1. Nutrition in Surgical Patients
Nicky Wyer MSc, RD
Senior Specialist Dietitian
UHCW Nutrition Support Team

2. Learning objectives To understand:
Who is at risk of malnutrition and how to identify
The impact of malnutrition on surgical plans and outcomes
Understanding of routes for nutrition support
How to address common symptoms in the surgical patient that impact on nutritional intake
Who to refer to

3. What is malnutrition?

4. Definition of Malnutrition
There is no universally accepted definition of malnutrition but the following is increasingly being used from RCP 2002:
A state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome
‘Malnutrition’ refers to both under and over-nutrition (but more commonly used for under-nutrition)

5. Malnutrition does it matter?
What is the overall aim of your surgical team?
A malnourished patient will have 3 x higher rate of complications and 4 x greater risk of death from the same surgery compared to a well nourished patient (NICE 2006)

6. Effects of Undernutrition
Psychiatric
Anhedonia
Depression
Confusion
Anorexia
?Micronutrient deficiency
Immunity
Increased infection risk
Impaired wound healing
Wound infections
Wound breakdown
Anastamotic leak
Hospital acquired pneumonia
Renal failure
Return to theatre for revisional surgery
Morbidity
Mortality
Respiratory
Decreased tidal volumes
Reduced muscle bulk
Loss of adaptive response to hypoxia
Cardiac
Reduced cardiac output
CCF
Hepatic
Fatty Liver
Necrosis/ Fibrosis
Renal
Reduced Na & H2O excretion
Gut
Reduced immunity
Reduced integrity
Oedema
Other
Reduced muscle strength
Neurological weakness
Inability to regulate temperature

7. The Extent of ‘The Problem’ [1]
Estimated > 3 million people in the UK are at risk of malnutrition at any one time (Elia & Russell, 2009)
Under-recognised & under-treated
Public health expenditure on disease-related malnutrition in the UK (2007) > 13 billion per annum (Elia & Russell, 2009)
Elia M, Russell CA. Combating malnutrition: Recommendations for action: A report from the Advisory Group on Malnutrition led by BAPEN,2009
80% of this expenditure was in England
40% of adult hospital patients are overtly malnourished on admission. 8% categorised as severe.

8. Who’s at risk? Patients with Altered Elderly Nutritional Requirements:
Critical care
Sepsis
Cancer
Trauma
Surgery
Renal Failure
Liver Disease
GI & pancreatic disorders
COPD
Pregnancy
Elderly
Chronic ill-health e.g. diabetes, renal, COPD, neuro
Cancer
Deprivation / poverty
GI disorders / post GI surgery
Alcoholics / Drug Dependency

9. Identification: Nutrition Screening

10. Sometimes we miss the obvious

11. Albumin
Commonly used by the medical profession as a marker for nutritional state
Albumin is not a marker for nutrition
Albumin indicates disease state not nutrition
Poor nutritional state can coexist with illness but albumin does not indicate malnutrition
No single biochemical marker can be used to assess nutrition

12. Other causes of Low Albumin
Common
Least Common
Sepsis - CRP; ALB
Acute & Chronic inflammatory conditions
Cirrhosis/ Liver disease
Nephrotic syndrome
Malabsorption
Malnutrition
Hypoalbuminaemia is an important prognostic indicator. The lower the level, the higher the mortality

13. ESPEN guidelines (2006) for enteral nutrition in surgery
Significantly malnourished pts having elective major surgery should be considered for preoperative nutrition support, this may involve tube feeding for days pre-op
Oral intake should be resumed as soon as possible after surgery, usually within 24hrs, with monitoring
Tube feeding (EN) should be given immediately post op for pts anticipated to be unable to eat for > 7days & for pts who cannot maintain oral diet >60% requirements for >10 days
PN should be reserved for malnourished patients who cannot be fed via the GIT for at least 7 days

14. Nutrition screen on admission
Elective
Emergency
Nutrition screen on admission
Nutrition screening in OPC
+/-ERAS protocol
High Risk
Low Risk
High Risk
Low Risk
Post operative nutrition support
Rescreen weekly
Pre-op nutrition support & goal setting

15. Components of the ERAS multimodal care pathway

16. Options for nutrition support
Oral nutrition support
Enteral tube feeding
Nasogastric
Nasojejunal
PEG / RIG
Jejunostomy
Parenteral feeding
Aim for the least invasive method required to achieve goals

17. Oral nutrition support – food first
High calorie, high protein diet
Snacks, puddings
Majority of patients can resume a normal diet within hours of surgery
Avoid unnecessary restrictions

18. Oral nutritional supplements
Not all the same!
Consideration should be given to what product best addresses the identified nutritional deficiencies prior to prescribing
Co-morbidities will also affect choice e.g. milk protein allergy, diabetes, fat malabsorption, renal disease, coeliac disease
Not all patients need supplements forever!!

