1. Nutrition Support of the Surgical Patient
Randa Jaroudi, Pharm.D
Clinical Coordinator
TPN Coordinator
KKUH

2. Nutrition
Nutrition allows the body to be provided with all basic nutrients substrates and energy required for maintaining or restoring all vital body functions from carbohydrate and fat and for building up body mass from amino acid.

3. Malnutrition
Malnutrition—come from extended inadequate intake of nutrient or severe illness burden on the body composition and function—affect all systems of the body

4. Type of Malnutrition Marasmus Protein – calorie malnutrition
The patient's oral diet may include an acceptable
protein:calorie ratio but is inadequate in quantity and calories.
(depleted somatic proteins, normal visceral proteins)
Normal Albumin and transferrin
Patients look thin and malnourished.
e.g. Patients with mild to moderate starvation, common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa 4

5. Clinical Manifestations
Weight loss
Reduced basal metabolism
Depletion skeletal muscle and adipose (fat) stores
Decrease tissue turgor
Bradycardia
Hypothermia

7. Type of Malnutrition Kwashiorkor (Kwa-shior-kor) Protein malnutrition
the diet contains various amounts of nonprotein calories
(inadequate, adequate, or excessive) from carbohydrates and fats,
but is deficient in total protein and essential amino acids.
(normal somatic proteins depleted visceral proteins)
↓ Serum Albumin and transferrin
Patients appear normal or overweight
e.g. Hypercatabolic critical care patients, chronic diarrhea, chronic kidney disease, trauma , burns, hemorrhage, and liver cirrhosis

8. Clinical Manifestations
Marked hypoalbuminemia
Anemia
Edema and ascites
Muscle atrophy
Delayed wound healing
Impaired immune function

10. Diagnosis Mixed Marasmus-Kwashiorkor:
(depleted somatic and visceral proteins)
All above data are reduced
Patients appear cachexic and severely malnourished.
e.g. *Chronic hypercatabolic patients (250 to 500g loss of weight)
*Prolonged starvation
Marasmic-kwashiorkor is a mixed form of any PCM
symptoms.
It frequently occurs when the marasmic patient experiences
the catabolic stress of illness or trauma. 10

11. Medical causes (Risk factors for malnutrition)
Recent surgery or trauma
Sepsis
Chronic illness
Gastrointestinal disorders
Anorexia, other eating disorders
Dysphagia
Recurrent nausea, vomiting, or diarrhea
Pancreatitis
Inflammatory bowel disease
Gastrointestinal fistulas
Cancer

12. Metabolic Rate
Normal range
Long CL, et al. JPEN 1979;3:452-6

13. Protein Catabolism
Normal range
Long CL. Contemp Surg 1980;16:29-42

14. The Goals of Preoperative Nutrition Support
↓ surgical mortality
↓surgical complications and infection
Reduce the catabolic state and restore anabolism
↓the hospital length of stay
Speed the healing/recovery process

15. Indications
Aggressive nutritional support (enteral or parenteral) should be considered in minimum 3 of:
Looks clinically malnourished.
Has a low serum albumin <3.5g/dL.
Has a recent loss of 10% or greater within
Has a history of recent poor intake.
Who as a consequence of his illness is going to be or has been NPO for 5-7 days.
The term “If gut works, use it” remains the golden rule. However, recently this was changed to: If gut works use it; and if gut works partially, use it partially.

16. Preoperative Nutrition Assessment-1
1. Medical & Nutritional History
Medical history includes acute or chronic disease, medication,
surgeries, & other therapies (i.e., chemotherapeutics,
immunosuppressive)
Nutrition History includes recent changes in appetite or
weight, activity level, use of diet.
Subject Global Assessment (SGA)

17. Preoperative Nutrition Assessment-2
2. Physical examination
Logical assessment from head to toe
3. Anthropometric parameters
% of IBW = Actual weight x 100/Ideal body weight
Triceps Skinfold Thickness (TSF) for assessing fat reserve. It is decreased when fat stores are depleted.
Midarm muscle circumference (MAC) to assess the degree of somatic protein depletion. TSF and Mid Arm Circumference are no more recommended as an accurate measurement.
Creatinine Height Index (CHI) to assess somatic protein stores.
Serum Protein Determination to assess the degree of visceral protein depletion, e.g. Albumin, Transferring, Prealbumin.
Measure Total Lymphocyte Count (TLC) to assess Immune function becomes impaired
4. Lab assessment

18. Fat, Anthropometric parameters
Assessment of body fat
Triceps Skinfold Thickness (TSF) for
assessing fat reserve. It is decreased when
fat stores are depleted.

