1. NUTRITION IN SURGICAL
PATIENTS
ENTERAL VIS A VIS PARENTERAL
NUTRITION
DR.BARUN KUMAR
UNIT IIA, GENERAL SURGERY

2. AT A GLANCE
• Basic principles guiding nutrition in
surgical patients
• Enteral nutrition
• Parenteral nutrition
• Immuno nutrition

3. GOAL OF NUTRITIONAL SUPPORT
• PREVENT OR REVERSE THE CATABOLIC
EFFEECT OF DISEASE OR INJURY
• TO MEET THE ENERGY REQUIREMENTS OF
METABOLIC PROCESS
• TO MAINTAIN A NORMAL CORE BODY
TEMPERATURE
• TO PROVIDE SUBSTRATES FOR ADEQUATE
TISSUE REPAIR

4. ESTIMATION OF ENERGY REQUIREMENT
• ASSESSMENT OF PRE SURGERY NUTRITIONAL
STATUS-
A] HISTORY, PHYSICAL EXAMINATION, BODY
WEIGHT, BMI
B] BIOCHEMICAL TESTS: CREATININE
EXCRETION, ALBUMIN , TOTAL COUNT, SERUM
TRANSFERRIN

5. EVALUATING CALORIC REQUIREMENT:
Calculating resting Energy Expenditure (REE)
• Harris-Benedict Equation
– Variables
gender, weight (kg), height (cm), age (years)
Men:
66.47 + (13.75 x weight) + (5 x height) – (6.76 x age)
Women:
65.51 + (9.56 x weight) + (1.85 x height) – (4.67 x age)
Calorie requirement = BEE x Activity factor x Stress
factor

6. EVALUATING CALORIC REQUIREMENT:
• INDIRECT CALORIMETRY:
REE (kcal/day)= 1.44(3.9 Vo2 (ml/min) + 1.1
Vco2 )
• DUAL ENERGY X-RAY ABSORPTIOMETRY:
measure lean body mass, fat mass, bone
density

7. Electrolyte requirements
• Na+ : 100-120 meq/day
• K+ : 80 – 120 meq/day
• Mg+ : 12 – 15 mmol/day
• Ca+ : around 5 mg/day
• Phosphorus : 14 – 16 mmol/day

8. Micro Nutrients
Agent Requirement/day
Iron 0 – 2 mg
Zinc 1 – 15 g
Copper 1 -5 g
Chromium 10 – 20 g
Selenium 20 – 100 g
Manganese 150 -800 mg
Vit E 10 – 50 IU
Vit A 2500 IU
Vit C 300 – 500 mg
Vit D 250 IU
Agent Requirement/day
Vit K 10 mg/week
Thiamine 50 – 250 mg
Riboflavin 5 mg
Niacin 50 mg
Pantothenate 15 mg
Pyridoxine 5 mg
Folic acid 600 g
BIZ 12g
Biotin 60g

9. PRINCIPLES GUIDING NUTRITION
• Use the oral route if the GI tract is fully functional
and there are no other contraindications to oral
feeding.
• Initiate nutrition via the enteral route if the patient is
not expected to be on a full oral diet within 7 days
post surgery and there are no GI tract
contraindications
• If the enteral route is contraindicated or not
tolerated, use the parenteral route within 24 to 48
hours in patients who are not expected to be able to
tolerate full enteral nutrition (EN) within 7 days.

10. • Administer at least 20% of the caloric and
protein requirements enterally while reaching
the required goal with additional PN.
• Maintain PN until the patient is able to
tolerate 75% of calories through the enteral
route and EN until the patient is able to
tolerate 75% of calories via the oral route

11. Contraindications to Enteral Nutrition
Intractable vomiting, diarrhea refractory to medical management
Paralytic ileus
Distal high-output intestinal fistulas (too distal to bypass with
feeding tube)
GI obstruction, ischemia
Diffuse peritonitis
Severe shock or hemodynamically instability
Severe GI hemorrhage
Severe short bowel syndrome (less than 100 cm of small bowel
remaining)
Severe GI malabsorption (e.g., enteral nutrition failed, as
evidenced by progressive deterioration in nutritional status)
Inability to gain access to GI tract
Need is expected for <7 days

