1. Surgery and Nutritional Support Chapter 22

2. Surgery and Nutritional Support Malnutrition continues to occur among hospitalized patients, many of whom are surgical patients Malnutrition continues to occur among hospitalized patients, many of whom are surgical patients The surgical process brings added nutritional demands and risks for clinical problems The surgical process brings added nutritional demands and risks for clinical problems Careful attention to preoperative and postoperative nutritional support can reduce complications and provide essential resource for healing and health Careful attention to preoperative and postoperative nutritional support can reduce complications and provide essential resource for healing and health

3. Surgery and Nutritional Support Key Concepts Key Concepts –Surgical treatment requires added nutritional support to tissue healing and rapid recovery –The special nutritional problems of GI surgery require diet modifications because of the surgery’s effect on normal food passage –To ensure optimal nutrition for surgery patients, diet management may involve enteral and/or parenteral nutrition support

4. Nutritional Needs of General Surgery Patients Nutritional deficiencies can easily develop  malnutrition and clinical complications Nutritional deficiencies can easily develop  malnutrition and clinical complications Pay careful attention to: Pay careful attention to: –Nutritional status pre-surgery –Individual nutritional needs post-surgery for wound healing and rapid recovery

5. Poor Nutritional Status Defining factors: Defining factors: –Impaired wound healing, immune system –Increased risk of postoperative infection –Reduced quality of life –Impaired immune system –Impaired function of gastrointestinal tract, cardiovascular system, respiratory system –Increased hospital stay, cost, mortality rate

6. Preoperative Nutritional Care: Nutrient Reserves Nutrient reserves can be built up prior to elective surgery to fortify a patient Nutrient reserves can be built up prior to elective surgery to fortify a patient Protein deficiencies among surgical patients are common Protein deficiencies among surgical patients are common Fortify with adequate body protein in tissues and plasma to counteract blood losses during surgery and prevent tissue breakdown in the immediate postop period Fortify with adequate body protein in tissues and plasma to counteract blood losses during surgery and prevent tissue breakdown in the immediate postop period

7. Preoperative Nutritional Care: Nutrient Reserves Energy: Sufficient kilocalories are required to spare protein for tissue-building – –Extra carbohydrates maintain glycogen stores Vitamin/mineral deficiencies should be corrected Water balance sufficient to prevent dehydration

8. Immediate Preoperative Period Patients are typically directed not to take anything orally for at least eight hours prior to surgery. Patients are typically directed not to take anything orally for at least eight hours prior to surgery. Prior to gastrointestinal surgery, a “nonresidue” diet may be prescribed. Prior to gastrointestinal surgery, a “nonresidue” diet may be prescribed. –P. 435 Table 22-1 Nonresidue elemental formulas provide complete diet in liquid form. Nonresidue elemental formulas provide complete diet in liquid form.

9. Nonresidue Diet Diet includes only those foods that are free of fiber, seeds, and skins. Diet includes only those foods that are free of fiber, seeds, and skins. Prohibited foods include fruits, vegetables, cheese, milk, potatoes, unrefined rice, fats, and pepper. Prohibited foods include fruits, vegetables, cheese, milk, potatoes, unrefined rice, fats, and pepper. Vitamin/mineral supplements are required for prolonged nonresidue diet. Vitamin/mineral supplements are required for prolonged nonresidue diet.

10. Post Operative Nutritional Care Nutrient Needs for Healing Nutrient Needs for Healing Postoperative nutrient losses are great, but food intake is diminished. Postoperative nutrient losses are great, but food intake is diminished. Protein: losses occur during surgery from tissue breakdown and blood loss. Protein: losses occur during surgery from tissue breakdown and blood loss. –Catabolism usually occurs after surgery (tissue breakdown and loss exceed tissue buildup).

11. Need for Increased Protein Building tissue for wound healing Building tissue for wound healing Controlling shock Controlling shock Controlling edema Controlling edema Healing bone Healing bone Resisting infection Resisting infection Transporting lipids Transporting lipids

12. Problems Resulting From Protein Deficiency Poor healing of wounds and fractures Poor healing of wounds and fractures Rupture of suture lines (dehiscence) Rupture of suture lines (dehiscence) Depressed heart and lung function Depressed heart and lung function Anemia, liver damage Anemia, liver damage Failure of GI stomas to function Failure of GI stomas to function Reduced resistance to infection Reduced resistance to infection Extensive weight loss Extensive weight loss Increased mortality risk Increased mortality risk

