1. Dr. Mahamed Hussein General Surgery Azadi Teaching Hospital
Nutrition
Dr. Mahamed Hussein
General Surgery
Azadi Teaching Hospital

2. Nutrition and Surgery
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.

3. The five steps to optimal nutrition support are:
Begin when the benefits are likely to exceed the risk,
Set protein and calorie goals,
Choose and establish a method for administering the nutrients, enteral (site and route) or parenteral (peripheral or central)
Choose or design a formula suitable for the particular patient
Monitor the patient for adequacy of nutrient intake and to avoid or minimize complications

4. Sources of energy (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

5. Carbohydrates
Limited storage capacity, needed for CNS (glucose) function
Yields 4 kcal/gm
Recommended 45-65% of total caloric intake
Simple vs Complex

6. Fats 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

7. Protein 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

8. Normal Nutrition Requirements
Healthy male & female
( for weight maintenance )
Caloric intake= kcal/kg/day
Protein intake= 0.8-1gm/kg/day (max=150gm/day)
Fluid intake= ~30 ml/kg/day
If patient’s BMI is >30, use IBW in kg to determine calorie and protein needs. Don’t want to feed the fat.
Fluid intake needs to be adjusted for patients in ESRD (especially those not on dialysis) and hepatic failure.

9. Nutrition Comparison HEALTHLY 70 kg MALE SURGERY PATIENT
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
Mild stress (in the hospital, inpatient)
Moderate stress (ICU patient)
Severe stress (burn patient)

10. Reasons for Malnutrition
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

11. 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.

12. 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

13. 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

14. 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.

15. Indications for Parenteral Nutrition
Primary therapy
Gastrointestinal fistula
Short bowel syndrome
Acute renal failure
Hepatic insufficiency
Inflammatory bowel disease

16. Indications for Parenteral Nutrition
Secondary therapy
Radiation enteritis/chemotherapy toxicity Hyperemesis gravidarum
Prolonged ileus
Preoperative therapy
Cardiac cachexia
Pancreatitis insufficiency
Cancer
Sepsis

17. Questions