Surgery I

Surgical Nutrition 1stSemester

Dr. Benedict E. Valencia / September 14, 2021
I. SURGICAL NUTRITION eventually leads to catabolism of carbohydrates,
• Learning objectives lipids and protein
o Discuss nutritional screening and assessment
o Discuss estimation of energy requirements o Inflammatory response
o Describe and discuss the rationale and different The injured tissues release inflammatory
types of enteral nutrition mediators like Cytokines and arachidonic acid
o Discuss the different access for nutritional support metabolism which are catabolic in nature. This
o Discuss the rational, types and initiation of increase catabolic response to injury aims to
parenteral nutrition restore homeostasis and the net effect of this
o Describe and discuss the complications associated metabolism is to provide glucose and amino acid
with nutritional support needed for repair and healing of the wound.
GOAL OF PERIOPERATIVE NUTRITIONAL MANAGEMENT
• The goal of perioperative management is to simply supply
specific requirements to:
o Promote wound healing
o Diminish the wound infection
o Prevent muscle wasting
o To meet the energy requirement for the metabolic
processes and maintain normal core body
temperature
• The goal of nutritional support in the surgical patient is to
• The magnitude of metabolic expenditure over time appears to be
prevent or reverse the catabolic effects of disease or injury
directly proportional to the severity of the insult with thermal injury
and severe infections having the highest energy demands
Surgical points with suboptimal nutritional support • This increase in energy expenditure is mediated by several
This is what happens to patient that has suboptimal nutritional support catabolic hormones but primarily by the Sympathetic Activation
1. Impaired Wound Healing
Estimation of Energy Requirements
2. Altered Immune responses
3. Accelerated Catabolism All patient submitted to the hospital should have their nutritional status
4. Increased Organ Failure assess. Overall, the nutritional assessment is undertaken to determine
5. Delayed recovery/Prolonged Hospitalization the severity of nutrient deficiencies or to predict nutritional requirements.
6. Increased Morbidity and Mortality 1. Clinical History
2. Physical Examination
MAIN STIMULI 3. Biochemical Determination
The two main stimuli that initiates metabolic response are: • These can be used to estimate the energy requirement of the
1. Starvation patient
2. Trauma I. CLINICAL HISTORY
MEATBOLISM AFTER INJURY Pertinent information is obtained by determining the:
The metabolic response in injury is slightly different from the body • Presence of weight loss
response to starvation • Chronic Illnesses (DM, Malignancy)
• Injuries or infections induce unique neuroendocrine and • Dietary Habits that influence the quantity and quality of food intake
immunologic responses that differentiate injury metabolism from • Social habits (alcoholism, stressful life) predisposing to
that of unstressed fasting malnutrition in the use of medications that might influence food
intake or Urination should also be investigated
II. PHYSICAL EXAMINATION
Physical examination seeks to assess loss of muscle and adipose tissues,
organ dysfunction and subtle changes in skin, hair or neuromuscular
function reflecting nutritional deficiency. A simple way of assessing
nutritional deficiency is
1. Body weight loss
Computation:
Weight loss (percentage) is equal to the usual weight minus the present
weight times 100 (percent). For Example:

Injury itself like trauma, surgery and infections are the stimuli that leads
to changes in normal homeostasis leading to responses.
• For example, in starvation:
o Neuroendocrine Response
there is release of catabolic hormones leading to 2. Ideal body weight
glycolysis in adipose tissue, proteolysis in Computation:
muscles and glycogenolysis/gluconeogenesis in Male = 106 lb (for 1st 5ft) and 6 lbs for every inch added
the liver. Female = 100 lb (for 1st 5ft) and 5 lbs for every inch added
All metabolism leads to hyperglycemia to provide Example: Male 5’4” = 106 + (4x6) =130 lbs
energy to work needed for wound healing and to
recover for the injury 3. Body Mass Index (BMI)
o Lactate It uses height and weight to provide an estimate of body far
The blood supply of the wound is relatively poor Computation:
due to injury of its vessels leading to anaerobic BMI= Weight (kg) / Height2 (m2)
producing the lactate than pyruvate that = 77kg / 2.62
= 29 (overweight)

