1. Surgical Nutrition

2. Objectives
To discuss basic steps in surgery – screening and assessment
To discuss major approaches to surgery management

3. Pre-operative Phase
As a basic requirement a systematic nutritional risk screening (NRS) has to be considered in all patients on hospital admission [30].
The items of the NRS comprise BMI <20.5 kg/m2, weight loss >5% within 3 months, diminished food intake, and severity of the disease.
In older adults comprehensive geriatric assessment is necessary and should definitely include NRS [31].
In order to improve oral intake documentation of food intake is necessary and nutritional counselling should be provided as needed.
Oral nutritional supplements (ONS) and EN (tube feeding) as well as PN offer the possibility to increase or to ensure nutrient intake in case of insufficient oral food intake.
It is recommended to assess the nutritional status before and after major surgery.

4. Nutritional Screening and Assessment
Weight:
Actual
Ideal
Tannhauser formula: Get the height in centimeters > subtract 100 from the height > multiply the result (1) by 10% > subtract this result(2) from result(1) > this is now the ideal body weight in kilograms
Acute weight loss is severe if:
2% of body weight in 1 week.
5% of body weight in 1 month.
7.5% of body weight in 3 months.
8% of body weight in 6 months
BMI screen
SGA (subjective global assessment)

5. If patient is not malnourished – go ahead with the expected surgery:

6. If patient is not malnourished – go ahead with the expected surgery:
No need for preoperative fasting necessary (Recommendation %)
Pre-operative carbo may or may not be given (Recommendation 1 – 100%)
Oral intake, including clear liquids, shall be initiated within hours after surgery in most patients. (Recommendation 3,4,5 – 90 to 100%)

7. However if the patient is to undergo surgery and there is malnutrition

8. However if the patient is to undergo surgery and there is malnutrition
Perioperative nutritional therapy is indicated in patients with malnutrition and those at nutritional risk. (Recommendation 7 – 92%)
Perioperative nutritional therapy should also be initiated, (Recommendation 7 – 92%)
if it is anticipated that the patient will be unable to eat for more than five days perioperatively.
It is also in patients expected to have low oral intake and who cannot maintain above 50% of recommended intake for more than seven days.
In these situations, it is recommended to initiate nutritional therapy (preferably by the enteral route = ONS-TF) without delay. (Recommendation 7 – 92%)
ONS-TF: oral nutritional supplements; tube feeding

9. However if the patient is to undergo surgery and there is malnutrition
If the energy and nutrient requirements cannot be met by oral and enteral intake alone (<50% of caloric requirement) for more than seven days, a combination of enteral and parenteral nutrition is recommended (GPP). (Recommendation 8 – 100%)
Parenteral nutrition shall be administered as soon as possible if nutrition therapy is indicated and there is a contraindication for enteral nutrition, such as in intestinal obstruction (A) (BM). (Recommendation 8 – 100%)
For administration of parenteral nutrition an all-in-one (three chamber bag or pharmacy prepared) should be preferred instead of multi bottle system (BM, HE). (Recommendation 9 – 100%)
GPP: good practice points; A: metaanalysis; BM: biomedical endpoints; HE: health care endpoint

10. Check the extent of malnutrition

11. Check the extent of malnutrition
THERE IS A NEED TO PREPARE FOR AT LEAST TWO WEEKS
Patients with severe nutritional risk shall receive nutritional therapy prior to major surgery (A) even if operations including those for cancer have to be delayed (BM). A period of 7-14 days may be appropriate (0). (Recommendation 14 – 95%)
Whenever feasible, the oral/enteral route shall be preferred (A) (BM, HE, QL). (Recommendation 15 – 100%)
When patients do not meet their energy needs from normal food it is recommended to encourage these patients to take oral nutritional supplements during the preoperative period unrelated to their nutritional status. (Recommendation 16 – 86%)
Preoperatively, oral nutritional supplements shall be given to all malnourished cancer and high-risk patients undergoing major abdominal surgery (BM, HE). (Recommendation 17 – 97%)
A special group of high-risk patients are the elderly people with sarcopenia. (Recommendation 17 – 97%)
O: evidence 3 to 4; A: metaanalysis; BM: biomedical endpoints; HE: health care endpoint; QL: quality of life