13. Wound Dehiscence

14. Other Postoperative Concerns and Care Water: Ensure sufficient fluids to prevent dehydration Water: Ensure sufficient fluids to prevent dehydration –Loss of water can occur from vomiting, hemorrhage, fever, infection, or diuresis Energy: Provide sufficient nonprotein kcalories for energy in order to spare protein for tissue building- mainly CHOs Energy: Provide sufficient nonprotein kcalories for energy in order to spare protein for tissue building- mainly CHOs

15. Other Postoperative Concerns and Care Vitamins: Ensure adequate vitamins – esp. Vit. C in the postop period; Vit. B’s become important as energy and protein intake are increased Vitamins: Ensure adequate vitamins – esp. Vit. C in the postop period; Vit. B’s become important as energy and protein intake are increased Minerals: Ensure adequate potassium, phosphorus, iron, zinc Minerals: Ensure adequate potassium, phosphorus, iron, zinc Avoid electrolyte imbalances Avoid electrolyte imbalances

16. Special Consideration Post op Bariatric surgery: Typically have deficiencies in macro- and micronutrients for an extended period of time Vitamin and mineral supplementation post op

17. Initial Intravenous Fluid and Electrolytes Oral feeding is encouraged as soon as possible after surgery. Oral feeding is encouraged as soon as possible after surgery. Routine postoperative intravenous fluids supply hydration and electrolytes, not kcalories and nutrients. Routine postoperative intravenous fluids supply hydration and electrolytes, not kcalories and nutrients.

18. Methods of Feeding Oral Feeding Allows more needed nutrients to be added Stimulates normal action of the gastrointestinal tract Can usually resume once regular bowel sounds and passing of gas return Progresses from clear to full liquids, then to a soft or regular diet Individual tolerance and needs are always the guide

19. Methods of Feeding Enteral: when regular oral feedings are not tolerated, nutrient formulas may be fed by tube Enteral: when regular oral feedings are not tolerated, nutrient formulas may be fed by tube –Preferred if the GI tract can be used Parenteral: nourishment administered directly into the blood circulation through small peripheral veins or large central vein Parenteral: nourishment administered directly into the blood circulation through small peripheral veins or large central vein

20. Tube Feeding Used when oral feeding cannot be tolerated d/t: Used when oral feeding cannot be tolerated d/t: –Coma state –Severely debilitated –Radical heal/neck/face surgery Nasogastric (NG) tube is most common route Nasogastric (NG) tube is most common route –Inserted through the nose  stomach

21. Tube Feeding Nasoduodenal (ND) or nasojejunal tube more appropriate for patients at risk for aspiration, reflux, or continuous vomiting Nasoduodenal (ND) or nasojejunal tube more appropriate for patients at risk for aspiration, reflux, or continuous vomiting –Tube passed through stomach into the appropriate section of the small intestine

22. Alternate Routes for Enteral Tube Feeding Esophagostomy – a cervical esophagostomy is placed at the level of the cervical spine to the side of the neck Esophagostomy – a cervical esophagostomy is placed at the level of the cervical spine to the side of the neck –This placement removes the discomfort of the nasal route and enables the entry point to be easily concealed under clothing

23. Alternate routes: enteral tube feeding Percutaneous endoscopic gastrostomy (PEG) – gastrostomy tube surgically placed through the abdominal wall into the stomach Percutaneous endoscopic gastrostomy (PEG) – gastrostomy tube surgically placed through the abdominal wall into the stomach

24. Alternate routes: enteral tube feeding Percutaneous endoscopic jejunostomy (PEJ) Percutaneous endoscopic jejunostomy (PEJ) –Surgical placement of jejunostomy tube through the stomach wall, passed through the duodenum  jejunum

25. Tube-Feeding Formula Generally prescribed by the physician and clinical dietician Generally prescribed by the physician and clinical dietician Important to regulate amount and rate of administration. Start slow - due to: Important to regulate amount and rate of administration. Start slow - due to: –Concentrated nutrients –Smaller capacity if not fed for several days Diarrhea is most common complication Diarrhea is most common complication Wide variety of commercial formulas available Wide variety of commercial formulas available

26. Parenteral Feeding Routes Peripheral parenteral nutrition (PPN): uses less concentrated solutions through small peripheral veins when feeding is necessary for a brief period (10 days) Peripheral parenteral nutrition (PPN): uses less concentrated solutions through small peripheral veins when feeding is necessary for a brief period (10 days) Total parenteral nutrition (TPN): used when energy and nutrient requirement is large or to supply full nutritional support for long periods of time through large central vein Total parenteral nutrition (TPN): used when energy and nutrient requirement is large or to supply full nutritional support for long periods of time through large central vein

