Surgical Nutrition Dr.

Cinio

Different tools for nutrition screening & assessment  8% of BW in 6months

 Nutrition screening  Anthropometric measurements
o Nutrition risk screening 2002 (NRS 2002) o BMI: (wt in kg/ ht (m2))
o Mini nutritional assessment (MNA)  <18.5 implies nutritional impairment
 Nutritional assessment  <15 is associated with significant mortality
o Subjective global assessment BMI
o Physical examination <18.5 Underweight
o Laboratory examination
18.5-24.9 Normal
25.-29.9 Overweight
Nutrition in the Surgical Patient
The goals of nutrition support: 30-34.9 Obese 1
1. To minimize protein breakdown 35-39.9 Obese 2
2. Preserve lean body mass 40+ Obese 3
3. Promote protein synthesis 
4. Optimize immune responses o Unplanned weight loss of >10% over a 6month period
 Good prognostic factor of poor clinical outcome
Physical nutrition
 Assess loss of muscle & adipose tissues, organ dysfunction Nutritional Screeing/Assessment
 Subtle changes in skin, hair, or neuromuscular function reflecting 1. Weight change
frank or impending nutritional deficiency 2. BMI
 Anthropometric data (i.e. weight change, skinfold thickness, arm 3. Anthropometric measurements
circumference muscle area) a. Mid- arm circumference (MAC)
 Biochemical determination (i.e. creatinine secretion, albumin b. Triceps skin fold (TSF) measurement
level, prealbuminlevl, total lymphocyte count, transferrin level) c. Mid- arm muscle circumference
 Appreciation for the stresses & natural history of disease process 4. Immune competence
a. Total lymphocyte count (TLC)
Energy Requirement b. Delayed skin hypersensitivity (DSH)
 Indirect calorimetry- often leads to overstimulation 5. Plasma proteins
 Serum markers- e.g. prealbumin level 6. Nitrogen balance
 Estimated from urinary nitrogen excretion- which is proportional
to resting energy expenditure Who is Severely Malnourished?
 Basal energy expenditure (BEE): examined using the Harris-  Weight loss >10%
Benedict equation  Poor intake for 2weeks or more
o Male BMR = 66.47 + (13.75×wt in kg) + (5×ht in cm) -  BMI <18.5
(6.76×age in yr)  Mid- arm circumference
o Female BMR = 655.1 + (9.56×wt in kg) + (1.85×ht in cm) - o Male <17.6cm
(4.68×age in yr) o Female <17.1cm
 Subjective global assessment: SGA “C”
Vitamins & minerals  Mini-nutritional assessment score: <25
 Patient maintained on elemental diets or parenteral  Albumin on entry <3gm%
hyperalimentation require complete vitamin & mineral  Total lymphocyte count <1500
supplementation
 Enteral diets contain varying amounts of essential minerals & Methods of Nutritional Assessment
vitamins 1. Clinical history
 Most do not contain vitamin K, vitamin B12 or folic acid 2. Body composition analysis
 Essential fatty acid supplementation may be necessary, especially o Bioelectrical impedance
in patients with depletion of adipose stores  Exchange of labeled ions
 Neutron actrivation analysis
Overfeeding o Cross-sectional imaging
 Results from overestimation of calorie needs  MRI
o Actual body wt. is used to calculate the BEE in patients with  CT
significant fluid overload, obesity 3. Indirect calorimetry
o Indirect calorimetry- overestimation BEE by 10 to 15% o Oxygen consumption
o Determination of respiratory quotient
Nutrition Screening/Assessment o Low sensitivity & specificity
 Weight change o Severe burn injury
o [(usual wt- actual wt)/ usual weight] x 100  Direct measurement of Vo2
o Severe:  Very useful in estimating calorie needs
 2% of BW in 1wk  Standard formula such as the Harris-Benedict
 5% of BW in 1month equation- inaccurate
 7.5% of BW in 3months o Metabolic casts
Medical Nutrition Midterms Page 1
Surgical Nutrition Dr. Cinio

