Nutrition in the Surgical Patient 
Annastasia King’ori 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction: 
The Nutrition Care Process consists of four 
distinct 
but 
interrelated 
steps: 
Assessment, 
Diagnosis, Intervention and Evaluation.  
All patients undergoing surgery need a 
nutrition work up pre- and post-operatively. 
Normally, well-nourished patients can survive 
without specific nutritional support for several days 
when they undergo an elective surgical procedure. 
However, numerous factors including a prolonged 
disease process, investigations, treatment, and 
postoperative complications, may lead to decline in 
nutritional status of a patient. Because only a small 
percentage of the population in low resource areas 
has access to affordable surgical care, there are few 
indicators 
to 
assess 
perioperative 
nutrition 
intervention in these areas. However, we know that 
malnutrition is a common risk factor among the poor. 
Malnutrition is common among hospitalized 
patients, particularly among patients suffering from 
acute and chronic life-threatening conditions. Such 
people often need surgical intervention. There is a 
great need to consider nutrition support as a 
component of surgical care both pre- and post-
operatively. This helps to address any form of 
malnutrition, optimizes the patients’ nutritional 
status, and improves outcomes.  
Some reasons for the development of 
undernutrition among hospitalized patients include 
limited awareness, knowledge, and training of staff 
at all levels. The overall problem is worsened by the 
following factors, that contribute to the development 
of malnutrition:  
● The broad perception that the provision of food 
and nutrition is of low priority  
● The alignment of nutrition with patient service 
rather than medical services  
● The difficult in responding to patient preferences, 
or clinician requests for certain types of food 
resources 
● Repeated fasting and skipping of meals 
associated 
with 
surgical 
and 
medical 
interventions 
The patient’s nutrition status is therefore a 
major determinant of outcomes for any type of 
surgery. Surgeons and surgical teams should have 
basic skills in nutrition screening and assessment of 
patients prior to a surgical procedure, to determine 
those at greatest risk for malnutrition development. 
 
Importance of Pre-operative Management 
Malnutrition is a modifiable risk factor. It can 
be tamed pre-operatively through nutritional support. 
Preoperative nutrition support optimizes patient 
nutrition status, preparing the patient for increased 
metabolic demands due to surgical injury.  
Under normal conditions, fatty acids are 
mobilized in states of starvation, in a process called 
ketosis. Infection and injury inhibit this response and 
instead cause the mobilization of muscle protein. 
This process leads to generalized muscle weakness, 
edema, and weight loss. Severe malnutrition can 
weaken the respiratory muscle, making the patient 
unable to cough effectively which promotes chest 
infection and atelectasis. The immune response to 
infection also becomes down-regulated and T-cell, 
B-cell and macrophage function deteriorates. 
Nutrition assessment includes collecting 
information about the patient’s medical history, 
clinical and biochemical characteristics, dietary 
practices, current medication(s), and food security 
situation, and taking anthropometric measurements. 
There is no single standard for identifying either 
nutrition risk or nutrition status. Any assessment 
should be valid, simple, easy to interpret and 
sensitive so that it can be widely and consistently 
implemented by non-specialists.  
Often simple questions about the patients’ 
practices and any dietary changes reported can give 
insight into the overall nutrition status in relation to 
the planned surgery. Those patients identified to be 
either at risk, or frankly malnourished, should be 
forwarded to a clinical nutritionist or dietitian for 
nutrition optimization prior to surgery. Preoperative 
patients found to be at risk or with malnutrition are 
scheduled on individualized treatment plans that may 
include therapeutic diets (e.g., F75, F100, and “Ready 
to Use Therapeutic Food-” RUTF), fortified foods, 
oral 
nutrition 
supplements 
(“Ready 
to 
Use 
Supplemental 
Food-” 
RUSF, 
commercial 
supplements like ENSURE), modified home or 
Kitchen diets addressing their specific needs e.g., full 
liquid diet, and/or parenteral nutrition.  
Postoperatively, management is continued in 
order to maintain the patient’s nutrition status, 
Nutrition in the Surgical Patient 
Annastasia King’ori 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
support wound healing and improve the immune 
function. Ideally, clinical nutritionists and dietitians 
continue to participate in the postoperative care, 
providing guidelines that allow systematic screening 
and 
assessments, 
as 
well 
as 
patient-based 
interventions that are discussed below.  
 
