. . . and the surgical patient Carli Schwartz, RD,LDN Nutrition . . . and the surgical patient Carli Schwartz, RD,LDN

Role of Nutrition In Surgical Patients Malnutrition may compound the severity of complications related to a surgical procedure A well-nourished patient usually tolerates major surgery better than a severely malnourished patient Malnutrition is associated with a high incidence of operative complications and death.

Normal Nutrition (EatRight.org)

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: http://www.choosemyplate.gov/ Includes interactive tools including a personalized daily food plan Plan, analyze and track diet and physical activity.

Macronutrients Carbohydrates Converted to glucose, body’s major source of energy Simple vs. Complex dependent on chemical structure Yields 3.4 kcal/gm Recommended 45-65% total daily calories. Fats Major endogenous fuel source in healthy adults Yields 9 kcal/gm Aids body in absorbing vitamins, proper growth and development Too little can lead to essential fatty acid (linoleic acid) deficiency and increased risk of infections Chose less saturated and trans fats Recommended 20-30% of total caloric intake Protein Needed to maintain anabolic state (match catabolism) Yields 4 kcal/gm Complete versus incomplete Build and maintain bones, muscles and skin Must adjust in patients with renal and hepatic failure Recommended 10-35% of total caloric intake. Simple sugars- found naturally in foods (milk/fruit) and added during refining and processing. Complex includes whole grains and foods with fiber (starchy veg, legumes, whole grains)

Normal Nutrition Requirements HEALTHLY male/female (weight maintenance) Caloric intake=25-30 kcal/kg/day Harris Benedict Equation for Basal Metabolic Rate (multiply by activity factor for REE): Women: BMR = 655 + ( 4.35 x weight in pounds ) + ( 4.7 x height in inches ) - ( 4.7 x age in years ) Men: BMR = 66 + ( 6.23 x weight in pounds ) + ( 12.7 x height in inches ) - ( 6.8 x age in year ) Protein intake=0.8-1gm/kg/day (max=150gm/day) Fluid intake=~ 30 ml/kg/day or 1 ml/kcal/day

Nutrition Requirements ? SURGICAL PATIENT ?

Increased Risk of Malnutrition Inadequate nutritional intake Metabolic response (hypermetabolism from long term inflammation or infectious conditions) Nutrient losses without proper replenishment Protein /energy store depletion Diminished nutrient intake (pre/post operative) Prevalence of GI obstruction, anorexia, malabsorption Extraordinary stressors (surgical stress, hypovolemia, sepsis, bacteremia, medications) Wound healing Anabolic state, higher demand for nutrients (amino acids, zinc, vitamin A & C, arginine)

Nutrition Needs HEALTHLY 70 kg MALE SURGERY PATIENT Caloric intake 25-30 kcal/kg/day Protein intake 0.8-1gm/kg/day (max=150gm/day) Fluid intake 30 ml/kg/day SURGERY PATIENT Caloric intake *Mild stress, inpatient 25-30 kcal/kg/day *Moderate stress, ICU patient 30-35 kcal/kg/day *Severe stress, burn patient 30-40 kcal/kg/day Protein intake 1-2 gm/kg/day Fluid intake INDIVIDUALIZED

Nutrition Needs for the Mechanically Ventilated Patient Support the Immune system, facilitate wound healing, prevent muscle breakdown and malnutrition Important NOT to overfeed! Permissive underfeeding is recommended if adequate protein is provided. Overfeeding total (not just carbohydrate) calories can exacerbate hyperglycemia, cause fatty liver, increase CO2 production, and burden the system by forcing it to deal with the excess caloric load. Respiratory quotient value ~1 when the organism is burning chiefly carbohydrates, near 0.7 when mainly fats, and near 0.8 when primarily burning protein Prolonged underfeeding may lead to excessive loss of lean body mass and prevent muscle breakdown. Providing adequate protein can help prevent this (1.5-2gm/kg non-obese, 2-2.5 gm/kg IBW for obese) To prevent over-feeding, use Penn State Equation (BEE obtained from Harris Benedict Equation): Obese critically ill vent dependent patients: REE= BEE (1.1) + VE (32) + Tmax (140)-5340 Non-obese critically ill patients REE= BEE(0.85) + VE(33) + Tmax (175)-6433 Mechanically ventillated Patients who are morbidly Obese with BMI >40 11-14 kcal/kg actual body weight per day.

Nutritional Labs Albumin Synthesized in and catabolized by the liver Pro: often ranked as the strongest predictor of surgical outcomes- inverse relationship between postoperative morbidity and mortality compared with preoperative serum albumin levels Con: lack of specificity due to long half-life (approximately 20 days). Not accurate in pt’s with liver disease or during inflammatory response Normal range: 3.5-5 g/dL.