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 Interpretation of BMI
Severe Underweight <16.5 Computed Caloric Requirement
Underweight 16.5 – 18.4
Normal Weight 18.5-24.9 STRESS STRESS FACTOR X BMR/BEE
Overweight 25-29.9 1. Minor and Major 1.1 to 1.2 x BMR/BEE
Obesity Grade I 30-34.9 Elective Surgery
Obesity Grade II 35-39.9 2. Skeletal Trauma and 1.35 to 1.6 x BMR/BEE
Obesity Grade III >40 Head Injury
3. Mild, Moderate and 1.1, 1.5 and 1.95 x BMR/BEE
• The normal BMI of a patient is usually from 18.5 to 24.9 Severe Infection
4. BURN (>40% TBSA) 1.2 to 1.95 x BMR/BEE
III. BIOCHEMICAL DETERMINATION
There are several biochemical tests used for detecting and quantifying Because surgical patients generally play distinct physiologic stresses,
malnutrition. (Albumin level, Creatinine excretion, Total lymphocyte multiplying the basal energy expenditure by stress factor of patient’s
count and transferrin level) injury is generally needed to compute the total energy requirement per
The most useful test is: day.
• Serum Albumin • In this total computed caloric requirement, a burn of more
o Albumin accounts for more than 50% percent for the total than 40 percent of total body surface area which will be
protein in serum, and this is the major contributor to your needing the highest computed calories per day
colloid oncotic pressure • For example, A major surgery called, craniectomy, we would
o Albumin requires significant energy stores for synthesis, be having a stress factor of 1.6 (#2) and the basal energy
and this is inhibited by inflammation and has a long half- expenditure of this patient is 1500kcal per day. You need to
life of approximately 2 days multiply it with 1.6. So, this patient will be needing a total of
o In patient undergoing elective surgery, a preoperative 2400 kcal/day
albumin level has with found to be a better prognostic
indicator than anthropometric measurements for
morbidity and mortality in surgical
o Preoperative albumin less than 3 grams per dL are
independently associated with the increased risk of
developing serious complication within 30 days of surgery
(sepsis, acute renal failure, coma, cardiac arrest,
pneumonia and wound infection) • Simpler way of computing caloric adjustment above the basal
o Albumin levels are also useful in detecting protein in energy expenditure in hypermetabolic condition that bypasses
malnutrition which is frequently difficult to recognize in the Harris-Benedict or the Curreri formula for burn cases
patients not presenting with low body weight and results o In the table, the condition is categorized as normal,
from increased demands associated with the stress in mild to severe stress and each condition has a value
less injury or infection of kcal per kg per day
o Just multiply the value of the stress the patient had
with its weight.
o To avoid overfeeding especially for obese patient,
better use the computed ideal weight based on he’s
actual height kasi kung cocomputin mo yung present
weight baka magoverfeed sa patient kasi malaki
Criteria to Initiate Perioperative Nutritional Support
• Surgical patients with suboptimal nutritional support have
impaired wound healing, altered immune responses,
Evaluation of Caloric Requirements exhilarated catabolism, increased organ dysfunction, delayed
There are two formulas computing for the basal energy expenditure or the recovery and increased morbidity and mortality
resting energy expenditure of a patient • Patients who are inadequately fed after surgery becomes
1. Harris-Benedict Equation critically undernourished within 10days. They have high
In this formula, the weight is in kg but you need to compute first for the increased risk of death
ideal weight so that you will avoid overfeeding in our patient. The height in • As mentioned, the goal of the perioperative nutritional
cm and the age in years are used in the computation for patient’s resting management is to meet the caloric and nutrient specific
energy expenditure. Those who are heavy and taller patients, have higher requirements simply to promote wound healing, diminished
basal requirement but the older patient will be needing lesser resting recent infection and prevent loss of muscle proteins
energy.
• So, any of the following makes a patient in severe nutritional
risk and nutritional support should be started perioperatively
• Perioperatively – meaning the entire course of the patient
while admitted in the hospital
SEVERE NUTRITIONAL RISK EXPECTED IN:
There will be nutritional deficiencies in these patients
1. PMHx- Severe under nutrition, chronic disease
2. Curreri Formula Patient with past medical history of severe under
This is used in computing daily caloric requirements in patients with major nutrition or with underlying chronic Dx
burns. Those patients with more than 40 percent surface area burns. 2. Wt. loss >10-15% w/in 6 months or >5% w/in 1 year
Patient with a weight loss of more than 10-15%
w/in 6 months
3. Expected blood loss of more than >500 mL during the surgery
4. Wt. of 20% under the IBW or BMI of less than <18.5 kg/m2
(undernourished)
5. Failure to thrive on pediatric growth and development curves
(less than the <5th percentile)