Assessment 1: History 
Nutrition screening involves the search for 
known risk factors such as those listed below. Its 
purpose is to identify individuals who are at risk of 
becoming malnourished or who are malnourished. 
For nutrition screening to be effective, it must use 
existing staff, be simple and inexpensive, and be 
initiated early before surgery. Known risk factors 
include:  
● Involuntary loss or gain before hospital 
admission of more than: 10 % of the usual body 
weight within 6 months, or 5 % of the usual body 
weight in the past 1 month. 
● A weight of 20 % over or under ideal body 
weight. 
● Presence of chronic disease 
● Disease-induced 
increased 
metabolic 
requirements.  
● Alterations to the normal diet required as a result 
of recent surgery, illness or trauma 
● Receiving artificial nutrition support as a result 
of recent surgery, illness or trauma 
● Inadequate nutritional intake, including not 
receiving food or nutrition products due to 
impaired ability to ingest or absorb food 
adequately for greater than 7 days 
 
A comprehensive dietary assessment should 
be done by a clinical nutritionist or dietitian and 
includes multiple components such as dietary intake, 
ability to chew and swallow, food intolerances, 
ability to digest and absorb food, and ability to 
comply with nutritional interventions. Decreased 
dietary intake may result from poor appetite, 
unavailability of food, or inappropriate diet. 
Available dietary history tools include 24-hour 
recall, diet history, food diaries, or food frequency 
questionnaires. 
Assessment 
of 
behavioral 
characteristics is important to assess the patient 
chewing and swallowing ability, especially in cases 
of stroke, dementia, or upper gastrointestinal 
obstruction. A patient may also have a history of 
impaired digestion and absorption e.g., in the 
presence of pancreatic disease, inflammatory bowel 
disease, or intestinal resection. There may be 
increased nutritional requirements in patients due to 
chronic disease, sepsis, burns, or multiple surgical 
procedures. 
Another important component of dietary 
assessment is determining the patient’s feeding 
practices. This is important to determine their dietary 
diversity, nutrient interactions, and to address any 
inappropriate dietary practices, such as skipping 
meals and unhealthy food regimens like fad diets, 
that may have adverse effects on nutritional status. 
While conducting nutrition screening, take 
caution with accepting the patient’s verbally reported 
weight. Most often, such a verbal report is unreliable. 
A full nutritional assessment considers both the 
measurement of body composition (specifically fat 
and muscle stores,) and the effects of nutritional 
status on physiological function. Assessment is more 
indicated when there is a prolonged disease process 
that led to weight loss, for example, esophageal 
carcinoma, high-stress disease, major burns, major 
surgery, 
sepsis, 
severe 
pancreatitis, 
and 
postoperative complications.  
 
Assessment 2: Physical Examination 
Monitoring weight loss is a useful means of 
nutritional assessment. 10% weight loss indicates 
mild malnutrition, while 30% loss is an alarming 
situation. Obvious clinical features of malnutrition 
are thin, lean wasted appearance, bilateral pitting 
edema, sunken eyes, easy shedding of body hairs, 
voice weakness, and enlargement of salivary glands. 
Midarm circumference for muscle mass should be 
assessed when the patient requires long-term 
nutritional support. Body mass index (BMI) gives 
information about the change in body weight. It is 
calculated by weight in kg/height in M2. Normal 
BMI is 18.5-25. These and other values are 
calculated as described below, and then summarized 
using an anthropometric table like the one at the end 
of this section.  
 
Mid-Upper Arm Circumference 
This measurement, commonly shortened as 
MUAC, is used as a screening tool for acute 
Nutrition in the Surgical Patient 
Annastasia King’ori 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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malnutrition.  MUAC is recommended for use with 
children between six months and 5 years of age, 
pregnant and lactating women, and in adults with 
clinical signs of undernutrition. A separate tape is 
used for adults. The major determinants of MUAC, 
arm muscle and subcutaneous fat, are both important 
determinants of survival in starvation.  
Other indices, such as weight and height-
based ones, are more often confounded by bipedal or 
nutritional oedema, periorbital oedema, or ascites. 
For this reason, MUAC is a more sensitive index of 
tissue atrophy than low body weight alone. It is also 
relatively independent of height and body shape.  
The right procedure should be employed 
when carrying out this assessment. First, measure the 
distance between the tip of the shoulder and the tip 
of the elbow and find the midpoint. Then, wrap the 
tape around the arm at this location as shown below. 
Take the correct reading here, to the nearest 1mm.  
 
