NUTRITIONAL SUPPORT
IN SURGICAL PATIENTS
Content
1. Overview of nutrition and malnutrition
2. Assessment of nutritional status
3. Assessment of nutritional requirement
4. Causes of inadequate intake
5. Methods of providing nutritional support
6. Monitoring of nutritional support
1. Overview of nutrition and malnutrition
Definition
Nutrition: The intake and metabolism of nutrients (food and
other nourishing material) by an organism so that life is
maintained and growth can take place
Malnutrition: A disorder of nutrition or a eating condition
resulting from energy and protein deficiency, sometimes
with vitamin and trace element deficiency as well.
Importance of nutrition in surgery
Surgical procedures and subsequent fasting can cause these patients to go
into severe malnutrition quickly, often before the treating team realises it.
There is evidence that patient with severe protein depletion have greater
incidence of postoperative complication such as pneumonia, wound
infection & prolonged hospital stay.
Objectives of nutritional support
Provide nutrition support consistent with patient’s medical condition
Prevent / treat macronutrient and micronutrient deficiency
Provide doses of nutrient compatible with existing metabolism
Avoid/ manage complications related to the technique of nutrient
delivery
Improve patient’s outcome such as those related to morbidity
To prevent and minimise the effect of catabolism
2. Assessment of nutritional status
2018. Bailey & Love's Short Practice of Surgery
When is nutritional assessment and therapy
indicated in the surgical patient?
It is recommended to assess the nutritional status before and after major surgery
Perioperative nutritional therapy is indicated in patients with malnutrition and those at nutritional risk.
Perioperative nutritional therapy should also be initiated, if it is anticipated that the patient will be unable to
eat for more than five days perioperatively.
It is also indicated in patients expected to have low oral intake and who cannot maintain above 50% of
recommended intake for more than seven days.
In these situations, it is recommended to initiate nutritional therapy (preferably by the enteral route) without
delay.
2017. ESPEN guideline: Clinical nutrition in surgery
Nutritional assessment
1. History
Medical illness
Oral intake
Marked weight loss
2. Physical examination
Oedema, ascites, cachexia, muscle wasting
Anthropometric measurements
3. Biochemical profile
Albumin, prealbumin, transferrin
Lymphocyte count
August. JPEN 2002.
Backburn. Surg Clin N Am 2011.
History
History of poor nutrient intake
Anorexia
Nausea
Vomiting
Early satiety
Food preference
Loss of body weight: weight loss more
than 10-15% in past 6 months
Physical examination
Physical examination
3. Assessment of nutritional
requirement
Uncomplicated Complicated/stressed
Energy (kcal/kg/day) 25 30-35
Protein (g/kg/day) 1.0 1.3-1.5
Energy and protein/nitrogen requirement vary, depending on weight, body composition, clinical status, mobility and dietary intake.
For most patient, an approximate based on weight and clinical status is sufficient.
-Particular caution must be exercised when refeeding the chronically starved patient because of the dangers of hypokalemia and hypophosphatemia.
Nutritional requirement
Essential
amino acids
Trace
Amino acids
elements
4 kcal/g
ENERGY
Carbohydrates Fluid &
4 kcal/g 20-35 kcal Electrolytes
/ kg / day
Lipids
Vitamins
9 kcal/g
Comparison of Protein/Energy
Demands
SURGERY PATIENT
HEALTHLY 70 kg MALE
Caloric intake
Caloric intake *Mild stress, inpatient
25-30 kcal/kg/day
25-30 kcal/kg/day *Moderate stress, ICU patient
30-35 kcal/kg/day
Protein intake *Severe stress, burn patient
0.8–1.5 g protein (0.13–0.24 g 30-40 kcal/kg/day
nitrogen)/kg/day Protein intake
1-2 gm/kg/day
Fluid intake
30–35 ml fluid/kg Fluid intake
INDIVIDUALIZED
2017. NICE. Nutrition support for adults: oral nutrition support
4. Causes of inadequate
intake
Patients with increased metabolic demands may have some difficulty in taking sufficient
food to meet such demands.
Patients with a normal functional gut may also have a reduced food intake due simply to
the cumulative effects of repeated periods of fasting to undergo investigation such as
endoscopy or radiology.
Some patient may suffer from ‘intestinal failure’ , a state in which the amount of
functioning gut is reduced below a level where enough food can be digested and absorbed
for nourishment.
Acute intestinal failure (when it is relatively reversible) is relatively common, especially
after abdominal surgery when it commonly result from the development of surgical
complication, whereas chronic intestinal failure is comparatively rare.
