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Title: Nutrition

  • . . . and the surgical patient
  • Carli Schwartz, RD/LDN

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
  • Malnutrition is associated with a high incidence
    of operative complications and death.

Normal Nutrition (
The Newest Food Guide Pyramid
  • Balancing Calories   ? Enjoy your food, but eat
    less.   ? Avoid oversized portions.    
  • Foods to Increase   ? Make half your plate fruits
    and vegetables.   ? Make at least half your
    grains whole grains.   ? Switch to fat-free or
    low-fat (1) milk.    
  • Foods to Reduce   ? Compare sodium in foods like
    soup, bread, and frozen meals ? and choose the
    foods with lower numbers.   ? Drink water instead
    of sugary drinks.   
  • Website http//
  • Includes interactive tools including a
    personalized daily food plan and food tracker

  • Carbohydrates
  • Limited storage capacity, needed for CNS
    (glucose) function
  • Yields 3.4 kcal/gm
  • Recommended 45-65 total daily calories.
  • 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
  • Recommended 20-30 of total caloric intake
  • Protein
  • Needed to maintain anabolic state (match
  • Yields 4 kcal/gm
  • Must adjust in patients with renal and hepatic
  • Recommended 10-35 of total caloric intake.

Normal Nutrition
  • Requirements
  • HEALTHLY male/female
  • (weight maintenance)
  • Caloric intake25-30 kcal/kg/day
  • Protein intake0.8-1gm/kg/day (max150gm/day)
  • Fluid intake 30 ml/kg/day

  • Requirements

Special considerations
  • Stress
  • Injury or disease
  • Surgery
  • Pre-hospital/pre-surgical nutrition
  • Nutrition history

  • The surgical patient . . . .
  • Increased risk of malnutrition due to
  • Inadequate nutritional intake
  • Metabolic response
  • Nutrient losses
  • Protein /energy store depletion
  • Diminished nutrient intake
  • Prevalence of GI obstruction, anorexia,
  • Extraordinary stressors (surgical
    stress,hypovolemia, bacteremia, medications)
  • Wound healing
  • Anabolic state, appropriate vitamins
  • Poor nutritionpoor outcomes
  • 33 mortality rate associated with weight loss
    greater than 20

HEALTHLY 70 kg MALE Caloric intake 25-30
kcal/kg/day Protein intake 0.8-1gm/kg/day
(max150gm/day) Fluid intake 30 ml/kg/day
SURGERY PATIENT Caloric intake Mild stress,
inpatient 25-30 kcal/kg/day Moderate stress,
ICU patient 30-35 kcal/kg/day Severe stress,
burn patient 30-40 kcal/kg/day Protein
intake 1-2 gm/kg/day Fluid intake INDIVIDUALIZED
Serum Nutrition Markers
  • Albumin
  • Synthesized in and catabolized by the liver
  • Pro often ranked as the strongest predictor of
    surgical outcomes- inverse relationship between
    postoperative morbidity and mortality compared
    with preoperative serum albumin levels
  • Con lack of specificity due to long half-life
    (approximately 20 days). Not accurate in pts
    with liver disease or during inflammatory
  • Normal range 3.5-5 g/dL.

serum markers (contd)
  • Prealbumin (transthyretin) - transport protein
    for thyroid hormone, synthesized by the liver and
    partly catabolized by the kidneys.
  • Pro Shorter half life (two to three days) making
    it a more favorable marker of acute change in
    nutritional status. A baseline prealbumin is
    useful as part of the initial nutritional
    assessment if routine monitoring is planned.
  • Cons More expensive than albumin. Levels may be
    increased in the setting of renal dysfunction,
    corticosteroid therapy, or dehydration, whereas
    physiological stress, infection, liver
    dysfunction, and over-hydration can decrease
    prealbumin levels.
  • Normal range16 to 40 mg/dL values of lt16 mg/dL
    are associated with malnutrition.

