For the Surgical Patient Nutrition For the Surgical Patient Kelly Sparks LDN, RD

Lecture Outline Energy Sources Nutrition Requirements Diet Advancement Micronutrients for wound healing Enteral versus Parenteral Nutrition Case studies

Energy Sources Carbohydrates Fats Protein Limited storage capacity, needed for CNS function Yields 3.4 kcal/gram Pitfall: too much=lipogenesis and increased CO2 production Fats Major endogenous fuel source in healthy adults Yields 9 kcal/gm Pitfall: too little=essential fatty acid (linoleic acid deficiency-dermatitis and increased risk of infections Protein Needed to maintain anabolic state (match catabolism) Yields: 4 kcal/gm Pitfall: must adjust in patient with renal and hepatic failure Elevated creatinine, BUN, and/or ammonia

Nutrition Requirements Healthy Adults Calories: 25-35 kcals/kg Protein: 0.8-1 gm/kg Fluids: 30 mls/kg Requirement Change for the Surgical Patient Special Considerations Stress Injury or disease Surgery Pre-hospital/pre-surgical nutrition

Nutrition The surgical patient… Poor Nutrition=Poor Outcomes Extraordinary stressors (hypovolemia, hypervolemia, bacteremia, medications) Wound Healing Anabolic state, appropriate vitamins (A, C, Zinc), and adequate kcals/protein. Poor Nutrition=Poor Outcomes For every gram deficit of untreated hypoalbuminemia there is ~30% increase in mortality

Post-Operative Nutrition Requirements Calories: Increase to 30-40 kcals/kg Patient on ventilator usually require less calories ~20-25 kcal/kg Protein: Increase to 1-1.8 grams/kg Fluids: Individualized

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

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,)

Keep in Mind… Per SLP When 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

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 deficiency Serum vitamin levels are not always accurate; therefore, must use subjective diet history and clinical judgment to determine deficiency.

Key Nutrients for Wound Healing Vitamin A: Cellular differentiation, proliferation, epithelialization, collagen synthesis, counteract catabolic effect of steroids. RDA=3333 International Units Appropriate 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.)

Key Nutrients for Wound Healing Vitamin C: Collagen synthesis RDA=50-90 mg/day Low levels are common in high risk population (elderly, smokers, cancer, liver disease). Appropriate dose: 500 mg x 10 days No vitamin C with renal failure due to risk for renal oxalate stone formation.

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 or 50 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.

What is nutrition support? An alternate means of providing nutrients to people who cannot eat any or enough food When is it needed? Illness resulting in inability to take in adequate nutrients by mouth Illness or surgery that results in malfunctioning gastrointestinal tract Two types: Enteral nutrition Parenteral nutrition

Indications for Enteral Nutrition Malnourished patient expected to be unable to eat adequately for > 5-7 days Adequately nourished patient expected to be unable to eat > 7-9 days Adaptive phase of short bowel syndrome Following severe trauma or burns

Contraindications to Enteral Nutrition Support Malnourished patient expected to eat within 5-7 days Severe acute pancreatitis High output enteric fistula distal to feeding tube Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted Expected need less than 5-7 days if malnourished or 7-9 days if normally nourished

Enteral Access Devices Nasogastric Nasoenteric Gastrostomy PEG (percutaneous endoscopic gastrostomy) Surgical or open gastrostomy Jejunostomy PEJ (percutaneous endoscopic jejunostomy) Surgical or open jejunostomy Transgastric Jejunostomy PEG-J (percutaneous endoscopic gastro-jejunostomy) Surgical or open gastro-jejunostomy

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?

Gastric vs. Small Bowel Access “If the stomach empties, use it.” Indications to consider small bowel access: Gastroparesis / gastric ileus Recent abdominal surgery Sepsis Significant gastroesophageal reflux Pancreatitis Aspiration Ileus Proximal enteric fistula or obstruction

Short-Term vs. Long-Term Tube Feeding Access No standard of care for cut-off time between short-term and long-term access However, if patient is expected to require nutrition support longer than 6-8 weeks, long-term access should be considered

Choosing Appropriate Formulas Categories of enteral formulas: Polymeric (Jevity) Whole protein nitrogen source, for use in patients with normal or near normal GI function Monomeric 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 function Disease specific (Nepro, Nutrahep, Glucerna) Formulas designed for feeding patients with specific disease states Formulas are available for respiratory disease, diabetes, renal failure, hepatic failure, and immune compromise *well-designed clinical trials may or may not be available