The principal causes of acute intestinal failure are mechanical
intestinal obstruction and paralytic ileus, frequently associated with
abdominal sepsis, as well as intestinal fistula formation, in which
bowel content is lost externally or short circuited (internal fistula)
before it can be adequately digested and absorbed.
Chronic intestinal failure may result from short bowel syndrome,
following extensive small bowel resection, extensive small bowel
disease such as Crohn’s disease, and motility disorder such as
chronic intestinal pseudo-obstruction.
4. Methods of providing
nutritional support
Traditional Method: Diet
advancement
Introduction of solid food depends on the condition of the GI tract.
Oral feeding delayed for 24-48 hours after surgery.
Wait for return of bowel sounds or passage of flatus.
Start clear liquids when signs of bowel function returns
Rationale
Clear liquid diets supply fluid and electrolytes that require minimal digestion and little stimulation of the
GI tract
Clear liquids are intended for short-term use due to inadequacy
Standard nutrition Enteral nutrition
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Methods of providing nutritional support
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Things to Consider…
Risk of malnutrition / indicated
for nutritional support
Safe to Unsafe to
swallow swallow
Oral nutritional Peforated GI /
support GI intact &
non-functional
functional
Parentral
Enteral feeding
feeding
Use the oral route if the GI tract is fully functional and there are no other
contraindications to oral feeding.
ENTERAL NUTRITION
2017. ESPEN guideline: Clinical nutrition in surgery
2021. Sabiston Textbook of Surgery
Enteral Access Devices
Nasoenteric
Nasogastric
Gastrostomy
PEG (percutaneous endoscopic gastrostomy)
Surgical or open gastrostomy
Jejunostomy
PEJ (percutaneous endoscopic jejunostomy)
Surgical or open jejunostomy
Transgastric Jejunostomy
PEG-J (percutaneous endoscopic gastro-jejunostomy)
Surgical or open gastro-jejunostomy
Feeding Tube Selection
Can the patient be fed into the stomach, or is small bowel access
required?
Gastric access: “If the stomach empties, use it.”
Indications to consider small bowel access:
Gastroparesis / gastric ileus
Recent abdominal surgery
Sepsis
Significant gastroesophageal reflux
Pancreatitis
Aspiration
Ileus
Proximal enteric fistula or obstruction
Administration of EN support
Intermittent bolus feeding
Start with 50ml Q3H.
Aspirate before every feed
If aspirate < 300cc, return aspirates to patient,
increase 50mls after every 2 feeds till caloric
needs are met.
If aspirate > 300mls,return 300mls aspirate to
patient and reduce by 50mls per feed and to
exclude bowel obstruction
If no clinical evidence of bowel obstruction,
administer prokinetic agent
Choosing Appropriate Formulas
Categories of enteral formulas:
Polymeric
Whole protein nitrogen source,
for use in patients with normal or near normal GI function.
Examples include Ensure.
Monomeric or elemental
Predigested nutrients; most have a low fat content or high % of medium chain trigleceride;
for use in patients with severely impaired GI function.
Examples include Peptamen and Optimental
Disease specific
Formulas designed for feeding patients with specific disease states
Formulas are available for respiratory disease, diabetes, renal failure, hepatic failure, and immune
compromise.
Examples include Glucerna and Nepro
Types of Enteral Nutrition Formulas | Physicians' Elemental Diet
Complication of enteral
nutrition
Diarrhoea is more common with nasogastric than with nasoenteric feeding. It may be manage by
reducing the rate of infusion and by ensuring the patient is not on broad-spectrum antibiotics.
Vomiting can be managed by reducing the rate of feeding and by the use of prokinetics drugs such as
metoclopramide or erythromycin.
Excessive infusion of nasogastric feed may cause marked abdominal bloating, resulting in splinting of
the diaphragm and impaired respiratory function.
Complication also occur because of difficulty in placing the tubes. Examples include a fine-bore NG
tube inserted wrongly in the respiratory tract, early accidental removal of a jejunostomy tube with
intraperitoneal leakage, or peritubal leakage with resultant intraperitoneal sepsis.
The fixation of the jejunal loop to the abdominal wall, required to minimize the risk of intraperitoneal
leakage associated with feeding jejunostomy, may in turn increase risk of small bowel volvulus.
