Nutrition

. . . and the surgical patient

 Nutrition
ENERGY SOURCES
 Carbohydrates

 Fats

 Proteins
Nutrition

 Carbohydrates
 Limited strorage capacity, needed for CNS
(glucose) function
 Yields 3.4 kcal/gm
 Pitfall: too much = lipogenesis and increased
CO2 production
Nutrition

 Fats
 Major endogenous fuel source in healthy
adults
 Yields 9 kcal/gm
 Pitfall: too little=essential fatty acid (linoleic
acid) deficiency—dermatitis and increased
risk of infections
Nutrition

 Proteins
 Needed to maintain anabolic state (match
catabolism)
 Yields 4 kcal/gm
 Pitfall: must adjust in patients with renal and
hepatic failure
Nutrition Fats

Non-protein
 Carbohydrates
Calories

Protein
Proteins

Calories
Nutrition
 Requirements

HEALTHLY 70 kg MALE
• Caloric intake=35 kcal/kg/day
(max=2500/day)
• Protein intake=0.8-1gm/kg/day
(max=150gm/day)
• Fluid intake=30 ml/kg/day
Nutrition

 Requirements
? SURGICAL PATIENT ?
Nutrition

 Special considerations
 Stress
 Injury or disease
 Surgery
 Prehospital/presurgical
nutrition
Nutrition
 The surgical patient . . . .
 Extraordinary stressors (hypovolemia,
bacteremia, medications)
 Wound healing
 Anabolic state, appropriate vitamins (A, C, Zinc)

 Poor nutrition=poor outcomes

 For every gm deficit of untreated hypoalbuminemia
there is ~ 30% increase in mortality
 Nutrition
HEALTHLY 70 kg MALE SURGERY PATIENT

Caloric intake Caloric intake

35 kcal/kg/day *Mild stres, inpatient
(max=2500/day) 20-25 kcal/kg/day
*Moderate stress, ICU patient
Protein intake 25-30kcal/kg/day
0.8-1gm/kg/day *Severe stress, burn patient
(max=150gm/day) 30-40 kcal/kg/day
Protein intake
Fluid intake 1-1.8gm/kg/day
30 ml/kg/day Fluid intake
INDIVIDUALIZE
Nutrition

Non-protein 30%
CHO
70% Fats

Calories

Protein
Proteins

Calories
Nutrition
 Measures of success
 Serum markers
 Retinol binding protein, prealbumin, transferrin,
albumin
Nutrition
 Measures of success
 Nitrogen balance
 Protein ~ 16% nitrogen
 Protein intake (gm)/6.25 - (UUN +4)= balance in
grams
 Metabolic cart (indirect calorimetry)
 ICU patient, measure of exchange of O2 and CO2
 Respiratory quotient =1
Nutrition
 What route to feed?
 GUT, GUT, GUT

 When to feed?
 EARLY, EARLY, EARLY
TPN
Diet Advancement
 Traditional Method
 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
Diet Advancement
 Recent Evidence
 Liquid diets and slow diet progression may not be
warranted!!
 Clinical study
 Early post-operative feeding with regular diets vs.
traditional methods demonstrated no difference in
post-operative complications
 Emesis, distention, NGT reinsertion, and Length of stay
Pitfalls…
 For liquid diets, patients must have adequate
swallowing functions
 Even patients with mild dysphagia often
require thickened liquids.
 Must be specific in writing liquid diet orders for
patients with dysphagia
Patients who cannot eat . . . ?

 Two types of nutritional support

 Enteral
 Parenteral
Indications for Enteral Nutrition
 Malnourished patient expected to be unable
to eat adequately for > 5-7 days
 Adequately nourished patient expected to be
unable to eat > 7-9 days
 Following severe trauma or burns
Enteral Access Devices
 Nasogastric/nasoenteric (temporary)
 Gastrostomy (long-term)
 Percutaneous endoscopic gastrostomy (PEG)
 Open gastrostomy
 Jejunostomy
 Percutaneous endoscopic jejunostomy (PEJ)
 Open jejunostomy
 Transgastric Jejunostomy
 Percutaneous endoscopic gastro-jejunostomy (G-J)
 Open gastro-jejunostomy
Feeding Tube Selection
 Can the patient be fed into the stomach, or is
small bowel access required?

 How long will the patient need tube feedings?

Gastric vs. Small Bowel Access
 “If the stomach empties, use it.”