13. ENTERAL NUTRITION
• ROUTES OF
ADMINISTRATION :
1. NASOGASTRIC
2. NASODUODENAL
3. NASOJEJUNAL
4. GASTROSTOMY-
percutaneous,
endoscopic, radiologic
5. JEJUNOSTOMY-
percutaneous,
endoscopic, radiologic

14.  PATIENT MUST BE HEMODYNAMICALLY STABLE BEFORE STARTING
ENETERAL NUTRITION
THE CONTRAINDICATIONS OF ENTERAL NUTRITION AS STATED
EARLIER MUST BE RULED OUT.
THE CHOICE OF ROUTE MUST BE MADE, THE LEAST INVASIVE
ONES ARE PREFFERED
NASOENTERIC:
PATIENTS WITH INTACT MENTATION AND PROTECTIVE LARYNGEAL
REFLEXES
HEAD END OF THE BED RAISED TO 35 DEGREES
RESIDUAL VOLUMES SHOULD BE CHECKED 1 HOUR AFTER MEAL
AND IT SHOULD NOT EXCEED 50ML/HR
SIGNS OF INTOLERANCE SHOULD BE MONITORED AND RATE AND
OSMOLARITY ADJUSTED ACCORDINGLY.

15. ENTERAL NUTRITION
Gastric feeding Jejunal feeding
Solution used
Hypertonic or
isotonic
Isotonic
Infusion rate
Bolus or
continuous
Continuous
Initiation of
infusion
25-30mL/hr
Increments 25-30 mL/hr daily
Intolerance Vomiting
Distention, diarrhea,
colic, reflux to NGT

16. Enteral formulas:
1. Low residue isotonic formulas:
• Calorie density of 1 kcal/ml
• Non protein-calorie:nitrogen ratio =150:1
• No fibre, no bulk, no residue
• Cheap, first line for stable gi tract
2.Isotonic formula with fibre :
• Soluble and insoluble fibre
• Stimulate pancreatic lipase activity
• Degradation into short chain fatty acids

17. Enteral formulas: (cont)
3. Immune enhancing formulas:
Glutamine, arginine, omega-3 fatty acids, nucleotides, beta
carotene
4. Calorie dense formula: 2kcal/ml
5.High protein formula
6.Elemental formula:
• predigested nutrients,
• Adv: ease of absorption in gut impairment, pancreatitis,
• Disadv: poor in fat, vitamin, trace elements
• High osmolarity, high cost
7. Special formulas: renal/pulmonary/hepatic failure
patients

18. Advantages of enteral nutrition
• Provides the advantage of trophic feeding
• Maintain structural and functional support of
intestinal mucosa by providing glutamine,
preserving blood supply and promoting
peristalsis
• Maintain integrity of int mucosa- prevents
bacterial translocation
• Cheap, easy to administer, safe.

19. PARAMETER ACUTE PATIENT STABLE PATIENT
Electrolytes Daily 1-2×/week
Complete blood count Daily 1-2×/week
Glucose level
3×/day; more often if poor
control
3×/day; less often if good
control
Creatinine and urea levels Daily Weekly or twice weekly
Nitrogen balance Daily 2-3×/week
Input and output Daily 2-3×/week
Body weight Daily 2-3×/week
Urine output Hourly every 4 hours
Stool Per motion Daily
Monitoring schedule for enteral feeding

20. Complications :
• Local problems: epistaxis, sinustis, nasal necrosis
• Mechanical problems: tube malpositioning,
dislodgement
• Gastroparesis: vomiting, aspiration
• REFEEDING SYNDROME:
after prolonged fasting period
leads to sudden rise in insulin and electrolyte
abnormailities resp, hepatic and renal
dysfunction
rate of feeding should be slow at starting

21. •Solute overload:
Diarrhoea, dehydration, electrolyte
disturbance, hyperglycemia,
Loss of trace elements
In severe cases, pneumatosis intestinalis
with bowel necrosis and perforation

22. PROBLEM COMMON CAUSES MANAGEMENT
Diarrhea
Medications (e.g., antibiotics,
H2blockers, laxatives, hyperosmotic,
hypertonic solutions), feeding
intolerance (osmolarity, fat),
acquired lactase deficiency
1.Measure stool output.
2.Rule out infection
(bacterial, viral, parasitic).
3.Supply fibre.
4.Change medication or
formula.
5.Check osmolarity and
infusion rate.
6.Administer antimotility
medications (e.g.,
loperamide, codeine).
Nausea and
vomiting
Delayed stomach emptying,
constipation, abdominal distention,
odor and appearance of
formulations
1.Administer feedings at
room temperature.
2.Use isotonic formulations.
3.Use a closed system when
possible.
4.Reduce doses of
narcotics.
5.Use gastroprokinetic
agents (metoclopramide).
6.Monitor gastric residuals
and stool output.

