Nutrition

For the Surgical Patient







Kelly Sparks LDN, RD

Lecture Outline



Energy Sources

Nutrition Requirements

Diet Advancement

Micronutrients for wound healing

Enteral versus Parenteral Nutrition

Case studies

Energy Sources

 Carbohydrates

 Limited storage capacity, needed for CNS function

 Yields 3.4 kcal/gram

 Pitfall: too much=lipogenesis and increased CO2 production

 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

 Protein

 Needed to maintain anabolic state (match catabolism)

 Yields: 4 kcal/gm

 Pitfall: must adjust in patient with renal and hepatic failure

 Elevated creatinine, BUN, and/or ammonia

Nutrition Requirements

Healthy Adults

Calories: 25-35 kcals/kg

Protein: 0.8-1 gm/kg

Fluids: 30 mls/kg

 Requirement Change for the Surgical Patient

 Special Considerations

Stress

 Injury or disease

 Surgery



 Pre-hospital/pre-surgical nutrition

Nutrition



The surgical patient…

Extraordinary stressors (hypovolemia,

hypervolemia, bacteremia, medications)

Wound Healing

Anabolic state, appropriate vitamins (A, C, Zinc), and

adequate kcals/protein.

Poor Nutrition=Poor Outcomes

For every gram deficit of untreated

hypoalbuminemia there is ~30% increase in

mortality

Post-Operative Nutrition Requirements



Calories:

Increase to 30-40 kcals/kg

Patient on ventilator usually require less

calories ~20-25 kcal/kg

Protein:

Increase to 1-1.8 grams/kg

Fluids:

Individualized

Diet Advancement



Traditional Method:

Start clear liquids when signs of bowel function

returns.

Rationale: Clear liquid diets supply fluid and

electrolytes in a form 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:

Suggests that liquid diets and slow diet progression

may not be warranted!!

Clinical study:

Looked at early post-operative feeding using

regular diets or very fast progression vs. traditional

methods of NPO until bowel function with slow diet

progression and found no difference in post-

operative complications. (emesis, distention, NGT

reinsertion, LOS,)

Keep in Mind…



Per SLP

When using liquid diets, patients must have

adequate swallowing functions.

Even patients with mild dysphagia often require

thickened liquids.

Therefore, be specific in writing liquid diet orders

for patients with dysphagia

Micronutrients in Wound Healing



Vitamin Supplementation to promote healing

has been somewhat disputed.

Some studies show no significant effect unless

there is a clinical vitamin deficiency

Serum vitamin levels are not always accurate;

therefore, must use subjective diet history and

clinical judgment to determine deficiency.

Key Nutrients for Wound Healing



 Vitamin A:

 Cellular differentiation, proliferation, epithelialization,

collagen synthesis, counteract catabolic effect of steroids.

 RDA=3333 International Units

 Appropriate dose=25,000 IU per day x 10 days in setting of high dose

steroids or deficiency.

 Avoid long term supplementation due to high risk of toxicity with fat-

soluble vitamins.





 No vitamin A with renal failure due to greater potent ional for

toxicity. (Can exceed the binding capacity of retinol binding

protein leading to elevated circulating levels.)

Key Nutrients for Wound Healing



Vitamin C:

Collagen synthesis

RDA=50-90 mg/day

Low levels are common in high risk population (elderly,

smokers, cancer, liver disease).

Appropriate dose: 500 mg x 10 days





No vitamin C with renal failure due to risk for renal

oxalate stone formation.

Key Nutrients for Wound Healing

Zinc:

 Protein synthesis, cellular replication, collagen formation; large

wounds, chest tubes, and wound drains contribute to further zinc

loses.

 Appropriate dose: 220 mg per day of Zinc Sulfate or

50 mg of elemental Zinc x 10 days.

 Prolonged Zinc supplementation interferes with copper

absorption and can lead to copper deficiency which delays wound

healing by impairing collagen synthesis.

MVI with minerals:

 1 tablet daily to compensate for any general micronutrient losses.

What is nutrition support?

 An alternate means of providing nutrients to people who cannot eat

any or enough food



 When is it needed?