PARENTERAL NUTRITION
Total Parenteral Peripheral Parenteral Nutrition
Nutrition The lower osmolarity of the solution used for
peripheral parenteral nutrition (PPN), secondary
Total parenteral nutrition (TPN), to reduced levels of dextrose (5% to 10%) and
also referred to as central parenteral protein (3%), allows its administration via
nutrition, requires access to a large- peripheral veins.
diameter vein to deliver the entire Some nutrients cannot be supplemented because
nutritional requirements of the they cannot be concentrated into small volumes.
individual. Therefore, PPN is not appropriate for repleting
patients with severe malnutrition.
Dextrose content of the solution is It can be considered if central routes are not
high (15% to 25%), and all other available or if supplemental nutritional support is
macronutrients and micronutrients required. Typically, PPN is used for short periods
are deliverable by this route. (<2 weeks).
Beyond this time, TPN should be instituted.
2021. Sabiston Textbook of Surgery
Indications & Contraindications of PN
Indications Contraindications
Severely undernourished patients =
enteral nutrition is not feasible / not
tolerated. Patient with functional and accessible GI tract
Impaired gastrointestinal function ->
unable to receive and absorb adequate Patients who are tolerating orally
amounts of oral/enteral feeding for at
least 7 days (e.g. paralytic ileus) Prognosis that does not warrant aggressive
nutrition support
Combination therapy should be considered
when patient not able to take 60% of calories End of life stage of cancer patients, DNA
enterally CPR
Massive small bowel resection Severe sepsis, shock
Untreatable malabsorption
Complete bowel obstruction
2021. Sabiston Textbook of Surgery
Complication of TPN
Catheter problems
Percutaneous insertion of a catheter may damage adjacent structures and can cause
pneumothorax, air embolus and hematoma.
Thrombophlebitis
Thrombosis is common when long lines are used, when the catheter tip is not in an
area of high flow, and when very hypertonic solutions are infused.
Infection
- Catheter related sepsis and blood stream infection are the most frequent complication of TPN.
- The usual organisms are coagulase-negative staphylococci, S. Aureus and coliform, but the incidence of fungal infections is
increasing, possibly because many of the patients requiring TPN are immunocompromised or receiving broad-spectrum antibiotics.
Detection and treatment of
catheter related sepsis
If a pyrexia > 38’C develops, or there is a further rise in temperature if already pyrexial,
1. Stop parenteral nutrition and check for other sources of pyrexia (eg: chest or urinary tract infection)
2. Take peripheral and central line blood cultures
3. Administer intravenous fluids
4. Heparinize catheter
5. If blood cultures is negative : Restart parenteral nutrition and continue to monitor for signs of sepsis
If blood cultures is positive:
Remove catheter and send tip for bacteriological analysis
6. Administer appropriate antibiotic therapy
7. If necessary, replace catheter and restart parenteral nutrition within 24-48 hours
Complication of TPN
Metabolic complication
Metabolic complication include over or underhydration.
There is a physiological upper limit to the amount of glucose that can be oxidized
(4mg/kg/min) and prolonged glucose infusion in excess of this rate may lead to hyperglycemia
and fatty infiltration of the liver with disordered liver function.
Mildly abnormal liver enzymes in patients receiving TPN are common. However, severe and
progressive abnormalities and in particular, biochemical or clinical jaundice should lead to a
prompt re-evaluation of the feeding regimen.
Excessive administration of glucose may also aggravate respiratory failure as a consequence of
the need to eliminate larger amounts of carbon dioxide consequent upon increased carbohydrate
oxidation.
Intolerance of glucose is particularly likely in sepsis and critical illness as a result of insulin
resistance.
Hypokalemia and hypophosphatemia are common when severely
malnourished patients are re-fed after a long period of starvation because
of the large flux of potassium and phosphate into the cells; correction is by
further supplementations.
Abnormal LFT may occur in severely stressed or septic patients.
