Surgery and Trauma

I. Definition
1. Surgery treatment of disease by manual or instrumental operations

2. Trauma
*severe injury caused by an accident or injury of the central nervous system and heart affected by shock
*severe injury caused by an accident or injury, violent disruption, or ingestion of a toxic substance

Classification according to etiology:
a. Thermal (burns)
b. Neurologic (central nervous system or brain)
c. Severe emotional shock
d. Chemical (toxic agent)
e. Physical (multiple fracture, major surgery)

3. Sepsis uncontrolled infection from fungal or bacterial agents
*the spread of infection from one part of the body to the other areas via the circulatory system is called
septicemia

4. Bacterial translocation migration of bacteria from wound infection sites into other sites via portal
circulation, leading to sepsis or multiple organ failure

5. Multiple Organ Dysfunction Syndrome (MODS) may occur following trauma, thermal injury, infection,
pancreatitis, and shock; it generally begins with lung failure followed by failure of the liver, intestine, kidney,
hematologic, and myocardial functions

II. Metabolic Response to Stress
A. Ebb phase immediately following injury; initial response to bodily insult
Characteristics: lower blood pressure, cardiac output, body temperature and oxygen consumption
associated with hypovolemia, hypoperfusion, and lactic acidosis

B. Flow phase a neuroendocrine response to physiologic stress that follows the ebb phase
follows after fluid resuscitation and restoration of oxygen transport
1. Acute Response (Catabolism)
Characteristics: increased cardiac output, oxygen consumption, body temperature, energy
expenditure, and total protein catabolism; increased production of glucose, free
fatty acid release, circulating levels of insulin, catecholamines, glucagons, and
cortisol

2. Adaptive Response (Anabolism)
Characteristics: associated with recovery, decreased metabolic rate, hormonal response gradually
diminishes, restoration of protein status, wound healing


Characteristics of metabolic phases occurring after severe injury
Flow Phase
Ebb-Phase Response Acute Response Adaptive Response
Hypovolemic Shock
Decreased
Tissue perfusion
Metabolic rate
Oxygen consumption
Blood pressure
Body temperature
Catabolism predominates
Increased
Glucocorticoids
Glucagon
Catecholamines
Excretion of nitrogen
Metabolic rate
Oxygen consumption
Release of cytokines, lipid mediators
Production of acute-phase proteins
Impaired use of fuels
Anabolism predominates
Hormonal response gradually
diminishes
Decreased hypermetabolic rate
Associated with recovery
Potential for restoration of body protein
Wound healing depends on nutrient
intake

III. Nutritional Care
Aim: to improve the preoperative nutritional state in preparation for the stress of surgery, to hasten
recovery, and to maintain good nutrition and rapid healing in the postoperative period

A. Preoperative Diet
1. High kilocalorie, high protein at least 7 days prior to surgery to improve nutritional status if
malnourished
2. Regular consistency 8 -12 hours prior to surgery
3. Low residue or clear liquid diet 24 36 hours prior to surgery if bowel preparation is indicated
4. NPO the night before surgery
5. Enteral and parenteral nutrition as needed

B. Postoperative Diet
1. NPO for 24 49 hours
2. Clear liquids to soft, then regular as bowel movement returns
3. High protein to promote wound healing
4. Vitamins and minerals as needed to promote wound healing
5. If surgery involves the GIT, further modifications may be needed

Cleft Lip and Palate (CLAP)

Cleft lip (harelip) a congenital cleft of the upper lip
Cleft palate congenital deformity characterized by incomplete closure of the lateral halves of the palate or roof of
the mouth

I. Etiology: inborn

II. Feeding difficulties
1. Inability to suck adequately
2. Food passes through the roof of the mouth into the nasal cavity
3. Food may back up in the nose and can cause choking

III. Treatment: Surgical repair


IV. Diet
A. For newborn infants
1. A medicine dropper or a plastic bottle and a soft nipple with enlarged hole may be used due to
inability to suck
2. Small feedings are given, slowly in an upright position to prevent aspiration
3. Frequent burping to expel large amount of air swallowed

B. For older infants
*supplementary foods are mixed with milk and given by bottle with large nipple holes

Gastrectomy surgical removal of all or part of the stomach
Nutritional Care
Aim: to provide a nutritionally adequate diet and reduce the symptoms of dumping syndrome to a level that
the patient finds tolerable

Diet
1. Small, frequent meals to decrease intestinal distention. Preferably easy to digest, soft, low-fiber diet
2. Simple CHO restricted to prevent the formation of hyperosmolar intestinal content
3. Milk and other lactose-containing foods should be regulated depending on tolerance
4. Fluids should not be taken with meals to delay emptying of solids, preferably taken with 45 60 minutes
before or after meals; important to prevent dehydration
5. High protein, high kilocalories to maintain weight
6. Fat: moderate to low due to malabsorption
7. MCT oil for better fat absorption
8. Vitamin B12 supplementation (100g IM monthly) to correct macrocytic anemia in the absence of intrinsic
factor; may also be given parenterally
9. Supplemental vitamins and minerals: folate, iron, calcium, and vitamin D