23. Constipation,
fecal impaction
Dehydration, lack or excess of fibre
1.Monitor fluid balance daily.
2.Carry out rectal
disimpaction.
3.Consider the use of
cathartics, stool softeners,
laxatives, or enemas.
Aspiration
pneumonitis
Long-term supine position, delayed
stomach emptying, altered mental
status, malpositioned feeding tube,
vomiting
1.Place head of bed at 45
degrees during feedings.
2.Stop EN if gastric residual
volume exceeds 200 mL.
3.Use nasoduodenal or
nasojejunal tubes in patients
at risk.
Hyponatremia,
overhydration
Excess fluid intake, refeeding syndrome,
organ failure (e.g., liver, heart, kidney)
1.Monitor fluid balance and
body weight daily.
2.Consider fluid restriction.
3.Change formula (avoid low-
sodium intake).
4.Initiate diuretic therapy

24. Hypernatremia
Dehydration, inadequate fluid
intake 1.Increase free water.
Dehydration Diarrhea, inadequate fluid intake 1.Determine cause.
2.Increase fluid intake.
Hyperglycemia
High content of carbohydrate in
feedings, insulin resistance
1.Evaluate and adjust
feeding formula.
2.Consider insulin
regimen.
Hypokalemia,
hypomagnesemia,
hypophosphatemia
Diarrhea, refeeding syndrome
1.Correct electrolyte
abnormalities.
2.Determine cause.
3.Reduce rate if refeeding
syndrome is present and
monitor patient.
Hyperkalemia
Excess potassium intake, renal
impairment
1.Change feeding formula.
2.Reduce potassium
intake.
3.Consider insulin
regimen.

25. TOTAL PARENTERAL NUTRITION
• IV INFUSION OF
NUTRIENTS IN
ELEMENTAL FORM
• THE HIGH COST AND
COMPLICATIONS HAS
LIMITED ITS USE FOR
PATIENTS IN WHICH
CONTRAINDICATIONS TO
ENTERAL FEEDING ARE
PRESENT
• PATIENT MUST BE
HEMODYNAMICALLY
STABLE BEFORE ITS USE

26. CONDITIONS REQUIRING CAREFUL USE OF TPN
CONDITION SUGGESTED CRITERIA
Hyperglycemia Glucose >300 mg/dL
Azotemia BUN >100 mg/dL
Hyperosmolality Serum osmolality >350 mOsm/kg
Hypernatremia Na >150 mEq/L
Hypokalemia K <3 mEq/L
Hyperchloremic metabolic acidosis Cl >115 mEq/L
Hypophosphatemia Phosphorus <2 mg/dL
Hypochloremic metabolic alkalosis Cl <85 mEq/L

27. FORMULATIONS
• 2IN 1 SOLUTION : 60-70% DEXTROSE
10-20% AMINO ACIDS
• 3 IN 1 SOLUTION : IN ADDITION HAS 10-30%
LIPID EMULSIONS
• IN ADDITION – STERILE WATER, ELECTROLYTE,
MINERAL AND VITAMINS

28. CARBOHYDRATE CONTENT
•dextrose
•provide 3.4kcal/kg
•Concentrated hypertonic solutions given via central line
•Contraindications – alcohal withdrawal dehydrated patient,
suspected ntracranial hemorrhage
•Sufficient carbohydrate prevents glycogen breakdown, protein
sparing effect
•Suggested guideline of 25% dextrose at a rate of 7mg/kg/min
LIPID CONTENT
•Dense source of energy 9kcal/gm
•Prevents essential fatty acid deficiency
•Soyabean oil(Omega-6 fatty acids) (linoleic acid) : pro
inflammatory potential
•Fish oil (omega-3 fatty acids) (eicosapentaenoic acid): lacks pro-
inflammatory potential