Formulas available in MGH
3-in-1 mixtures : glucose + lipids + proteins
1. NuTRIflex Lipid Peri (1435kcal in 1875ml)
2. NuTRIflex Lipid Plus (1900kcal in 1875ml)
3. SmofKabiven peripheral (1000kcal in 1500ml)
4. Smofkabiven central (2200kcal in 2000ml)
1. Carbohydrate (glucose)
2. Lipid emulsion
3. Amino acids
4. Electrolytes
CENTRAL PREPARATION
Osmolarity 1500 mosmol/L
Nitrogen 12 grams
Non protein calorie 1300 kcal
PERIPHERAL PREPARATION
Osmolarity 750 mosmol/L
Nitrogen 5.4 grams
Non protein calorie 900 kcal
[SmofKabiven 1470mL & Kabiven Peripheral
1440mL. Fresenius Kabi AG, Germany]
Calculation for PN + Total
Fluid Requirement 60 years old planned for
TPN 30% Smof Kabiven peripheral
Patient body weight is 40 kg, indication: complete GOO
Smof Kabiven (1000kcal in 1500cc)
Total energy requirement of the patient:
25kcal x 40kg= 1000kcal, 30% of
1000kcal is 300kcal
300/1000 kcal x 1500mL = 450mL
Total fluid requiremen: 1900mL** (10 kg x 100cc/kg/d) + (10 x 50cc/kg/d) +
(20 kg x 20cc/kg/d)
450 mL SmofKabiven to runs at 28cc/hr over 16 hours,
with remaining 8 hours for 181 mL/hr
isotonic fluid (0.9% NS) infusion
Weaning off PN
Combinations of EN and PN
When >60% of energy needs cannot be met via the enteral route, e.g. in high output enterocutaneous fistulae
partly obstructing benign or malignant gastrointestinal lesions which do not allow sole enteral feeding
1. Once EN is able to provide >70% of daily requirement, TPN can be weaned off
2. PN may be rapidly discontinued if patient is able to tolerate tube feeding
3. Glucose levels return to preinfusion baseline without symptoms of hypoglycemia
4. Initiation enteral feeding depends on patient’s GIT function, risk of aspiration and
patient motivation
5. Monitoring of nutritional
support
Patients receiving nutritional support are monitored to detect deficiency states, assess the adequacy of
energy and protein provision, and anticipate complications
Pulse rate, blood pressure and temperature are recorded regularly, an accurate fluid balance chart is
maintained ( including insensible losses), and the urine is checked daily for glycosuria. Body weight is
measured twice weekly.
FBC, LFT, serum albumin, calcium, magnesium and phosphate are monitored once or twice weekly.
For patients on long-term enteral nutrition or TPN (i.e longer than 2-3 weeks) less intense monitoring is
appropriate once they are stable.
Dangers of Over and Under Feeding
Risks associated with over-feeding:
Hyperglycemia
Hepatic dysfunction from fatty infiltration
Respiratory acidosis from increased CO 2 production
Difficulty weaning from the ventilator
Refeeding syndrome
Risks associated with under-feeding:
Depressed ventilatory drive
Decreased respiratory muscle function
Impaired immune function
Increased infection
Weight loss and malnutrition
Complications - Total Parenteral Nutrition | Stanford Health Care
Physiologic and metabolic sequelae may include:
EKG changes, hypotension, arrhythmia, cardiac arrest
Weakness, paralysis
Respiratory depression
Ketoacidosis / metabolic acidosis
• defined as the potentially fatal shifts in fluid and
electrolytes that may occur in malnourished patients after
nutritional support institution
2018. European Journal of Gastroenterology & Hepatology
Prevention and Therapy
1. Correct electrolyte abnormalities
before starting nutrition support
2. Continue to monitor serum
electrolytes after nutrition support
begins and replete aggressively
3. Initiate nutrition support at low
rate/concentration (~ 50% of
estimated needs) and advance to
goal slowly in patients who are at
high risk
2018. European Journal of Gastroenterology & Hepatology
Nutrition support should be cautiously introduced in seriously ill or injured people
requiring enteral tube feeding or parenteral nutrition.
should be started at no more than 50% of the estimated target energy and protein
needs.
It should be built up to meet full needs over the first 24–48 hours according to metabolic
and gastrointestinal tolerance.
Full requirements of fluid, electrolytes, vitamins and minerals should be provided from the
outset of feeding.
People who have eaten little or nothing for more than 5 days should have nutrition support
introduced at no more than 50% of requirements for the first 2 days, before
increasing feed rates to meet full needs if clinical and biochemical monitoring reveals no
refeeding problems.
2018. NICE guideline: nutrition support for adults
The prescription for people at high risk of developing refeeding problems should
consider:
Starting nutrition support at a maximum of 10 kcal/kg/day, increasing levels
slowly to meet or exceed full needs by 4–7 days
Only 5 kcal/kg/day in extreme cases (for example, BMI less than 14 kg/m2 or
negligible intake for more than 15 days) and monitoring cardiac rhythm
continually in these people and any others who already have or develop any
cardiac arrythmias
Restoring circulatory volume and monitoring fluid balance and overall
clinical status closely
Providing immediately before and during the first 10 days of feeding: oral
thiamin 200–300 mg daily, vitamin B co strong 1 or 2 tablets, three times a
day (or full dose daily intravenous vitamin B preparation, if necessary) and a
balanced multivitamin/trace element supplement once daily
2018. NICE guideline: nutrition support for adults
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