Other measures of protein status
  • Nitrogen balance measures net changes in body
    protein mass
  • Protein 16 nitrogen
  • Protein intake (gm)/6.25 - (UUN 4) balance in
  • Positive value found during periods of growth,
    tissue repair or pregnancy. This means that the
    intake of nitrogen into the body is greater than
    the loss of nitrogen from the body, so there is
    an increase in the total body pool of protein.
  • Negative value can be associated with burns,
    fevers, wasting diseases and other serious
    injuries and during periods of fasting. This
    means that the amount of nitrogen excreted from
    the body is greater than the amount of nitrogen
    ingested. Often seen following major surgery-
    person likely will require extra protein for
    tissue building.
  • Healthy Humans Nitrogen Equilibrium
  • Complex determination of balance, measures of
    losses difficult and limited utility in clinical

Postoperative Nutritional Care
  • Traditional Method Diet advancement
  • Introduction of solid food depends on the
    condition of the GI tract.
  • Oral feeding delayed for 24-48 hours after
  • Wait for return of bowel sounds or passage of
  • Start clear liquids when signs of bowel function
  • Rationale
  • Clear liquid diets supply fluid and electrolytes
    that require minimal digestion and little
    stimulation of the GI tract
  • Clear liquids are intended for short-term use due
    to inadequacy

Things to Consider
  • For liquid diets, patients must have adequate
    swallowing functions
  • Even patients with mild dysphagia often require
    thickened liquids.
  • Must be specific in writing liquid diet orders
    for patients with dysphagia
  • There is no physiological reason for solid foods
    not to be introduced as soon as the GI tract is
    functioning and a few liquids are being
    tolerated. Multiple studies show patients can be
    fed a regular solid-food diet after surgery
    without initiation of liquid diets.

Diet Advancement
  • Advance diet to full liquids followed by solid
    foods, depending on patients tolerance.
  • Consider the patients disease state and any
    complications that may have come about since
  • Ex steroid-induced diabetes in a post-kidney
    transplant patient.

Patients who cannot eat . . . ?
Consider Nutrition Support!
Nutrition Support
  • Length of time a patient can remain NPO after
    surgery without complications is uknown, however
    depends on
  • Severity of operative stress
  • Patients preexisting nutritional status
  • Nature and severity of illness
  • Two types of nutritional support
  • Enteral
  • Parenteral

What is enteral nutrition?
  • Enteral Nutrition
  • Also called "tube feeding," enteral nutrition is
    a liquid mixture of all the needed nutrients.
  • Consistency is sometimes similar to a milkshake.
  • It is given through a tube in the stomach or
    small intestine.
  • If oral feeding is not possible, or an extended
    NPO period is anticipated, an access devise for
    enteral feeding should be inserted at the time of

Indications for Enteral Nutrition
  • Malnourished patient expected to be unable to eat
    adequately for gt 5-7 days
  • Adequately nourished patient expected to be
    unable to eat gt 7-9 days
  • Adaptive phase of short bowel syndrome
  • Following severe trauma or burns

Contraindications to Enteral Nutrition Support
  • Malnourished patient expected to eat within 5-7
  • Severe acute pancreatitis
  • High output enteric fistula distal to feeding
  • Inability to gain access
  • Intractable vomiting or diarrhea
  • Aggressive therapy not warranted
  • Expected need less than 5-7 days if malnourished
    or 7-9 days if normally nourished

Enteral Access Devices
  • Nasogastric/nasoenteric
  • Nasoduodenal, Nasojejunal
  • Gastrostomy
  • PEG (percutaneous endoscopic gastrostomy)
  • Surgical or open gastrostomy
  • Jejunostomy
  • PEJ (percutaneous endoscopic jejunostomy)
  • Surgical or open jejunostomy
  • Transgastric Jejunostomy
  • PEG-J (percutaneous endoscopic gastro-jejunostomy)
  • Surgical or open gastro-jejunostomy

Feeding Tube Selection
  • Can the patient be fed into the stomach, or is
    small bowel access required?
  • How long will the patient need tube feedings?

