Nutrition Surgery😍

Nutrition Assessment

• No single reliable biochemical marker.

• Poor prognosis:
• Unintentional weight loss >10% in 3 months
• (Cancer)
• Low albumin
• (Liver Cirrhosis)
• BMI <15
• (Malnutrition)

• Assessment methods:
• Fat: Skin fold thickness.
• Muscle mass: Mid arm circumference.

Malnutrition Universal Screening Tool (MUST)

• Assesses risk based on:
• BMI.
• Weight loss.
• Acute disease.

• Mnemonic: Must (MUST Tool) Lose (Weight loss) BMI () Fast (Acute)

Types of Nutrition

• Enteral (Oral/gut).

• Parenteral (IV route).

Enteral Nutrition

Benefits of Enteral Nutrition

• Better method.

• More physiological.

• Prevents translocation of gut bacteria.

Best Route

• Oral.

If oral not possible:

Ryle's Tube (NG tube)

• Length assessment:
• Nose → Ear → Xiphoid.

• Patient position for insertion: 
• Sitting with neck slightly flexed.

Check NG tube position by:

• Clinical methods:
• Aspirating gastric contents.
• Whoosh test:
• Pushing air F/B auscultation in epigastrium.

• Imaging: 
• Chest x-ray

Techniques for Gastrostomy and Jejunostomy

Open Techniques

• a. Stamm method:
• Uses purse string suture.
• ↑ Chances of peri-drain leak.
• Mnemonic: Stamm → Stab → ↑↑ Leak

• b. Witzel technique:
• Creates a tunnel.
• ↓ peri-drain leak.
• Mnemonic: Witzel → Wizard tunnel ()

Percutaneous Endoscopic Gastrostomy (PEG)

• Method of insertion:
• Endoscope passed in stomach.
• Illuminated site palpated & punctured.
• PEG tube inserted over guide wire and secured.
• Introducer of PEG is part of the PEG set.

Radiologically Inserted Gastrostomy (RIG)

• Done when endoscopy is not possible.

Complications of Enteral Nutrition

• Tube related:
• Blockade.
• Migration.
• Leak.

• Feeding regime related:
• Osmotic diarrhoea (Sugar rich fluids).
• Overfeeding (↑Risk of aspiration).

Parenteral Nutrition

• Best Route
• Central line.

• Indications
• Prolonged paralytic ileus (>72 hours).
• Short bowel syndrome (<200 cm small intestine).
• High output faecal fistula (>500 cc/24 hours).
• Acute episodes of inflammatory bowel disease.
• Acute severe pancreatitis (initial phase only).

Central Line Types and Characteristics

Internal Jugular Vein – Preferred in

Post-Insertion Check

• Chest x-ray:
• Look for central line tip.
• Rule out pneumothorax.
• Catheter tip position:
• In SVC.
• Just above the Rt atrium.

PICC line (Peripherally Inserted Central Catheter).

• Just above the Rt atrium.

TPN solution

• Contents: Lacks fibre content.

• Protein : Fat : Carbohydrate
• = 20 : 30 : 50.

• Infusion rate: 1-2 litres/24 hours.

TPN solution modifications:

• Respiratory failure:
• ↓ Carbohydrate (Osmolar).
• ↑↑ Carbohydrate → ↑ CO2
• ↓ Quantity.

• Renal failure:
• ↑ Carbohydrate.
• Less Protein (d/t creatinine)
• ↓ Quantity.

Monitoring of Patients on Feeding Regimes

• Daily (Clinical measures):
• Pulse, BP, Temperature.
• Body weight (↑: earliest sign of overfeeding).
• Input/output chart.
• Type of nutrition given.

• Biochemical measures 
• (Initially daily, then later once/twice a week):
• Blood glucose.
• Magnesium, Phosphate.
• Liver function tests.
• RFT
• Sodium, Potassium, Urea, Creatinine.
• C-reactive protein.

Complications of TPN

• Central line related:
• Pneumothorax.
• Arrhythmias, Thrombosis, Air embolism.
• Migration.
• Catheter related sepsis (m/c central line complication).

• Feeding regime related:
• Hyperglycemia (m/c).
• Excess weight gain.
• Cholestasis (withhold TPN).
• Micronutrient deficiency (m/c: Zinc deficiency).
• Refeeding syndrome.

Catheter Related Sepsis

• On fluid administration: Fever + chills & rigors.

• Investigation:
• Cultures from:
• Catheter tip.
• Peripheral line.
• Central line.

• Management:
• Remove catheter if it is the source.

Refeeding Syndrome

• Large quantities of nutrition given to chronically malnourished.

• Prevention:
• ↑ Feeds gradually
• initially 10 kcal/kg/day
• Full feeds in 4-7 days
• Strict electrolyte levels monitoring.
• Thiamine supplementation.

Liver Dysfunction in TPN

• Long term TPN use leads to Fatty liver (m/c).
• Children (m/c).
• Can be modified using lipid free solutions.

• Intestinal Failure Associated Liver Disease (IFALD):
• Occurs in small number of patients.

Hartmann's/Ringer Lactate (RL) Solution

Composition (in meq/L):

• Lactate → Always Ringer Lactate

Parameter	Value	ㅤ
Na⁺	131	131 → normal level
Cl⁻	111	1 → 111
K⁺	5	5 → normal level
Ca²⁺	2	2 → 2
Lactate	29	ㅤ

ORS Contents

Component	Standard (mEq/L)	Reduced Osmolarity (mmol/L)
Glucose	111	75
Sodium	90	75
Chloride	80	65
Potassium	20	20
Citrate	10	10
Osmolarity	311	245 mOsm/L
ㅤ	ㅤ	Sodium (75) chloride (65) Potassium (20) Citrate (10)

Reduced Osmolarity ORS Ingredients (g per 1L)

Component	g/L
Glucose (anhydrous)	13.5
Trisodium citrate hydrate	2.9
Sodium chloride	2.6
Potassium chloride	1.5
Total	20.5 g

• Use 1 packet in 1L water.

• Consume within 24 hours.

Special ORS Types

• Resomal (for malnourished): Na 45, K 40
• For SAM children
• Not freely available (costly)
• more potassium
• less sodium
• some minerals.

• Super ORS:
• Uses rice/non-starch sugars (glycine, alanine)
• Low shelf life

Which and how much maintenance fluid to use?

• In children
• NS with 5% dextrose
• + 1 ml KCl/100 ml
• (20 meq/L of K+)
• 1 mL KCl = 2 meq KCL
• For 1st 10 kg:
• 100 ml/kg
• Next 10 kg:
• 50 ml/kg
• Beyond 20 kg:
• 20 ml/kg

• Example:
• Weight of child = 18kg
• For 1st 10kg = 10x100=1000ml
• For next 8kg = 8x50=400ml
• So, child needs 1400 ml of IV fluid in 24 hours