Institute for Health and
Clinical Excellence(NICE) Guidelines
For identifying patients at high risk of refeeding problems
Either the patient has one or more of the following:
• Body mass index (kg/m2) <16
• Unintentional weight loss >15% in the past three to six months
• Little or no nutritional intake for >10 days
• Low levels of potassium, phosphate, or magnesium before feeding
Or
the patient has two or more of the following:
• Body mass index <18.5
• Unintentional weight loss >10% in the past three to six months
• Little or no nutritional intake for >5 days
• History of alcohol misuse or drugs, including insulin, chemotherapy,
antacids, or diuretics
NICE guidelines for management
 Contraindications to enteral nutrition
• Intractable vomiting, diarrhoea refractory to medical management.

• Paralytic ileus

• Distal high output intestinal fistula(too distal to bypass with feeding

tube)

• GI obstruction, ischaemia

• Diffuse Peritonitis

• Severe shock /haemodynamic instability

 Contraindications to enteral nutrition

• Severe GI haemorrhage

• Severe short bowel syndrome(< 100 cm of small bowel remaining)

• Severe GI malabsorption(enteral nutrition failed as evidenced by

progressive detoriation in nutritional status)

• Inability to gain access to GI tract.

• Need is expected for < 7 days.

Villet S et al Clin Nutr 24: 502-9,2005

 Parenteral nutrition

• TPN (Total Parenteral Nutrition)

• Provision of nutrients intravenously

• Central
• Peripheral

• For patients who are already malnourished or have the potential for
developing malnutrition and who are not candidates for enteral nutrition

Sabiston textbook of surgery 20th ed, pg 117-122

 Parenteral nutrition
Advantage-

Potentially life-saving when GI tract cannot be used or when

oral/parenteral nutrition cannot meet nutrient requirements of
patient.

Disadvantages-

• Costly

• Long term risk of liver dysfunction, kidney and bone disease, and
nutrient deficiencies
 Routes for parenteral nutrition

Central Parenteral Nutrition (CPN):

• Utilization of large central veins for the administration of
a patient’s complete nutrient needs
• Preferred Route
• Can deliver daily requirement for kcals, protein, micronutrients
in concentrated volumes
• PICC Line -Peripherally inserted central catheter
Benefits
• Access to central vein
• Can accommodate hypertonic fluids
• Lower risk of phlebitis than PPN
• Easier to insert than central line
 Indications for TPN

• NPO for extended period

• Short bowel syndrome

• Severe acute pancreatitis

• High output enterocutaneous fistulas

• Contraindications for enteral nutrition present

 TPN Solution

Carbohydrate: Dextrose
• Most common concentrations: 50% and 70%
Protein: Amino Acids
• Most common concentrations: 8.5% and 15%.

Lipid: IV emulsion

• 10% solution
• 20% solution
• Concentrated source of kcals
• Helps minimize hyperglycemia
 TPN Solution

Lipid:
• Helps prevent respiratory acidosis (in respiratory failure)

• Need at least 10% of kcals from lipid to prevent EFA deficiency

• Excessive lipid administration may suppress immune function.

• Admixtures (3:1) becoming more common

• Potential source of vitamin K: potential problem if

anticoagulants used
 TPN Solution

Vitamins

Daily MV in formula is standard

Electrolytes

– Start with standard amounts

– Adjust as needed

Common Medications
– Insulin
– H2 antagonists
– heparin
 Peripheral parenteral nutrition(PPN)

Utilization of peripheral veins for the administration

of nutrients

Indications for use:

• PN necessary but no access to central vein

• Malnourished patients with frequent NPO for

procedures/tests

• Required for shorter period

 Limitations of PPN

• Peripheral site more prone to

inflammation/infection

• Catheter may need to be repeatedly inserted Poor

choice for long-term nutrition
 TPN administration
Continuous infusion

• Start slowly, Allows blood to adapt to increased glucose/osmolality

• Infusion pump is used to ensure proper rate.

• Example: Start at 40ml/hr x 24hr. Then progress to 80ml/hr x 24h

(equivalent to increasing TPN by 1 liter per day). until goal rate has
been reached or patient intolerance is noted.

• If rate is increased too quickly, hyperglycemia may result

• Monitor tolerance: electrolytes, blood glucose, triglycerides,

ammonia, etc.
 TPN administration
• Introduce lipids gradually to avoid adverse reactions (fever, chills,
backache, chest pain, allergic reactions, palpitations, rapid
breathing, wheezing, cyanosis, nausea, and unpleasant taste in the
mouth)

• When pt. is taken off TPN, rate must be tapered off gradually to
prevent hypoglycemia.

• ( TPN by ½ X 2 hrs. then Discontinue – usually sufficient to prevent

hypoglycemia)

• PPN doesn’t need to be tapered off (uses more dilute solution

w/less dextrose)
 TPN administration
Cyclic Infusion
• TPN infused at a constant rate for only <24 hours/day (e.g. 12-14hr
overnight)

• Allows more freedom/normal daytime activity

• Can be used to reverse fatty liver resulting from continuous infusion

(Chronically high insulin levels may inhibit fat mobilization  fatty liver)

• Fewer kcals may be necessary to maintain N balance (body fat better

mobilized for energy)

• Requires higher infusion rate: not all patients can tolerate it(cardiac
patients, renal failure patients).
 TPN complications
Catheter or Care-Related Complications:
• Hydrothorax

• Pneumothorax

• Hemothorax

• Sepsis

• Blood clot thrombosis

• Infusion pump malfunctions

• Myocardial or arterial puncture

 TPN complications
Metabolic or Nutrition-related Complications

• Hyperglycemia/Hypoglycemia

• Dehydration/Fluid overload

• Electrolyte imbalances

• Hyperammonemia

• Acid-base imbalance

• Fatty liver

• Bone demineralization
 Immunonutrition
• Major injury- traumatic/induced by surgery cause
immunosuppression

• Specific nutrients-arginine omega 3 PUFA, glutamine,

nucleotides – modulate immune response

• Arginine-stimulates T lymphocytes & provide substrate

for synthesis of NO

Sabiston text book of surgery- 20th ed pg-110

 Immunonutrition

• Omega 3 PUFA- decreases production of inflammatory

eicosanoids, cytokines, adhesion molecule & promotes
production of resolvins

• Nucleotides enhances immune competence.

• Several trials have shown superior outcome with immune

enhancing enteral diet in certain patient population

• To be started 7 days prior to till 7 days after surgery

 Immunonutrition
Immunonutrition recommended in following circumstances- shown superior
outcomes compared to standard formulations.

• Major neck surgery for cancers(laryngectomy, pharyngectomy)

• Severely malnourished patient(serum albumin < 2.8 g/dl)

• Undergoing major oncologic GI surgery

• Patients with trauma to 2 or more body systems

• Injury Severity Score(ISS) ≥18 or abdominal trauma index ≥ 20

• Patients with mild sepsis (APACHE II score <15)

• Patients with ARDS