Presentation on theme: ". . . and the surgical patient Carli Schwartz, RD,LDN"— Presentation transcript:
1 . . . and the surgical patient Carli Schwartz, RD,LDN Nutrition. . . and the surgical patientCarli Schwartz, RD,LDN
2 Nutrition and SurgeryMalnutrition may compound the severity of complications related to a surgical procedureA well-nourished patient usually tolerates major surgery better than a severely malnourished patientMalnutrition is associated with a high incidence of operative complications and death.
4 The Newest Food Guide Pyramid Balancing Calories ● Enjoy your food, but eat less. ● Avoid oversized portions. Foods to Increase ● Make half your plate fruits and vegetables. ● Make at least half your grains whole grains. ● Switch to fat-free or low-fat (1%) milk. Foods to Reduce ● Compare sodium in foods like soup, bread, and frozen meals ― and choose the foods with lower numbers. ● Drink water instead of sugary drinks. Website:Includes interactive tools including a personalized daily food plan and food tracker
5 Macronutrients Carbohydrates Main sources include grains, fruits and beansLimited storage capacity, needed for CNS (glucose) functionYields 3.4 kcal/gmRecommended 45-65% total daily calories.FatsMain sources include oil, nuts, butter, milk and cheeseMajor endogenous fuel source in healthy adultsYields 9 kcal/gmToo little can lead to essential fatty acid (linoleic acid) deficiency and increased risk of infectionsRecommended 20-30% of total caloric intakeProteinMain sources include fish, beef, poultry and dairy productsNeeded to maintain anabolic state (match catabolism)Yields 4 kcal/gmMust adjust in patients with renal and hepatic failureRecommended 10-35% of total caloric intake.
9 The surgical patient . . . . Increased risk of malnutrition due to: Nutrient depletion occurs in the surgical patient due to decreased intake, increased metabolic expenditure and altered nutrient use.Increased risk of malnutrition due to:Inadequate nutritional intakeMetabolic response (hypermetabolism from long term inflammation or infectious conditions)Nutrient losses without proper replenishmentProtein /energy store depletionDiminished nutrient intake (pre/post operative)Prevalence of GI obstruction, anorexia, malabsorptionExtraordinary stressors (surgical stress, hypovolemia, sepsis, bacteremia, medications)Wound healingAnabolic state, higher demand for nutrients (amino acids, zinc, vitamin A & C, arginine)
10 Perioperative Nutritional Assessment Individuals are generally classified as well nourished or mildly, moderately, or severely malnourished1: well nourished: no significant weight change; preoperative serum albumin > 3.5 g/dL2. Mildly malnourished: <10% wt loss; preoperative serum albumin g/dL3. Moderately malnourished: 10-20% wt loss; preoperative serum albumin g/dL4. Severely malnourished: >20% wt loss; preoperative serum albumin < 2.5 g/dLNutritional assessment parameters also include a complete medical history, surgical history, social history, diet history, physical exam, anthropometric and laboratory evaluations.
11 Visceral Proteins Albumin Normal range: 3.5-5 g/dL. Synthesized in and catabolized by the liverPro: often ranked as the strongest predictor of surgical outcomes- inverse relationship between postoperative morbidity and mortality compared with preoperative serum albumin levelsCon: lack of specificity due to long half-life (approximately 20 days). Not accurate in pt’s with liver disease or during inflammatory response
12 Visceral proteinsPrealbumin (transthyretin) - transport protein for thyroid hormone, synthesized by the liver and partly catabolized by the kidneys.Normal range:16 to 40 mg/dL; values of <16 mg/dL are associated with malnutrition.Pro: Shorter half life (two to three days) making it a more favorable marker of acute change in nutritional status. A baseline prealbumin is useful as part of the initial nutritional assessment if routine monitoring is planned.Cons: More expensive than albumin. Levels may be increased in the setting of renal dysfunction, corticosteroid therapy, or dehydration, whereas physiological stress, infection, liver dysfunction, and over-hydration can decrease prealbumin levels.