Gastric vs. Small Bowel Access
  • If the stomach empties, use it.
  • Indications to consider small bowel access
  • Gastroparesis / gastric ileus
  • Recent abdominal surgery
  • Sepsis
  • Significant gastroesophageal reflux
  • Pancreatitis
  • Aspiration
  • Ileus
  • Proximal enteric fistula or obstruction

Short-Term vs. Long-Term Tube Feeding Access
  • No standard of care for cut-off time between
    short-term and long-term access
  • If the patient is expected to require nutrition
    support longer than 6-8 weeks, long-term access
    should be considered
  • NG tubes have been used successfully for long
    term enteral nutrition.
  • -Not deal for long term feeding due to risk of
    non-elective extubation, tube misplacement, and
    ccasional need to check position of the tube
    by x ray

Choosing Appropriate Formulas
  • Categories of enteral formulas
  • Polymeric
  • Whole protein nitrogen source, for use in
    patients with normal or near normal GI function
  • Monomeric or elemental
  • Predigested nutrients most have a low fat
    content or high of MCT for use in patients
    with severely impaired GI function
  • Disease specific
  • Formulas designed for feeding patients with
    specific disease states
  • Formulas are available for respiratory disease,
    diabetes, renal failure, hepatic failure, and
    immune compromise
  • well-designed clinical trials may or may
    not be available

Tulane Enteral Nutrition Product Formulary
Enteral Nutrition Prescription Guidelines
  • Gastric feeding
  • Continuous feeding
  • Start at rate 30 mL/hour
  • Advance in increments of 20 mL q 8 hours to goal
  • Check gastric residuals q 4 hours
  • Bolus feeding
  • Start with 120 mL bolus
  • Increase by 60 mL q bolus to goal volume
  • Typical bolus frequency every 3-8 hours
  • Small bowel feeding
  • Continuous feeding only do not bolus due to risk
    of dumping syndrome
  • Start at rate 20 mL/hour
  • Advance in increments of 20 mL q 8 hours to goal
  • Do not check gastric residuals

Aspiration Precautions
  • To prevent aspiration of tube feeding, keep HOB gt
    30 at all times
  • Use of blue dye to test for aspiration is
    controversial and has been discontinued in
    practice. (FDA Public Health Advisory 2003)
  • Lacks sensitivity
  • Falsely positive reading on guaiac tests
  • Several adverse events reported including ,
    including gastric bacterial colonization and
    diarrhea, systemic dye absorption, and death
    (especially in septic patients)

Complications of Enteral Nutrition Support
  • Issues with access, administration, GI
    complications, metabolic complications. These
  • Nausea, vomitting, diarrhea, delayed gastric
    emptying, malabsorption, refeeding syndrome,
    hyponatremia, microbial contamination, tube
    obstruction, leakage from ostomy/stoma site,
    micronutrient deficiencies (if patient not at

Enteral Nutrition Case Study
  • 78-year-old woman admitted with new CVA
  • Significant aspiration detected on bedside
    swallow evaluation and confirmed with modified
    barium swallow study speech language pathologist
    recommended strict NPO with alternate means of
  • PEG placed for long-term feeding access
  • Plan of care is to stabilize the patient and
    transfer her to a long-term care facility for

Enteral Nutrition Case Study (continued)
  • Height 54 IBW 120 /- 10
  • Weight 130 / 59kg 100 IBW
  • BMI 22
  • Usual weight 130 no weight change
  • Estimated needs
  • 1475-1770 kcal (25-30 kcal/kg)
  • 59-71g protein (1-1.2 g/kg)
  • 1770 mL fluid (30 mL/kg)

Steps to determine the Enteral Nutrition
  1. Estimate energy, protein, and fluid needs
  2. Select most appropriate enteral formula
  3. Determine continuous vs. bolus feeding
  4. Determine goal rate to meet estimated needs
  5. Write/recommend the enteral nutrition prescription

