1. NUTRITIONAL SUPPORT IN SURGICAL PATIENTS

2. INTRODUCTION
Nutritional disorders in surgical patients have 2 principal components
Starvation – effect of the disease, restriction of oral intake, or both
- Metabolic effects of stress/inflammation,increased catabolism,decreased
anabolism

3. ASSESSMENT OF NUTRITIONAL REQUIREMENTS
ESTIMATION OF ENERGY AND PROTEIN REQUIREMENTS IN ADULT SURGICAL PATIENTS
Uncomplicated Complicated/stressed
Energy
(Kcal/kg/day)
Protein
(g/kg/day)

4. CAUSES OF ADEQUATE INTAKE
Patient with normal gut
cumulative effects of repeated periods of fasting to undergo investigations such as endoscopy or contrast radiology.
Patient with intestinal failure
* Short bowel syndrome
* Fistula formation
* Motility disorders
* Expensive small bowel disease(e.g.crohn’s disease)

5. CAUSES OF ANOREXIA IN SURGICAL PATIENTS
INTESTINAL OBSTRUCTION
ILEUS
CANCER ANOREXIA
DEPRESSION,STRESS,ANXIETY
DRUGS e.g Opiates
ORAL ULCERATION/INFECTION
GENERAL DEBILITY/WEAKNESS

6. METHODS OF ADMINISTRATION OF ENTERAL FEEDS
NASOGASTRIC OR NASOJEJUNAL TUBES
GASTROSTOMY
JEJUNOSTOMY

7. COMPLICATIONS OF ENTERAL NUTRITION
DIARRHOEA
VOMITING
DIFFICULTY IN PLACING THE TUBE

8. PARENTERAL NUTRITION INDICATION FOR TPN (Total Parenteral Nutrition)
COMPOSITION OF TPN

9. STANDARD PARENTERAL NUTRITION REGIMEN
Non-protein energy kcal
Nitrogen g
Volume ml
Sodium mmol
Pottasium mmol
Calcium mmol
Magnesium mmol
Phosphate mmol
Zinc mmol
Chloride mmol
Acetate mmol
Adequate vitamins and trace elements

10. COMPLICATIONS OF TPN (Total Parenteral Nutrition)
CATHETER PROBLEMS
THROMBOPHLEBITIS
INFECTION
METABOLIC COMPLICATIONS

11. PERIPHERAL VEIN NUTRITION
Lipid emulsion & Isotonic Solutions of Amino Acids infused into peripheral veins
Less irritant than TPN
Short term usage
Complication with long term (Thrombophlebitis)

12. MONITORING OF NUTRITIONAL SUPPORT
DEFICIENCY STATES
ASSESS THE ADEQUACY OF ENERGY
PROTEIN PROVISION
ANTICIPITATE COMPLICATION
Pulse rate / Blood Pressure – regularly recorded
Accelerate fluid Balance Chart
Urine checked for glycosuria daily
Body weight measured twice weekly
Serum Urea &Electrolyte – daily
F.B.C, L.F.T , Serum Albumin , Ca+,Magnesium,Phosphate – once or twice weekly
Urine collected over one or two 24 hr periods each week for Nitrogen balance.

13. NUTRITIONAL SUPPORT IN SURGICAL PATIENTS
Clinical Scenarios

14. 1)A 69 year old man presented with significant weight loss and change in bowel habit. A mass was felt per rectum and he underwent a difficult abdomino-perineal resection, with some feacal contamination perioperatively. He has not passed flatus since the operation.Recovery is anticipated to take a long time.
Discuss the method of feeding ?

15. 2) A 72 year old woman suffered a left sided cerebrovascular accident during an elective abdominal aortic aneurysm repair. Four weeks later she still has no gag reflex. It is anticipated that she will be unable to feed herself for sometime
Discuss the method of feeding?

16. 3) A 71 year old man suffers increasing dysphagia over some months
3) A 71 year old man suffers increasing dysphagia over some months.He has a lower oesophageal carcinoma.It proves impossible to pass a nasogastric tube.He is malnourished and it is decided that he will need nutritional support before surgery.
Discuss the method of feeding ?