Nutritional Labs Prealbumin (transthyretin) - transport protein for thyroid hormone, synthesized by the liver and partly catabolized by the kidneys. 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. Normal range:16 to 40 mg/dL; values of <16 mg/dL are associated with malnutrition. **Expect an increase of .1 mg/dL per day if adequate protein is being provided. **

Nutritional Labs Markers of Inflammation- WBC and CRP If elevated, PAB and Albumin not a good measure of nutrition status due to suppression of production during inflammatory response.

Nitrogen Balance Protein intake (gm)/6.25 - (UUN +4)= balance in grams Nitrogen balance: measures net changes in body protein mass Positive 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. Nitrogen Equilibrium: Expected in Healthy Individuals Requires 24 hour urine collection Can determine minimum adequate protein with losses through hypermetabolism. Complex determination of balance, measures of losses difficult and limited utility in clinical setting

Postoperative Nutritional Care Traditional Method: Diet advancement Introduction of solid food depends on the condition of the GI tract. Oral feeding delayed for 24-48 hours after surgery Wait for return of bowel sounds or passage of flatus. Start clear liquids when signs of bowel function returns Rationale Clear liquid diets supply fluid and electrolytes that require minimal digestion and little stimulation of the GI tract Clear liquids are intended for short-term use due to inadequacy

Things to Consider… For liquid diets, patients must have adequate swallowing functions Even patients with mild dysphagia often require thickened liquids. Must be specific in writing liquid diet orders for patients with dysphagia There 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.

Diet Advancement Advance 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.

Special Dietary Restrictions General GI surgery: Manage nausea/vomiting/diarrhea Avoid foods high in sugar and high in fiber Have protein foods at every meal Eat small and frequent meals (5-6 “meals/day”) Avoid foods high in fat, fried foods, spicy foods Have drinks between and not during meals Choose soft and well cooked foods Utilize Nutrition Care Manual for education handouts!

Special Dietary Restrictions Low Fiber Diet (Low Residue) There is no scientifically acceptable definition of residue. The amount of residue produced by digestion of various foods cannot be estimated from widely available sources. Data documenting the efficacy of a low residue diet are unavailable in the literature. The low fiber diet is the preferred alternative to the low residue diet because the amount of fiber in the diet can be estimated from food composition tables. Intended to reduce the frequency and volume of stools Appropriate for new ileostomy/colostomy, s/p recent GI surgery, Crohn’s disease, ulcerative colitis, diverticulitis, radiation therapy to bowel or pelvis. Includes white and refined breads/pasta, well cooked fruits and vegetables (without pulp or skins), meats, seafood, oils, dairy if tolerated.

Special Dietary Considerations Elemental Diet Also referred to as “chemically defined” diet Amino acid based, low residue, for patients with chronically impaired GI function. Avoids whole or partial proteins and provides fat in small quantities. Often used as treatment during flare up of IBD or after major bowel resection when pt is not tolerating p.o. diet. Helps to manage inflammation and symptoms of GI intolerance. Improves absorption of nutrients. Requires specifically tailored Nutritional supplement meant for oral or enteral feeding. Vital AF or Vivonex products used. NO other food is allowed on an elemental diet. Elemental does NOT mean low residue, low fat or low fiber. Elemental diets are often poorly tolerated when given by mouth due to poor taste of supplement. Some patients prefer diet to be given enterally.

Nutrition and Wound Healing Adequate intake of fat, carbohydrates and protein needed for wound healing to take place. Physiologic stress caused by wounds can increase need for dietary sources of conditionally essential amino acids (arginine and Glutamine) Encourage RDA recommendations for micronutrients. Consider MVI, vitamin C, Vitamin A and Zinc supplementation Nutritional drinks to help patients meet nutritional needs. Glucose control important with diabetics

Nutrition Involvement in Wound Healing Vitamin A – enhances early inflammatory phase, promotes epithelial cell differentiation Protein– prevent prolonging inflammatory phase. Protein deficiency inhibits wound remodeling. Wound repair and immune function associated with glutamine and arginine supplementation. Vitamin C – enhances neutrophil migration and lymphocyte transformation, necessary for collagen synthesis, proper immune function and tissue antioxidant. Zinc – required for DNA synthesis, cell division, and protein synthesis

Patients who cannot eat . . . ? Consider Nutrition Support!