Enteral Nutrition Prescription
  • Tube feeding via PEG with full strength
  • Jevity 1.2
  • Initiate at 30 mL/hour, advance by 20 mL q 8
    hours to goal
  • Goal rate 55 mL/hour continuous infusion
  • Above goal will provide 1584 kcal, 73g protein,
    1069 mL free H2O
  • Give additional free H2O 175 mL QID to meet
    hydration needs and keep tube patent
  • Check gastric residuals q 4 hours hold feeds for
    residual gt 200 mL
  • Keep HOB gt 30 at all times

What is parenteral nutrition?
  • Parenteral Nutrition
  • also called "total parenteral nutrition," "TPN,"
    or "hyperalimentation."
  • It is a special liquid mixture given into the
    blood via a catheter in a vein.
  • The mixture contains all the protein,
    carbohydrates, fat, vitamins, minerals, and other
    nutrients needed.

Indications for Parenteral Nutrition Support
  • Malnourished patient expected to be unable to eat
    gt 5-7 days AND enteral nutrition is
  • Patient failed enteral nutrition trial with
    appropriate tube placement (post-pyloric)
  • Enteral nutrition is contraindicated or severe GI
    dysfunction is present
  • Paralytic ileus, mesenteric ischemia, small bowel
    obstruction, enteric fistula distal to enteral
    access sites

  • TPN (total parenteral nutrition)
  • High glucose concentration (15-25 final
    dextrose concentration)
  • Provides a hyperosmolar formulation (1300-1800
  • Must be delivered into a large-diameter vein
  • PPN (peripheral parenteral nutrition)
  • Similar nutrient components as TPN, but lower
    concentration (5-10 final dextrose
  • Osmolarity lt 900 mOsm/L (maximum tolerated by a
    peripheral vein)
  • May be delivered into a peripheral vein
  • Because of lower concentration, large fluid
    volumes are needed to provide a comparable
    calorie and protein dose as TPN
  • Often used in conjunction with other nutrition
    therapy and for short period of time.

Parenteral Access Devices
  • Peripheral venous access
  • Catheter placed percutaneously into a peripheral
  • Central venous access (catheter tip in SVC)
  • Percutaneous jugular, femoral, or subclavian
  • Implanted ports (surgically placed)
  • PICC (peripherally inserted central catheter)

Writing TPN prescriptions
  • Determine total volume of formulation based on
    individual patient fluid needs
  • Determine amino acid (protein) content
  • Adequate to meet patients estimated needs
  • Determine dextrose (carbohydrate) content
  • 70-80 of non-protein calories or 45-65 total
  • Determine lipid (fat) content
  • 20-30 non-protein calories
  • Determine electrolyte needs
  • Determine acid/base status
  • Check to make sure desired formulation will fit
    in the total volume indicated

Tulane Daily Parenteral Nutrition Order Form
Parenteral Nutrition Monitoring
  • Check daily electrolytes and adjust TPN/PPN
    electrolyte additives accordingly
  • Check accu-check glucose q 6 hours (regular
    insulin may be added to TPN/PPN bag for glucose
    control as needed)
  • Non-diabetics or NIDDM start with half of the
    previous days sliding scale insulin requirement
    in TPN/PPN bag and increase daily in the same
    manner until target glucose is reached
  • IDDM start with 0.1 units regular insulin per
    gram of dextrose in TPN/PPN, then increase daily
    by half of the previous days sliding scale
    insulin requirement
  • Check triglyceride level within 24 hours of
    starting TPN/PPN
  • If TG gt250-400 mg/dL, lipid infusion should be
    significantly reduced or discontinued
  • Consider adding carnitine 1 gram daily to TPN/PPN
    to improve lipid metabolism
  • 100 grams fat per week is needed to prevent
    essential fatty acid deficiency

