Nutrition Assessment and Post-Surgical Advancement Rebecca Cohen, MS, RD, LDN Transplant Dietitian Tulane Transplant Institute

Nutrition and Surgery Reported 40% incidence of malnutrition in acute hospital setting 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) Progression of food pyramids

The Newest Food Guide Teaches ● 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 and food tracker MyPlate introduced in 2010 for a better visual of how your plate should look at each meal

Carbohydrates Limited storage capacity, needed for CNS (glucose) function Yields 3.4 kcal/gm Recommended 45-65% of total caloric intake Simple vs Complex

Fats Major endogenous fuel source in healthy adults Yields 9 kcal/gm Too little can lead to essential fatty acid (linoleic acid) deficiency and increased risk of infections Recommended 20-30% of total caloric intake

Protein Needed to maintain anabolic state (match catabolism) Yields 4 kcal/gm Must adjust in patients with renal and hepatic failure Recommended 10-35% of total caloric intake

Normal Nutrition Requirements HEALTHLY male/female Caloric intake= 25-30 kcal/kg/day Protein intake= 0.8-1gm/kg/day (max=150gm/day) Fluid intake= ~30 ml/kg/day* If patient’s BMI is >30, use IBW in kg to determine calorie and protein needs. Don’t want to feed the fat. Fluid intake needs to be adjusted for patients in ESRD (especially those not on dialysis) and hepatic failure. *Unless medical state warrants fluid restriction

Reasons for Malnutrition Inadequate nutritional intake Metabolic response Nutrient losses Protein/energy store depletion Prevalence of ileus, anorexia, malabsorption Extraordinary stressors (surgical stress, hypovolemia, bacteremia, medications) Wound healing Anabolic state May require appropriate vitamins

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

Albumin Synthesized in and catabolized by the liver Normal range: 3.5-5 g/dL Half-life: 20 days Pros Cons Ranked as the strongest predictor of surgical outcomes Lack of specificity due to long half-life Inverse relationship between postoperative morbidity and mortality compared with preoperative serum albumin levels Not accurate in pt’s with liver disease (elevated Tbili) or during inflammatory response (elevated WBC or CRP) Serum protein markers

Prealbumin Synthesized by the liver and partly catabolized by the kidneys Normal range:16-40 mg/dL Values of <16 mg/dL are associated with malnutrition Half-life: 2-3 days Pros Cons Shorter half life than albumin More expensive than albumin More favorable marker of acute change in nutritional status (compared to albumin) Levels may be increased in the setting of renal dysfunction, corticosteroid therapy, or dehydration *A baseline prealbumin is useful as part of the initial nutritional assessment if routine monitoring is planned Over-hydration can decrease prealbumin levels; result in false negative

Nitrogen Balance Measures net changes in body protein mass Nitrogen Balance = protein intake (gm) - (UUN +4) 6.25 Healthy individuals= nitrogen balance (-1 to +1) Positive Value Negative Value Found during periods of growth, tissue repair, or pregnancy Associated with burns, fevers, wasting diseases and other serious injuries, & during periods of fasting Intake of nitrogen into the body is greater than the loss of nitrogen from the body Amount of nitrogen excreted from the body is greater than nitrogen intake Increase in the total body pool of protein Often seen following major surgery *Patient will likely require extra protein for tissue building

Postoperative Diet Advancement Delay feeds for 24-48 hours until bowel sounds & function return Begin with clear liquids Supply fluids and electrolytes Require minimal digestion and stimulation of GI tract Intended for short-term use due to inadequacy of nutritional needs

Clear Liquid Diet Acceptable food items Water (plain, carbonated or flavored) Fruit juices without pulp, such as apple or white grape Fruit-flavored beverages, such as fruit punch or lemonade Plain gelatin Tea or coffee without milk or cream Strained tomato or vegetable juice Sports drinks Clear, fat-free broth Hard candy, such as lemon drops or peppermint rounds Ice pops without milk, bits of fruit, seeds or nuts (except red) http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/clear-liquid-diet/art-20048505

