Presentation on theme: "For the Surgical Patient"— Presentation transcript:
1 For the Surgical Patient NutritionFor the Surgical PatientKelly Sparks LDN, RD
2 Lecture Outline Energy Sources Nutrition Requirements Diet Advancement Micronutrients for wound healingEnteral versus Parenteral NutritionCase studies
3 Energy Sources Carbohydrates Fats Protein Limited storage capacity, needed for CNS functionYields 3.4 kcal/gramPitfall: too much=lipogenesis and increased CO2 productionFatsMajor endogenous fuel source in healthy adultsYields 9 kcal/gmPitfall: too little=essential fatty acid (linoleic acid deficiency-dermatitis and increased risk of infectionsProteinNeeded to maintain anabolic state (match catabolism)Yields: 4 kcal/gmPitfall: must adjust in patient with renal and hepatic failureElevated creatinine, BUN, and/or ammonia
4 Nutrition Requirements Healthy AdultsCalories: kcals/kgProtein: gm/kgFluids: 30 mls/kgRequirement Change for the Surgical PatientSpecial ConsiderationsStressInjury or diseaseSurgeryPre-hospital/pre-surgical nutrition
5 Nutrition The surgical patient… Poor Nutrition=Poor Outcomes Extraordinary stressors (hypovolemia, hypervolemia, bacteremia, medications)Wound HealingAnabolic state, appropriate vitamins (A, C, Zinc), and adequate kcals/protein.Poor Nutrition=Poor OutcomesFor every gram deficit of untreated hypoalbuminemia there is ~30% increase in mortality
6 Post-Operative Nutrition Requirements Calories:Increase to kcals/kgPatient on ventilator usually require lesscalories ~20-25 kcal/kgProtein:Increase to grams/kgFluids:Individualized
7 Diet Advancement Traditional Method: Start clear liquids when signs of bowel function returns.Rationale: Clear liquid diets supply fluid and electrolytes in a form that require minimal digestion and little stimulation of the GI tract.Clear liquids are intended for short-term use due to inadequacy
8 Diet Advancement Recent Evidence: Clinical study: Suggests that liquid diets and slow diet progression may not be warranted!!Clinical study:Looked at early post-operative feeding using regular diets or very fast progression vs. traditional methods of NPO until bowel function with slow diet progression and found no difference in post-operative complications. (emesis, distention, NGT reinsertion, LOS,)
9 Keep in Mind…Per SLPWhen using liquid diets, patients must have adequate swallowing functions.Even patients with mild dysphagia often require thickened liquids.Therefore, be specific in writing liquid diet orders for patients with dysphagia
10 Micronutrients in Wound Healing Vitamin Supplementation to promote healing has been somewhat disputed.Some studies show no significant effect unless there is a clinical vitamin deficiencySerum vitamin levels are not always accurate; therefore, must use subjective diet history and clinical judgment to determine deficiency.
11 Key Nutrients for Wound Healing Vitamin A:Cellular differentiation, proliferation, epithelialization,collagen synthesis, counteract catabolic effect of steroids.RDA=3333 International UnitsAppropriate dose=25,000 IU per day x 10 days in setting of high dose steroids or deficiency.Avoid long term supplementation due to high risk of toxicity with fat-soluble vitamins.No vitamin A with renal failure due to greater potent ional for toxicity. (Can exceed the binding capacity of retinol binding protein leading to elevated circulating levels.)
12 Key Nutrients for Wound Healing Vitamin C:Collagen synthesisRDA=50-90 mg/dayLow levels are common in high risk population (elderly, smokers, cancer, liver disease).Appropriate dose: 500 mg x 10 daysNo vitamin C with renal failure due to risk for renal oxalate stone formation.
13 Key Nutrients for Wound Healing Zinc:Protein synthesis, cellular replication, collagen formation; large wounds, chest tubes, and wound drains contribute to further zinc loses.Appropriate dose: 220 mg per day of Zinc Sulfate or50 mg of elemental Zinc x 10 days.Prolonged Zinc supplementation interferes with copper absorption and can lead to copper deficiency which delays wound healing by impairing collagen synthesis.MVI with minerals:1 tablet daily to compensate for any general micronutrient losses.