13 Visceral proteinsTransferrin: acute-phase reactant and a transport protein for ironnormal range: 200 to 360 mg/dL.Medium half-life (8-10 days)Smaller body pool than albumin, reflects more acute changes.influenced by several factors, including liver disease, fluid status, inflammation, iron status and illness.Cons: not studied extensively as albumin and pre-albumin in relation to nutritional status, may indicator more about iron metabolismLevels decrease in the setting of severe malnutrition, however unreliable in the assessment of mild malnutrition
14 Other measures of nutrition status Nitrogen balance: the relationship between the amount of nitrogen taken into the body, usually as food, and that excreted from the body in urine and feces. Most of the body's nitrogen is incorporated into protein.Protein ~ 16% nitrogenProtein intake (gm)/ (UUN +4)= balance in gramsPositive value: found during periods of growth, tissue repair or pregnancy. This means that the intake of nitrogen into the body is greater than the loss of nitrogen from the body, so there is an increase in the total body pool of protein.Negative value: can be associated with burns, fevers, wasting diseases and other serious injuries and during periods of fasting. This means that the amount of nitrogen excreted from the body is greater than the amount of nitrogen ingested.Healthy Humans= Nitrogen EquilibriumCons: Complex determination of balance, measures of losses difficult and limited utility in clinical setting
15 Feeding the patient: Post-operative Nutrient Provision
16 Traditional Method: Diet advancement Introduction of solid food depends on the condition of the GI tract.Oral feeding delayed for hours after surgeryWait for return of bowel sounds or passage of flatus.Start clear liquids when signs of bowel function returnsRationaleClear liquid diets supply fluid and electrolytes that require minimal digestion and little stimulation of the GI tractClear liquids are intended for short-term use due to inadequacy
17 Things to Consider…For liquid diets, patients must have adequate swallowing functionsEven patients with mild dysphagia often require thickened liquids.Must be specific in writing liquid diet orders for patients with dysphagiaThere is no physiological reason for solid foods not to be introduced as soon as the GI tract is functioning and a few liquids are being tolerated. Multiple studies show patients can be fed a regular solid-food diet after surgery without initiation of liquid diets.
18 Diet AdvancementAdvance diet to full liquids followed by solid foods, depending on patient’s tolerance.Consider the patient’s disease state and any complications that may have come about since surgery.Ex: steroid-induced diabetes in a post-kidney transplant patient.
20 Perioperative Nutritional Support Length of time a patient can remain NPO after surgery without complications is unknown, however depends on:Severity of operative stressPatient’s preexisting nutritional statusNature and severity of illness“In uncomplicated cases, well nourished patients tolerate up to 10 days of starvation with no medical complications. Moderately or severely malnourished patients usually require nutritional support earlier.” (A.S.P.E.N Nutrition Support Practice Manual 2nd Ed)
21 Goals of perioperative Nutrition Support Decrease surgical mortalityDecrease surgical complications and infectionReduce the catabolic state and restore anabolismSupport the depleted patient throughout the catabolic phase of recoveryDecrease hospital LOSSpeed the healing/recovery processEnsure the prompt return of GI function to resume standard oral intake as soon as possible
22 Perioperative Nutrition Support Guidelines The American Society for Parenteral and Enteral Nutrition evidence-based practice guidelines1. preoperative specialized nutrition support should be administered for 7-14 days to moderately or severely malnourished pts undergoing major surgery2. PN should not be routinely given in the immediate post-op period to pts undergoing major GI procedures3. Postoperative nutrition support should be administered to patients who are expected to be unable to meet their nutrient needs orally for 7-10 days
24 Nutrition Support Enteral Nutrition Support Parenteral Nutrition support
25 What is enteral nutrition? Also called "tube feeding," enteral nutrition is a liquid mixture of all the needed nutrients.Consistency is sometimes similar to a milkshake.It is given through a tube in the stomach or small intestine.If oral feeding is not possible, or an extended NPO period is anticipated, an access devise for enteral feeding should be inserted at the time of surgery.Feeds can meet 100% of patient’s needs or can be used to supplement poor po intake.
26 Indications for Enteral Nutrition When the GI tract is functional or partially functional and…..Patient has inability to consume or absorb adequate nutrients.Patient is not meeting > 75% of needs with po intake.Malnourished patient expected to be unable to eat adequately for > 5-7 daysAdequately nourished patient expected to be unable to eat > 10 days
27 Contraindications to Enteral Nutrition Support Expected need less than 5-7 days if malnourished or 7-9 days if normally nourishedSevere acute pancreatitisSmall bowel obstruction, ileus or high output enteric fistula distal to feeding tubeInability to gain accessHemodynamic instabilityNeed for high dose pressors/vasoactivesMAP consistently < 60 mmHgIntractable vomiting or diarrheaThose requiring massive fluid resuscitation
28 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
29 Feeding Tube Selection Can the patient be fed into the stomach, or is small bowel access required?2) How long will the patient need tube feedings?
30 Gastric vs. Small Bowel Access Gastric access: “If the stomach empties, use it.”Indications to consider small bowel access:Gastroparesis / gastric ileusRecent abdominal surgerySepsisSignificant gastroesophageal refluxPancreatitisAspirationIleusProximal enteric fistula or obstruction
31 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
32 Choosing Appropriate Formulas Categories of enteral formulas:PolymericWhole protein nitrogen source, for use in patients with normal or near normal GI function. Examples include Ensure and Jevity.Monomeric or elementalPredigested nutrients; most have a low fat content or high % of MCT; for use in patients with severely impaired GI function. Examples include Peptamen and OptimentalDisease specificFormulas designed for feeding patients with specific disease statesFormulas are available for respiratory disease, diabetes, renal failure, hepatic failure, and immune compromise. Examples include Glucerna and Nepro*well-designed clinical trials may or may not be available
34 Complications of Enteral Nutrition Support Issues with access, administration, GI complications, metabolic complications. These include:Nausea, vomitting, diarrhea, constipation, delayed gastric emptying, malabsorption, refeeding syndrome, hyponatremia, microbial contamination, tube obstruction, leakage from ostomy/stoma site, micronutrient deficiencies.