19. Protein (Somatic Protein)
Assessment of the fat-free muscle mass (Somatic Protein) depletion
Mid-upper-arm circumference (MAC)
TSF and MAC are no more
recommended as an accurate measurement

20. Creatinine-height index (CHI )
[measured urinary creatinine (24hr)/ Ideal urinary creatinine for a given height]
Ideal Cr = IBW x 23 mg/kg male
= IBW x 18 mg/kg female
CHI > mild depletion
CHI – 80 moderate
CHI < severe

21. Average Body Mass Index (BMI) for Adult
Classification
BMI (kg/m2)
Obesity Class
Underweight
<18.5
Normal
Overweight
Obesity I
Moderate obesity II
Extreme obesity
>40.0
III

22. Nutrition Provides Energy Amino Acid Fluid & Electrolyte
Trace minerals (elements)
Vitamin
Certain drugs

23. Fluid Requirement

24. Fluid Requirement Amount of fluid requirement needed depend on age
Pediatric: 1st 10kg = 100ml/kg
2nd 10kg = 50ml/kg
3rd 10kg & up 20ml/kg
Adult: ml/kg
Additional fluid for vomiting, nasogastric tube
output, diarrhea, large open wound, fever,
hyperventilation, fistula drainage.

25. Fluid Requirements Special situation for fluid restriction:
Fluid overload,
Cardiac, Renal, or Liver failure
Elderly
Medication
NRC* recommends 1 to 2 ml of water for each kcal
of energy expenditure
*NRC= National research council

26. Energy Requirements

27. Total Energy Expenditure
TEE (kcal/day) = BEE x stress/activity factor
BEE:
The Harris-Benedict equation is a mathematical formula used to calculate BEE

28. Harris-Benedict Equation
Women =
655 + (9.6 x wt) + (1.7 x ht) - (4.7 x age)
Men =
66 + (13.7 x wt) + (5 x ht) - (6.8 x age)
Calories Multiply by stress factor

29. A correlation factor that estimates the extent of hyper-metabolism
1.15 for bedridden patients
1.10 for patients on ventilator support
1.25 for normal patients
The stress factors are:
1.3 for low stress
1.5 for moderate stress
2.0 for severe stress
for burn

30. Calories Requirements
Obesity: 18-20kcal/kg/day of IBW
Normal need: 25-30kcal/kg/day
Elective surgery: 28-30kcal/kg/day
Severe injury: 30-40kcal/kg/day
Extensive trauma/burn: 40-45kcal/kg/day

31. Carbohydrate Primary energy substrate
The amount of carbohydrate is determined by
patient’s calorie requirement
glucose oxidation rate
optimal balance of carbohydrate and fat
Maximum oxidized rate 4 - 7mg/kg/min (adult).

32. Carbohydrate Provide from a non nitrogen source
Energy requirement depends on number of factors!
Stress factors, increase calories requirements
60% - 80% of caloric requirement as glucose

33. CHO Oxidation Rate 1gm = 3.4kcal Kcl ÷ 3.4 x 1000 ÷ 1440 ÷ wt kg =
not more than 5mg/kg/min
e.g ÷ 3.4 x 1000 ÷ 1440 ÷ 70 =
4.9mg/kg/min or
5 mg x 3.4 ÷ 1000 x wt x 1440
5 x 3.4 ÷ 1000 x 70 x 1440 = ~ 1700 kcal

34. Carbohydrate Source Starting with:
gm or 15% dextrose solution started or 2.5 mg/kg/min
gm or 10% - 15% dextrose solution in stress & DM
Increase gradually up to 5 mg/kg/min,
Max 7 mg/kg/min

35. How to Calculate Percentage
Total volume of fluid x 3.4 x %
e.g ml x 3.4 x 0.20 = 1360 kcal. Or
1400 ÷ 3.4 ÷ 2000ml = 20% as started then
1700 ÷ 3.4 ÷ 2000ml = 25% full requirement

36. Protein (Amino Acid) AAs are the vital components of body protein. The
primary aim of providing AAs to the body is to
prevent:
Disease related catabolic state.
The development of manifest protein deficiency with subsequent impaired wound healing.
Disturbances of blood clotting.
The impairment of hepatic and renal function.
A reduced immuno-competence.