14 What is nutrition support? An alternate means of providing nutrients to people who cannot eat any or enough foodWhen is it needed?Illness resulting in inability to take in adequate nutrients by mouthIllness or surgery that results in malfunctioning gastrointestinal tractTwo types:Enteral nutritionParenteral nutrition
15 Indications for Enteral Nutrition Malnourished patient expected to be unable to eat adequately for > 5-7 daysAdequately nourished patient expected to be unable to eat > 7-9 daysAdaptive phase of short bowel syndromeFollowing severe trauma or burns
16 Contraindications to Enteral Nutrition Support Malnourished patient expected to eat within 5-7 daysSevere acute pancreatitisHigh output enteric fistula distal to feeding tubeInability to gain accessIntractable vomiting or diarrheaAggressive therapy not warrantedExpected need less than 5-7 days if malnourished or 7-9 days if normally nourished
17 Enteral Access Devices NasogastricNasoentericGastrostomyPEG (percutaneous endoscopic gastrostomy)Surgical or open gastrostomyJejunostomyPEJ (percutaneous endoscopic jejunostomy)Surgical or open jejunostomyTransgastric JejunostomyPEG-J (percutaneous endoscopic gastro-jejunostomy)Surgical or open gastro-jejunostomy
18 Feeding Tube Selection Can the patient be fed into the stomach, or is small bowel access required?How long will the patient need tube feedings?
19 Gastric vs. Small Bowel Access “If the stomach empties, use it.”Indications to consider small bowel access:Gastroparesis / gastric ileusRecent abdominal surgerySepsisSignificant gastroesophageal refluxPancreatitisAspirationIleusProximal enteric fistula or obstruction
20 Short-Term vs. Long-Term Tube Feeding Access No standard of care for cut-off time between short-term and long-term accessHowever, if patient is expected to require nutrition support longer than 6-8 weeks, long-term access should be considered
21 Choosing Appropriate Formulas Categories of enteral formulas:Polymeric (Jevity)Whole protein nitrogen source, for use in patients with normal or near normal GI functionMonomeric or elemental (Perative, Optimental)Predigested nutrients; most have a low fat content or high % of MCT oil (medium-chain triglycerides); for use in patients with severely impaired GI functionDisease specific (Nepro, Nutrahep, Glucerna)Formulas designed for feeding patients with specific disease statesFormulas are available for respiratory disease, diabetes, renal failure, hepatic failure, and immune compromise*well-designed clinical trials may or may not be available
22 Enteral Nutrition Prescription Guidelines Gastric feedingContinuous feeding:Start at rate 30 mL/hourAdvance in increments of 20 mL q 8 hours to goalCheck gastric residuals q 4 hoursBolus feeding:Start with mL bolusIncrease by 60 mL q bolus to goal volumeTypical bolus frequency every 3-8 hoursSmall bowel feedingContinuous feeding only; do not bolus due to risk of dumping syndromeStart at rate 20 mL/hourDo not check gastric residuals
23 Aspiration Precautions To prevent aspiration of tube feeding, keep HOB > 30° at all timesDo not use methylene blue to test for aspiration; regular blue food dye OK but not proven effective method of detecting aspiration
24 Complications of Enteral Nutrition Support Nausea and vomiting / delayed gastric emptyingMalabsorptionCommon manifestations include unexplained weight loss, steatorrhea, diarrheaPotential causes include gluten sensitive enteropathy, Crohn’s disease, radiation enteritis, HIV/AIDS-related enteropathy, pancreatic insufficiency, short gut syndrome
25 Enteral Nutrition Case Study 78-year-old woman admitted with new CVASignificant aspiration detected on bedside swallow evaluation and confirmed with modified barium swallow study; speech language pathologist recommended strict NPO with alternate means of nutritionPEG placed for long-term feeding accessPlan of care is to stabilize the patient and transfer her to a long-term care facility for rehabilitation
26 Enteral Nutrition Case Study (continued) Height: 5’4” IBW: 120# +/- 10%Weight: 130# / 59kg % IBWBMI: 22Usual weight: ~130# no weight changeEstimated needs:kcal (25-30 kcal/kg)59-71g protein (1-1.2 g/kg)1770 mL fluid (30 mL/kg)
27 Steps to determine the Enteral Nutrition Prescription Estimate energy, protein, and fluid needsSelect most appropriate enteral formulaDetermine continuous vs. bolus feedingDetermine goal rate to meet estimated needsWrite/recommend the enteral nutrition prescription
28 Enteral Nutrition Prescription Tube feeding via PEG with full strengthJevity 1.2Initiate at 30 mL/hour, advance by 20 mL q 8 hours to goalGoal rate = 55 mL/hour continuous infusionAbove goal will provide 1584 kcal, 73g protein, 1069 mL free H2OGive additional free H2O 175 mL QID to meet hydration needs and keep tube patentCheck gastric residuals q 4 hours; hold feeds for residual > 200 mLKeep HOB > 30° at all times
29 What is parenteral nutrition? also called "total parenteral nutrition," "TPN," or "hyperalimentation."It is a special liquid mixture given into the blood via a catheter in a vein.The mixture contains all the protein, carbohydrates, fat, vitamins, minerals, and other nutrients needed.