29. PROTEIN CONTENT:
•RDA = 0.8G/KG/DAY
•20% of total energy requirements must be met by protein
•Fasted surgical patients – 1.5 to 2 gm protein/kg/day
•Severely injured patients – 3g/kg/day
•Nitrogen to calorie ratio (1:150)
•Low protein preparations in renal and hepatic failure
FLUID AND ELECTROLYTES:
•Fluid : 30 to 40ml/ kg
•Sod and pot- 1to 2 mEq/kg
•Calcium- 10 to 15 mEq/kg
•Magnesium- 8 to 20 mEq/kg
•Phosphate- 20 to 40 mmol

30. COMPLICATIONS OF TPN
A.TECHNICAL PROBLEMS:
• Sepsis sec to contamination of the central venous
catheter
earliest sign may be glucose intolerance
Fever without any other septic focus for more than
48 hours removal of catheter and reintroduction
at new site
• Pneumo/hydro/hemothorax
• Cardiac arrhythmias, cardiac tamponade
• Air embolism, thoracic duct injury

31. COMPLICATIONS OF TPN(cont)
B.METABOLIC COMPLICATIONS:
• HYPERGLYCEMIA
• ELECTROLYTE ABNORMALITY
• OVERFEEDING – co2 retention and repiratory
insufficiency, hepatic steatosis,
• Cholestasis and gall stones
• Raised liver enzymes
C.INTESTINAL ATROPHY

32. IMMUNO NUTRITION
• Nutrients affecting the immune system
• Recognised: arginine, glutamine, omega-3
fatty acids, nucleotides
• Potential : vit c and e, selenium copper zinc,
taurine, branched chain amino
acids, n acetyl-cysteine

33. ARGININE
• Semi essential amino acid
• Relative deficiency in metabolic stress
• Metabolic role : a. collagen synthesis
b.secretagouge for insulin, prolactin, growth
harmone
c.nitric oxide donor
• Counteract myeloid suppressor cells alongwith omega-3
fatty acids
• Zeta chain in t cell receptor complex is arginine sensitive
• Evidence based role in patients following burns
• Pro inflammatory role: might be counterproductive in
sepsis
• Dosage : 12gm/1000 calorie

34. GLUTAMINE
• Semi essential amino acid
• Fuel for enterocyte , colonocyte, lymphocyte
• Component of glutathione,
• precursor of nucleotide synthesis, neoglucogenesis
• Synthesis of mucin protecting gut mucosa
• Downregulate toll-like receptor, reduce inflammatory
cytokines
• Proven benefit in post-burn
• Early studies shows beneficial effects in critically ill patients
• Unstable in solution – packed in dipeptide form,
powder/granule form
• Dosage: eneteral- 3.5gm/100 gm of protein
• parenteral- 0.285 to 0.4 g/kg/day

35. OMEGA-3 FATTY ACIDS
• ALPHA-LINOLEIC ACID, EICOSAPENTANOIC ACID,
DOCOSAHEXAENOIC ACID
• As discussed earlier omega-6 FA has pro and omega-3 FA has
anti inflammatory effects
• Anti-inflammatory effects of O3FA
i. Displaces arachadonic acid from memb phospholipids
ii. Inhibits conversion of linoleic to arachdonic acid
iii. Activates peroxisomal receptors
iv. Stabilise nf-kb, suppress pro-inflammatory genes
v. Reduce expression of icam-1 & E-SELECTINS
• Stabilise myocardium, reduce arrhythmia
• Reduced risk of ards

36. NUCLEOTIDES
• Essential for dna and rna synthesis
• Proliferation and normal functioning of
phagocytes
• Protects guts from mucosal atrophy
• Most standard enteral and parenteral
formulas lacks nucleotides

37. TAKE HOME MESSAGE
• The role of nutrition in surgical patients with
increased metabolic demands cannot be over-
emphasized
• A clear understanding of body’s energy, fluid,
electrolytes and micro nutrients is essential
• Whenever the gut is available for use, USE
IT!!!!
• Parenteral nutrition should be reserved for the
patients in whom a clear contraindication to
enteral nutrition is present

38. •Even with parenteral nutrition, 20% of the total energy
requirement should be tried to meet with enteral
nutrition for the trophic effect on gut
•A careful watch for possible complications should be
kept on patients receiving both enteral and parenteral
nutrition
• overfeeding should be avoided for its dangerous
complications in critically ill patients
•The role of immuno nutrients are still under study and
till then, its use can be reserved for the patients in
which proven efficacy has been shown in studies.

39. Thank you