37. Protein (Amino Acid) 1g of protein = 4 Kcal
1g of nitrogen is equivalent to 6.3g of protein
Non-protein k.cal: nitrogen
: 1 (normal patient)
 Note:
In renal and hepatic failure the ratio is 1:
Adult dose: Normal patients requirement g/kg
max. 2.5g/kg depend on patient status
Renal failure patient 0.6 g/kg

38. Protein (Amino Acid) 12% - 16% of calories as protein Note:
Products containing only essential Aas have been formulated for renal failure.
BCAA (Branched Chain Amino Acids) are used for Hepatic Encephalopathy or in severely stressed patients.

39. Fat Emulsion
Essential linoleic acid stabilized by egg yolk phospholipids
Delivered in the form of an emulsion
fat emulsion has no isotonicity by itself, glycerol is added to render emulsion isotonic (300 mosm/l).
Concentrated source of calories
Source of essential fatty acids (EFAs)
Substitute for carbohydrate in diabetic & fluid restricted patients

40. Fat Emulsion Fat should provide 20-40% of total calories.
Fat provides a concentrated caloric source. 1g provide 10 Kcal.
Also fat is an alternative source to dextrose to the patients with compromised respiration since it does produce little CO2 in its metabolism. While dextrose, when oxidized, it produces CO2 which must be eliminated via lungs.
Start with 0.5g/kg/d  gradually up to1.5g/kg/d.
Administer over 12hr or max rate 15ml/hr

41. Fat Emulsion The caloric density 10% FE is 1.1 kcal/ml
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Fat Emulsion
The caloric density
10% FE is 1.1 kcal/ml
20% FE is 2 kcal/ml
30% FE is 3 kcal/ml
There is LCT, and MCT/LCT products
1gm = 9kcal of fat
Each 1ml = 2kcal
Lipid emulsions contain glycerol, so lipid emulsion does not have 9 kcal per gram as it would if it were pure fat. Some use 10 kcal/gm for lipid emulsions.
Propofol: Soybean oil in water emulsion, 1ml kcal
Randa Jaroudi

42. Fat Emulsion Contraindications
Hyperlipdemia
Acute pancreatitis
Previous history of fat embolism
Severe liver disease
Allergies to egg, soybean oil or safflower oil

44. Electrolytes Na, K, CL, Ca, Mg, PO4, & acetate.
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Electrolytes
Na, K, CL, Ca, Mg, PO4, & acetate.
Electrolytes given to maintain normal serum concentration or to correct deficit.
Requirements for specific electrolytes will vary according to the patients disease state
Randa Jaroudi

46. Restrict electrolytes
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Restrict electrolytes
Severe renal dysfunction.
Edema & congestive heart failure.
Patients on corticosteroids.
Metabolic acidosis, acute pancreatitis fistulas, or diarrhea.
Metabolic alkalosis, vomiting.
Randa Jaroudi

47. Multivitamins
B – Complex: Co-enzyme in absorptive and metabolic processes,
transfer of energy from protein, fat and carbohydrate to the cells and their
storage as ATP.
Ascorbic Acid: Required for collagen synthesis, wound healing. An
additional amount may be required in major burns, traumas, and extensive
surgeries.
Vitamin A: Essential for vision, the production of mucus-secreting
epithelial cells and bone growth.
Vitamin D: For calcium and phosphate hemeostasis and boncalcification.
Vitamin K: For prothrombin generation (Fibrin Fibrinogen).

48. Vitamin K
TPN solution does not contain vitamin K and it can predispose patient to deficiency
Vitamin K 10 mg should be given weekly IV or IM if patient is on long-term TPN

49. Multivitamin and Trace Minerals
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Multivitamin and Trace Minerals
Standard form of multivitamin & trace mineral use.
Zinc, copper, manganese & chromium.
Additional of trace mineral required depend on GI losses.
Renal failure patients reduce dose
Biliary stasis disease, avoid copper & manganese
Randa Jaroudi

51. Additives
INSULIN: For hyperglycemia when glucose is spilling in urine.
HEPARIN: To promote blood circulation (especially with peripheral TPN) and to prevent thrombophlebitis.
HYDROCORTISONE: To prevent thrombophlebitis in patients receiving peripheral TPN.
ACETATE: For acidosis.
ZINC: Extra amount is needed for patient with severe stress, diarrhea, and ileostomy.