30 Indications for Parenteral Nutrition Support Malnourished patient expected to be unable to eat > 5-7 days AND enteral nutrition is contraindicatedPatient failed enteral nutrition trial with appropriate tube placement (post-pyloric)Enteral nutrition is contraindicated or severe GI dysfunction is presentParalytic ileus, mesenteric ischemia, small bowel obstruction, enteric fistula distal to enteral access sites
31 PPN vs. TPN TPN (total parenteral nutrition) High glucose concentration (15%-25% final dextrose concentration)Provides a hyperosmolar formulation ( mOsm/L)Must be delivered into a large-diameter vein through central line.PPN (peripheral parenteral nutrition)Similar nutrient components as TPN, but lower concentration (5%-10% final dextrose concentration)Osmolarity < 900 mOsm/L (maximum tolerated by a peripheral vein)May be delivered into a peripheral veinBecause of lower concentration, large fluid volumes are needed to provide a comparable calorie and protein dose as TPN
32 Parenteral Access Devices Peripheral venous accessCatheter placed percutaneously into a peripheral vesselCentral venous access (catheter tip in SVC)Percutaneous jugular, femoral, or subclavian catheterImplanted ports (surgically placed)PICC (peripherally inserted central catheter)
33 Writing TPN prescriptions Determine total volume of formulation based on individual patient fluid needsDetermine amino acid (protein) contentAdequate to meet patient’s estimated needsDetermine dextrose (carbohydrate) content~70-80% of non-protein caloriesDetermine lipid (fat) content~20-30% non-protein caloriesDetermine electrolyte needsDetermine acid/base statusCheck to make sure desired formulation will fit in the total volume indicated
34 Parenteral Nutrition Monitoring Check daily electrolytes and adjust TPN/PPN electrolyte additives accordinglyCheck accu-check glucose q 6 hours (regular insulin may be added to TPN/PPN bag for glucose control as needed)Non-diabetics or NIDDM: start with half of the previous day’s sliding scale insulin requirement in TPN/PPN bag and increase daily in the same manner until target glucose is reachedIDDM: start with 0.1 units regular insulin per gram of dextrose in TPN/PPN, then increase daily by half of the previous day’s sliding scale insulin requirementCheck triglyceride level within 24 hours of starting TPN/PPNIf TG > mg/dL, lipid infusion should be significantly reduced or discontinuedConsider adding carnitine 1 gram daily to TPN/PPN to improve lipid metabolism~100 grams fat per week is needed to prevent essential fatty acid deficiency
35 Parenteral Nutrition Monitoring (continued) Check LFT’s weeklyIf LFT’s significantly elevated as a result of TPN, then minimize lipids to < 1 g/kd/day and cycle TPN/PPN over 12 hours to rest the liverIf Bilirubin > 5-10 mg/dL due to hepatic dysfunction, then discontinue trace elements due to potential for toxicity of manganese and copperCheck pre-albumin weeklyAdjust amino acid content of TPN/PPN to reach normal pre-albumin mg/dLAdequate amino acids provided when there is an increase in pre-albumin of ~1 mg/dL per day
36 Parenteral Nutrition Monitoring (continued) Acid/base balanceAdjust TPN/PPN anion concentration to maintain proper acid/base balanceIncrease/decrease chloride content as neededSince bicarbonate is unstable in TPN/PPN preparations, the precursor—acetate—is used; adjust acetate content as needed
37 Complications of Parenteral Nutrition Hepatic steatosisMay occur within 1-2 weeks after starting PNMay be associated with fatty liver infiltrationUsually is benign, transient, and reversible in patients on short-term PN and typically resolves in daysLimiting fat content of PN and cycling PN over 12 hours is needed to control steatosis in long-term PN patients
38 Complications of Parenteral Nutrition Support (continued) CholestasisMay occur 2-6 weeks after starting PNIndicated by progressive increase in TBili and an elevated serum alkaline phosphataseOccurs because there are no intestinal nutrients to stimulate hepatic bile flowTrophic enteral feeding to stimulate the gallbladder can be helpful in reducing/preventing cholestasisGastrointestinal atrophyLack of enteral stimulation is associated with villus hypoplasia, colonic mucosal atrophy, decreased gastric function, impaired GI immunity, bacterial overgrowth, and bacterial translocationTrophic enteral feeding to minimize/prevent GI atrophy
