Surgery Essay

Outline the principles involved in the nutritional support

of the surgical patient

The pre-op patient must not be malnourished as this will result

in: decreased wound healing, muscle weakness and an
increased tendency to infection. Hospital patients become
malnourished due to: decreased appetite, increased nutritional
demands, impaired digestion, dislike of hospital food,
interruptions of meals by scheduled tests and ‘nil by mouth’
orders. If oral intake is not anticipated within 7-10 days from
surgery (perhaps even 5 days for the malnourished), then
nutritional support is indicated. The main indication for pre-op
support is a weight loss greater than 10%. Nutritional support
ranges from a supplementation of vitamins, or proteins only to
complete replacement of foodstuffs.

Enteral diets are those given via the gut, and includes oral
intake. The ideal scenario would be that the patient ingests all
the required nutrients, however when this is not possible,
enteric feeding is the next best option. This involves passing
food to the gut such as through an NG tube or for longer term
,the use of gastrostomy/Jejunostomy. In the gut the food is
absorbed as normal. This is ideal for surgical patients having
problems swallowing such as after a stroke or oesophageal
obstruction. Complications include diarrhoea and vomiting, but
this can be prevented by reducing the rate of infusion.

Whenever possible, enteral nutrition is preferred to parenteral

as the latter has more serious complications. Parenteral feeding

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Surgery Essay

is given to people who cannot take enteral feeding, such as

those with short gut syndrome, where large pieces of gut have
been removed surgically. Parental feeding can be combined
with enteral feeding, where it is given through a cannula in a
peripheral vein. Total Parenteral Nutrition (TPN) is used to
deliver complete nutritional supplements. The TPN has a high
osmolality and hence toxic to veins. Hence, TPN is given via a
central line, where a small cannula is inserted into a vein with a
high rate of blood flow. For longer use, a Hickman is preferred,
as it is inserted subcutaneously to make it more secure and has
a Dacron cuff to prevent infection. The disadvantages of
parenteral nutrition include infection; villous atrophy, as enteral
cells derives nutrition from the lumen. Electrolyte imbalances
are common, as well as hyperglycaemia, fatty liver and a
cholestatic picture with increased alkaline phosphatase,
therefore LFTs are important.

The requirements include water: depending on the negative

water balance of the patient, energy: about 1800kcal obtained
from carbohydrates and fats, Nitrogen 8-20g/day in protein,
vitamins: fat-soluble vitamins need careful adjusting to avoid
over-dose, minerals: sodium, potassium, calcium, magnesium,
phosphate and trace elements: zinc, copper, and iron.

A multidisciplinary team including the surgeon, dietician,

pharmacist and nurses is important for a patient’s nutritional
support. The best indicators of success in nutria of a patient are
the physical appearance and weight. And the best chemical
marker of nutritional status for day to day monitoring is
prealbumin.
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Surgery Essay

01/02/09