Nutrition Support Length of time a patient can remain NPO after surgery without complications is unknown, however depends on: Severity of operative stress Patient’s preexisting nutritional status Nature 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)

Goals of Nutrition Support post-surgery Decrease surgical mortality Decrease surgical complications and infection Reduce the catabolic state and restore anabolism Support the depleted patient throughout the catabolic phase of recovery Decrease hospital LOS Speed the healing/recovery process Ensure the prompt return of GI function to resume standard oral intake as soon as possible

Nutrition Support Enteral Nutrition Support Parenteral Nutrition support

What is enteral nutrition? Also called "tube feeding," enteral nutrition is a liquid mixture of all the needed macro and micronutrients. Consistency is sometimes similar to a milkshake. It is given through a tube in the stomach or small intestine. Can be sole or partial source of nutrition 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.

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 days Adequately nourished patient expected to be unable to eat > 10 days

Contraindications to Enteral Nutrition Support Expected need less than 5-7 days if malnourished or 7-9 days if normally nourished Severe acute pancreatitis (NPO required) Small bowel obstruction, ileus or high output enteric fistula distal to feeding tube Inability to gain or maintain access Hemodynamic instability/poor profusion: MAP consistently < 60 mmHg Need for high dose pressors/vasoactives Intractable vomiting, diarrhea or high gastric residuals Septic shock, persons requiring massive fluid resucitation

Feeding Tube Access www.medscape.com

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 (PEG tube placement)

Tulane Enteral Nutrition Product Formulary

Choosing Appropriate Formulas Categories of enteral formulas: Polymeric Whole protein nitrogen source, for use in patients with normal or near normal GI function Monomeric or elemental Predigested nutrients; most have a low fat content or high % of MCT and peptide or amino acid based; for use in patients with severely impaired GI function Disease specific * Formulas designed for feeding patients with specific disease states Formulas are available for respiratory disease, diabetes, renal failure, hepatic failure, and immune compromise Concentrated Formulas for patients who are volume-sensitive (1.2, 1.5, 2 cal/ml) *well-designed clinical trials may or may not be available

Complications of Enteral Nutrition Support Issues with access, administration, GI complications, metabolic complications. These include: Nausea, vomitting, diarrhea, delayed gastric emptying, malabsorption, refeeding syndrome, hyponatremia, microbial contamination, tube obstruction, leakage from ostomy/stoma site, micronutrient deficiencies.

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 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

Tulane Daily Parenteral Nutrition Order Form

Parenteral Nutrition Monitoring Electrolytes -adjust TPN/PPN electrolyte additives daily according to labs Check accu-check glucose q 6 hours Regular insulin may be added to TPN/PPN bag for glucose control as needed Check triglyceride level within 24 hours of starting TPN/PPN If TG >250-400 mg/dL, lipid infusion should be significantly reduced or discontinued ~100 grams fat per week is needed to prevent essential fatty acid deficiency Check LFT’s weekly If LFT’s significantly elevated as a result of TPN, then minimize lipids to < 1 g/kg/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

Complications of Parenteral Nutrition Hepatic steatosis (fatty liver disease) Thought to be related to excessive dextrose administration due to storage of glucose in the liver May occur within 1-2 weeks after starting PN Usually is benign, transient, and reversible in patients on short-term PN and typically resolves in 10-15 days

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, causing disruption or blockage 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 Prescription Important to consider: Glucose infusion rate should be < 5 mg/kg/minute (maximum tolerated by the liver) to prevent hepatic steatosis Lipid infusion should be < 0.1 g/kg/hour (ideally < 0.4 g/kg/day to minimize/prevent TPN-induced liver dysfunction) Hyperglycemia and re-feeding syndrome. Initiate TPN slowly if patient is severely malnourished or diabetic.

Benefits of Enteral Nutrition over parenteral nutrition Cost Tube feeding cost ~ $10-20 per day TPN cost ~ $100 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 Tube feeding—very small risk of infection and may prevent bacterial translocation across the gut wall TPN—high risk/incidence of line infection and sepsis

Nutrition support: Clinical Decision Algorithm AAFP.org

Refeeding Syndrome Defined as “the metabolic and physiologic consequences of depletion, repletion, compartmental shifts, and interrelationships of phosphorus, potassium, and magnesium…” Severe drop in serum electrolyte levels (K, PO4, Mg) 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 over 2-3 days 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 in mechanically ventilated patients Risks associated with under-feeding: Depressed ventilatory drive Decreased respiratory muscle function Impaired immune function Increased infection Loss of lean body mass and malnutrition if chronic

Patient Handouts and Nutrition Education Nutrition Care Manual- Nutrition resources from The Academy of Nutrition and Dietetics (AND, formerly ADA) NutritionCareManual.org Username: Member@tuhc.com Passoword: Tulane1

Questions Contact Information: Carli Schwartz, RD/LDN Dietitian, Tulane Abdominal Transplant Institute (504) 988-1176 Carli.Schwartz@hcahealthcare.com

References 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. Krause’s Food, Nutrition & Diet Therapy, 11th Ed. Mahan, K., Stump, S. Saunders, 2004.