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 6. Serum albumin less than <3.0 g/dL or transferrin <200mg/dL • Contraindicated in patients with
in the absence of an inflammatory state, hepatic Paralytic ileus (picture – mabagal galaw
dysfunctional or renal dysfunction ng bituka, hindi naman obstruction),
7. Anticipate that the patient will be unable to meet caloric gastrointestinal obstruction (tumors),
requirements with 7-10 days peri-operatively GIT ischemia (mesenteric ischemia),
8. Catabolic Dx like severe burns or trauma, sepsis and laparotomy
pancreatitis)
ELECTIVE SURGERY in Pts w/ severe nutritional risk should be
postponed after 10-14 days of nutritional support (beneficial)
o Examples of elective surgery: You’re going to
operate on a patient with colon cancer but
preoperatively the Pts is undernourished. You must
delay the surgery and you need to build up the
nutrition, if not it would entail a lot of morbidity.
o Example. An undernourished patient with complete
obstruction in colon (mass) and must have
immediate surgery, what you can do is you can
Contraindication • Severe short bowel syndrome wherein
divert first. You do a two-stage procedure on that there is less than 100 cm of small bowel
patient check mo muna bituka by putting a was only left (multiple traumas, buong
colostomy (ilalabas mo bituka sa tyan), so that you blood supply, bowel namatay na bituka,
can divert the fecal materials and now you build up
so you need to resect, kaya naliit bituka)
the nutrition or established and diagnose and
prepare the patient for the second operation
Patients with significant body weight loss or a pre-morbid
state should receive support immediately (less than <3 days)
after admission. Meaning pagka-admit ng patient,kita m na
agad na undernourished, you can initiate na agad. That would
be one of your preparations for the patient. Sometimes, if it is
not for emergency, you can build the nutrition while not
admitted, you can still initiate their nutritional build up.
Principles Guiding Routes of Nutrition • Severe GI hemorrhage
The best route for nutritional support is Enteral (mouth), which is more • Severe GI malabsorption
physiological, has less complication, and cheaper than Parenteral • Intractable vomiting, diarrhea refractory
nutrition. to medical management
1. Use the oral route if the GI tract is fully functional and there DELIVERY OF EN
are no other contraindications to oral feeding a. Oral Feeding
2. In patients, who do not have any absolute contraindication to o For a conscious patient with intact appetite and has
EN and who are expected to be unable to take adequate swallowing function, direct or oral intake is the prepared
nutrition orally within 24-48 hours, initiate or attempt direct feeding modality
EN as soon as possible. This includes patients who are o The swallowing must be sufficient to avoid food aspiration
physically capable of PO nutrition but fall to take in food orally and the risk of having pneumonia
because of appetite suppression or behavioral challenges o When prescribing oral diet, the physician must
(gumagana ang sikmura pero di makakain sa bibig) continuously monitor the adequate intake for the patient
3. If the enteral route is contraindicated or not tolerated o In the acute surgical setting, the patient may fail to take in
a. Initiate TPN within 24-48 hours in all critically ill or adequate calories because of the decreased appetite. If a
injured patients who are not expected to be able to patient consistently fails to meet the estimated caloric
tolerate significant EN within 48-72 hours (patients na needs with an oral diet, supplemental feeds via NGT
trauma, nadulas, coma) should be considered (not forced feeding, dadagdagan mo
b. Initiate supplemental PN in any critically ill or injured siya)
patient who can tolerate only limited enteral feeding
and who is not expected to tolerate sufficient enteral b. Nasogastric Tube (NGT)
feeds to meet 60%- 80% of projected protein-caloric c. Nasoduodenal Tube
needs within 48-72 hours d. Nasojejunal Tube
4. Administer at least 20% of the caloric and protein There is now a way of checking if the NGT is in place, you
requirements enterally while reaching the required goal with do auscultation over the stomach while quickly delivering a
additional PN (combination EN and PN) 50mL of air with an irrigation syringe. Head is in 45-degree
5. Maintain PN until the patient can tolerate 75% of calories angle. Measure the tube from the tip of the nose up to the
through the enteral route, and maintain EN until the patient is Tragus of the ear insert it going to the xiphoid. After that,
able to tolerate 75% of calories via the oral route (monitor the use your stethoscope to know that you are already inside.
patient kung kelan makakaya na niya mag EN via oral route) NGT tube has a marker with a certain length.
In NGT and Nasojejunal tube, feeding is always checked.
Route of Administration Always check the position of tube prior to feeding and the
1. Enteral Route (EN) patient should be awake. The head should be 90 degrees
2. Parenteral Route (TPN) up. Usually in between meals, it is recommended that the
3. Combination head of the bed will be raised at least 35 degrees to
ENTERAL ROUTE (EN) decrease the risk of aspiration.
e. Percutaneous Endoscopic Gastrostomy Tube
• More physiological because the liver is
Insertion
not bypassed
This is for patient who are expected to require EN
• Lesser cardiac work If long term (more than 4 weeks) you can put this. This tube
Advantages
• Safer and more efficient is under general anesthesia, because the patient is asleep.
• Better tolerated by the patient The Gastrotomy tube is placed under endoscopy guidance.
• More economical Endoscope is passes through the mouth going to the