Enteral Nutrition Prescription Guidelines Gastric feeding Continuous feeding: Start at rate 30 mL/hour Advance in increments of 20 mL q 8 hours to goal Check gastric residuals q 4 hours Bolus feeding: Start with 100-120 mL bolus Increase by 60 mL q bolus to goal volume Typical bolus frequency every 3-8 hours Small bowel feeding Continuous feeding only; do not bolus due to risk of dumping syndrome Start at rate 20 mL/hour Do not check gastric residuals

Aspiration Precautions To prevent aspiration of tube feeding, keep HOB > 30° at all times Do not use methylene blue to test for aspiration; regular blue food dye OK but not proven effective method of detecting aspiration

Complications of Enteral Nutrition Support Nausea and vomiting / delayed gastric emptying Malabsorption Common manifestations include unexplained weight loss, steatorrhea, diarrhea Potential causes include gluten sensitive enteropathy, Crohn’s disease, radiation enteritis, HIV/AIDS-related enteropathy, pancreatic insufficiency, short gut syndrome

Enteral Nutrition Case Study 78-year-old woman admitted with new CVA Significant aspiration detected on bedside swallow evaluation and confirmed with modified barium swallow study; speech language pathologist recommended strict NPO with alternate means of nutrition PEG placed for long-term feeding access Plan of care is to stabilize the patient and transfer her to a long-term care facility for rehabilitation

Enteral Nutrition Case Study (continued) Height: 5’4” IBW: 120# +/- 10% Weight: 130# / 59kg 100% IBW BMI: 22 Usual weight: ~130# no weight change Estimated needs: 1475-1770 kcal (25-30 kcal/kg) 59-71g protein (1-1.2 g/kg) 1770 mL fluid (30 mL/kg)

Steps to determine the Enteral Nutrition Prescription Estimate energy, protein, and fluid needs Select most appropriate enteral formula Determine continuous vs. bolus feeding Determine goal rate to meet estimated needs Write/recommend the enteral nutrition prescription

Enteral Nutrition Prescription Tube feeding via PEG with full strength Jevity 1.2 Initiate at 30 mL/hour, advance by 20 mL q 8 hours to goal Goal rate = 55 mL/hour continuous infusion Above goal will provide 1584 kcal, 73g protein, 1069 mL free H2O Give additional free H2O 175 mL QID to meet hydration needs and keep tube patent Check gastric residuals q 4 hours; hold feeds for residual > 200 mL Keep HOB > 30° at all times

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.

Indications for Parenteral Nutrition Support Malnourished patient expected to be unable to eat > 5-7 days AND enteral nutrition is contraindicated Patient failed enteral nutrition trial with appropriate tube placement (post-pyloric) Enteral nutrition is contraindicated or severe GI dysfunction is present Paralytic ileus, mesenteric ischemia, small bowel obstruction, enteric fistula distal to enteral access sites

PPN vs. TPN TPN (total parenteral nutrition) High glucose concentration (15%-25% final dextrose concentration) Provides a hyperosmolar formulation (1300-1800 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 vein Because of lower concentration, large fluid volumes are needed to provide a comparable calorie and protein dose as TPN

Parenteral Access Devices Peripheral venous access Catheter placed percutaneously into a peripheral vessel Central venous access (catheter tip in SVC) Percutaneous jugular, femoral, or subclavian catheter Implanted ports (surgically placed) PICC (peripherally inserted central catheter)

Writing TPN prescriptions Determine total volume of formulation based on individual patient fluid needs Determine amino acid (protein) content Adequate to meet patient’s estimated needs Determine dextrose (carbohydrate) content ~70-80% of non-protein calories Determine lipid (fat) content ~20-30% non-protein calories Determine electrolyte needs Determine acid/base status Check to make sure desired formulation will fit in the total volume indicated

Parenteral Nutrition Monitoring Check daily electrolytes and adjust TPN/PPN electrolyte additives accordingly Check 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 reached IDDM: 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 requirement Check triglyceride level within 24 hours of starting TPN/PPN If TG >250-400 mg/dL, lipid infusion should be significantly reduced or discontinued Consider 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

Parenteral Nutrition Monitoring (continued) Check LFT’s weekly If 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 liver If Bilirubin > 5-10 mg/dL due to hepatic dysfunction, then discontinue trace elements due to potential for toxicity of manganese and copper Check pre-albumin weekly Adjust amino acid content of TPN/PPN to reach normal pre-albumin 18-35 mg/dL Adequate amino acids provided when there is an increase in pre-albumin of ~1 mg/dL per day