Diet Advancement cont. Advance diet to full liquids Middle step Meet daily calorie and protein needs Acceptable food items Coffee, tea, cream, carbonated beverages Fruit and vegetable juices Milk & Milkshakes Nutritional supplements Custard-style yogurt, pudding, custard Plain ice cream, sherbet, sorbet Jell-o (any flavor) Cream soups, strained, cream of wheat, cream of rice, grits Pureed soups & Tomato puree Gravy, margarine Sugar, syrup, jelly, honey http://www.upmc.com/patients-visitors/education/nutrition/pages/full-liquid-diet-facts.aspx

Diet Advancement cont. Advance diet to solid foods Appropriate to introduce solids as soon as the GI tract is functioning & liquids are tolerated Diets available: Regular Pediatric Heart healthy ADA/Diabetic Renal Low sodium (2 gm) Bland/Soft/Low residue

Key considerations Condition of the GI tract Disease state Complications that may have resulted from surgery Ex: diabetes in a post-kidney transplant patient. Why? For liquid diets, patients must have adequate swallowing functions, as determined by SLP Mechanical soft Pureed Thicken liquids Must be specific in writing liquid diet orders for patients with dysphagia

Nutrition Support Options Length of time a patient can remain NPO without complications is unknown Tulane Protocol: NPO > 4 days Two types of nutritional support Enteral Parenteral NPO time depends on: severity of operative stress, pre-existing nutritional status, nature and severity of illness

Enteral Nutrition Liquid mixture designed to meet nutrient needs Goal rates are individidualized Given through a tube in the stomach or small intestine Nasogastric tube Nasoduodenal tube Nasojejunal tube Gastrostomy/Jejunostomy Continuous or Bolus feeds Specialized formulas for select disease states Glucerna Suplena Nepro Elemental formulas NG tube, J tube, PEG, etc

Indications Contraindications Functioning GI tract Severe acute pancreatitis Adaptive phase of short bowel syndrome High output enteric fistula distal to feeding tube Following severe trauma or burns Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted Indications: Malnourished patient: Expected to be unable to eat adequately for > 5-7 days Nourished patient: Expected to be unable to eat > 7-9 days Contraindications: Malnourished patient: Expected need less than 5-7 days Nourished patient: Expected need less than 7-9 days

Gastric vs. Small Bowel “If you don’t use it, you lose it.” Indications to consider small bowel access: Gastroparesis Recent abdominal surgery Sepsis Significant gastroesophageal reflux (GERD) Aspiration risk Mild ileus Proximal enteric fistula or obstruction

Short-term vs Long-term No standard of care for cut-off time between short-term and long-term access Long-term access should be considered if the patient is expected to require nutrition support longer than 6-8 weeks NG tubes can be used for long term enteral nutrition However, complications can include: Non-elective extubation Tube misplacement Occasional need to check position of the tube

Choosing Appropriate Formulas Polymeric Monomeric/elemental Disease specific Basic Info: Uses whole proteins as nitrogen source Predigested nutrients; most have a low fat content or high % of MCT Specific formulas for Respiratory disease Diabetes Renal failure Hepatic failure Immune compromise Consider for patients with: Normal or near normal GI function Impaired GI function Specific disease states

Tulane Enteral Nutrition Product Formulary

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

Complications of Enteral Nutrition Support Access Administration GI complications Metabolic complications

Enteral Nutrition Case Study 78-year-old woman admitted with new CVA Significant aspiration detected on bedside swallow evaluation SLP recommends strict NPO with alternate means of nutrition PEG placed for long-term feeding access Plan: stabilize the patient and transfer her to a long-term care facility for rehabilitation

Enteral Nutrition Case Study (continued) Height: 5’4” Weight: 130# / 59kg BMI: 22 IBW: 120# +/- 10% Usual weight: 130# Estimated needs: Calories? Protein? Fluid? 25-30 kcal/kg 1-1.2 gm/kg 30 ml/kg

Enteral Nutrition Prescription Jevity 1.2 (via PEG) Initiate at 30 mL/hour, advance by 20 mL q 8 hours to goal Goal rate = 55 mL/hour 1584 kcal 73g protein 1069 mL free H2O, additional ~515mL needed Check residuals q 4 hours hold feeds for residual > 200 mL Aspiration precautions To prevent aspiration

