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Nutrition
. . . and the surgical patient
Carli Schwartz, RD/LDN
Nutrition and Surgery


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.
Normal Nutrition
(EatRight.org)
Nutrition

Carbohydrates
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
Limited strorage capacity, needed for CNS
(glucose) function
Yields 3.4 kcal/gm
Recommended 45-65% total daily calories.
Nutrition

Fats
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Major endogenous fuel source in healthy
adults
Yields 9 kcal/gm
Too little can lead to essential fatty acid
(linoleic acid) deficiency and increased risk of
infections
Recommended 20-30% of total caloric intake
Nutrition

Protein
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Needed to maintain anabolic state (match
catabolism)
Yields 4 kcal/gm
Must adjust in patients with renal and hepatic
failure
Recommended 10-35% of total caloric intake.
Normal Nutrition

Requirements
HEALTHLY male/female
(weight maintenance)
• Caloric intake=25-30 kcal/kg/day
• Protein intake=0.8-1gm/kg/day
(max=150gm/day)
• Fluid intake=~ 30 ml/kg/day
Nutrition

Requirements
? SURGICAL PATIENT ?
Special considerations

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Stress
 Injury or disease
 Surgery
Pre-hospital/presurgical nutrition
 Nutrition history
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The surgical patient . . . .

Increased risk of malnutrition due to:
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Inadequate nutritional intake
surgical stress
subsequent increase in metabolic rate.
Extraordinary stressors (hypovolemia, bacteremia,
medications)
Wound healing

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Anabolic state, appropriate vitamins
Poor nutrition=poor outcomes

For every gm deficit of untreated hypoalbuminemia
there is ~ 30% increase in mortality
Nutrition
HEALTHLY 70 kg MALE
Caloric intake
25-30 kcal/kg/day
Protein intake
0.8-1gm/kg/day
(max=150gm/day)
Fluid intake
30 ml/kg/day
SURGERY PATIENT
Caloric intake
*Mild stress, inpatient
25-30 kcal/kg/day
*Moderate stress, ICU patient
30-35 kcal/kg/day
*Severe stress, burn patient
30-40 kcal/kg/day
Protein intake
1-2 gm/kg/day
Fluid intake
INDIVIDUALIZED
Measures of success:
serum markers

Albumin
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Synthesized in and catabolized by the liver
Pro: often ranked as the strongest predictor of surgical
outcomes- inverse relationship between postoperative
morbidity and mortality compared with preoperative
serum albumin levels
Con: lack of specificity due to long half-life
(approximately 20 days).
Normal range: 3.5-5 g/dL.
The National Veterans Affairs Surgical Risk Study
evlauated 87,000 noncardiac surgeries in 44 Veteran’s
Administration medical centers and found preoperative
serum albumin to the bet strongest predictor of
postoperative mortality
Measures of success:
serum markers (cont’d)

Prealbumin (transthyretin) - transport protein for thyroid
hormone, synthesized by the liver and partly catabolized by
the kidneys.
Normal range:16 to 40 mg/dL; values of <16 mg/dL are associated with
malnutrition.
 Levels may be increased in the setting of renal dysfunction, corticosteroid therapy,
or dehydration, whereas physiological stress, infection, liver dysfunction, and overhydration can decrease prealbumin levels.[8,30,37]
 Pro: Shorter half life (two to three days) making it a more favorable marker of acute
change in nutritional status. A baseline prealbumin is useful as part of the initial
nutritional assessment if routine monitoring is planned.
 Cons: More expensive than albumin.
 Reasonable goal would be to increase prealbumin by 3-5 mg/dL/wk until values are
within normal limits.[This goal would be valid only in the absence of other factors
that can influence prealbumin
(Elevated concentrations of C-reactive protein (>10 mg/dL) suggest physiological
stress that requires continued hepatic synthesis of acute-phase reactants and
delays production of markers of nutritional rehabilitation, such as prealbumin. Until
this stress response subsides, practitioners may not see improvement in
prealbumin levels no matter how much nutrition is being provided)