39 Parenteral Nutrition Case Study 55-year-old male admitted with small bowel obstructionHistory of complicated cholecystecomy 1 month ago. Since then patient has had poor appetite and 20-pound weight lossPatient has been NPO for 3 days since admitRight subclavian central line was placed and plan noted to start TPN since patient is expected to be NPO for at least 1-2 weeks
40 Parenteral Nutrition Case Study (continued) Height: 6’0” IBW: 178# +/- 10%Weight: 155# / 70kg % IBWBMI: 21Usual wt: 175# % wt loss x 1 mo.Estimated needs:kcal (30-35 kcal/kg)84-98g protein ( g/kg)mL fluid (30-35 mL/kg)
41 Parenteral Nutrition Prescription TPN via right-SC line2200 mL total volume x 24 hoursAmino acid: 45 g/liter=45g x 2.2 L= 99 grams x 4 kcals/gram =369 kcalsDextrose 175 g/liter=175g x 2.2 L= 385 grams x 3.4 kcals/gram= 1309 kcalsLipid 20% 285 mL over 24 hours285 mls x 2= 570 kcalsAbove will provide 2275 kcal, 99g protein,DIR=(385 g dex/ 70 kg /1440 minute in a day)*1000= 3.8mg/kg/minLIR= (285 mls lipid * 20%)/ 70 kg=0.8 g/kg/day
42 Parenteral Nutrition Prescription Important items to consider:Dextrose infusion rate should be < 4 mg/kg/minute (maximum tolerated by the liver) to prevent hepatic steatosisLipid infusion rate should be less than 1 g/kg/day to minimize/prevent TPN-induced liver dysfunctionYou may need to adjust/eliminate lipids if patient is on propofol. (1 ml propofol =1.1 kcal)Ex. 10 ml/hr would provide 264 kcals(10 ml/hr x 1.1 kcal/ml, x 24 hrs)Initiate TPN at ~½ of goal rate/concentration and gradually increase to goal over 2-3 days to optimize serum glucose control
43 Benefits of Enteral Nutrition Over Parenteral Nutrition CostTube feeding cost ~ $10-20 per dayTPN costs up to $1000 or more per day!Maintains integrity of the gutTube feeding preserves intestinal function; it is more physiologicTPN may be associated with gut atrophyLess infectionEnteral feeding—very small risk of infection and may prevent bacterial translocation across the gut wallTPN—high risk/incidence of infection and sepsis
44 Refeeding Syndrome“the metabolic and physiologic consequences of depletion, repletion, compartmental shifts, and interrelationships of phosphorus, potassium, and magnesium…”Severe drop in serum electrolyte levels resulting from intracellular electrolyte movement when energy is provided after a period of starvation (usually > 7-10 days)Physiologic and metabolic sequelae may include:EKG changes, hypotension, arrhythmia, cardiac arrestWeakness, paralysisRespiratory depressionKetoacidosis / metabolic acidosis
45 Refeeding Syndrome (continued) Prevention and TherapyCorrect electrolyte abnormalities before starting nutrition supportContinue to monitor serum electrolytes after nutrition support begins and replete aggressivelyInitiate nutrition support at low rate/concentration (~ 50% of estimated needs) and advance to goal slowly in patients who are at high risk
46 Consequences of Over-feeding Risks associated with over-feeding:HyperglycemiaHepatic dysfunction from fatty infiltrationRespiratory acidosis from increased CO2 productionDifficulty weaning from the ventilatorRisks associated with under-feeding:Depressed ventilatory driveDecreased respiratory muscle functionImpaired immune functionIncreased infection
47 QuestionsReference:American Society for Parenteral and Enteral Nutrition. The Science and Practice of Nutrition SupportHan-Geurts, I.J, Jeekel,J.,Tilanus H.W, Brouwer,K.J., Randomized clinical trial of patient-controlled versus fixed regimen feeding after elective abdominal surgery. British Journal of Surgery. 2001, Dec;88(12):Jeffery K.M., Harkins B., Cresci, G.A., Marindale, R.G., The clear liquid diet is no longer a necessity in the routine postoperative management of surgical patients. American Journal of Surgery.1996 Mar; 62(3):167-70Reissman.P., Teoh, T.A., Cohen S.M., Weiss, E.G., Nogueras, J.J., Wexner, S.D. Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial. Annals of Surgery July;222(1):73-7.Ross, R. Micronutrient recommendations for wound healing. Support Line. 2004(4): 4.