Parenteral Nutrition Monitoring (continued)
  • Check LFTs weekly
  • If LFTs significantly elevated as a result of
    TPN, then minimize lipids to lt 1 g/kd/day and
    cycle TPN/PPN over 12 hours to rest the liver
  • If Bilirubin gt 5-10 mg/dL due to hepatic
    dysfunction, then discontinue trace elements due
    to potential for toxicity of manganese and copper
  • Check pre-albumin weekly
  • Adjust amino acid content of TPN/PPN to reach
    normal pre-albumin 18-35 mg/dL
  • Adequate amino acids provided when there is an
    increase in pre-albumin of 1 mg/dL per day

Parenteral Nutrition Monitoring(continued)
  • Acid/base balance
  • Adjust TPN/PPN anion concentration to maintain
    proper acid/base balance
  • Increase/decrease chloride content as needed
  • Since bicarbonate is unstable in TPN/PPN
    preparations, the precursoracetateis used
    adjust acetate content as needed

Complications of Parenteral Nutrition
  • Hepatic steatosis
  • May occur within 1-2 weeks after starting PN
  • May be associated with fatty liver infiltration
  • Usually is benign, transient, and reversible in
    patients on short-term PN and typically resolves
    in 10-15 days
  • Limiting fat content of PN and cycling PN over 12
    hours is needed to control steatosis in long-term
    PN patients

Complications of Parenteral Nutrition Support
  • Cholestasis
  • May occur 2-6 weeks after starting PN
  • Indicated by progressive increase in TBili and an
    elevated serum alkaline phosphatase
  • Occurs because there are no intestinal nutrients
    to stimulate hepatic bile flow
  • Trophic enteral feeding to stimulate the
    gallbladder can be helpful in reducing/preventing
  • Gastrointestinal atrophy
  • Lack of enteral stimulation is associated with
    villus hypoplasia, colonic mucosal atrophy,
    decreased gastric function, impaired GI immunity,
    bacterial overgrowth, and bacterial translocation
  • Trophic enteral feeding to minimize/prevent GI

Parenteral Nutrition Case Study
  • 55-year-old male admitted with small bowel
  • History of complicated cholecystecomy 1 month
    ago. Since then patient has had poor appetite
    and 20-pound weight loss
  • Patient has been NPO for 3 days since admit
  • Right subclavian central line was placed and plan
    noted to start TPN since patient is expected to
    be NPO for at least 1-2 weeks

Parenteral Nutrition Case Study(continued)
  • Height 60 IBW 178 /- 10
  • Weight 155 / 70kg 87 IBW
  • BMI 21
  • Usual wt 175 11 wt loss x 1 mo.
  • Estimated needs
  • 2100-2450 kcal (30-35 kcal/kg)
  • 84-98g protein (1.2-1.4 g/kg)
  • 2100-2450 mL fluid (30-35 mL/kg)

Parenteral Nutrition Prescription
  • TPN via right-SC line
  • 2 L total volume x 24 hours
  • Amino acid 4.5 (or 45 g/liter)
  • Dextrose 17.5 (or 175 g/liter)
  • Lipid 20 285 mL over 24 hours
  • Above will provide 2120 kcal, 90g protein,
    glucose infusion rate 3.5 mg/kg/minute, lipid 0.9

Parenteral Nutrition Prescription
  • Important items to consider
  • Glucose infusion rate should be lt 5 mg/kg/minute
    (maximum tolerated by the liver) to prevent
    hepatic steatosis
  • Lipid infusion should be lt 0.1 g/kg/hour
    (ideally lt 0.4 g/kg/day to minimize/prevent
    TPN-induced liver dysfunction)
  • Initiate TPN at ½ of goal rate/concentration and
    gradually increase to goal over 2-3 days to
    optimize serum glucose control

Benefits of Enteral Nutritionover parenteral
  • Cost
  • Tube feeding cost 10-20 per day
  • TPN cost 100 or more per day!
  • Maintains integrity of the gut
  • Tube feeding preserves intestinal function it is
    more physiologic
  • TPN may be associated with gut atrophy
  • Less infection
  • Tube feedingvery small risk of infection and may
    prevent bacterial translocation across the gut
  • TPNhigh risk/incidence of infection and sepsis

TPN research/controversy
  • Lipid source often cited for being
    pro-inflammatory and causing impaired immune
  • No safeguards developed against TPN complications
  • Lipid source alteration may improve outcomes ex
    replacing LCT (soybean oil derivative) with
    monounsaturated fatty acids (olive oil, fish
    oil), MCT (coconut oil) or MCT/LCT mix
  • Not yet available in U.S. (omegaven)
  • Studies show mixed evidence of efficacy. Some
    show reduced mortality and antibiotic use with
    omega 3 fat source.