3|Surgery I DOKKAEBI
 stomach and the surgeon can see the stomach because of
the light through the scope so you can see where to
puncture. A PEG tube will pass through the skin of the
abdomen through a very small incision into the stomach
and a balloon blown up by the end of the tube to secure it
in place

• Fiber based solution that reduces

diarrhea by delaying intestinal transit
time
• This is most beneficial regarding patient
na nag di-diarrhea
• The fiber stimulates a pancreatic lipase
activity and is degraded by the gut
bacteria into short chain fatty acid.
SCFA is an important fuel for
colonocytes.
Isotonic • Recent data have also demonstrated
f. Open Gastrostomy Formulas with the expression of SCFA receptors on
It can either be under general or regional anesthesia. leukocytes suggesting the fiber
Fiber
A midline supraumbilical incision is done, and you look for fermentation by the colonic microbiota
the anterior wall of the stomach, a catheter is inserted, do may indirectly regulate immune cell
a small incision where the tube will be anchored function
g. Open Jejunostomy Tube Feeding • Example: Jevity
This will require laparotomy; an upper midline incision is
also performed. You get a loop of the proximal jejunum
that will easily reach the anterior abdominal wall and you
create an initial first-string suture on the area before you
create a stab on the jejunum then you insert your tube, and
you close that with the first-string suture
• EN after major surgery minimizes the risk
of hypermetabolic response as seen after • The provision of your immune
surgery modulating nutrients term as
• It also maintains the structural and “immunonutrition” is one of the
functional support of the intestinal mucosa mechanisms by which the immune
by providing nutrients like Glutamine, response can be supported and attempt
preserving the blood supply and promotes made to lower infectious risk
peristalsis • Studies have shown that in variety of
Beneficial • Maintaining integrity of intestinal mucosa nutrients including Amino Acids like
effects reduces the risk of sepsis caused by Immune- Glutamine and Arginine; Lipids like
bacterial translocation. Enhancing Omega 3 polysaturated FA and
• Early full nutrition is likely to be harmful micronutrient like Vitamin C and
Formulas
and is associated with a higher infection Selenium can provide support to the
rate immune system
• The aim is a caloric target below the actual • Example: Manapol
energy expenditure with a goal of providing
more than 80% of the estimate total energy
gradually by 3 to 4 days