12. Check the extent of malnutrition
THERE IS A NEED TO PREPARE FOR AT LEAST TWO WEEKS
Immune modulating oral nutritional supplements including arginine, omega-3 fatty acids and nucleotides can be preferred (0) (BM, HE) and administered for five to seven days preoperatively (GPP). (Recommendation 18 – 64%)
Preoperative enteral nutrition/oral nutritional supplements should preferably be administered prior to hospital admission to avoid unnecessary hospitalization and to lower the risk of nosocomial infections (BM, HE, QL). (Recommendation 19 – 91%)
Preoperative PN shall be administered only in patients with malnutrition or severe nutritional risk where energy requirement cannot be adequately met by EN (A) (BM). A period of 7-14 days is recommended (0). (Recommendation 20 – 100%)
GPP: good practice points; A: metaanalysis; BM: biomedical endpoints; HE: health care endpoint; QL: quality of life

13. Preparation is in the form of:
ADEQUATE INTAKE OF ALL NUTRIENTS
ADEQUATE HYDRATION (done in another section)

14. Daily intake and fluid balance

15. Adequate intake and survival in surgery
St., Luke’s Medical Center, General Surgery (From admission to discharge)
Del Rosario et al. Available at:
When adequate intake was achieved in both calorie and protein intake improvement in mortality and morbidity outcomes in the surgical patients were noted whether they are nutritionally high risk or low risk. In this study no significant difference is seen in the mortality rate.
Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, Accessed in:
Local Philippine data

16. Paul Wischmayer. Ensuring Optimal Survival and Post-ICU Quality of Life in High-Risk ICU Patients: Permissive Underfeeding Is Not Safe!
Crit Care Med Aug; 43(8):

17. Enteral feeding alone vs. Supplemental PN
Supplemental parenteral nutrition allows achievement of full adequacy of intake
Heidegger et al. Lancet 2013; 381:

18. How to manage delivery Lower Higher Calories 14.5 kcal/kg/day
Lower
Higher
Calories
14.5 kcal/kg/day
29.3 kcal/kg/day
Protein
0.7 g/kg/day
1.12 g/kg/day
36% mortality in 60 days was lowered
Clinical outcome of critically ill septic patients: secondary analysis of a large international nutrition database: Analysis of daily intake within one week. Elke et al. Critical Care 2014; 18: R29. EN
SPN+EN
Calories
18.5 kcal/kg/day
23.7 kcal/kg/day
Protein
0.96 g/kg/day
1.2 g/kg/day
A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial. Wischmeyer et al. Critical Care 2017; 21: 142.

19. Surgery

20. Surgery
EARLY FEEDING
Early tube feeding (within 24 h) shall be initiated in patients in whom early oral nutrition cannot be started, and in whom oral intake will be inadequate (<50%) for more than 7 days. (Recommendation 21 – 97%)
Special risk groups are: (Recommendation 21 – 97%)
Patients undergoing major head and neck or gastrointestinal surgery for cancer (A) (BM)
Patients with severe trauma including brain injury (A) (BM)
Patients with obvious malnutrition at the time of surgery (A) (BM) (GPP)
In most patients, a standard whole protein formula is appropriate. (Recommendation 22 – 94%)
For technical reasons with tube clogging and the risk of infection the use of kitchen-made (blenderized) diets for tube feeding is not recommended in general. (Recommendation 22 – 94%)
A: metaanalysis; BM: biomedical endpoint

21. Total patients = 161.
11 (6.8%) were reopened, five (3.1%) had fistulas, three (1.9%) wound dehiscence, three (1.9%) fistula more wound dehiscence and six (3.7%) other non-infectious complications
However, the limitation of the present study is that it is observational, retrospective and unicentric
No one died in either group

22. Nutrition has two different directions in its effect on catabolic change
In order to sustain the continuous supply of nutrients (EAA) external supply by enteral or parenteral nutrition is needed
Without external support the nutrients (EAA) will tend to downgrade
1.3%-1.4% increase
(20%)
The catabolic effect does not downgrade, maybe a bit, but it will be there until the damage is resolved
REE: Resting energy expenditure
EAA: Essential amino acid

23. Calories: 25 - 30 kcal/kg/day on 2nd to 3rd week and after
How to manage delivery
Lower
Higher
Calories
14.5 kcal/kg/day
29.3 kcal/kg/day
Protein
0.7 g/kg/day
1.12 g/kg/day
36% mortality in 60 days was lowered
Clinical outcome of critically ill septic patients: secondary analysis of a large international nutrition database: Analysis of daily intake within one week. Elke et al. Critical Care 2014; 18: R29.
Calories: kcal/kg/day
Protein: gm/kg/day EN
SPN+EN
Calories
18.5 kcal/kg/day
23.7 kcal/kg/day
Protein
0.96 g/kg/day
1.2 g/kg/day
Calories: kcal/kg/day on 2nd to 3rd week and after
Protein: gm/kg/day up to 2 gm/kg/day on the 2nd to 3rd week and after
A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial. Wischmeyer et al. Critical Care 2017; 21: 142.