35 Implementation of Enteral Nutrition Gastric feedingPump assisted: Continuous feeding and cyclic feedingAllows for max nutrient absoroption and improved tolerancebest in sicker/hospitalized patientsStart at rate 30 mL/hour and advance in increments of 20 mL q 8 hours to goal. Check gastric residuals q 4 hours for toleranceGravity Controlled: Bolus feedingInfusion of a predetermined volume of formula at specified intervals. Example: 1 can Glucerna (240 ml) via PEG tube q 4 hours.Easiest, least expensive, more physiologic (mimic normal eating pattern)Small bowel feedingContinuous feeding only; do not bolus due to risk of dumping syndromeStart at low volume to assess tolerance (20 mL/hour)Advance in increments of 20 mL q 8 hours to goalDo not check gastric residuals
36 Determining Your 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
37 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
38 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)
39 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
40 What is parenteral nutrition? also called "total parenteral nutrition," "TPN," or "hyperalimentation."Defined as nutrients provided intravenously.Components of a PN mixture include:Protein (Amino Acids) , carboydrates (dextrose) , Fats (Long-chain fatty acids), sterile water, electrolytes, vitamins and trace mineralsFor use in nutritionally compromised patients when enteral nutrition is contra-indicated.
41 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
42 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 veinPPN (peripheral parenteral nutrition)Similar nutrient components as TPN, but lower glucose 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
43 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)
44 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 calories or ~50% calorie needsDetermine lipid (fat) content~20-30% non-protein caloriesDetermine electrolyte needsDetermine acid/base status based on chloride and co2 levelsCheck to make sure desired formulation will fit in the total volume indicated
45 Parenteral Nutrition Prescription Important items to consider:Glucose infusion rate should be < 5 mg/kg/minute (maximum tolerated by the liver) to prevent hepatic steatosisLipid infusion should be < 0.1 g/kg/hour (ideally < 0.4 g/kg/day to minimize/prevent TPN-induced liver dysfunction)Initiate TPN at ~½ of goal rate/concentration and gradually increase to goal over 2-3 days to optimize serum glucose control
47 Parenteral Nutrition Monitoring Electrolytes -adjust TPN/PPN electrolyte additives daily according to labsCheck accu-check glucose q 6 hoursRegular insulin may be added to TPN/PPN bag for glucose control as neededCheck triglyceride level within 24 hours of starting TPN/PPNIf TG > mg/dL, lipid infusion should be significantly reduced or discontinuedDaily addition of Carnitine to TPN/PPN may improve lipid metabolism~100 grams fat per week is needed to prevent essential fatty acid deficiencyCheck 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 dayAcid/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
48 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 patientsCholestasisOccurs because there are no intestinal nutrients to stimulate hepatic bile flowMay occur 2-6 weeks after starting PNIndicated by progressive increase in TBili and an elevated serum alkaline phosphatase*Trophic 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 translocation*Trophic enteral feeding to minimize/prevent GI atrophy
49 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
50 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)
51 Parenteral Nutrition Prescription TPN via right-SC line2 L total volume x 24 hoursAmino acid 4.5% (or 45 g/liter)Dextrose 17.5% (or 175 g/liter)Lipid 20% 285 mL over 24 hoursAbove will provide 2120 kcal, 90g protein, glucose infusion rate 3.5 mg/kg/minute, lipid 0.9 g/kg/day
52 Benefits of Enteral Nutrition over parenteral nutrition CostTube feeding cost ~ $10-20 per dayTPN cost ~ $100 or more per day!Maintains integrity of the gutTube feeding preserves intestinal function; it is more physiologicTPN may be associated with gut atrophyLess infectionTube feeding—very small risk of infection and may prevent bacterial translocation across the gut wallTPN—high risk/incidence of infection and sepsis
53 Transitional Feedings Parenteral to enteral feedingsIntroduce a minimal amount of enteral feeding at a low rate (30-40 ml/hr) to establish tolerance.Decrease PN level slowly to keep nutrient levels at same prescribed amountAs enteral rate is increased by ml/hr increments every 8-24 hrs, parenteral can be reducedDiscontinue PN solution if 75% of nutrient needs met by enteral route.Parenteral/Enteral to oral feedingsIdeally accomplished by monitoring oral intake and concomitantly decreasing rate of nutrition support until 75% of needs are met.Oral supplements are useful if needs not met 100% by diet. Ex (Nepro, Glucerna, Boost, Ensure).
54 Dangers of Over and Under Feeding Risks associated with over-feeding:HyperglycemiaHepatic dysfunction from fatty infiltrationRespiratory acidosis from increased CO2 productionDifficulty weaning from the ventilatorRefeeding syndromeRisks associated with under-feeding:Depressed ventilatory driveDecreased respiratory muscle functionImpaired immune functionIncreased infectionWeight loss and malnutrition
55 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
56 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
58 ReferencesAmerican 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.Krause’s Food, Nutrition & Diet Therapy, 11th Ed. Mahan, K., Stump, S. Saunders, 2004.