Transitional Feedings
  • Parenteral to enteral feedings
  • Introduce a minimal amount of enteral feeding at
    a low rate (30-40 ml/hr) to establish tolerance.
  • Decrease PN level slowly to keep nutrient levels
    at same prescribed amount
  • As enteral rate is increased by 25-30 ml/hr
    increments every 8-24 hrs, parenteral can be
  • Discontinue PN solution if 75 of nutrient needs
    met by enteral route.
  • Parenteral/Enteral to oral feedings
  • Ideally accomplished by monitoring oral intake
    and concomitantly decreasing rate of nutrition
    support until 75 of needs are met.
  • Oral supplements are useful if needs not met 100
    by diet. Ex (Nepro, Glucerna, Boost, Ensure).

Refeeding Syndrome
  • the metabolic and physiologic consequences of
    depletion, repletion, compartmental shifts, and
    interrelationships of phosphorus, potassium, and
  • Severe drop in serum electrolyte levels resulting
    from intracellular electrolyte movement when
    energy is provided after a period of starvation
    (usually gt 7-10 days)
  • Physiologic and metabolic sequelae may include
  • EKG changes, hypotension, arrhythmia, cardiac
  • Weakness, paralysis
  • Respiratory depression
  • Ketoacidosis / metabolic acidosis

Refeeding Syndrome(continued)
  • Prevention and Therapy
  • Correct electrolyte abnormalities before starting
    nutrition support
  • Continue to monitor serum electrolytes after
    nutrition support begins and replete aggressively
  • Initiate nutrition support at low
    rate/concentration ( 50 of estimated needs) and
    advance to goal slowly in patients who are at
    high risk

Consequences of Over-feeding
  • Risks associated with over-feeding
  • Hyperglycemia
  • Hepatic dysfunction from fatty infiltration
  • Respiratory acidosis from increased CO2
  • Difficulty weaning from the ventilator
  • Risks associated with under-feeding
  • Depressed ventilatory drive
  • Decreased respiratory muscle function
  • Impaired immune function
  • Increased infection

  • Contact Information
  • Carli Schwartz, RD/LDN
  • Dietitian, Tulane Abdominal Transplant Institute
  • (504) 988-1176

  • References
  • American Society for Parenteral and Enteral
    Nutrition. The Science and Practice of Nutrition
    Support. 2001.
  • Han-Geurts, I.J, Jeekel,J.,Tilanus H.W,
    Brouwer,K.J., Randomized clinical trial of
    patient-controlled versus fixed regimen feeding
    after elective abdominal surgery. British Journal
    of Surgery. 2001, Dec88(12)1578-82
  • Jeffery K.M., Harkins B., Cresci, G.A.,
    Marindale, R.G., The clear liquid diet is no
    longer a necessity in the routine postoperative
    management of surgical patients. American Journal
    of Surgery.1996 Mar 62(3)167-70
  • Reissman.P., Teoh, T.A., Cohen S.M., Weiss, E.G.,
    Nogueras, J.J., Wexner, S.D. Is early oral
    feeding safe after elective colorectal surgery? A
    prospective randomized trial. Annals of Surgery.
    1995 July222(1)73-7.
  • Ross, R. Micronutrient recommendations for wound
    healing. Support Line. 2004(4) 4.
  • Krauses Food, Nutrition Diet Therapy, 11th Ed.
    Mahan, K., Stump, S. Saunders, 2004.
  • American Society for Parenteral and Enteral
    Nutrition. The Science and Practice of Nutrition
    Support. 2001.
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