Enteral Formulas
1.
Low residue isotonic formulas • At present, the best studied of the
2.
Isotonic formulas with fiber immunonutrients are Glutamine,
3.
Immune formulas with fiber Arginine and Omega 3 polysaturated FA
4.
Calorie dense formulas 1. Glutamine – most abundant amino
5.
Elemental formulas acid, a major fuel for enterocytes,
6.
Renal failure formulas a fuel source for immunocytes
7.
Pulmonary failure formulas (lymphocytes and macrophages),
8.
Hepatic failure formulas precursor for Glutathione, a major
• Usually as first-line formulas for stable intracellular antioxidant
patients Immunonutrients
2. Arginine- Immuno enhancing
• Caloric density of 1.0 kcal/ml with 1.5- properties, wound healing benefits
1.5 liter to meet daily requirement and association with improved
Low Residue • It has CHO, CHON, electrolytes, H20 survival in sepsis and injury
fat- and fat-soluble vitamins 3. Omega 3 PUFAs- (canola or fish
Isotonic oil) displaces omega-6 FA in cell
• It has no fiber; hence it leaves minimum
Formulas residue. Prolonged use of this leads to membranes which reduces
constipation proinflammatory response from
• On-protein-calorie: nitrogen ratio of prostaglandin production
150:1 Calorie-Dense • Has a greater caloric value for the same
• Example: Ensure volume (kaunti ang volume pero mataas
Formulas ang calorie)

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 • Provide 1.5 to 2 kcal/mL and therefore • The protein restriction should be
suitable for patients requiring fluid avoided in end stage liver Dx because
restriction or unable to tolerate large these patients have significant protein
volume infusion energy malnutrition
• Has higher osmolality than standard • If the patient has liver dx nagmamanas
formulas na sila kasi mababa ang albumin
• Suitable for intragastric feedings (responsible for oncotic pressure)
• Example: Pentasure kulang sa protein ang patients
• Example: NutriHep

• These are available in isotonic and non-

isotonic mixtures and are for critically ill
or trauma patients with high protein
requirements Monitoring Schedule for Enteral Feeding
• These formulas have non-protein- PARAMETER ACUTE PATIENT STABLE PATIENT
calorie: nitrogen ratios between 80:1
High Protein Electrolytes Daily 1-2x/week
and 120:1
Formulas CBC Daily 1-2x/week
• Example: Ensure Glucose level 3x/day; more often if 3x/day; less often if
poor control good control
Creatinine and Urea Daily Weekly or twice
levels weekly
Nitrogen Balance Daily 2-3x/week
Input and Output Daily 2-3x/week
• Predigested nutrients and provide Body weight Daily 2-3x/week
proteins in the form of small peptides
Urine Output Hourly Every 4 hours
• Small molecules of CHO Stool Per motion Daily
• Fat content in the form of MCTs and
LCTs is minimal
Complications of Enteral Feeding
• Primary advantage is ease of
absorption, but the inherence scarcity • Diarrhea
of fat associated, and elements limits o due to medications like antibiotic, feeding intolerance or
its long-term use as a primary source of sometimes lactate deficiency. Replace the fluid loss as
Elemental nutrients needed. Rule out the possibility of infection as a cause of
Formulas • Used frequently in patients with diarrhea. You may use fiber formulas for patients having
malabsorption, gut impairment and diarrhea
pancreatitis • Nausea and Vomiting
• Relatively expensive o due to delayed stomach emptying or can be secondary to
medications. This can be corrected by using isotonic
• Example: Peptamen
formulation or you can reduce the dosage of narcotics and
use gastroprokinetic agents like Metoclopramide or
Erythromycin.
• Aspiration pneumonia
o can be due to long term supine position of a patient or
• Has lower fluid volume and maybe the patient has delayed stomach emptying. The
concentration of potassium, position of the feeding tube is not in position. It can be
phosphorus and magnesium needed to prevented if you place the head of the patient in 45 degrees
make the daily calorie requirements during feedings. You stop EN if you have a gastric residual
• This type of formulation almost of more than 200 mL
exclusively contains essential AA and
• Hyperglycemia
has a high nonprotein-calorie: nitrogen
ratio o high content of carbohydrate in feedings causes
Renal Failure hyperglycemia. Trauma patients usually have insulin
Formulas • However, these formulas do not contain
resistance called “stress hyperglycemia”. You may
elements and vitamins
consider insulin regimen as part of the management of the
• Example: Renalcal and Renovit
patient
• Hypervolemic and hyponatremia
o due to excess fluid intake and if the patient has organ
failure like the river, kidney and the heart. This can be
corrected with fluid restriction. You may change the
formula and avoid low sodium intake. In hypervolemia you
• 50% of protein are usually branch-chain may initiate diuretic therapy
AA (leucine, isoleucine, and valine) • Other electrolyte imbalance hypo and hyperkalemia,
• To reduce aromatic amino acids and hypomagnesemia and hypophosphatemia could be due to
Hepatic Failure increase the levels of branch -chain diarrhea or excessive intake or most probably this patient have
Formulas amino acids renal failure.
• This can potentially reverse
encephalopathy in patients with hepatic
failure