MUAC tape, showing measurements for Severe (Red) Yellow 
(Moderate) and Green (Not Present) Acute Malnutrition. 
Source: UNICEF Technical Bulletin No. 13 Revision 2 
https://www.unicef.org/supply/media/1421/file/mid-upper-
arm-circumference-measuring-tapes-technical-bulletin.pdf  
 
 
Using the MUAC tape to determine the midpoint between the 
acromion and the ulna.  
 
 
Using the MUAC tape to determine the circumference at the 
mid-humerus. Note that this child’s measurement displays 
severe malnutrition.  
 
Height  
The patient’s height is needed for calculating 
body mass index. If height cannot be measured or is 
unknown, the following measurements can be used 
to calculate height: ulna length, knee height, or 
demispan (do not use if the patient has severe or 
obvious curvature of the spine.) For patients who are 
bed-bound, those with severe disabilities and those 
with kyphosis or scoliosis, it is preferable to use ulna 
length to estimate height. 
 
These values are measured as shown below, 
then the derived height values are used to calculate 
the body mass index. This value is then used in the 
anthropometric tables provided in the following 
section, Diagnosis.  
 
 
Measuring knee height, the distance from the bottom of the 
patient’s foot (resting on the floor) to the top of thigh above the 
lower leg.  
Nutrition in the Surgical Patient 
Annastasia King’ori 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Estimating Patient Height From Knee Height: 
Females 
Height in cm = 84.88 - (0.24 X age) + (1.83 X 
knee height) 
Males 
Height in cm= 64.19 - (0.04 X age) + (2.02 X 
knee height) 
 
 
 
Measuring the demispan, the distance between the suprasternal 
notch and the base of the space between the middle and ring 
fingers. 
 
Estimating Patient Height from Demispan: 
Females 
Height in cm = (1.35 x demispan (cm)) + 60.1 
Males 
Height in cm = (1.40 x demispan (cm)) + 57.8 
 
 
Ulna length, measured from the tip of the olecranon to the ulnar 
styloid process. Source: 
https://www.uhs.nhs.uk/Media/Southampton-Clinical-
Research/Procedures/BRCProcedures/Procedure-for-adult-
ulna-length.pdf  
 
 
Table for estimating patient height from ulna length. Source: 
https://www.uhs.nhs.uk/Media/Southampton-Clinical-
Research/Procedures/BRCProcedures/Procedure-for-adult-
ulna-length.pdf  
 
Weight, Z-Score 
 
In children, the Z-score is a comparison of 
weight vs. age, based on standard growth curves. 
One example is shown here and all the curves are 
reproduced at the end of this chapter. They are 
published for general use by the World Health 
Organization- 
https://www.who.int/tools/child-
growth-standards/standards/weight-for-age  
 
Nutrition in the Surgical Patient 
Annastasia King’ori 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
One example of a weight for age curve, this one for girls aged 
0-6 months. This graph is used to derive Z-score (Black, Red 
and Green numbers on Right.) Source: WHO, website above.  
 
Calf Circumference 
 
Calf circumference measurement is useful in 
assessing the nutritional state of hospitalized elderly 
people. The cut off of 30.5cm in adults provides a 
good diagnostic capacity. 
 
Calf circumference is measured at the widest point of the calf. 
Note that in this patient, wasting of the temporalis muscle is 
visible. This is another potential indicator of severe 
malnutrition.  
 
Blood Testing 
Blood tests are not absolutely necessary, and 
the interpretation may give a confusing picture. 
Generally, testing will reveal low serum proteins, 
low lymphocyte count, and delayed hypersensitivity 
reaction. As below, laboratory testing is best used to 
supplement history and physical examination data, 
rather than independently in isolation.  
The flow chart below can work as a screening 
tool to aid in nutrition screening and diagnosis for 
preoperative patients:  
 
 
Diagnosis: 
These anthropometric values and historical data can 
be entered into tables like the one below to determine 
the patient’s degree of malnutrition:  
 
 
Nutrition in the Surgical Patient 
Annastasia King’ori 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Anthropometric criteria for acute malnutrition. Source: Kenya 
National Clinical Nutrition and Dietetics Reference Manual, 1st 
Edition 
http://guidelines.health.go.ke/#/category/12/179/meta 
 
The Ministry of Health, Kenya has developed 
a nutrition risk screening tool that can be used in a 
hospital as shown in the table below. Like the above 
table, it uses a combination of history and 
examination findings. It is a simple nutrition 
screening procedure that can help to distinguish 
between patients not at nutritional risk and those who 
require a more detailed nutrition assessment.  
 