24. Surgery IF INTAKE IS INADEQUATE ORALLY, GIVE ENTERAL NUTRITION
With special regard to malnourished patients, placement of a nasojejunal tube (NJ) or needle catheter jejunostomy (NCJ) should be considered for all candidates for tube feeding undergoing major upper gastrointestinal and pancreatic surgery (BM). (Recommendation 23 – 95%)
If tube feeding is indicated, it shall be initiated within 24 h after surgery (BM). (Recommendation 24 – 91%)
It is recommended to start tube feeding with a low flow rate (e.g max. 20 ml/h) and to increase the feeding rate carefully and individually due to limited intestinal tolerance. The time to reach the target intake can be very different, and may take five to seven days. (Recommendation 25 – 85%)
BM: biomedical endpoints

25. Surgery IF INTAKE IS INADEQUATE ORALLY, GIVE ENTERAL NUTRITION
If long term TF (>4 weeks) is necessary, e.g. in severe head injury, placement of a percutaneous tube (e.g. percutaneous endoscopic gastrostomy with PEG) is recommended. (Recommendation 26 – 94%)
Regular reassessment of nutritional status during the stay in hospital and, if necessary, continuation of nutrition therapy including qualified dietary counselling after discharge, is advised for patients who have received nutrition therapy perioperatively and still do not cover appropriately their energy requirements via the oral route. (Recommendation 27 – 97%)

26. Surgery
IF ENTERAL NUTRITION IS STILL INADEQUATE, GIVE PARENTERAL NUTRITION
If the energy and nutrient requirements cannot be met by oral and enteral intake alone (<50% of caloric requirement) for more than seven days, a combination of enteral and parenteral nutrition is recommended (GPP). (Recommendation 8 – 100%)
Parenteral nutrition shall be administered as soon as possible if nutrition therapy is indicated and there is a contraindication for enteral nutrition, such as in intestinal obstruction (A) (BM). (Recommendation 8 – 100%)
GPP: good practice points; BM: biomedical endpoints; A: metaanalysis

27. Surgery
IF ENTERAL NUTRITION IS STILL INADEQUATE, GIVE PARENTERAL NUTRITION
For administration of parenteral nutrition an all-in-one (three chamber bag or pharmacy prepared) should be preferred instead of multi bottle system (BM, HE). (Recommendation 9 – 100%)
Regular reassessment of nutritional status during the stay in hospital and, if necessary, continuation of nutrition therapy including qualified dietary counselling after discharge, is advised for patients who have received nutrition therapy perioperatively and still do not cover appropriately their energy requirements via the oral route. (Recommendation 27 – 97%)
BM: biomedical endpoints; HE: health care endpoint; QL: quality of life

28. Surgery OTHER CONSIDERATIONS
Parenteral glutamine supplementation may be considered in patients who cannot be fed adequately enterally and, therefore, require exclusive PN (0) (BM, HE). (Recommendation 11 – 76% or 100%)
Postoperative parenteral nutrition including omega-3-fatty acids should be considered only in patients who cannot be adequately fed enterally and, therefore, require parenteral nutrition (BM, HE). (Recommendation 12 – 65%)
Peri- or at least postoperative administration of specific formula enriched with immunonutrients (arginine, omega-3-fatty acids, ribonucleotides) should be given in malnourished patients undergoing major cancer surgery (B) (BM, HE). (Recommendation 13 – 89%)
0: evidence 3 or 4; BM: biomedical endpoints; HE: health care endpoint

29. Protein and calorie deficit and outcomes
D. Dante Yeh, MD, Miroslav P. Peev, MD, Sadeq A. Quraishi, MD, MHA, MMSc, Polina Osler, MS, Yuchiao Chang, PhD, Erin Gillis Rando, RD, LDN, CNSC, Caitlin Albano, RD, LDN, CNSC, Sharon Darak, RD, LDN, CNSC, and George C. Velmahos, MD, PhD. CLINICAL OUTCOMES OF INADEQUATE CALORIE DELIVERY AND PROTEIN DEFICIT IN SURGICAL INTENSIVE CARE PATIENTS. AMERICAN JOURNAL OF CRITICAL CARE, July 2016, Volume 25, No. 4.

30. Malnutrition in surgery
Yun Tae Jung, Jung Yun Park, Jiyeon Jeon, Myung Jun Kim, Seung Hwan Lee and Jae Gil Lee. Association of Inadequate Caloric Supplementation with 30-Day Mortality in Critically Ill Postoperative Patients with High Modified NUTRIC Score. Nutrients 2018, 10, 1589; doi: /nu

31. Thank You