Measures of success:
serum markers (cont’d)
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Transferrin: acute-phase reactant and a
transport protein for iron
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normal range: 200 to 360 mg/dL.
Medium half-life (8-10 days)
influenced by several factors, including liver disease,
fluid status, stress, and illness.
Levels decrease in the setting of severe malnutrition,
however unreliable in the assessment of mild
malnutrition,
Cons: not studied extensively as albumin and
prealbumin in relation to nutritional status, can be
expensive.
Other measures of success
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Nitrogen balance
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Protein ~ 16% nitrogen
Protein intake (gm)/6.25 - (UUN +4)= balance in
grams
Positive value: found during periods of growth, tissue repair or pregnancy. This means
that the intake of nitrogen into the body is greater than the loss of nitrogen from the body,
so there is an increase in the total body pool of protein.
Negative value: can be associated with burns, fevers, wasting diseases and other serious
injuries and during periods of fasting. This means that the amount of nitrogen excreted
from the body is greater than the amount of nitrogen ingested.
Healthy Humans= Nitrogen Equilibrium
Metabolic cart (indirect calorimetry)
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ICU patient, measure of exchange of O2 and CO2
Respiratory quotient =1
Postoperative Nutritional Care
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Traditional Method: Diet advancement
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Introduction of solid food depends on the
condition of the GI tract.
Oral feeding delayed for 24-48 hours after surgery

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Start clear liquids when signs of bowel function
returns
Rationale
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Wait for return of bowel sounds or passage of flatus.
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
Things to Consider…

For liquid diets, patients must have adequate
swallowing functions
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Even patients with mild dysphagia often require
thickened liquids.
Must be specific in writing liquid diet orders for
patients with dysphagia
There is no physiological reason for solid foods not to be
introduced as soon as the GI tract is functioning and a few
liquids are being tolerated. Multiple studies show patients
can be fed a regular solid-food diet after surgery without
initiation of liquid diets.
Diet Advancement

Advance diet to full liquids followed by solid
foods, depending on patient’s tolerance.

Consider the patient’s disease state and any
complications that may have come about since
surgery.

Ex: steroid-induced diabetes in a post-kidney
transplant patient.
Patients who cannot eat . . . ?
Consider Nutrition Support!
Nutrition Support

Length of time a patient can remain NPO
after surgery without complications is
uknown, however depends on:
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Severity of operative stress
Patient’s preexisting nutritional status
Nature and severity of illness
Two types of nutritional support
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Enteral
Parenteral
What is enteral nutrition?
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Enteral Nutrition
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Also called "tube feeding," enteral nutrition is a
liquid mixture of all the needed nutrients.
Consistency is sometimes similar to a milkshake.
It is given through a tube in the stomach or small
intestine.
If oral feeding is not possible, or an extended
NPO period is anticipated, an access devise for
enteral feeding should be inserted at the time of
surgery.
Indications for Enteral
Nutrition

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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
Adaptive phase of short bowel syndrome
Following severe trauma or burns
Contraindications to Enteral
Nutrition Support
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Malnourished patient expected to eat within 5-7
days
Severe acute pancreatitis
High output enteric fistula distal to feeding tube
Inability to gain access
Intractable vomiting or diarrhea
Aggressive therapy not warranted
Expected need less than 5-7 days if
malnourished or 7-9 days if normally nourished
Enteral Access Devices
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Nasogastric
Nasoenteric
Gastrostomy
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Jejunostomy
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PEG (percutaneous endoscopic gastrostomy)
Surgical or open gastrostomy
PEJ (percutaneous endoscopic jejunostomy)
Surgical or open jejunostomy
Transgastric Jejunostomy
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PEG-J (percutaneous endoscopic gastro-jejunostomy)
Surgical or open gastro-jejunostomy
Feeding Tube Selection
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Can the patient be fed into the stomach, or is
small bowel access required?
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How long will the patient need tube feedings?
Gastric vs. Small Bowel
Access
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“If the stomach empties, use it.”
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Indications to consider small bowel access:
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Gastroparesis / gastric ileus
Recent abdominal surgery
Sepsis
Significant gastroesophageal reflux
Pancreatitis
Aspiration
Ileus
Proximal enteric fistula or obstruction
Short-Term vs. Long-Term
Tube Feeding Access