Nutrition screening tool for preoperative patients who will be 
hospitalized. Source: Kenya National Clinical Nutrition and 
Dietetics Reference Manual, 1st Edition 
http://guidelines.health.go.ke/#/category/12/179/meta 
 
Ideally, 
nutritional 
screening 
using 
techniques such as those above should be quick and 
simple. They should be done for every preoperative 
patient who needs them within the first 24-48 hours 
of the patient entering the hospital. More intensive 
assessments should be done for those identified to be 
at nutritional risk. The surgeon should assess every 
patient for this history and physical findings 
described here and attempt to make a diagnosis and 
implement 
intervention 
and 
monitoring 
as 
appropriate.  
 
Intervention: 
Nutrition therapy refers to provision of 
nutrition or nutrients. This can be done in the 
following manners:   
● Orally: Regular diet or therapeutic diet (fortified 
food, oral nutritional supplements)  
● Enteral nutrition: Tube feeds via nasogastric 
tube, nasojejunal tube, or surgical gastrostomy or 
jejunostomy access. 
● Parenteral nutrition: Intravenous provision of 
nutrients, into central or peripheral veins. 
Medical nutrition therapy is a subset of 
nutritional therapy that encompasses oral nutritional 
supplements, enteral tube feeding (enteral nutrition) 
and parenteral nutrition. Nutrition therapies are 
individualized and targeted nutrition care measures, 
using diet or medical nutrition approaches. Dietary 
education or counseling can be part of nutrition 
therapy, especially when dietary modifications are 
required.  
For a surgical patient, the indications for 
nutritional therapy are prevention and treatment of 
catabolism, and malnutrition. This mainly affects the 
perioperative maintenance of the nutritional state, in 
order to prevent postoperative complications. 
Nutritional therapy starts as a nutritional risk 
becomes obvious. Criteria for the success of the 
intervention are the “outcome” parameters of 
mortality, morbidity, and length of hospital stay, 
while 
taking 
into 
consideration 
economic 
implications. The improvement of nutritional status 
and functional recovery including quality of life are 
most important nutritional goals in the late 
postoperative period.  
Nutrition therapy may be indicated even in 
patients 
without 
obvious 
disease-related 
malnutrition, if it is anticipated that the patient will 
be unable to eat or cannot maintain appropriate oral 
intake for a longer period perioperatively. In these 
situations, nutrition therapy may be initiated without 
delay. One example of this is placing a jejunostomy 
feeding tube during an esophageal or gastric 
resection. 
We strongly recommend that you do not wait 
until 
severe 
disease-related 
malnutrition 
has 
developed, but start nutrition therapy as soon as a 
nutritional risk becomes apparent. Most nutritional 
care protocols for the surgical patient usually include 
a detailed nutritional and medical history as 
described above. It is important to document clear 
and accurate assessment of nutritional and clinical 
outcome whenever possible. 
Adequate energy and protein intakes are 
needed to limit catabolic process. However, many 
Nutrition in the Surgical Patient 
Annastasia King’ori 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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patients are not able to consume enough to meet their 
needs before or after the surgery. Some signs and 
symptoms of the condition i.e.; nausea, pain, 
medications, dry mouth and multiple fasting 
potentially reduce appetite and intake. The stress 
from trauma and surgery creates a catabolic state, 
increasing protein and energy requirements and 
utilization. Fat, protein and glycogen from the body 
reserves are redistributed to visceral organs leading 
to negative nitrogen and energy balance. This is  
defined as negative balance of 100g of nitrogen and 
10,000kcals of energy within a few days. Nutrition 
intervention is achieved through accurate estimation 
of energy requirements and provision of available 
food.  
 