Ostomy the surgical procedure of creating an opening, or stoma, in the wall of the abdomen

I. Conditions usually requiring Ostomy Procedure
a. Colon and rectal cancers
b. Ulcerative colitis
c. Crohns disease
d. Severe diverticulitis
e. Familial polyposis

II. Types of Feeding Ostomies
a. Esophagostomy surgical opening into the esophagus (not common)
b. Gastrostomy surgical opening into the stomach
c. Jejunostomy surgical opening into the jejunum

III. Nutritional Care
Aim: to maintain or improve nutritional status, to avoid or reduce gas, odor, or obstruction of the ostomy

Diet
1. to avoid obstruction
a. drink plenty of fluids c. chew foods thoroughly
b. avoid high-fiber foods d. avoid corn, coleslaw, lettuce, fruits

2. to avoid flatulence or undesirable odor
Avoid gas-forming foods such as cabbage, beans, beer, carbonated beverages, fish, and onions
Short Bowel Syndrome (SBS) set of symptoms resulting from massive resection of the small intestine; it is life-
threatening especially if more than 50% of the organ is removed

I. Etiology
a. Treatment of cancer
b. Diverticulitis
c. Local abscess
d. Fistula
e. Ulcerative colitis
f. Crohns disease
g. Perforation
h. Scleroderma
i. Mesenteric vascular accident
j. Obstruction
k. Radiation enteritis


II. Characteristics
a. Maldigestion
b. Malabsorption
c. Electrolyte abnormalities
d. Dehydration
e. Nutrient deficiencies

III. Complications of SBS
a. Malabsorption of micronutrients and macronutrients
b. Fluid and electrolyte imbalances
c. Weight loss
d. Growth failure (in children)

IV. Nutritional Care
Aim: to provide nutrition parenterally and/or enterally; to enable the remaining small bowel to increase its
absorptive surface area through hyperplasia and the formation of higher villi and deeper crypts of
Lieberkuhn

Diet
1. Removal of >100 cm of small bowel usually requires total parenteral nutrition (TPN) for nutrition support
2. TPN initially required for several weeks until patient can tolerate feeding per orem or enteral diet
3. High protein, high kilocalories to restore protein losses and stabilize weight within normal
4. Supplements, specifically calcium, magnesium, iron, zinc, fluids, and fat-soluble vitamins and multivitamins
when shifted to an oral diet
5. Six small meals daily for better tolerance
6. Restrict fiber, lactose, and fat to reduce stool output
7. Glutamine-enriched enteral feeding solutions

Post-surgical Phases
a. 7 10 days of severe diarrhea, fluid losses, and electrolyte imablances
b. 2 months or more of anorexia, mild diarrhea, steatorrhea, and weight loss
c. Up to 2 years of continued bowel adaptation after surgery, with accompanying consequences
including anemia, osteomalacia, gallstone formation, gastric hyperacidity, dehydration, diarhea,
steatorrhea, hypocalcemia, hypomagnesemia, vitamin deficiencies (A, D, E, K, B12) and PEM

Tonsillectomy and Adenoidectomy (T & A) surgery to remove diseased tonsils and/or to correct adenoidal impairment

Diet
1. Full liquid diet for the first meal
2. Mechanical soft diet for the second and third meals
3. Regular or general diet for subsequent meals
4. Avoid foods that are irritating to the throat like citrus fruits and juices
5. Avoid dry foods (ex. Toasts) and very hot liquids
Burns tissue injury or destruction caused by excessive heat, caustics (acids or alkalis), friction, electricity, or radiation

I. Classification
A. Partial or full thickness burns
1. Partial thickness (PT) burns (first and second degree burns): not all of the epithelium is destroyed,
therefore these wounds can regenerate
2. Full thickness (FT) burns (third degree burns): all epithelial remnants are destroyed and
autografting is required

B. Burn injury severity
1. Minor Adults: PT<15% TBSA; FT<2% TBSA
Children: PT or FT<10% TBSA
2. Moderate Adults: PT>15 to 25% TBSA; FT<10% TBSA
Children: PT>10 to 20% TBSA; FT<10% TBSA
3. Major Adults: PT>25% TBSA; FT>10%TBSA
Children: PT>20% TBSA; FT <10% TBSA

II. Characteristics
a. hypermetabolism
b. protein catabolism and increased urinary nitrogen excretion
c. protein losses through the burn wound exudates
d. susceptibility to infection
e. ileus or loss of intestinal peristalsis
f. loss of fluids and electrolytes
g. Curlings ulcer
h. Anorexia
i. Pain and anxiety

III. Management
1. Fluid and electrolyte repletion within the first 24 to 48 hours
*the volume of fluid needed based on:
a. age of the patient
b. weight of the patient
c. extent of the burn

2. Wound management wounds are covered to reduce evaporative and nitrogen losses; to prevent
infection
*management depends on the depth and extent of the burn