27. Peripheral Parenteral Nutrition

28. Catheter Placement for TPN

29. Central Venous Catheter

30. Mouth, Throat, and Neck Surgery This surgery requires modification in the mode of eating. This surgery requires modification in the mode of eating. Patients cannot chew or swallow normally. Patients cannot chew or swallow normally. Oral liquid feedings ensure adequate nutrition. Oral liquid feedings ensure adequate nutrition. When able to advance: mechanical soft diets When able to advance: mechanical soft diets Tube feedings are required for radical neck or facial surgery or comatose state Tube feedings are required for radical neck or facial surgery or comatose state

31. Stomach Surgery Because the stomach is the first major food reservoir in the GI tract, stomach surgery poses special problems in maintaining adequate nutrition. Because the stomach is the first major food reservoir in the GI tract, stomach surgery poses special problems in maintaining adequate nutrition. Problems may develop immediately after surgery or after regular diet resumes. Problems may develop immediately after surgery or after regular diet resumes.

32. Gastrectomy

33. Immediate Postoperative Period Serious nutritional deficits may occur immediately after surgery –esp. total gastrectomy Serious nutritional deficits may occur immediately after surgery –esp. total gastrectomy –Increased gastric fullness and distention may result if gastric resection involved a vagotomy (cutting of the vagus nerve which supplies major stimulus for gastric secretions)  atonicity & poor emptying of the stomach. Food fermentation  flatus (gas), diarrhea Weight loss is common. Weight loss is common. Patient may be fed via jejunostomy. Patient may be fed via jejunostomy. Frequent small, simple oral feedings are resumed according to patient’s tolerance. Frequent small, simple oral feedings are resumed according to patient’s tolerance.

34. Dumping Syndrome Frequent complication of extensive gastric resection in which readily soluble carbohydrates rapidly “dump” into small intestine Frequent complication of extensive gastric resection in which readily soluble carbohydrates rapidly “dump” into small intestine When the patient begins to feel better and eats a regular diet in greater volume and variety, discomfort may occur 30-60 minutes after meals When the patient begins to feel better and eats a regular diet in greater volume and variety, discomfort may occur 30-60 minutes after meals Symptoms include: Symptoms include: –Cramping, full feeling –Rapid pulse –Wave of weakness, cold sweating, dizziness –Nausea, vomiting, diarrhea Results in patient eating less food Results in patient eating less food

35. Dumping Syndrome When the stomach has been removed, food passes directly from the esophagus into the small intestine When the stomach has been removed, food passes directly from the esophagus into the small intestine This rapidly entering food mass is a concentrated solution (higher osmolality) in relation to the surrounding circulation of blood This rapidly entering food mass is a concentrated solution (higher osmolality) in relation to the surrounding circulation of blood –To achieve osmotic balance, water is drawn from the blood into the intestine  rapidly shrinks the vascular fluid volume  BP drop

36. Dumping Syndrome Also, the initial concentrated solution that has been rapidly digested and absorbed  rapid rise in blood glucose level  stimulates overproduction of insulin  eventual drop of blood glucose to below normal levels with sx. of hypoglycemia Dramatic relief from these sx. and stabilization of weight follows careful control of diet

37. Diet for Postoperative Gastric Dumping Syndrome Five or six small meals daily Five or six small meals daily Relatively high fat content, low simple carbohydrate content, low-roughage foods, high protein content Relatively high fat content, low simple carbohydrate content, low-roughage foods, high protein content No milk, sugar, alcohol, or sweet sodas; no very hot or very cold foods No milk, sugar, alcohol, or sweet sodas; no very hot or very cold foods Fluids avoided one hour before and after meals; minimal fluids during meals Fluids avoided one hour before and after meals; minimal fluids during meals

38. Gallbladder Surgery For pts. with cholecystitis or cholelithiasis For pts. with cholecystitis or cholelithiasis Tx.: Cholecystectomy - the removal of the gallbladder. Tx.: Cholecystectomy - the removal of the gallbladder. Surgery is minimally invasive - laproscopic Surgery is minimally invasive - laproscopic Some moderation in dietary fat is usually indicated after surgery. Some moderation in dietary fat is usually indicated after surgery. Depending on individual tolerance and response, a relatively low-fat diet may be needed over a period of time. Depending on individual tolerance and response, a relatively low-fat diet may be needed over a period of time.