Energy Requirements: 
The standard approach used is to estimate 
energy requirements from the basal energy 
expenditure accompanied by the stress factors. 
Energy is provided by carbohydrate and fat, while 
protein is used to compete with the metabolic 
response of the body to trauma.  
In sepsis, there will be increased protein 
breakdown. The body utilizes lipid more easily than 
glucose, therefore sepsis is associated with 
hyperglycaemia (septic diabetes.)  
Typical adult surgical patients need 1800 to 
2500kcal/day. The average daily requirement, in 
seriously ill patients, is 25 - 30 kcal/kg/day. 
Regarding protein requirement, 6.25 gm of protein 
provides 1 gm of nitrogen. Daily nitrogen 
requirement is 0.2 grams/kg.  
Typically, energy is given to the patient in the 
following distributions: carbohydrate 50%, fat 35%, 
protein 15%. One gram of carbohydrate provides 
4kcal, 1gram of protein provide 4kcal, while 1gm of 
fat provide 9 kcal. These energy sources must be 
delivered in combination with fluid, electrolytes, 
vitamins and trace elements. Fluid requirement is 
typically 30-35ml/kg/day. Major electrolytes like 
Na, K, and Cl requirement are 1.0 mmol/kg/day each. 
Zinc, Magnesium, and Phosphorus are the main trace 
elements required in daily diet. 
The Harris-Benedict Equation is a common 
method for calculating energy requirements. The 
figure below summarizes the daily requirement for 
patients: 
 
The Harris Benedict equation for calculation of daily energy 
requirements among patients receiving surgical care. 
 
Enteral Feeding: 
The preferred route is oral/enteral rather than 
parenteral, because it preserves intestinal structure 
and the role of the intestine in immune function. 
Nonuse of enteral feeding is related to villous and 
cellular atrophy leading to bacterial translocation and 
migration into systemic circulation. This may start or 
worsen systemic inflammatory response syndrome.  
Enteral nutrition is used in patients with a 
normal functioning gastrointestinal tract. It may be 
given orally or via nasogastric, nasoduodenal, or 
naso-jejunal tube feeding, or surgically placed 
feeding tubes depending on the patient's condition.  
 
Types of Enteral Feeds 
i. 
Polymeric diet: A high molecular weight diet 
that 
is 
used 
in 
normal 
functioning 
gastrointestinal tract. It is composed of intact 
proteins, starch and long chain fatty acids. 
ii. 
Elemental diet: A low molecular diet that is 
composed of amino acids, oligosaccharides 
and medium chain triglycerides. These 
products require minimal digestion and are 
easily absorbed. These diets are helpful in 
patient with pancreatitis, inflammatory bowel 
disease, and distal intestinal fistulas. 
iii. 
Disease specific diet: These diets are 
specially prepared for renal, hepatic or 
pulmonary dysfunction patients. These are 
expensive. One example is Glucena®, a 
special 
formulation 
for 
patients 
with 
diabetes.  
 
 
Nutrition in the Surgical Patient 
Annastasia King’ori 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Feeding Infusion:  
Feeding infusion starts with a small volume 
of diluted formula initially. Concentration is 
gradually increased based on the patient’s tolerance. 
Enough water should be provided to avoid osmotic 
dehydration. Tube feeding residual should be 
checked every 4 to 8 hours. More than 100ml residue 
requires holding the feeding for 2 hours. The feeding 
tube should be flushed routinely with 25 to 100 ml of 
water to prevent clogging. Feeds directly into the 
jejunum should be given as continuous infusion 
rather than “bolus” as the small intestine has no 
reservoir capacity.  
 
Complication of Enteral Feeding  
The most frequently seen complications are 
cramping, distension, vomiting and diarrhea. These 
may be managed by altering the fluid dilution or rate 
of administration. Mechanical problems include tube 
displacements, malposition, intra peritoneal leakage 
and intestinal obstruction. Other complications are 
dehydration, electrolyte imbalances and changes in 
blood sugar level. Aspiration can be a lethal 
complication. Therefore, if the stomach is being fed 
directly, the patient should have their head elevated 
at 45 degrees, during feeding. For recently placed 
nasogastric tubes, position of the tube should be 
confirmed prior to use. 
 
Parenteral Feeding: 
 
Parenteral nutrition is indicated when there is 
failure of enteral feeding. Enteral feeding will not be 
possible in the presence of proximal intestinal 
fistulas, intestinal obstruction, acute inflammatory 
bowel disease, inoperable malignancy, hepatic and 
renal failure, post chemotherapy or radiotherapy 
mucositis, malabsorption syndromes, prolonged 
ileus, pancreatitis, hypercatabolic states like burn, 
trauma, or major surgery.  
 
