1. |George RWAKASHAMBO, Nutritionist|
Topic: Nutrition For the Surgical Patient
Presenter:
|George RWAKASHAMBO, Nutritionist|

2. Contents Energy Sources Nutrition Requirements Diet Advancement
Immuno nutrition
Therapeutic Nutrition
Feeding Types
Summary

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

4. Nutrition Requirements
Healthy Adults
Calories: kcals/kg
Protein: gm/kg
Fluids: 30 mls/kg
Requirement Change for the Surgical Patient
Special Considerations
Stress
Injury or disease
Surgery
The surgical patient…
Extraordinary stressors (hypovolemia, hypervolemia, bacteremia, medications)

5. Immuno-Nutrition
Immuno nutrition involves feeding (enteral or TPN) enriched with various pharmaconutrients (arginine, glutamine, omega-3-fatty acids, nucleotides and anti- oxidants: copper, selenium, zinc, vitamins B, C and E) to improve immune responses and modulate inflammatory responses
‘Immune modulating diets’ (IMD) are the complete supplemented nutritional formulations used
Wound Healing
Anabolic state, appropriate vitamins & Minerals (A, C, Zinc), and adequate kcals/protein.
Poor Nutrition=Poor Outcomes
For every gram deficit of untreated hypoalbuminemia there is ~30% increase in mortality

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

7. Diet Advancement Initial phase:
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 Nutrition inadequacy

8. Managing Side effects with Nutrition
Weight loss/Cachexia: Close monitoring on healthy weight gain, proper food intake. Nutrition Education: educational strategies, accompanied by environmental supports, designed to facilitate voluntary adoption of food choices and other food- and nutrition-related behaviors conducive to health and well-being (WHO/FAO)
Fatigue/Low energy: Small, frequent meals and nutrient-dense foods
Constipation: Increased fiber intake and hydration (warm liquids).
Diarrhea: BRAT diet; of Bananas, White rice/porridge, Apple sauce and Toast, and water soluble fiber supplements ( e.g. pectin)- aids in forming firmer stool
Anemia: Iron and folic acid supplements boosts red blood cell count.
Low blood counts: A well balanced, protein-rich diet to return blood counts to safe level

9. 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

10. Indications for Enteral Nutrition
Patient must be hemodynamically stable before starting 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

11. 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

12. 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 (celiac), Crohn’s disease (IBD), radiation enteritis, HIV/AIDS-related enteropathy, pancreatic insufficiency, short gut syndrome

13. Enteral Access Devices
Nasogastric
Nasoenteric
Passed proximally from the nose distally into the stomach or small bowel. Orogastric: passed through the mouth.
Gastrostomy
PEG (percutaneous endoscopic gastrostomy)
Surgical or open gastrostomy
Jejunostomy
PEJ (percutaneous endoscopic Jejunostomy)
Surgical or open Jejunostomy
Trans gastric Jejunostomy
PEG-J (percutaneous endoscopic gastro-Jejunostomy)
Surgical or open gastro-Jejunostomy

14. 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 (Do not consider automatic cessation of EN until a second high GRV is demonstrated at least four hours after the first).
Bolus feeding:
Start with 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

15. 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

16. Choosing Appropriate Formulas
Categories of enteral formulas:
Polymeric (Jevity, Fresubin P.E drink)
Whole protein nitrogen source, for use in patients with normal or near normal GI function
Monomeric or elemental (Perative, Optimental, Supportan drink)
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, Diben drink)
Formulas designed for feeding patients with specific disease states
Formulas are available for respiratory disease, diabetes, renal failure, hepatic failure, and immune compromise

17. Inpatient care for surgical adult px
Malnutrition in adults is commonly associated with other diseases and improper/delayed post-surgical feeding. These include chronic and acute infections, intestinal malabsorption, liver and endocrine disease, alcoholism and other addictions as well as cancer and RVD. Even in times of famine, these conditions may present as the first cause of malnutrition. However, they may have been exacerbated by weakness, immune depression and weight loss in a malnourished patient, or be directly due to primary malnutrition itself. In all cases, both the underlying disease and malnutrition must be treated.

18. T
herapeutic I
npatient
treatment: P
hase
I (
Stabilization ) :
F75 milk
Adolescents (12 to 17 years) ml/kg/day (50 kcal/kg/day
Adults (18 to 50 years) ml/kg/day (40 kcal/kg/day
Older persons (> 50 years
) ml/kg/day (35 kcal/kg/day
Transition phase:
F100
milk
Use the same amounts as fo
r F75 in phase I
( Increase progressively) alternating with other foods e.g. CSB (FBF)
Adolescents (12 to 1
7 years) ml/kg/day(65
kcal/kg/day
Adults (18 to 50 years)
55 ml/kg/day
(55
) ml/kg/day(4
5 kcal/kg/day II
(Rehabilitation
/Rapid catch - up ):
Adoles
cents (12 to 17 years)
ml/kg/day (100
Adults (18 to
50 years)
ml/kg/day(80 )
ml/kg/day (70

19. Gastric Residual Volume
Aspiration Precautions
Gastric Residual Volume
To prevent aspiration of tube feeding, keep HOB > 30° at all times.
Clinically assess patient for:
– Abdominal distension/discomfort
– Bloating/Fullness
– Nausea/Vomiting
Gradually switch to a more calorically dense product to decrease the total volume infused.

20. Parenteral Nutrition. 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.

21. 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

22. 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 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

23. 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)

24. Parenteral Nutrition Monitoring
Check daily electrolytes and adjust TPN/PPN electrolyte additives accordingly
Check accu-chek 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 > mg/dL, lipid infusion should be significantly reduced or discontinued
Consider adding carnitine (plays a critical role in energy production. It transports long-chain fatty acids into the mitochondria so they can be oxidized (“burned”) to produce energy) 1 gram daily to TPN/PPN to improve lipid metabolism
~100 grams fat per week is needed to prevent essential fatty acid deficiency

25. Parenteral Nutrition administered
Kabiven central vein
Vol: 2053 mL, Osmolality:1060 mosm/l, Total energy: 1900 Kcal
Kabiven peripheral or central vein
Vol: 1440 mL, Osmolality: 750 mosm/l, Total energy: 1000 Kcal
NuTRIflex (B-Braun) peri or central line
Vol 1875 mL, Osmolality:920 mosm/l, Total energy:1435 Kcal

26. 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 mg/dL
Adequate amino acids provided when there is an increase in pre-albumin of ~1 mg/dL per day

27. 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

28. 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 days
Limiting fat content of PN and cycling PN over 12 hours is needed to control steatosis in long-term PN patients

29. 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

30. 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 > days)
Physiologic and metabolic sequelae may include:
EKG changes, hypotension, arrhythmia, cardiac arrest
Weakness, paralysis
Respiratory depression
Ketoacidosis / metabolic acidosis

31. 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

32. 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

35. Reference:
American Society for Parenteral and Enteral Nutrition. The Science and Practice of Nutrition Support
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):
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 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 July;222(1):73-7.
Ross, R. Micronutrient recommendations for wound healing. Support Line. 2004(4): 4.

36. Thank You!

37. Questions