3. Nutritional care
Aim: to maintain or attain optimal nutritional status in patients with burn injury by:
a. assessing metabolic and nutritional need
b. providing nutrition support enterally and/or parenterally to promote wound healing, prevent
infection, and to prevent rapid or severe weight loss
c. monitoring and evaluating the effectiveness of the treatment

IV. Stages of Nutritional Care
A. Shock Period first 24 to 48 hours postburn
1. Fluid and electrolyte replacement/resuscitation
Evaporative water loss can be estimated at 2.0 to 3.1 ml/kg BW per hours/% TBSA burn
*to replace massive intravascular fluid and electrolyte losses; correct hypovolemia
*to maintain circulatory volume and prevent ischemia
2. No attempt is made to meet nutritional requirements at this stage
3. Feeding should be initiated once resuscitation is complete (within 4 to 12 hours)

B. Recovery Period 48 to 72 hours postburn
Fluid balance is gradually re-established

C. Secondary feeding Period towards the end of the first postburn week; as adequate bowel function
returns, vigorous feeding must be initiated

V. Nutrient Modifications
A. High Energy
1. Requirements may vary according to the size of the burn
2. May be calculated using various formulas (ex. Curreri formula)
3. Additional calories may be required due to fever, sepsis, multiple trauma

B. Protein
1. High requirements due to losses through the urine and wounds; increased used in
gluconeogenesis and wound healing
2. 20 to 25% of total kilocalories
3. High biologic value
4. 2.5 to 3.0g/kg body weight for children

C. Carbohydrates
1. Main energy source for protein-sparing
2. Maximum glucose load of 7 mg/kg/min
3. Excessive glucose can aggravate hyperglycemia

D. Fats
1. 15 20% of non-protein kilocalories
2. Too high levels may cause deleterious immunologic response and increased susceptibility to
infections
3. Use of MCT ad structured lipids are currently under investigation

E. Vitamins and Minerals
1. Increased needs but exact requirements have not been established
2. Vitamin C is increased for wound healing; 500 mg twice daily is recommended
3. Vitamin A for immune function and epithelialization; 5000 IU per 1000 calories of enteral nutrition is
recommended
4. Increased Na and K to correct hyponatremia
5. Ca supplements to treat symptomatic hypocalcemia or losses due to immobalization or treatment
with silver nitrate soaks
6. Phosphorus and magnesium given parenterally to avoid GI irritation
7. Zinc supplementation with 220mg of zinc sulfate

Trauma
I. Characteristics
a. Hypermetabolism
b. Hypercatabolism
c. Lipolysis
d. Skeletal muscle proteolysis


II. Metabolic and Endocrine Response
*elevated serum concentration of cortisol, catecholamines, glucagons, growth hormone, aldosterone, and
antidiuretic hormone

III. Nutritional care
Aim: to provide adequate nutrition support; to minimize infection during a prolonged course of healing,
hypermetabolism, and immobilization

Diet
1. Energy: 30 35 kilocalories/kg IBW/day is often sufficient to achieve anabolism and positive nitrogen
balance
*requirements of severely stressed patients are higher
2. Protein: 1.0-1.5 g/kg IBW/day for moderately stressed patients; 1.5-2.0g/kg IBW/day for severely stressed
patients
3. Vitamin and mineral requirements are elevated, however, no specific levels have been established
4. Daily supplements of
Vitamin A: 5,000 to 20,000 IU
Vitamin C: 250 to 1000 g
Zinc: 220 mg zinc sulfate bid
B-complex vitamin supplement daily is essential to energy/carbohydrate metabolism
5. Adjunct enteral and parenteral nutrition in malnourished patients

Transplantation involves the transfer of a graft (organ tissues) from one body area or person to another site or person to
replace a disease organ or tissue

Kidney transplant the surgical implantation of a kidney from a living related donor, a living non-related donor, or a
cadaver
Nutritional care
1. provide adequate calories and protein to counteract the catabolic effects of surgery during the early post-
transplant period
2. Manage nutritional side effects of immunosuppressive drugs

Diet
a. Up to one 1 month post-transplant
Initial diet depends on function of the transplanted kidney
1. Liquid to solid diet, progressive depending on tolerance
2. Protein: 1.3 to 1.5 g/kg to promote nitrogen balance
3. Calories: 30 35 kcal/kg/day to spare protein for anabolism and meet increased needs due to surgery
b. After 1-month post-transplant
Management of nutritional side effects of immunosuppressive therapy and kidney functions
1. Protein 1g/kg/day to promote nitrogen balance and prevent damage to transplanted kidney by
excessive dietary protein
2. Calories sufficient to control weight to counteract increased appetite and weight gain caused by
immunosuppressive therapy
3. CHO preferably complex to minimize hyperglycemia due to steroid-induced diabetes
4. Low cholesterol: <300mg and saturated fats since corticosteroid and cyclosporine therapy may
contribute to atheroscletoric disease
c. Long term goals
1. Prevent excessive weight gain
2. Restore nitrogen balance
3. Minimize muscle wasting
4. Minimize post-transplant glucose tolerance and hyperlipidemia