A brief summary of surgical nutrition, routes and requirements

1. Brooke Sachs
Surgical Teaching
April 2018
Resources list plus with the help of lecture notes from Surgical Metabolism subject USYD 2015

2.  Born April 25 1906, died Sept 17 1991
 Wanted to be an artist but his parents did not approve
 Obtained a scholarship to the National Academy of
Design, training there while completing high school
 Went to Medical School to appease his parents – worked
at the peak of the Great Depression and struggled to
make money
 Went back to illustrating in order to make ends meet
 Wrote/illustrated over 200 pamphlets and 13 atlases
 According to Dr Michael DeBakey, Netter’s contribution
to our understanding of anatomy is the greatest
advancement since Vesalius in the 16th century
 Now has a medical school in Conneticut named after him

3.  Gain an understanding of surgical metabolism
 Understand how to optimise peri-operative nutrition in elective patients
 Understand how to optimise metabolic outcomes through nutrition in
emergency/non-elective patients
 Understand the different feeding methods and their relative risks, benefits and
uses in surgical patients
 Define and understand re-feeding syndrome

4.  Body builders
 Fitness fanatics
 Dieticians and nutritionists
 The Paleo Chef
 And so on and so on

5.  Elderly folk
 Post-trauma
 Cancer patients
 Liver disease patients
 Burns
 And so on, and so on

6.  37 M presents to hospital with severe epigastric pain  pancreatitis
 Diagnosed as severe, has SIRS then MODS response requiring ICU support
 Necrotising pancreatitis
 BMI 30, no recent weight loss or gain
 Doesn’t normally go to the doctor, no known background health conditions
 Normally eats meat, pies, doesn’t like fruit or vegetables
 Works as a truck driver, smokes 10 cigarettes/day for 20 years
 Normally drinks 1 carton of beer/week
 12 hours prior to presentation had pain start after celebrating his birthday by
drinking a bottle of whiskey

7.  70 F presented last night with small bowel obstruction and strangulation
requiring urgent laparotomy – 20cm bowel resected and re-anastomosed,
adhesiolysis
 Background previous open cholecystectomy, TAHBSO, AF on warfarin, PVD, HTN
 No recent weight loss, BMI 19
 Was well prior to the last 24h
 Previous smoker 50 pack years, quit 5 years ago, teetotaler, lives in assisted
living, normally walks with a 4ww but does her own grocery shopping, able to
complete ADLs
 What is your nutrition plan?

8.  Micronutrient deficiencies in the absence of macronutrient deficiency (enough
energy, not enough vitamins … all our patients who eat a lot of KFC)
 Macronutrient deficiency
 Pure starvation
 Relative protein deficiency
 Micro- and macronutrient deficiencies
 Often seen in the developing world
 Cachexia
 Cytokine mediated
 Cancer
 INADEQUATE NUTRITION CAN OCCUR IN PEOPLE EATING A NORMAL
DIET
 SURGICAL PATIENTS ARE IN A CATABOLIC STATE

9.  Sepsis, surgery, acute and chronic illness predispose individuals to metabolic
derangement
 This is driven by a pro-inflammatory state
 Can occur even when eating ”adequately”
 Can be worsened by anorexia promoted by illness
 Protein intake is the most important component of macronutrition in these patients
 This leads to:
 Loss of lean body mass (i.e. muscle)
 Structural and functional impairment (muscle wasting, organ impairment)
 Dysregulation of energy utilisation pathways
 Ineffective antioxidation  build up of toxins
 INCREASED COMPLICATIONS AND MORTALITY

10.  Detsky et al. JPEN 1987
 9% of moderately malnourished patients have major complications
 42% of severely malnourished patients have major complications
 Severely malnourished patients are four-times more likely to suffer post operative
complications than well-nourished patients
 Hypoalbuminaemia is associated with higher surgical morbidity and mortality
 Infectious complications are increased with malnutrition

11.  Our patients are septic, broken or inflammed
 Their endocrine systems are hyperactive (adrenal response, thyroid response)
 Surgery may resolve part of their inflammation, however the process of
performing surgery is extremely physiologically stressful
 Post-operative outcomes are impacted by
 Nutrition
 pre- and post-operative body composition
 Medications
 Post operative management

12. https://thoracickey.com/metabolism-in-surgical-patients/

13.  Desky et al
 Hx
 Weight change
 Dietary intake change
 GI symptoms
 Functional capacity
 Underlying disease and metabolic
demand
 Physical exam
 Loss of subcutaneous fat
 Muscle wasting
 Ankle oedema
 Sacreal oedema
 Ascites
 Also consider:
 Weight fluctuations – a patient who
lost 10% of their BW, then regained
3% is in a better position than
someone who lost 7% in the same time
frame
 Intention – someone intentionally
losing weight on a healthy diet is in a
better position than someone trying to
gain weight but losing it
 Previous surgeries/known background
GIT issues
 Medications