 Also determine which fuel is being consumed in a Components of Nutrition Care Plan
clinical setting 1. Nutritional assessment
 RQ 2. Nutritional requirements
 1: indicates pure carbohydrate utilization a. Macro & micronutrients
 0.8: indicates pure protein oxidation b. Fluid requirements
 0.7: pure fat utilization 3. Access: oral, enteral, parenteral, or combinations
 Theoretically, the RQ with lipogenesis can be as high 4. Nutrient formulation
as 9 5. Nutrient delivery
 RQ>1: indicates overfeeding of glucose or fat, or both 6. Monitoring strategies
 RQ<0.7: ketogenesis
4. Anthropometric measurements Nutrition Algorithm
5. Biochemical measurements
o Often inaccurate
o Do not usually give added value when compared w/a
clinical approach to nutritional assessment
o Serum proteins
 Albumin
 Often used as an index of malnutrition
 Concentration of <3.0 g/dL
 Half- life of albumin: 14-18days
 Transferrin
 <200mg/dL, half-life: 7days
 More sensitive indicators of rapid changes in
nutritional status
 Prealbumin
 Half-life: 3-5days
6. Measurement of nitrogen balance
7. Measurement of immunologic function

Estimation of Energy Need

1. Indirect calorimetry
2. IBW
3. Calculation by standard methods: Harris-Benedict equation
 Resting energy expenditure/ basal metabolic rate (BMR) by
Harris-Benedict equation relies on the following formulas:
o Male BMR = 66 + (13.7×wt in kg) + (5×ht in cm) - Routes for Administration of Enteral Feeding
(6.8×age in yr)  Candidates for feeding tube placement
o Female BMR = 65.5 + (9.6×wt in kg) + (1.7×ht in cm) - o Patients with functioning GI tract who cannot achieve
(4.7×age in yr) adequate nutritional intake orally, are malnourished or at
risk for development of malnutrition
Nutritional assessment o Choice of access route & device must be tailored to the
o Process by which changes in body nutritional composition are individual by considering:
estimated, in part to predict risk for surgery  Disease process
o Functional measures of lean body mass  Timing on how long patient will probably require
 Skeletal muscle strength nutritional support
 Respiratory & cardiac performance o Associated with multiple adverse consequences
 Hepatic synthetic function  Tube migration
 Renal status  Esophageal & gastric mucosal erosion
 Immunologic reactivity  Pulmonary aspiration
Laboratory data:  Sinusitis
Test At risk level  Pneumothorax
Serum albumin <3 gm %  Esophageal stricture
 Esophageal perforation
Total lymphocyte count <1500
 Fatal arrhythmias
Serum cholesterol <150 mg/dL
Serum transferrin <140 mg/dL Postpyloric feeding
Serum pre-albumin <17 mg/dL  Nasogastrically fed patients- higher gastric residual volumes
Total iron-binding <250 mcg/dL o Receive amounts of enteral nutrition equivalent to those fed
capacity nasojejunally
 Postoperative trauma patients

Medical Nutrition Midterms Page 2

Surgical Nutrition Dr. Cinio

o Jejunal feeding attained a significantly higher percentage of o Central parenteral nutrition