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 PARENTERAL ROUTE (TPN) peripheral parenteral nutrition is not appropriate for repleting
• PN is infusion of a hyperosmolar solution patients with severe malnutrition.
containing carbohydrates proteins, fat • For supplemental nutritional support is required. Typically, it
and other necessary nutrients through is used for short periods (less than 2 weeks) and beyond this
an indwelling catheter inserted into the time if still needed you must change to TPN
superior vena cava
• To obtain the maximum benefit, the TPN formulations
calorie: protein ratio must be adequate 2-in-1 • Contains 60-70% of dextrose and 10-20%
(at least 100 to 150 kcal/g nitrogen), and Solution of amino acids
both carbohydrates and proteins must • Administered daily
be infused simultaneously in the
solution.
3-in-1 • 10-30% lipid emulsion is added to above
Solution solution.
• The problem of PN is it is associated with
• Given once or 2x a week
higher rate of infectious complications
• PN is also used to supplement
inadequate oral intake (combination EN
Definition Composition of Parenteral Nutrition Formulations
and PN)
• Principal indication are malnutrition,
sepsis, surgical or traumatic injury in
seriously ill patients for whom use of
gastrointestinal tract for feeding is not
possible
• PN can rapidly improve nitrogen balance
which may enhance immune function
and eventually lower the chance of
postoperative or post trauma infection.
• Fundamental goals are to provide
sufficient calories and nitrogen substrate
to promote tissue repair and to maintain
the integrity or growth of lean tissue • Dextrose, Amino Acids, Lipid emulsion with different
mass concentrations
• Patients for whom a specific goal for
patient management is lacking Ordering Parenteral Nutrition
• Patients experiencing cardiovascular • Computation of the number of calories from carbohydrates,
instability or severe metabolic proteins and fat in grams in total parenteral nutrition for 1 2in1
derangement requiring control or and 3in1 solution
correction before the hypertonic
Contraindication intravenous feeding is attempted
• Patients for whom GIT feeding is feasible
• Patient with good nutritional status
• Infants with less than 8cm of small
bowel
• Patients who are irreversibly decerebrate
or otherwise dehumanized
Central hyperalimentation.
• Use a gauge 16, 8-12 inches radio
opaque catheter end at SVC; Check the
position with X/ray • Patient that will undergo major operation have a caloric
o Subclavian vein
Route of TPN adjustment above the basal energy expenditure usually 25-35
o Internal Jugular vein
kcal/kg/day
o Femoral vein
• You need to observe sepsis and 2-IN-1 SOLUTION
antisepsis in placing the catheter.
• The patient can be local anesthesia.