No standard of care for cut-off time between
short-term and long-term access

However, if patient is expected to require
nutrition support longer than 6-8 weeks, longterm access should be considered
Choosing Appropriate
Formulas
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Categories of enteral formulas:
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Polymeric
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Monomeric or elemental
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Whole protein nitrogen source, for use in patients with normal
or near normal GI function
Predigested nutrients; most have a low fat content or high % of
MCT; for use in patients with severely impaired GI function
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
*well-designed clinical trials may or may not be available
Tulane Enteral Nutrition
Product Formulary
Enteral Nutrition Prescription
Guidelines
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Gastric feeding
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Continuous feeding:
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Bolus feeding:
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Start at rate 30 mL/hour
Advance in increments of 20 mL q 8 hours to goal
Check gastric residuals q 4 hours
Start with 120 mL bolus
Increase by 60 mL q bolus to goal volume
Typical bolus frequency every 3-8 hours
Small bowel feeding
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Continuous feeding only; do not bolus due to risk of
dumping syndrome
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Start at rate 20 mL/hour
Advance in increments of 20 mL q 8 hours to goal
Do not check gastric residuals
Aspiration Precautions
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To prevent aspiration of tube feeding, keep
HOB > 30° at all times
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Use of blue dye to test for aspiration is
controversial and has been discontinued in
practice.
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Discoloration
Falslely positive reading on guaiac tests
Reported deaths
Complications of Enteral
Nutrition Support
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Issues with access, administration, GI
complications, metabolic complications.
These include:
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Nausea, vomitting, diarrhea, delayed gastric
emptying, malabsorption, refeeding syndrome,
hyponatremia, microbial contamination, tube
obstruction, leakage from ostomy/stoma site,
micronutrient deficiencies.
Enteral Nutrition Case Study
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78-year-old woman admitted with new CVA
Significant aspiration detected on bedside
swallow evaluation and confirmed with modified
barium swallow study; speech language
pathologist recommended strict NPO with
alternate means of nutrition
PEG placed for long-term feeding access
Plan of care is to stabilize the patient and
transfer her to a long-term care facility for
rehabilitation
Enteral Nutrition Case Study
(continued)
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Height: 5’4”
Weight: 130# / 59kg
BMI: 22
Usual weight: ~130#
Estimated needs:
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IBW: 120# +/- 10%
100% IBW
no weight change
1475-1770 kcal (25-30 kcal/kg)
59-71g protein (1-1.2 g/kg)
1770 mL fluid (30 mL/kg)
Steps to determine the
Enteral Nutrition Prescription
1.
2.
3.
4.
5.
Estimate energy, protein, and fluid needs
Select most appropriate enteral formula
Determine continuous vs. bolus feeding
Determine goal rate to meet estimated
needs
Write/recommend the enteral nutrition
prescription
Enteral Nutrition Prescription
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Tube feeding via PEG with full strength
Jevity 1.2
Initiate at 30 mL/hour, advance by 20 mL q 8
hours to goal
Goal rate = 55 mL/hour continuous infusion
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Above goal will provide 1584 kcal, 73g protein, 1069
mL free H2O
Give additional free H2O 175 mL QID to meet
hydration needs and keep tube patent
Check gastric residuals q 4 hours; hold feeds for
residual > 200 mL
Keep HOB > 30° at all times
What is parenteral nutrition?
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Parenteral Nutrition
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also called "total parenteral nutrition," "TPN," or
"hyperalimentation."
It is a special liquid mixture given into the blood
via a catheter in a vein.
The mixture contains all the protein,
carbohydrates, fat, vitamins, minerals, and other
nutrients needed.
Indications for Parenteral
Nutrition Support
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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)
Enteral nutrition is contraindicated or severe
GI dysfunction is present
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Paralytic ileus, mesenteric ischemia, small bowel
obstruction, enteric fistula distal to enteral access
sites
PPN vs. TPN
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TPN (total parenteral nutrition)
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High glucose concentration (15%-25% final dextrose
concentration)
Provides a hyperosmolar formulation (1300-1800
mOsm/L)
Must be delivered into a large-diameter vein
PPN (peripheral parenteral nutrition)
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Similar nutrient components as TPN, but lower
concentration (5%-10% final dextrose concentration)
Osmolarity < 900 mOsm/L (maximum tolerated by a
peripheral vein)
May be delivered into 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
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Peripheral venous access
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Catheter placed percutaneously into a peripheral
vessel
Central venous access (catheter tip in SVC)
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Percutaneous jugular, femoral, or subclavian
catheter
Implanted ports (surgically placed)
PICC (peripherally inserted central catheter)
Writing TPN prescriptions
1.
2.
Determine total volume of formulation based on
individual patient fluid needs
Determine amino acid (protein) content
Adequate to meet patient’s estimated needs
3.
Determine dextrose (carbohydrate) content
~70-80% of non-protein calories
4.
Determine lipid (fat) content
~20-30% non-protein calories
5.
6.
7.
Determine electrolyte needs
Determine acid/base status
Check to make sure desired formulation will fit in the
total volume indicated
Tulane Daily Parenteral
Nutrition Order Form
Parenteral Nutrition
Monitoring
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Check daily electrolytes and adjust TPN/PPN electrolyte
additives accordingly
Check accu-check glucose q 6 hours (regular insulin may be
added to TPN/PPN bag for glucose control as needed)
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Non-diabetics or NIDDM: start with half of the previous day’s
sliding scale insulin requirement in TPN/PPN bag and increase
daily in the same manner until target glucose is reached
IDDM: start with 0.1 units regular insulin per gram of dextrose in
TPN/PPN, then increase daily by half of the previous day’s
sliding scale insulin requirement
Check triglyceride level within 24 hours of starting
TPN/PPN
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If TG >250-400 mg/dL, lipid infusion should be significantly
reduced or discontinued
Consider adding carnitine 1 gram daily to TPN/PPN to improve
lipid metabolism
~100 grams fat per week is needed to prevent essential fatty acid
deficiency
Parenteral Nutrition
Monitoring (continued)