Remember to address the overall picture 
when considering parenteral nutrition. A patient with 
malignant inoperable intestinal obstruction is better 
served by an honest discussion with the family 
followed by comfort care, rather than the provision 
of an expensive therapy such as intravenous 
nutrition.  
Parenteral nutrition can be administered 
peripherally via superficial veins or centrally via a 
central vein. Peripheral Vein Nutrition is used as 
temporary nutritional support, when the anticipated 
period of starvation is less than 14 days. It is actually 
less complicated than central nutrition. Isotonic 
solution composed of amino acids, 5-10% dextrose 
and fat emulsion are commonly used. Phlebitis is the 
main problem resulting from use of a hyperosmolar 
solution. If osmolality exceeds 600 mmols, which is 
almost equal to a 10% glucose solution, it may cause 
line failure. Therefore, the full caloric requirement 
cannot be delivered by the peripheral veins. Regular 
change of the IV cannula is needed to avoid phlebitis.  
This can be controlled by using a long peripheral line 
such as a peripherally inserted central catheter 
(PICC) line.  
Central Vein Nutrition requires insertion of a 
catheter into a central vein (subclavian, internal 
jugular vein) under aseptic conditions. Central vein 
nutrition, 
unlike 
peripheral 
nutrition, 
allows 
provision of full nutritional support for a long term 
period. Hyperosmolar solutions 
like 25-50% 
dextrose can be given by this route. It therefore 
allows minimized volume while optimizing calorie 
delivery. Precise and independent calories can be 
given, allowing the patient to achieve an anabolic 
state. However, as this is not a physiologically 
normal activity, it has some potentially severe 
adverse consequences:  
● Gastrointestinal mucosal atrophy 
● Hormonal imbalances  
● Hyper- or hypo-glycemia 
● Changes in hepatic metabolism  
 
TPN is contraindicated in the presence of 
severe hepatic failure with encephalopathy, severe 
glucose intolerance, and extreme fluid restriction in 
renal failure patients. It should be avoided if 
experienced personnel (dietician, pharmacist, trained 
nurse, physician) are not available. 
 
Parenteral Feeding Solutions: 
The available feeding solution is delivered in 
one bag to be given over 24 hours. It includes 
solutions containing all nutrients including, glucose, 
fat, amino acids, vitamins, trace elements, mineral, 
electrolytes in required amount of fluid. The main 
advantage of using one single bag that contains all 
the ingredients are decreased risk of infection, 
Nutrition in the Surgical Patient 
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decreased manipulation, cost saving and time saving. 
Complete data regarding the patient's requirements is 
provided to the pharmacist by a nutritionist, to 
prepare a fresh infusion bag for 24 hours infusion.  
Individual solutions of glucose (5%, 10%, 25% 
dextrose), fat (10%, 20% lipids,) and amino acids are 
not usually available in resource-limited settings. 
 
Conclusion: 
In resource limited areas, the most available 
nutrition support is oral and enteral nutrition because 
of low cost and low risk of complication. This can be 
used in the provision of calories, protein, 
electrolytes, vitamins, minerals, trace elements, and 
fluids via an intestinal route. There are a wide range 
of hospital made oral nutrition supplements that can 
be delivered via this route depending on the 
nature/location of the condition. These include: 
(yogurt, milk shakes for high protein, juices for 
minerals and vitamins) formulas (clear liquids for gut 
assessment after procedures, soft liquid, thick fluids 
for individuals with dysphagia), and other types 
(high protein, high fiber, high calorie formulas.)  
Diet-based 
prescriptions 
are 
strictly 
individualized. Requirements are determined as per 
the patient’s physiological, functional, and nutrition 
status, and age. Some hospitals made oral 
supplements that can provide up to 300kcals and 12 
g of proteins and a full range of vitamins and 
minerals. In general, high protein oral supplements 
are most suitable for patients with wounds and those 
with malignancy.  
Post-operatively, surgeons normally indicate 
the format of nutrition support the patient will 
tolerate and what type to request for their patients. In 
consultation with the surgeon, the nutritionist then 
determines the patient’s requirements, and schedules 
a feeding regimen.  
 
Annastasia Waithera Maina 
AIC Kijabe Hospital 
Kenya 
 
 
Nutrition in the Surgical Patient 
Annastasia King’ori 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
 
 
Nutrition in the Surgical Patient 
Annastasia King’ori 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
All graphs source: World Health Organization 
https://www.who.int/tools/child-growth-
standards/standards/weight-for-age  
 
 
