Surgical nutrition * Malnutrition causes: o Delayed wound healing o Reduced ventilatory capacity o Reduced immunity and increased risk

of infection * Does improving nutritional status influence outcome? * Currently the topic of intensive investigation Nutritional assessment * Clinical assessment o Weight loss o 10% =mild malnutrition o 30% = severe malnutrition o Body mass index * Anthropometric assessment o Triceps skin fold thickness o Mid arm circumference o Hand grip strength * Blood indices o Reduced serum albumin, prealbumin or transferrin o Lymphocyte count * End-of-bedogram * No index of nutritional assessment shown to be superior to clinical assessment Methods of nutritional support * Use gastrointestinal tract if available * Prolonged post-operative starvation is probably not required * Early enteral nutrition reduced post-operative morbidity Enteral feeding * Prevents intestinal mucosal atrophy * Supports gut associated immunological shield * Attenuates hypermetabolic response to injury and surgery * Cheaper than TPN and has fewer complications * Polymeric liquid diet o Short peptides, medium chain triglycerides and polysaccharides o Vitamins and trace elements * Elemental diet o L-amino acids, simple sugars o Expensive and unpalatable o High osmolarity can cause diarrhoea * Enteral feed can be taken orally or by NGT * Nasoenteral tube - usually fine bore * Long term feeding can be by: o Surgical gastrostomy, jejunostomy o Percutaneous endoscopic gastrostomy o Needle catheter jejunostomy * Rate of infusion often started at low rate and increased * Strength of initial feed often diluted and strength gradually increased * Complications of enteral feeding o Malposition and blockage of tube o Gastrooesophageal reflux

o Feed intolerance Parenteral nutrition * Intestinal failure = A reduction in functioning gut mass below the minimal necessary for adequate digestion and absorption of nutrients * Useful concept for assessing need for TPN * Can be given by either a peripheral or central line Indications for total parenteral nutrition * Absolute indications o Enterocutaneous fistulae * Relative indications o Moderate or severe malnutrition o Acute pancreatitis o Abdominal sepsis o Prolonged ileus o Major trauma and burns o Severe inflammatory bowel disease Peripheral parenteral nutrition * Hyperosmotic solution * Significant problem with thrombophlebitis * Need to change cannulas every 24- 48 hours * No evidence to support it as a clinically important therapy * Composition - 12g nitrogen, 2000 Calories Central parenteral nutrition * Hyperosmolar, low pH and irritant to vessel walls * Typical feed contains the following in 2.5L * 14g nitrogen as L amino acids * 250g glucose * 500 ml 20% lipid emulsion * 100 mmol Na+ * 100 mmol K+ * 150 mmol Cl* 15 mmol Mg2+ * 13 mmol Ca2+ * 30 mmol PO42* 0.4 mmol Zn2+ * Water and fat soluble vitamins * Trace elements Complications of subclavian and jugular central venous lines 10% of central lines develop significant complications * Problems of insertion o Failure to cannulate o Pneumothorax o Haemothorax o Arterial puncture o Brachial plexus injury

o Mediastinal haematoma o Thoracic duct injury * Problems of care o Line and systemic sepsis o Air embolus o Thrombosis o Catheter breakage Monitoring of parenteral nutrition * Feeding lines should only be used for that purpose * Drugs and blood products should be given via separate peripheral line * 5% patients on TPN develop metabolic derangement * Nutrition should be monitored: o Clinically Weight o Biochemically twice weekly o FBC, U+Es, LFTs, o Mg2+, Ca2+, PO42-, Zn2+ o Nitrogen balance * Blood cultures on any sign of sepsis Metabolic complications of parenteral nutrition * Hyponatraemia * Hypokalaemia * Hyperchloraemia * Trace element and folate deficiency * Deranged LFTs * Linoleic acid deficiency