Check LFT’s weekly
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If LFT’s significantly elevated as a result of TPN, then
minimize lipids to < 1 g/kd/day and cycle TPN/PPN
over 12 hours to rest the liver
If Bilirubin > 5-10 mg/dL due to hepatic dysfunction,
then discontinue trace elements due to potential for
toxicity of manganese and copper
Check pre-albumin weekly

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Adjust amino acid content of TPN/PPN to reach
normal pre-albumin 18-35 mg/dL
Adequate amino acids provided when there is an
increase in pre-albumin of ~1 mg/dL per day
Parenteral Nutrition
Monitoring
(continued)

Acid/base balance
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
Adjust TPN/PPN anion concentration to maintain
proper acid/base balance
Increase/decrease chloride content as needed
Since bicarbonate is unstable in TPN/PPN
preparations, the precursor—acetate—is used;
adjust acetate content as needed
Complications of Parenteral
Nutrition

Hepatic steatosis
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May occur within 1-2 weeks after starting PN
May be associated with fatty liver infiltration
Usually is benign, transient, and reversible in
patients on short-term PN and typically resolves in
10-15 days
Limiting fat content of PN and cycling PN over 12
hours is needed to control steatosis in long-term
PN patients
Complications of Parenteral
Nutrition Support (continued)

Cholestasis
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May occur 2-6 weeks after starting PN
Indicated by progressive increase in TBili and an elevated serum
alkaline phosphatase
Occurs because there are no intestinal nutrients to stimulate
hepatic bile flow
Trophic enteral feeding to stimulate the gallbladder can be helpful
in reducing/preventing cholestasis
Gastrointestinal atrophy