52. Status of Organic failure
Hypermetabolism
Tachycardia, Tachypnea, Fever, Leucocytosis
Hypercatabolism
Hyperglycemia, Uremia, Hypertriglyceridemia, -NB

53. Renal Failure Considerations
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Renal Failure Considerations
Present with problems of volume limitation and poor tolerance of nitrogen wastes.
Treated with g/kg amino acid, higher glucose and lipid concentration.
Limit amounts of sodium, potassium, magnesium, and phosphate.
Randa Jaroudi

54. Liver Failure Considerations
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Liver Failure Considerations
Inability to tolerate large fluid volume and difficulty with nitrogen loads
Maintain glucose
Supply moderate protein( g/kg) and fat intake up to 30% of T.k.calorie
Restrict fluid and salt intake
BCAA
Randa Jaroudi

55. Fluid Restricted Considerations
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Fluid Restricted Considerations
As pulmonary, cardiac failure, head injuries, and elderly.
Special concentrated TPN solution.
High fat emulsion, low glucose.
Normal protein requirement.
Normal electrolyte.
Randa Jaroudi

56. Writing TPN Order
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Respiratory Failure
Non-protein calories to nitrogen ration is not a major consideration.
Major problem total calories, either from CHO or fat or both
Protein increases oxygen consumption demands and that is not indicated to reducing protein
Randa Jaroudi

57. Going to surgery In postoperative surgical patients;
TPN is indicated if the patient is indicated
to stay NPO for 5 – 7 days in malnourished
patients, and 7 – 10 days in well-nourished
patients.
In preoperative patients;
TPN should be considered in patients who
cannot or should not eat for more than 3 – 5
days.

58. Practice Guidelines Preoperative
NS should be administered for 7-14 days to moderately or severely malnourished patients undergoing major GI surgery
PN should NOT be routinely given in the immediate postoperative period to patients undergoing major GI procedures

59. OR Patient Hold TPN during OR if it more than 1 1/2 hrs
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OR Patient
Hold TPN during OR if it more than 1 1/2 hrs
2hrs pre-operation:
↓ TPN rate 50% for 1hr
Hold TPN
Start D10% infusion at same TPN rate
6hrs post – operation
Start new TPN bottle at 50% of TPN rate for 1hr
↑ TPN rate as in order
MONITORING BLOOD SUGAR
Randa Jaroudi

60. Routes of Nutrition Support

62. Enteral Nutrition

63. Enteral Nutrition Indication
Inability to consume or absorb adequate nutrition
e.g. who do not eat or receive nutrition support for ≥10-14 days after hospital admission
Functional or partially functional gut
e.g. who are unable or not allowed to eat, or partial functional gut

64. Potential benefits of EN over PN
Nutrients are metabolized and utilized more effectively via the enteral than parenteral route
Gut and liver process EN before their release into systemic circulation
Gut and liver help maintain the homeostasis of the AA pool and skeletal muscle tissue

65. EN (Immunologic)
Gut integrity is maintained by enteral feeding and prevent the bacterial translocation from the gut and minimize risk of gut related sepsis

66. Enteral nutrition (EN)
Long-term nutrition:
Gastrostomy
Jejunostomy
Short-term nutrition:
Nasogastric feeding
Nasoduodenal feeding
Nasojejunal feeding

68. Benefits of EN Physiological/metabolic benefits Safety benefits
The gut can be used for administration of complex nutrients that cannot be given intravenously e.g. intact protein, peptides, fiber
Safety benefits
Safer than PN and less side effects
Cost benefits

69. Contraindication to EN
Terminal illness
Short bowel
Obstruction
GI bleeding
Vomiting and diarrhea
Fistulas
GI ischemia
Illues
GI inflammation
A. pancreatitis

70. Enteral Nutrition Complications
Mechanical complication
During placement of feeding tube
Airway injury, infection, ↑ICP
Presence of a feeding tube
Tube clogging
Declogging methods
Aspiration
GI complication
Gastroesophageal reflux duodenal gastric reflux
Diarrhea
Metabolic complication

71. Enteral Nutrition Complications
Metabolic complication
Hyperglycemia
Electrolyte and mineral deficiences
Refeeding syndrome

72. Total Parentral Nutrition

73. Total Parenteral Nutrition Indication
When normal oral feeding is not possible.
e.g.: Chron’s disease, gastric & esophageal carcinoma, paralytic ileus, generalized peronitis, GI. obstruction, intractable vomiting.
When food is incompletely absorbed.
e.g.: Major burns, multiple injuries, radiation therapy, ulcerative colitis, chemotherapy treatment, short bowel syndrome.
When food intake is undesirable, in case it is prudent to rest the bowel.
e.g.: Post GIT surgery, chronic inflammatory diseases, intractable diarrhea.

