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Nutrition
Dr. Mahamed Hussein
General Surgery
Azadi Teaching Hospital
Nutrition and Surgery
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Reported 40% incidence of malnutrition in acute
hospital setting
Malnutrition may compound the severity of
complications related to a surgical procedure
A well-nourished patient usually tolerates major
surgery better than a severely malnourished
patient
Malnutrition is associated with a high incidence
of operative complications and death.
The five steps to optimal
nutrition support are:
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Begin when the benefits are likely to exceed the risk,
Set protein and calorie goals,
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Choose and establish a method for administering the
nutrients, enteral (site and route) or parenteral
(peripheral or central)
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Choose or design a formula suitable for the particular
patient
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Monitor the patient for adequacy of nutrient intake and
to avoid or minimize complications
Sources of energy
(Calories)
Calories:There are three major sources of energy:
Carbohydrates.
Fat
Protein
Of normal daily energy expenditure, 85 per cent is from fat
and carbohydrates, and 15 per cent from protein
Carbohydrates
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Limited storage capacity, needed for CNS (glucose) function
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Yields 4 kcal/gm
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Recommended 45-65% of total caloric intake
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Simple vs Complex
Fats
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Major endogenous fuel source in healthy adults
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Yields 9 kcal/gm
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Too little can lead to essential fatty acid (linoleic acid) deficiency and
increased risk of infections
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Recommended 20-30% of total caloric intake
Protein
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Needed to maintain anabolic state (match catabolism)
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Yields 4 kcal/gm
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Must adjust in patients with renal and hepatic failure
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Recommended 10-35% of total caloric intake
Normal Nutrition Requirements
Healthy male & female
( for weight maintenance )
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 Caloric intake= 25-30 kcal/kg/day
 Protein intake= 0.8-1gm/kg/day (max=150gm/day)
 Fluid intake= ~30 ml/kg/day
Nutrition Comparison
HEALTHLY 70 kg MALE
1) Caloric intake
25-30 kcal/kg/day
2) Protein intake
0.8-1gm/kg/day
(max=150g)
3) Fluid intake
30 ml/kg/day
SURGERY PATIENT
1) Caloric intake
*Mild stress
25-30 kcal/kg/day
*Moderate stress
30-35 kcal/kg/day
*Severe stress
30-40 kcal/kg/day
2) Protein intake
1-2 gm/kg/day
3) Fluid intake
INDIVIDUALIZED
Reasons for Malnutrition
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Inadequate nutritional intake
Metabolic response
Nutrient losses
Protein/energy store depletion
Prevalence of ileus, anorexia, malabsorption
Extraordinary stressors (surgical stress,
hypovolemia, bacteremia, medications)
Wound healing
 Anabolic state
 May require appropriate vitamins
ENTERAL NUTRITION
ADVANTAGES
1.Maintains git integrity and positive effect on immunity
of small intestine.
2. Enhanced utilization of nutrients.
3. More efficient plasma insulin response.
4. Ease and safety of administration.
5. Less cost than TPN .
6. Mechanical, infectious and metabolic complications less
severe than with TPN.
ENTERAL NUTRITION
INDICATIONS
Any condition which requires nutritional support and in which the GIT is
functional.
CONTRAINDICATIONS
1.Generalized peritonitis
2. Shock
3. Complete intestinal obstruction
4. Intractable vomiting/severe diarrhoea
5. Paralytic ileus
6. Severe git bleeding
7. High output fistula
8. Early stages of short bowel syndrome
9. Acute severe pancreatitis
Complications Of Enteral Nutrition
1.Gastro-intestinal :
diarrhoea, vomiting, bloating, abdominal cramps.
2. Metabolic:
glucose intolerance, excess CO2 production, electrolyte
imbalances
3. Mechanical:
Blocked tube, tube dislodgement, nasopharyngeal discomfort,
nasalerosions and necrosis (esp. children)
4. Complications of surgery ( gastrostomy; jejunostomy)
Perforation ,Haemorrhage, Wound infection, Bowel
obstruction/necrosis, Stomal
leakage
5. Infection :
Aspiration pneumonia, contaminated feeds - gastroenteritis
PARENTERAL NUTRITION
If enteral nutrition is not possible in the
malnourished or at-risk patient, the parenteral
route must be utilized. Parenteral nutrition may
be used for either primary or supportive
(Secondary) therapy.
Indications for Parenteral
Nutrition
Primary therapy
1)Gastrointestinal
fistula
2)Short bowel syndrome
3)Acute renal failure
4)Hepatic insufficiency
5)Inflammatory bowel disease
Indications for Parenteral
Nutrition
Secondary therapy
1.Radiation
enteritis/chemotherapy toxicity
Hyperemesis gravidarum
2.Prolonged ileus
3.Preoperative therapy
4.Cardiac cachexia
5.Pancreatitis insufficiency
6.Cancer
7.Sepsis
Questions