 Illness resulting in inability to take in adequate nutrients by

mouth

 Illness or surgery that results in malfunctioning gastrointestinal

tract



 Two types:

 Enteral nutrition

 Parenteral nutrition

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

Adaptive phase of short bowel syndrome

Following severe trauma or burns

Contraindications to Enteral Nutrition Support





 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

 Nasogastric

 Nasoenteric

 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?



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

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, long-

term access should be considered

Choosing Appropriate Formulas



 Categories of enteral formulas:

Polymeric (Jevity)

 Whole protein nitrogen source, for use in patients with normal

or near normal GI function

Monomeric or elemental (Perative, Optimental)

 Predigested nutrients; most have a low fat content or high % of

MCT oil (medium-chain triglycerides); for use in patients with

severely impaired GI function

Disease specific (Nepro, Nutrahep, Glucerna)

 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

Enteral Nutrition Prescription Guidelines

 Gastric feeding

Continuous feeding:

 Start at rate 30 mL/hour

 Advance in increments of 20 mL q 8 hours to goal

 Check gastric residuals q 4 hours

Bolus feeding:

 Start with 100-120 mL bolus

 Increase by 60 mL q bolus to goal volume

 Typical bolus frequency every 3-8 hours

 Small bowel feeding

Continuous feeding only; do not bolus due to risk of dumping

syndrome

 Start at rate 20 mL/hour

 Advance in increments of 20 mL q 8 hours to goal

 Do not check gastric residuals

Aspiration Precautions



To prevent aspiration of tube feeding, keep

HOB > 30° at all times



Do not use methylene blue to test for

aspiration; regular blue food dye OK but not

proven effective method of detecting

aspiration

Complications of Enteral Nutrition Support





Nausea and vomiting / delayed gastric

emptying

Malabsorption

Common manifestations include unexplained weight

loss, steatorrhea, diarrhea

Potential causes include gluten sensitive

enteropathy, Crohn’s disease, radiation enteritis,

HIV/AIDS-related enteropathy, pancreatic

insufficiency, short gut syndrome

Enteral Nutrition Case Study

 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)



Height: 5’4” IBW: 120# +/- 10%

Weight: 130# / 59kg 100% IBW

BMI: 22

Usual weight: ~130# no weight change

Estimated needs:

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. Estimate energy, protein, and fluid needs

2. Select most appropriate enteral formula

3. Determine continuous vs. bolus feeding

4. Determine goal rate to meet estimated needs

5. Write/recommend the enteral nutrition

prescription

Enteral Nutrition Prescription

 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

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?



Parenteral Nutrition

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



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

Paralytic ileus, mesenteric ischemia, small bowel

obstruction, enteric fistula distal to enteral access

sites

PPN vs. TPN

 TPN (total parenteral nutrition)

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.

 PPN (peripheral parenteral nutrition)

Similar nutrient components as TPN, but lower concentration

(5%-10% final dextrose concentration)

Osmolarity 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

If LFT’s significantly elevated as a result of TPN, then

minimize lipids to 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

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

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

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

 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

 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



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)





Height: 6’0” IBW: 178# +/- 10%

Weight: 155# / 70kg 87% IBW

BMI: 21

Usual wt: 175# 11% wt loss x 1 mo.

Estimated needs:

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



 TPN via right-SC line

 2200 mL total volume x 24 hours

 Amino acid: 45 g/liter=

 45g x 2.2 L= 99 grams x 4 kcals/gram =369 kcals

 Dextrose 175 g/liter=

 175g x 2.2 L= 385 grams x 3.4 kcals/gram= 1309 kcals

 Lipid 20% 285 mL over 24 hours

 285 mls x 2= 570 kcals

 Above will provide 2275 kcal, 99g protein,

 DIR=(385 g dex/ 70 kg /1440 minute in a day)*1000=

3.8mg/kg/min

 LIR= (285 mls lipid * 20%)/ 70 kg=0.8 g/kg/day

Parenteral Nutrition Prescription

Important items to consider:

Dextrose infusion rate should be 7-10

days)

 Physiologic and metabolic sequelae may include:

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 Over-feeding

 Risks associated with over-feeding:

Hyperglycemia

Hepatic dysfunction from fatty infiltration

Respiratory acidosis from increased CO2 production

Difficulty weaning from the ventilator



 Risks associated with under-feeding:

Depressed ventilatory drive

Decreased respiratory muscle function

Impaired immune function

Increased infection

Questions







 Reference:

 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.