What is parenteral nutrition? It is a special liquid mixture given into the blood via a catheter in a vein Contains all the, carbohydrates, protein, fat, vitamins, minerals, and other nutrients needed Light sensitive, always covered in a light resistant bag

Indications for TPN Two criteria, need both Malnourished patient expected to be unable to eat > 5-7 days Failed enteral nutrition trial per SLP Appropriate tube placement EN is contraindicated or severe GI dysfunction is present Ex: paralytic ileus, mesenteric ischemia, small bowel obstruction, enteric fistula distal to enteral access sites

(total parenteral nutrition) (peripheral parenteral nutrition) TPN (total parenteral nutrition) PPN (peripheral parenteral nutrition) High glucose concentration (15-25% final dextrose concentration) Similar nutrient components as TPN, but lower concentration (5%-10% final dextrose concentration) Provides a hyperosmolar formulation (1300-1800 mOsm/L) Osmolarity < 900 mOsm/L (maximum tolerated by a peripheral vein) Must be delivered into a large-diameter vein May be delivered into a peripheral vein Large fluid volumes needed to meet same calorie and protein dose as TPN (because lower in concentration) Often used with other MNT and for a short period of time

Parenteral Access Devices Peripheral venous access Catheter placed percutaneouly 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 content Determine dextrose content Determine lipid content Check to make sure desired formulation will fit in the total volume indicated

Tulane TPN Order Form

Parenteral Nutrition Monitoring Check electrolytes daily and adjust TPN/PPN additives accordingly Check accu-check glucose q 6 hours Check triglyceride level within 24 hours of starting TPN/PPN and weekly while patient remains on it

Parenteral Nutrition Monitoring (continued) Check LFT’s weekly Check pre-albumin weekly Acid/base balance Increase/decrease chloride as needed Bicarbonate is unstable in TPN/PPN prep Precursor—acetate—is used

Complications of TPN/PPN Hepatic steatosis Usually benign in patients on short-term PN Resolves in 10-15 days Limiting fat content of PN to control steatosis in long-term use

Complications of TPN/PPN (continued) Cholestasis Due to no intestinal nutrients to stimulate hepatic bile flow Gastrointestinal atrophy Trophic enteral feeding to minimize/prevent GI atrophy

TPN/PPN Case Study 55-year-old male admitted with small bowel obstruction Complicated cholecystecomy 1 month ago. Since, poor po intake and 20 # weight loss NPO for 3 days since admitright subclavian central line was placed Plan: start TPN since patient is expected to be NPO for at least 1-2 weeks

TPN/PPN Case Study (continued) Height: 6’0” Weight: 155# / 70kg BMI: 21 IBW: 178# +/- 10% Usual wt: 175# Estimated needs: Calories? Protein? Fluid? 30-35 kcal/kg 1.2-1.4 gm protein/kg 30-35 mL/kg

TPN/PPN Prescription Amino acid 4.5% (or 45 g/liter) Dextrose 17.5% (or 175 g/liter) Lipid 20% 285 mL over 24 hours 2120 kcal, 90g protein (2 liters/24 hrs) GIR: 3.5 mg/kg/minute

Enteral Nutrition > Parenteral Nutrition Cost $10-20 per day $100 or more per day Gut Preserves intestinal function May be associated with gut atrophy Infection Very small risk of infection High risk/incidence of infection and sepsis

Miscellaneous Thoughts Transitional feeds PNEN PN/EN oral feeds Refeeding syndrome Caused by intracellular movement when energy is provided after a period of starvation (usually > 7-10 days) Hypomagnesaemia, hypokalemia, hypophosphatemia Close monitoring of electrolytes Initiate feeds slowly, work towards goal rate

Miscellaneous Thoughts Under-feeding Over-feeding Depressed ventilatory drive Hyperglycemia Decreased respiratory muscle function Hepatic dysfunction from fatty infiltration Impaired immune function Respiratory acidosis from increased CO2 production Increased infection Difficulty weaning from the ventilator

Questions Contact Information: Rebecca Cohen, MS, RD, LDN Transplant Dietitian, Tulane Transplant Institute (504) 988-1176 Rebecca.Cohen@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.