74. Total Parenteral Nutrition Indication
In patients who are able to ingest food, but refuse to do so.
e.g.: Geriatric post-operative patients, adolescents with anorexia nervosa, some psychiatric patients with prolonged depression.
In patients who, as a consequence of their illness are going to be, or have been NPO for 5 – 7 days.

75. Administration

76. Parenteral Nutrition Central Nutrition Subclavian line Long period
Hyperosmolar solution
Full requirement
Minimum volume
Expensive
More side effect
Peripheral nutrition
Peripheral line
Short period < 14days
Low osmolality
< 900 mOsm/L
Min. requirement
Large volume
Thrombophlebitis

77. Routes of TPN Central TPN (usual osmolarity = 2000 mosmol/L)
Advantages:
Can provide full nutritional support (No
limits in concentration of dextrose and amino acids)
No risk of thrombophlebitis, No pain.
Disadvantages:
Requires surgery
More risk of sepsis than peripheral TPN
High risk of mechanical complications

78. Routes of TPN maximum osmolarity;
Peripheral TPN
maximum osmolarity;
neonates = 1100/L, Pediatrics = 1000/L, Adults = 900/L
Advantages:
Does not require surgery
Less risk of sepsis than central TPN
No risk of mechanical complications
Disadvantages:
High risk of thrombophlebitis
Painful
Does not provide full nutrition support. Needs more
fluids to provide more nutrition. (maximum dextrose
= 7.5% and AA = 2.5%).

79. Note PPN can infuse through central line but
central TPN can NOT infuse through
the peripheral line

80. Calculating the Osmolarity of a Parenteral Nutrition Solution
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Calculating the Osmolarity of a Parenteral Nutrition Solution
Multiply the grams of dextrose per liter by 5.
Example: 100 g of dextrose x 5 = 500 mOsm/L
Multiply the grams of protein per liter by 10.
Example: 30 g of protein x 10 = 300 mOsm/L
Multiply the (mEq per L sodium + potassium + calcium + magnesium) X 2
Example: 80 X 2 = 160
Total osmolarity = = 960 mOsm/L
Randa Jaroudi

81. Monitoring

82. Monitoring Avoid overfeeding Avoid respiratory problem
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Monitoring
Avoid overfeeding
Avoid respiratory problem
Promote nitrogen retention
Triglyceride clearance
Fluid and electrolyte
Weight
Liver function
Randa Jaroudi

83. Monitoring for Complications
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Monitoring for Complications
Malnourished patients at risk for refeeding syndrome should have serum phosphorus, magnesium, potassium, and glucose levels monitored closely
In patients with diabetes or risk factors for glucose intolerance, insulin infusion should be initiated with a low dextrose infusion rate and blood and urine glucose monitored closely.
Blood glucose should be monitored frequently upon initiation, any change in insulin dose, and until measurements are stable.
Randa Jaroudi

84. Monitoring for Complications
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Monitoring for Complications
Serum electrolytes (sodium, potassium, chloride, and bicarbonate) should be monitored frequently until measurements are stable.
Patients receiving intravenous fat emulsions should have serum triglyceride levels monitored until stable and when changes are made in the amount of fat administered.
Liver function tests should be monitored periodically in patients receiving PN.
Randa Jaroudi

85. Complications of TPN

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Complication
Mechanical: occlusion, catheter removal, improper rate, thromboses, pneumothorax.
Infection: catheter related
Metabolic: re-feeding syndrome, hyperglycemia, fluid & electrolyte disturbance
(cont..)
Randa Jaroudi

88. Complication Organic system: hepatobiliary complication respiratory
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Complication
Organic system:
hepatobiliary complication
respiratory
cardiovascular
renal
Randa Jaroudi

89. Writing TPN Order
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Transitional Feeding
Maintain full PN support until pt is tolerating 1/3 of needs via enteral route
Decrease TPN by 50% and continue to taper as the enteral feeding is advanced to total
TPN can reduce appetite if >25% of calorie needs are met via PN
TPN can be tapered when pt is consuming greater than 500 calories/d and d-c’d when meeting 60% of goal
TPN can be rapidly d-c’d if pt is receiving enteral feeding in amount great enough to maintain blood glucose levels
Randa Jaroudi

90. Defense Against NS Complications
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Defense Against NS Complications
Select appropriate patients to appropriate nutrition
Aseptic technique
Do not overfeed
Maintain glycemic control < mg/dl
Limit lipids to 1 gm/kg and monitor TG levels
Adjust protein based on metabolic demand and organ function
Monitor fluid/electrolyte/mineral status
Provide standard vitamin and trace element preps daily
Randa Jaroudi

91. Thank you