their daily caloric goal than did patients fed intragastrically
 Specific indications Principles of enteral feeding
o Significant gastroparesis  Stomach: principal defense against enteral osmotic load
o Severe pancreatitis o Bolus of hyperosmotic fluid-gastric motility is
inhibited- gastric secretion proceeds until gastric
Gastrostomy contents are isosmotic-transfer across the pylorus
 Long-term access to stomach  Small bowel: less able to dilute & tolerate large osmotic
 Open approach or by percutaneous feeding loadss
 Stoma gastrostomy- small laparotomy incision o Principal area for nutrient absorption
o Most widely used open technique
 Percutaneous endoscopic gastrostomy (PEG) Principles of Enteral Feeding
o Procedure of choice “if the gut works, use it”
o Less expensive & less morbid  GIT
o Necrosis of gastric wall, attributable to excessive o Digestion, absorption
tension o Protection, synergistic metabolic interaction between
 Percutaneous gastric tube oragans
o Higher incidence of complications & need for open  Immune defense maintained
revision o HCL, mucus, secretory IgA; macrophages, cytotoxic T cells,
o Moribound patients or those requiring gastric peyer’s patches; commensal bacteria
drainage with no attractive operative approach  Early enteral nutrition
(carcinomatosis) o Initiated w/in 24-48 hours following hospitalization, trauma
o Limitation- history of previous upper abdominal or injury
surgery  Parenteral nutrition
o Difficult to aspirate & check gastric residual o Supplement enteral nutrition
volumes o Act as substitute for EN
 Complications of enteral feedings result from solute overload
Jejunostomy  Inappropriately rapid administration of hyperosmolar solutions
 Open jejunostomy may result in:
 Percutaneously by extension through an existing gastrostomy o Diarrhea, dehydration, electrolyte imbalance, hyperglycemia,
tube (often termed as G-J tube) loss of potassium, magnesium, & other ions through diarrhea
 Laparoscopic approach  Administration of hyperosmolar solute continues:
 Percutaneous jejunostomy placed under fluoroscopic or CT pneumatosisintestinalis w/bowel necrosis & perforation
guidance  Hyperosmolar, nonketotic coma can also occur with enteral
o Complications feedings as w/ parenteral nutrition
 Dislodgement
 Occlusion ENTERAL NUTRITION RATIONALE
 Bowel obstruction o Enteral nutrition generally is preferred over parenteral nutrition
 Small bowel ischemia  lower cost
 Small bowel- does not accommodate bolus feeding  associated risks of the intravenous route
o Continuous fashion  luminal nutrient contact reduces intestinal mucosal atrophy
o Sign of intolerance  reduced infectious complications and acute phase protein
 Abdominal distention production
 Abdominal pain or tenderness  normalization of intestinal permeability and barrier function
 Diarrhea  44% reduction in infectious complications
 Constipation o Early gastric feeding after closed-head injury
o Critically ill patient- hypo-osmolar or at most iso-osmolar  Frequently associated w/ underfeeding & calorie
solutions should generally be used deficiency
o Hyper-osmolar solutions- not tolerated in critical illness  Due to difficulties in overcoming gastroparesis & the
because the bowel is stressed to begin with high risk of aspiration
o Initiation of enteral nutrition should occur immediately after
Practical approach to artificial nutrition adequate resuscitation, most readily determined by adequate
 Feed through oral route, if not possible, insert NGT urine output
 Patient able to eat but 50% or less daily requirement o Gastric residuals of 200mL or more in a 4-6hour period or
o Oral supplements abdominal distension requires cessation of feeding & adjustment
o Tube feeding of infusion rate
 Refused tube feeding: parenteral feeding o Enteral feeding should also be offered to patients with short
 NGT, full oral route not achieved in 3-4weeks bowel syndrome or clinical malabsorption, but necessary calories,
o PEG essential minerals, and vitamins should be supplemented using
o Gastrostomy parenteral modalities
 PN> 2weeks o bowel resection
Medical Nutrition Midterms Page 3
Surgical Nutrition Dr. Cinio
o low-output enterocutaneous fistulas of <500 mL/d
Factors that influence the choice of enteral formula:
o extent of organ dysfunction (e.g., renal, pulmonary, hepatic,
or gastrointestinal)
o nutrients needed to restore optional function & healing and
cost of specific products
o most cost-efficient enteral formulary for most commonly
encountered disease categories within the institution
LOW-RESIDUE ISOTONIC FORMULAS
• provide a caloric density of 1.0 kcal/mL, and approximately 1500
to 1800 mL are required to meet daily requirements
o These low-osmolarity compositions provide baseline
carbohydrates, protein, electrolytes, water, fat, and fat-
soluble vitamins
• Do not have vit. K
• contain no fiber bulk and therefore leave minimum residue
• leave a nonprotein-calorie:nitrogen ratio of 150:1
• considered to be the standard or first-line formulas for stable
patients with an intact gastrointestinal tract
ISOTONIC FORMULAS WITH FIBER
• contain soluble and insoluble fiber, which is most often soy based
• Physiologically, fiber-based solutions delay intestinal transit time
and may reduce the incidence of diarrhea compared with
nonfiber solutions
• Fiber stimulates pancreatic lipase activity
• degraded by gut bacteria into short-chain fatty acids, an
important fuel for colonocytes
IMMUNE-ENHANCING FORMULAS
• fortified with special nutrients that are purported to enhance
various aspects of immune or solid organ function
• additives include glutamine, arginine, branched-chain amino
acids, omega-3 fatty acids, nucleotides, and beta carotene
• trials have proposed that one or more of these additives reduce
surgical complications and improved outcome
• The addition of amino acids to these formulas generally doubles
the amount of protein (nitrogen) found in standard formula;
CALORIE-DENSE FORMULAS
• greater caloric value for the same volume
• Most commercial products of this variety provide 1.5 to 2 kcal/mL
• suitable for patients requiring fluid restriction or those unable to
tolerate large-volume infusions
• have higher osmolality than standard formulas and are suitable
for intragastric feedings
HIGH-PROTEIN FORMULAS
• available in isotonic and nonisotonic mixtures
• proposed for critically ill or trauma patients with high protein
requirements
• have nonprotein-calorie:nitrogen ratios between 80:1 and 120:1
ELEMENTAL FORMULAS
• contain predigested nutrients and provide proteins in the form of
small peptides
• Complex carbohydrates are limited, and fat content, in the form
of MCTs and LCTs, is minimal
• primary advantage of such a formula is ease of absorption
Medical Nutrition Midterms
• inherent scarcity of fat, associated vitamins, and trace elements
limits its long-term use as a primary source of nutrients
• Due to its high osmolarity, dilution or slow infusion rates usually
are necessary, particularly in critically ill patients
• These formulas have been used frequently in patients with
malabsorption, gut impairment, and pancreatitis
• Cost is significantly higher than standard formulas
RENAL-FAILURE FORMULAS
• primary benefits of renal formulas are the lower fluid volume and
concentrations of potassium, phosphorus, and magnesium
• exclusively contains essential amino acids and has a high
nonprotein-calorie:nitrogen ratio; however, it does not contain
trace elements or vitamins
PULMONARY-FAILURE FORMULAS
• fat content is usually increased to 50% of the total calories, with a
corresponding reduction in carbohydrate content
• The goal is to reduce carbon dioxide production and alleviate
ventilation burden for failing lungs
HEPATIC-FAILURE FORMULAS
 Close to 50% of the proteins in hepatic-failure formulas are
branched-chain amino acids (e.g., leucine, isoleucine, and valine)
 The goal of such a formula is to reduce aromatic amino acid levels
and increase the levels of branched-chain amino acids, which can
potentially reverse encephalopathy in patients with hepatic
failure
 Protein restriction should be avoided in patients with end-stage
liver disease, because such patients have significant protein
energy malnutrition that predisposed them to additional
morbidity and mortality
Enteral formulas & approach to feeding advancement
 Gastric residual volumes remain <100 to 150mL feeding is
advanced in 10-20mL increments until goal rate is attained
 Feeding is advanced more aggressively
o Gastric residual volumes as high as 250-300mL increase
infusion rates in increments of 20mL every 2-4hrs.
 Small bowel
o Volume is increased first, then osmolality
o Greater than 300-400mOsm not tolerated
Enteral formulas
 Most formulas provide 1kcal/mL
 Higher-caloric formulas (1.5-2cal/mL)- allows smaller volumes
o High density formulas> proportions of fat> protein
 Patients with normal gut function: inexpensive tube feeding
analogous to a blendered meal
 Degree of complexity
o From oligopeptides to individual amino acids
 Carbohydrate source
o Dextrose to complex starches
 Modular diets
o Protein, fat, carbohydrates components can be individually
supplied
PARENTERAL NUTRITION
 Continuous infusion of hyperosmolar carbs, proteins, fats and
other nutrients through a catheter into the SVC
 Optimal > 100-150 kcal/g nitrogens
Page 4
Surgical Nutrition Dr. Cinio