Total Parenteral Nutrition

• Is also referred as Central Parenteral Nutrition
• It requires access to a large diameter vein (Superior Vena
Cava) to deliver entire nutritional requirements of the patient
• Dextrose content of the solution is usually high (15-25%)
• All the other macronutrients and micronutrients are
deliverable by this route

Peripheral Parenteral Nutrition

• Lower osmolality of solution used for peripheral parenteral
nutrition secondary to reduced level of dextrose (5-10%) and
protein (3%) via peripheral veins (pwede na siya sa swero) • For TPN formulated without lipid (2-in-1 solution; in our
• Some nutrients cannot be supplemented because they cannot practice, we recommend lipid infusion at least every 1 to 2
be concentrated into small volume. So therefore, your weeks for most patients to prevent essential FA deficiency.

6|Surgery I DOKKAEBI
 o 2-in-1 only include calories coming from Complication of TPN
carbohydrates and proteins 1. Sepsis complication
• What is the total kilocalories (Normal:25-35kcal/kg/day) of a
70kg man?
• Total kcalories needed per day
o = 30 kcal/kg/day x 70kg
o = 2100 kcal needed per day
• Amount of protein that the patient need (Normal:1.5-2kg/day)
o =1.5kcal/kg/day x 70kg
o =105 g protein needed per day a. Catheter Infection
• Calories from amino acids
• Most lethal complication of TPN
o 105g x 4kcal/g (amino acid) = 420 kcal
• Bacterial/fungal (candida)
• Remaining calories
• The common complication associated with long term
o 2100-420 = 1680 kcal (the amount kcal of
parenteral feeding is sepsis secondary to
carbohydrate needed to complete that 2100 kcal
contamination of the central venous catheter
needed by the patient in a day)
• Site of entry of the organism site of Catheter –
• Then, make up the difference with dextrose
o The Central Line Associate – Blood Stream
o 1680kcal/(3.4kcal/g) = 494g dextrose
Infection (CLA-BSI)
(carbohydrate kcal into grams)
• Symptom:
• Submit this computation to the nutritionist and they will
o Earliest sign is sudden development of glucose
prepare a 2-in-1 solution containing 494 grams of dextrose
intolerance
and 105g of protein and this solution will deliver a total of
o Sudden spike of fever (>38.5 deg Celsius) develops
2100 kcal for the patient. This solution somehow lowers the
without obvious cause
proteolysis or the catabolism of the muscle protein to the
patient. • If the Catheter is the cause of the fever remove all the
infection source, the catheter should be replaced in the
3-IN-1 SOLUTION opposite subclavian or the internal jugular vein
• Use of multi-lumen catheters may be associated with
slightly increased risk of infection due to greater
manipulation (this catheter should only be used for
feeding, because if used for multiple purposes it can be
a cause of infection)
• Rate of infection is highest when placed in the femoral
vein and lower for those in the jugular vein and the
lowest in the subclavian vein
• Indwelling catheters
o < 3 days – negligible risk of infection (wala
• For TPN formulated with lipid (3-in-1 solution). It is given once nadevelop)
or twice a week to prevent essential fatty acid deficiency o 3-7 days – 3-5% at risk of developing catheter
o 3-in-1 only include calories coming from infection
carbohydrates, proteins and lipids o >7 days – 5-10% at risk of developing catheter
infection
• What is the total kilocalories (Normal:25-35kcal/kg/day) of a
70kg man? 2. Technical Complication
a. Early: related catheter insertion
• Total kcalories needed per day
• Pneumothorax – presence of air in the thoracic cavity
o = 30 kcal/kg/day x 70kg
o = 2100 kcal needed per day • Arterial Laceration
• Provide 20-30% of the total calories as lipid: use 20 percent • Hemothorax – presence of blood (subclavian to
o Lipid= 2100 kcal x 0.2 = 420 kcal lipid per day thoracic cavity)
o 420 kcal/ 9kcal/g (fats) = 47 g lipid (lipid kcal into • Hydrothorax – presence of fluid
grams) • Pneumohemothorax- combination of hemothorax and
• Calories from amino acids pneumothorax
o 105 g X 4kcal =420 kcal (calories from amino • Mediastinal hematoma
acid) • Nerve injury to the brachial plexus
• Subtract now the 420 kcal of protein and 420 kcal of lipid • Air embolism
o Remaining Calories: • Catheter embolism
o 2100 – 420-420 = 1260kcal (the amount kcal of • Cardiac tamponade
carbohydrate needed to complete that 2100 kcal 3. Metabolic Complication
needed by the patient in a day) a. Inadequate administration of certain nutrients
• Then make up the difference with dextrose • Trace metal deficiency – Zinc and Copper are not
o 1260 kcal/3.4 kcal/g) = 370 g dextrose included in parenteral fluid
(carbohydrate kcal into grams) Zinc deficiency:
o Perioral pustular rash
o Darkening of the skin creases
o Neuritis
Copper deficiency