Parenteral Nutrition Monitoring (continued) Acid/base balance Adjust TPN/PPN anion concentration to maintain proper acid/base balance Increase/decrease chloride content as needed Since bicarbonate is unstable in TPN/PPN preparations, the precursor—acetate—is used; adjust acetate content as needed

Complications of Parenteral Nutrition Hepatic steatosis May occur within 1-2 weeks after starting PN May be associated with fatty liver infiltration Usually is benign, transient, and reversible in patients on short-term PN and typically resolves in 10-15 days Limiting fat content of PN and cycling PN over 12 hours is needed to control steatosis in long-term PN patients

Complications of Parenteral Nutrition Support (continued) Cholestasis May occur 2-6 weeks after starting PN Indicated by progressive increase in TBili and an elevated serum alkaline phosphatase Occurs because there are no intestinal nutrients to stimulate hepatic bile flow Trophic enteral feeding to stimulate the gallbladder can be helpful in reducing/preventing cholestasis Gastrointestinal atrophy Lack 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

Parenteral Nutrition Case Study 55-year-old male admitted with small bowel obstruction History of complicated cholecystecomy 1 month ago. Since then patient has had poor appetite and 20-pound weight loss Patient has been NPO for 3 days since admit Right subclavian central line was placed and plan noted to start TPN since patient is expected to be NPO for at least 1-2 weeks

Parenteral Nutrition Case Study (continued) Height: 6’0” IBW: 178# +/- 10% Weight: 155# / 70kg 87% IBW BMI: 21 Usual wt: 175# 11% wt loss x 1 mo. Estimated needs: 2100-2450 kcal (30-35 kcal/kg) 84-98g protein (1.2-1.4 g/kg) 2100-2450 mL fluid (30-35 mL/kg)

Parenteral Nutrition Prescription TPN via right-SC line 2200 mL total volume x 24 hours Amino acid: 45 g/liter= 45g x 2.2 L= 99 grams x 4 kcals/gram =369 kcals Dextrose 175 g/liter= 175g x 2.2 L= 385 grams x 3.4 kcals/gram= 1309 kcals Lipid 20% 285 mL over 24 hours 285 mls x 2= 570 kcals Above will provide 2275 kcal, 99g protein, DIR=(385 g dex/ 70 kg /1440 minute in a day)*1000= 3.8mg/kg/min LIR= (285 mls lipid * 20%)/ 70 kg=0.8 g/kg/day

Parenteral Nutrition Prescription Important items to consider: Dextrose infusion rate should be < 4 mg/kg/minute (maximum tolerated by the liver) to prevent hepatic steatosis Lipid infusion rate should be less than 1 g/kg/day to minimize/prevent TPN-induced liver dysfunction You may need to adjust/eliminate lipids if patient is on propofol. (1 ml propofol =1.1 kcal) Ex. Propofol @ 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

Benefits of Enteral Nutrition Over Parenteral Nutrition Cost Tube feeding cost ~ $10-20 per day TPN costs up to $1000 or more per day! Maintains integrity of the gut Tube feeding preserves intestinal function; it is more physiologic TPN may be associated with gut atrophy Less infection Enteral feeding—very small risk of infection and may prevent bacterial translocation across the gut wall TPN—high risk/incidence of infection and sepsis

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 arrest Weakness, paralysis Respiratory depression Ketoacidosis / metabolic acidosis

Refeeding Syndrome (continued) Prevention and Therapy Correct electrolyte abnormalities before starting nutrition support Continue to monitor serum electrolytes after nutrition support begins and replete aggressively Initiate nutrition support at low rate/concentration (~ 50% of estimated needs) and advance to goal slowly in patients who are at high risk

Consequences of Over-feeding Risks associated with over-feeding: Hyperglycemia Hepatic dysfunction from fatty infiltration Respiratory acidosis from increased CO2 production Difficulty weaning from the ventilator Risks associated with under-feeding: Depressed ventilatory drive Decreased respiratory muscle function Impaired immune function Increased infection

Questions Reference: American Society for Parenteral and Enteral Nutrition. The Science and Practice of Nutrition Support. 2001. Han-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):1578-82 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):167-70 Reissman.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. 1995 July;222(1):73-7. Ross, R. Micronutrient recommendations for wound healing. Support Line. 2004(4): 4.