19. Altered level of consciousness
Nausea
Diarrhoea
Key symptoms which affect ability for patient to take oral or enteral nutrition
Vomiting or
high NG
aspirates
Pain
Constipation

20. Addressing symptoms
Nausea / vomiting: anti emetics, prokinetics, ensuring bowels opening
Pain: analgesia
Constipation: laxatives, enemas
Swallowing: SALTx, altered consistency diet/fluids

21. Feeding routes - enteral
Gastric
Nasogastric tube: patients at high risk of aspiration, swallowing problems, unconscious. Can be used in addition to oral nutrition. Nasal bridles for some patients

22. Feeding routes - enteral
Gastric
PEG / RIG / surgical gastrostomy: the placement of a tube through the abdominal wall directly into the stomach. Long term nutrition support. Prophylactic in H&N cancer

23. Feeding routes - enteral
Jejunal
Nasojejunal (NJ) tube - jejunal feeding tube passed endoscopically via the nasal passage
Surgical jejunostomy – jejunal feeding tube directing through the abdomen into the small bowel
Gastroparesis, UGI
surgery

24. Parenteral nutrition (PN)
Administration of nutrients, fluids and electrolytes directly into a central or peripheral vein
Traditionally associated with complications
However PN used appropriately, with close attention to glycaemic control and avoidance of overfeeding can safely deliver adequate nutrition

25. Who needs it?
Patients who are malnourished or who are likely to become malnourished and where the GI tract is not fully functional or is inaccessible (NICE 2006)
PN anticipated to be needed >7/7
TPN should be avoided where aggressive nutritional support not indicated or where the risks outweigh the benefits

26. If the gut works, use it! If the gut works a little, use it a little

27. Referrals
Dietitian – oral nutrition support (food, supplements), enteral feed rotas (NG, PEG, NJ, jej), other dietary modifications
Nutrition Team – PEG assessments, assessment for nasal bridle, complicated EN, ethical dilemas re feeding route, all PN patients

28. Case examples Mr X, 75, admitted as emergency with #NOF
PMH HTN, osteoporosis
Post operatively: poor intake of diet
What would you want to know?
What would you do?

29. Mr X
Pre admission nutritional state – weight, height, BMI, usual intake, weight history
Symptoms which may be affecting his appetite – nausea/pain/constipation
Nutrition risk score (MUST)
Plan: ONS – food first / supplements, Dietitian, consider NGT

30. Case examples Outpatient clinic
Mrs S has oesophageal cancer, due for an elective oesophagectomy
PMH Type 2 DM
What would you want to know
What might your plan be?

31. Mrs S
Nutritional state: weight, weight history, BMI, swallowing, current nutritional intake / any impairment, other symptoms. Nutrition risk score: MUST
Consider pre operative nutrition support if malnourished – outpatient / inpatient
Consider post operative feeding tube due to impact that surgery will have on ability to eat – surgical jejunostomy or NJ

32. Case example Inpatient
Mr D. Emergency admission with severe abdo pain. Emergency laparotomy for ischaemic bowel with stoma formation
What would you want to know
What might the plan be?

33. Mr D
Nutritional state: weight, BMI, weight loss, intake prior to admission, symptoms – type/duration. MUST score
How much bowel remaining and site of stoma. Quality of remaining bowel
Nutrition route could be oral +/- enteral tube or equally may need PN for short or long term

34. Conclusion Malnutrition significantly affects outcomes from surgery
Identification of malnourished patients enables appropriate treatments to be initiated to promote the rapid recovery and discharge of surgical patients
Nutrition support should be provided for patients identified at risk of malnutrition from nutrition screening aiming for the least invasive route
Treatment of symptoms inhibiting oral or enteral nutrition an important aspect of surgical teams plan

35. References
Anderson MR, O’Connor M, Mayer P, O’Mahony D, Woodward J, Kane,K. (2003). The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high- risk dysphagia stroke patients. Clinical Nutrition. Vol 23. No 4
ERAS society guidelines (joint publications with ESPEN):
ESPEN (2006). Guidelines on enteral nutrition: surgery including organ transplantation. Clinical Nutrition 25: 224 – 244
ESPEN (2009). Guidelines on parenteral nutrition: surgery. Clinical Nutrition 28:
Gustafsson UO, Nygren J, Thorell A, Soop M, Hellström PM, Ljungqvist O, Hagström-Toft E. (2008). Pre-operative carbohydrate loading on postoperative hyperglycaemia in hip fracture patients: A randomised control clinical study. Acta Anaesthesiol Scand Aug;52(7):946-51
NICE (2006) Nutrition Support in Adults: oral supplements, enteral and parenteral feeding. NICE
Powell-Tuck et al. (2011) British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP). BAPEN