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Lack of enteral stimulation is associated with villus hypoplasia,
colonic mucosal atrophy, decreased gastric function, impaired GI
immunity, bacterial overgrowth, and bacterial translocation
Trophic enteral feeding to minimize/prevent GI atrophy
Parenteral Nutrition Case
Study
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

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
Parenteral Nutrition Case
Study
(continued)
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Height: 6’0”
Weight: 155# / 70kg
BMI: 21
Usual wt: 175#
Estimated needs:
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IBW: 178# +/- 10%
87% IBW
11% wt loss x 1 mo.
2100-2450 kcal
(30-35 kcal/kg)
84-98g protein
(1.2-1.4 g/kg)
2100-2450 mL fluid (30-35 mL/kg)
Parenteral Nutrition
Prescription
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TPN via right-SC line
2 L total volume x 24 hours
Amino acid 4.5% (or 45 g/liter)
Dextrose 17.5% (or 175 g/liter)
Lipid 20% 285 mL over 24 hours
Above will provide 2120 kcal, 90g protein,
glucose infusion rate 3.5 mg/kg/minute, lipid
0.9 g/kg/day
Parenteral Nutrition
Prescription

Important items to consider:

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Glucose infusion rate should be < 5 mg/kg/minute
(maximum tolerated by the liver) to prevent
hepatic steatosis
Lipid infusion should be < 0.1 g/kg/hour (ideally <
0.4 g/kg/day to minimize/prevent TPN-induced
liver dysfunction)
Initiate TPN at ~½ of goal rate/concentration and
gradually increase to goal over 2-3 days to
optimize serum glucose control
Benefits of Enteral Nutrition
over parenteral nutrition

Cost

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Maintains integrity of the gut

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Tube feeding cost ~ $10-20 per day
TPN cost ~ $100 or more per day!
Tube feeding preserves intestinal function; it is more
physiologic
TPN may be associated with gut atrophy
Less infection

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Tube feeding—very small risk of infection and may
prevent bacterial translocation across the gut wall
TPN—high risk/incidence of infection and sepsis
Transitional Feedings
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Parenteral to enteral feedings
 Introduce a minimal amount of enteral feeding at a low
rate (30-40 ml/hr) to establish tolerance.
 Decrease PN level slowly to keep nutrient levels at
same prescribed amount
 As enteral rate is increased by 25-30 ml/hr increments
every 8-24 hrs, parenteral can be reduced
 Discontinue PN solution if 75% of nutrient needs met
by enteral route.
Parenteral/Enteral to oral feedings
 Ideally accomplished by monitoring oral intake and
concomitantly decreasing rate of nutrition support until
75% of needs are met.
 Oral supplements are useful if needs not met 100% by
diet. Ex (Nepro, Glucerna, Boost, Ensure).
Refeeding Syndrome

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“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)
Physiologic and metabolic sequelae may include:



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EKG changes, hypotension, arrhythmia, cardiac arrest
Weakness, paralysis
Respiratory depression
Ketoacidosis / metabolic acidosis
Refeeding Syndrome
(continued)

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
Consequences of Overfeeding

Risks associated with over-feeding:

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Hyperglycemia
Hepatic dysfunction from fatty infiltration
Respiratory acidosis from increased CO2 production
Difficulty weaning from the ventilator
Risks associated with under-feeding:
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
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Depressed ventilatory drive
Decreased respiratory muscle function
Impaired immune function
Increased infection
Questions
Contact Information:
Carli Schwartz, RD/LDN
Dietitian, Tulane Abdominal Transplant Institute
(504) 988-1176
[email protected]
References
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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.
Krause’s Food, Nutrition & Diet Therapy, 11th Ed. Mahan, K., Stump, S.
Saunders, 2004.
American Society for Parenteral and Enteral Nutrition. The Science and
Practice of Nutrition Support. 2001.