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 o Patients look pale due to microcytic 1. Compare his actual weight from his ideal body weight
anemia 2. Get his body mass index to know if the patient undernourished,
Essential fatty acid deficiency overweight., etc.
o Manifest as a dry flaky skin with small 3. Take the patient’s serum albumin for patients undergoing elective
reddish papules and alopecia surgery
o This can be prevented by giving 3 in 1 • Preoperative albumin levels have been found to be a better
solution of TPN is given once or twice a prognostic indicator for morbidity and mortality than your
week anthropometric measurement
b. Disorder of Glucose Metabolism 4. If a patient needs nutritional supplements, you compute for the
• Hypoglycemia resting energy expenditure using Harris-Benedict equation then you
Seldom occurs in TPN but it can happen if for multiply this on the stress factor based on the degree of stress the
example there is slow glucose infusion or patient has
either excessive insulin administration 5. Computed total calorie the patient needs in a day is ordered for the
• Hyperglycemia nutritionist to prepare
is considered the most dangerous metabolic 6. If the patient can consume the entire nutrient orally – Oral
complication of TPN nutrition, but initiate EN via NGT feeding if 60% of the required
Due to rapid infusion (60 mL/ hour the needs cannot be met for more than 10 days
increase of 20 mL/ hr every 24-48 hours 7. If the oral route is expected to be impossible, inadequate or unsafe
Or secondary to DM with Hyperosmolar for more than 7 day perioperatively, give EN
nonketotic coma due to osmotic diuresis 8. If the EN is expected to be needed for less than 4 weeks you can
leading to severe dehydration, fever, use your NGT, Nasoduodenal tube and Nasojejunal tube feeding
obtundation, coma death and shift to oral feeding if the patient improves
Overfeeding may result in CO2 retention and 9. But if EN is expected to be needed in more than 4 weeks better
respiratory insufficiency convert to PEG or Gastrostomy/Jejunostomy.
Tx: Insulin 200 units/day and administration of 10. If the EN is contraindicated, you proceed and give nutrition
large dextrose free hypo-osmolar solution Parenterally (PN)
(0.45% NSS (normal saline) with K+) 11. If the PN is only needed for 1-2 weeks, you may give Peripheral PN,
c. Liver function derangement otherwise if more than 2 weeks PN is needed you can shift to
• Other related complication may lead to the Central PN.
development of hepatic steatosis
• Cholestasis and formation of gallstones are common in REFERENCES
long term PN A. Lecture and Slides by Dr. Benedict Valencia, Sept 14,
• Mild but transient abnormalities in serum 2021
transaminases (SGOT/SGPT) and alkaline phosphatase
and nitrogen levels that usually occurs in patients in PN
4. Intestinal Atrophy
a. Caused by lack of intestinal stimulation
• Diminished villous height
• Bacterial overgrowth
• Reduced lymphoid tissue size
• Reduced IgA production
• Impaired GUT immunity
• Bacterial translocation sepsis (animal model)
b. Tx: Provide some nutrient enterally

Algorithm for Route of Nutritional Support in Surgical

patients

8|Surgery I DOKKAEBI