14.  Occurs when a patient has been under-nourished or not nourished at all for a
period of time, then switched suddenly to adequate/excess calories
 Precipitates an insulin surge
 Metabolic rate increases, therefore the O2 consumption and CO2 production
increase
 Insulin stimulates shift of phosphate, potassium and magnesium from serum into
cells, resulting in electrolyte imbalances
 The whole-body stores of these electrolytes are likely to already be low
 Critically low serum levels can precipitate cardiac/neuromuscular compromise
leading to arrhythmias, CHF, acute respiratory failure and death
 Thiamine deficiency contributes to adverse outcomes

15.  Take baseline EUC, CMP, lipid studies
 Repeat these at least BD for the first few days in most patients at risk
 Involve a dietician in management
 Replace electrolytes, aiming for K>4, Mg >1, Phosphate >1
 Add thiamine and multivitamin to the diet/IV administration
 Slowly increase calories to the patient’s calculated requirements

17.  Oral
 Water
 Clear fluids
 Free fluids
 Light diet
 Full diet
 NGT/OGT/NDT/ODT/NJT/OJT/PEG (percutaneous endoscopic gastrostomy)/PEJ
 Enteral feed formula
 TPN/parenteral nutrition
 Central for long term feeds
 Peripheral for short term feeds
 Both can be supplementary to any of the above options

18.  Clear fluid diets – about 400-500 kcal/day
 Free fluids – 900-1000kcal/day
 Energy requirements are 25-35 kcal/kg/day
 With 1.5g/kg/day ideal body weight of protein
 Protein: Fat: Glucose ratio 20:30:50% of daily calories

19.  Our GIT is designed for digestion and absorption
 Enteral feeds promote immunocompetence and maintenance of the integrity of
tissues
 Non-utilisation of the GIT leads to complications in critical care and geriatric
patients, even when for short periods
 It is cost effective compared to TPN, and does not have the risk of line sepsis

20.  To avoid periods of starvation within 24-72 h with oral/enteral feeds will be
INSUFFICIENT to achieve adequate intake in moderate-severely malnourished
patients
 When unable to use the GIT
 Intestinal obstruction
 Short bowel/intestinal failure/malabsorption
 High output enterocutaneous fistula(e)
 Non-functioning GIT
 Ischaemic bowel
 Severe shock with impaired splanchnic perfusion
 ESPEN Guidelines on Parenteral Nutrition

21.  37 M presents to hospital with severe epigastric pain  pancreatitis
 Diagnosed as severe, has SIRS then MODS response requiring ICU support
 Necrotising pancreatitis
 BMI 30, no recent weight loss or gain
 Doesn’t normally go to the doctor, no known background health conditions
 Normally eats meat, pies, doesn’t like fruit or vegetables
 Works as a truck driver, smokes 10 cigarettes/day for 20 years
 Normally drinks 1 carton of beer/week
 12 hours prior to presentation had pain start after celebrating his birthday by
drinking a bottle of whiskey

22.  http://espen.info/documents/Acutepancreatitis.pdf
 Mild to moderate pancreatitis
 No evidence that enteral vs paerenteral has a beneficial effect
 Nutritional therapy to be considered if refeding is delayed
 Usually fast for 2-5 days, treat cause, replace fluids and electrolytes, analgese, then
commence oral feeds from day 3-7) with a carbohydrate-rich, moderate-protein,
moderate-fat diet prior to normal diet
 Severe pancreatitis
 Essential to have nutritional support
 Parenteral vs enteral based on patient tolerance. ENTERAL FEEDS should be
attempted in all patients  some patients will require a combination
 Some authorities suggest early jejunal feeds, some suggest parental with small enteral
based on tolerance
 IV lipids safe with hypertriglyceridaemia is avoided
 Feeds of any kind reduce the hypercatabolic state seen in severe pancreatitis

23.  70 F presented last night with small bowel obstruction and strangulation
requiring urgent laparotomy – 20cm bowel resected and re-anastomosed,
adhesiolysis
 Background previous open cholecystectomy, TAHBSO, AF on warfarin, PVD, HTN
 No recent weight loss, BMI 19
 Was well prior to the last 24h
 Previous smoker 50 pack years, quit 5 years ago, teetotaler, lives in assisted
living, normally walks with a 4ww but does her own grocery shopping, able to
complete ADLs
 What is your nutrition plan?

24.  It is helpful to give epidural analgesia peri-operatively to decrease opioid
requirements, reduce effects on peristalsis, and improve post-operative cognitive
functions
 Anaesthetic guidelines have changed in many centres to allow clear fluids until 2h
pre-op (though not in this lady’s case) – pre operative glucose reduces insulin
resistance
 Aim would be to commence enteral feeds within hours of completing surgery
 NG/NJ vs oral dependent on patient status post operatively
 Oral is preferable – decreased length of stay associated with consuming orally vs having
a tube
 Consideration of TPN only if patient is not expected to meet >50% of required caloric
intake within 7 days of operation

25.  Surgical nutrition is complicated
 It’s not something you do on your own – involve the dietician, the patient and the
nursing staff
 It’s easy to make a big difference with small tweaks, even in the absence of allied
health input
 Always think about the little things you can do to optimise your patients
 Good peri-operative nutrition reduces cost and complications acutely as well as
improving survival at 5 years in oncological surgeries
 Educate
 Educate
 Educate