 Indications to consider small bowel access

 Gastroparesis/gastric ileus
 Abdominal surgery
 Significant gastroesophageal reflux
 Pancreatitis
 Aspiration
 Proximal enteric fistula or obstruction
Enteral Nutrition Case Study
 78-year-old woman admitted with new CVA
 Significant aspiration detected on bedside swallow
evaluation, confirmed on modified barium swallow
study
 Speech language pathologist recommended strict
NPO with alternate means of nutrition
What is parenteral nutrition?
 Parenteral Nutrition
 AKA
 total parenteral nutrition
 TPN
 hyperalimentation
 Liquid mixture of nutrients given via the blood
through a catheter in a vein
 Mixture contains all the protein, carbohydrates, fats,
vitamins, minerals, and other nutrients needed to
maintain nutrition balance
Indications for Parenteral Nutrition
 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)
 Severe GI dysfunction is present
 Paralytic ileus, mesenteric ischemia, small bowel
obstruction, enteric fistula distal to enteral access
sites
TPN vs. PPN
 TPN
 High glucose concentration (15%-25% final dextrose
concentration)
 Provides a hyperosmolar formulation (1300-1800
mOsm/L)
 Must be delivered into a large-diameter vein through
central line
 Peripheral parenteral nutrition (PPN)
 Similar nutrient components as TPN, but lower
concentration (5%-10% final dextrose concentration)
 Osmolarity < 900 mOsm/L (maximum tolerated by a
peripheral vein)
 Because of lower concentration, large fluid volumes are
needed to provide a comparable calorie and protein
dose as TPN
Parenteral Access Devices
 Peripheral venous access
 Catheter placed percutaneously into a peripheral
vessel
 Central venous access (catheter tip in SVC)
 Percutaneous jugular, femoral, or subclavian
catheter
 Implanted ports (surgically placed)
 PICC (peripherally inserted central catheter)
Complications of
Parenteral Feeds

 Hepatic steatosis
 May occur within 1-2 weeks after starting TPN
 May be associated with fatty liver infiltration
 Usually is benign, transient, and reversible in
patients on short-term TPN—typically resolves in
10-15 days
 Limiting fat content and cycle feeds over 12 hours
to control steatosis in patients on long-term TPN
Parenteral Nutrition Case Study
 55-year-old male admitted with small bowel
obstruction
 History of complicated cholecystecomy 1
month ago. Since then patient has had poor
appetite and 20-pound weight loss
 Patient has been NPO for 3 days since admit
 Right subclavian central line was placed and
plan noted to start TPN since patient is
expected to be NPO for at least 1-2 weeks
Nutrition
 What route to feed?

VS TPN
Nutrition
 What route to feed?

TPN TPN
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 feeding—very small risk of infection and
may prevent bacterial translocation across the gut
wall
 TPN—high 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)
 Sequelae may include
 EKG changes, hypotension, arrhythmia, cardiac arrest
 Weakness, paralysis
 Respiratory depression
 Ketoacidosis / metabolic acidosis
 Refeeding Syndrome
 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
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

 Risks associated with under-feeding

 Depressed ventilatory drive
 Decreased respiratory muscle function
 Impaired immune function
 Increased infection
 Food for Thought
(that is . . . nutrition for your brain)

Life is not measured by the number of breaths we take,

but by the moments that take our breath away.  

TPN
References
 American Society for Parenteral and Enteral Nutrition. The
Science and Practice of Nutrition Support. 2001.
 Han-Geurts, I.J, Jeekel,J.,Tilanus H.W, Brouwer,K.J.,
Randomized clinical trial of patient-controlled versus fixed
regimen feeding after elective abdominal surgery. British
Journal of Surgery. 2001, Dec;88(12):1578-82
 Jeffery K.M., Harkins B., Cresci, G.A., Marindale, R.G., The
clear liquid diet is no longer a necessity in the routine
postoperative management of surgical patients. American
Journal of Surgery.1996 Mar; 62(3):167-70
 Reissman.P., Teoh, T.A., Cohen S.M., Weiss, E.G.,
Nogueras, J.J., Wexner, S.D. Is early oral feeding safe after
elective colorectal surgery? A prospective randomized trial.
Annals of Surgery. 1995 July;222(1):73-7.
 Ross, R. Micronutrient recommendations for wound healing.
Support Line. 2004(4): 4.