 Higher rates of infection compared to enteral  Indications for PN may be organized into 3 categories, depending
 Studies with parenteral nutrition and complete bowel rest results on desired outcome:
in increased stress hormone and inflammatory responses 1. Primary therapy, in which parenteral nutrition is thought to
 Rationale influence disease process beneficially
o Seriously ill patients with malnutrition, sepsis or 2. Supportive therapy, in which nutritional support is important
surgery/trauma when use of the GI tract for feeding is not but does not alter the primary disease process
possible 3. Controversial indications or those under ongoing study
 Short bowel syndrome after massive resection
 Prolonged paralytic ileus (>7 days) Primary therapy: efficacy shown
 Severe intestinal malabsorption  Gastrointestinal-Cutaneous Fistulas
 Functional GI disorders – esophageal dyskinesia o classic indication for TPN
 Indications 1. increases spontaneous closure of fistulas
o Absolute 2. has not resulted in decreased mortality
 Alimentary tract obstruction 3. has probably contributed to decreased mortality in
 Short bowel syndrome patients with fistulas in most other institutions
 Severe ileus o If spontaneous closure does not occur, patients are in better
 Hyperemesis gravidarum condition for surgery after being supported by TPN
o Relative  Renal Failure
 Enterocutaneous fistula o decreased mortality in patients with acute renal failure
 Partial intestinal obstruction o mixture of essential amino acids w/ hypertonic dextrose,
 Acute pancreatitis largely in patients with surgically related renal failure
o Primary Therapy o decreased appearance of urea, earlier diuresis, and a
o Efficacy shown[*] statistically significant improvement in survival
1. Gastrointestinal cutaneous fistulas o complete amino acid formula and for dealing with the rise in
2. Renal failure (acute tubular necrosis) BUN by dialysis
3. Short-bowel syndrome o use essential amino acids early in an effort to avoid dialysis,
4. Acute burns but once dialysis is required, a complete formulation is used
5. Hepatic failure (acute decompensation superimposed  Short-Bowel Syndrome
on cirrhosis) o Repeated small bowel resections for Crohn's disease
o Efficacy not shown o major enterectomy after mesenteric thrombosis or volvulus
1. Crohn's disease o no alternative to long-term home TPN
2. Anorexia nervosa o Patients receiving home TPN who would otherwise almost
o Supportive Therapy certainly have died commonly survive for 10 to 20 years,
 Efficacy shown[*] even longer
1. Acute radiation enteritis o Some patients - hypertrophy of the remaining small bowel
2. Acute chemotherapy toxicity that the need for home TPN is ultimately decreased or
3. Prolonged ileus obviated
4. Weight loss preliminary to major surgery o If a patient is left with 1.5 ft of small bowel anastomosed to
 Efficacy not shown the left colon, hypertrophy in 1 or 2 years will, in most cases,
1. Before cardiac surgery enable survival without daily parenteral nutritional support
2. Prolonged respiratory support  Burns
3. Large wound losses o Early aggressive nutritional support in patients with major
 Areas Under Intensive Study burns is associated with improved survival
1. Patients with cancer o aggressive enteral feeding within 3hours of burn injury
2. Patients with sepsis o parenteral nutritional support is reserved for those few
patients in whom enteral nutrition cannot meet their caloric
TOTAL PARENTERAL NUTRITION needs
 Central parenteral nutrition (TPN) Primary therapy : efficacy NOT shown
 Requires access to large diameter vein  Inflammatory Bowel Disease
 Dextrose content is high (15-25%) o oral intake - often provokes diarrhea, protein-losing
enteropathy, bleeding, and abdominal pain
PERIPHERAL PARENTERAL NUTRITION o TPN and bowel rest are useful in the treatment of Crohn's
 Lower osmolality disease
 Reduced dextrose (5-10%) o Patients with extensive, severe, and chronically recurrent
 Protein (3%) Crohn's disease are suitable for home hyperalimentation,
 Not appropriate for severe malnutrition due to need for larger particularly when surgical therapy would leave the patient
volumes of some nutrients almost anenteric
 Shorter periods, < 2 wks o Patients with ulcerative colitis should not receive long-term
TPN to induce remission because definitive resection with a
Who benefits from Parenteral Nutrition? sphincter-saving operation (e.g., an ileoanal pouch or Soave
procedure) produces a long-term cure

Medical Nutrition Midterms Page 5

Surgical Nutrition Dr. Cinio

o TPN for usually less than 2 weeks, in conjunction with IV

antibiotics, may allow the rectal mucosa to heal and thus
facilitates rectal mucosal stripping
 Anorexia Nervosa
o starve to a moribund state, with enormous loss of lean body
mass, tissue, and protein
o Anorectic patients are difficult to treat and can be self-
destructive, for example, by disconnecting their IV lines and
thus inviting air embolism

Supportive therapy: Efficacy Shown

 Acute Radiation Enteritis or Chemotherapy Toxicity
o Acute radiation enteritis or GI complications of
chemotherapy, or both, may prevent oral intake
o TPN must be administered until the gut mucosa heals and
clearly enables the patient to survive
o Chronic radiation enteritis with multiple strictures may
render the patient a candidate for home parenteral nutrition
or, rarely, enteral feeding with minimal-residue diets,
provided that the original neoplasm has been cured
 Prolonged Ileus
o TPN until the ileus subsides

Supportive Therapy: efficacy PROBABLY Present

 Weight Loss Preliminary to Major Surgery (Perioperative
Parenteral Nutrition)
Cancer
 evidence suggested that tumor growth is stimulated by such
intervention and that nutritional supplementation of patients
undergoing chemotherapy or radiation therapy (or both) might
decrease survival or the remission-free interval
 The sources of calories supplied in standard feeding regimes may
also be inappropriate in a patient with cancer because glucose
rather than fat may be used preferentially by many tumors
 patients with carcinoma of the esophagus or the gastric
cardiabenefited from perioperative nutritional support and had
decreased mortality and morbidity without apparent stimulation
of the tumor
Cardiac Surgery
• Patients w/ cardiac cachexia are at increased risk for
complications & mortality after cardiac surgery
• Anecdotal clinical evidence suggests that patients with cardiac
cachexia require nutritional supplementation for at least 2 to 3
weeks and perhaps as long as 6 weeks before surgery

Medical Nutrition Midterms Page 6