39. Gallbladder with Stones

40. Intestinal Surgery Intestinal resections are required in cases involving tumors, lesions, or obstructions. Intestinal resections are required in cases involving tumors, lesions, or obstructions. In complicated cases when most of the small intestine is removed, TPN is used with small allowance of oral feeding. In complicated cases when most of the small intestine is removed, TPN is used with small allowance of oral feeding. Stoma may be created for elimination of fecal waste (ileostomy, colostomy). Stoma may be created for elimination of fecal waste (ileostomy, colostomy). –See p. 449

41. Colostomy

42. Rectal Surgery Clear fluid or nonresidue diet may be indicated after surgery to reduce painful elimination and allow healing. Clear fluid or nonresidue diet may be indicated after surgery to reduce painful elimination and allow healing. Return to a regular diet is usually rapid. Return to a regular diet is usually rapid.

43. Nutritional Needs for Burn Patients Tremendous nutritional challenge Tremendous nutritional challenge Plan of care influenced by: Plan of care influenced by: –Age –Health condition –Burn severity Plan constantly adjusted Plan constantly adjusted The depth of the burn affects tx. and healing process The depth of the burn affects tx. and healing process Critical attention paid to amino acid needs for tissue rebuilding; fluid and electrolyte balance, and energy (kcal) support. Critical attention paid to amino acid needs for tissue rebuilding; fluid and electrolyte balance, and energy (kcal) support.

44. Nutritional Needs for Burn Patients 3 periods of care during the immediate shock, recovery, and secondary feeding periods 3 periods of care during the immediate shock, recovery, and secondary feeding periods –Stage 1/ Part I Immediate shock period –Stage 1/part II Recovery Period –Stage 2/ Part I Secondary Feeding Period –Stage 2 / Part II Nutrition Therapy –Stage 2/ Part III Dietary management –Stage 3/Follow-up Reconstruction

45. Nutritional Care for Burns: Stage 1, Part 1 – Immediate Shock Period Massive flooding edema at the burn site occurs from the first hours through the second day after a burn Massive flooding edema at the burn site occurs from the first hours through the second day after a burn Large losses of water, electrolytes, and protein due to destruction of protective skin Large losses of water, electrolytes, and protein due to destruction of protective skin Blood volume drops, blood pressure drops, urine output decreases Blood volume drops, blood pressure drops, urine output decreases

46. Nutritional Care for Burns: Stage 1, Part 1 – Immediate Shock Period Cell dehydration and cell potassium loss occurs Cell dehydration and cell potassium loss occurs Intense IV fluid replacement (e.g. LR) followed by albumin solutions or plasma to restore blood volume and help prevent shock Intense IV fluid replacement (e.g. LR) followed by albumin solutions or plasma to restore blood volume and help prevent shock Protein and energy requirements are not met at this time Protein and energy requirements are not met at this time

47. Nutritional Care for Burns: Stage 1, Part 2 – Recovery Period 48 to 72 hours after burns 48 to 72 hours after burns Fluids and electrolytes are gradually reabsorbed Fluids and electrolytes are gradually reabsorbed Balance is re-established Balance is re-established Diuresis occurs Diuresis occurs Constant evaluation of intake and output must occur Constant evaluation of intake and output must occur Enteral nutrition may be initiated Enteral nutrition may be initiated

48. Nutritional Care for Burns: Stage 2, Part 1 – Secondary Feeding Period End of first week End of first week Bowel function returns Bowel function returns Vigorous feeding program begins Vigorous feeding program begins Patient may be depressed and may have lack of appetite Patient may be depressed and may have lack of appetite

49. Nutritional Care for Burns: Stage 2, Part 1 – Secondary Feeding Period 3 major reasons exist for the increased nutrient and energy demands: 3 major reasons exist for the increased nutrient and energy demands: –Tissue destruction – large loses of protein and electrolytes that need to be replaced –Tissue Catabolism – loss of lean body mass and N+ –Increased metabolism

50. Nutritional Care for Burns: Stage 2, Part 2 – Nutrition Therapy High protein High protein –Promotes healing –Promotes immune function High energy High energy –Spares protein for tissue healing –Supplies energy for increased metabolic demands

51. Nutritional Care for Burns: Stage 2, Part 2 – Nutrition Therapy High vitamin and minerals High vitamin and minerals –Vitamin C partners with amino acids for tissue rebuilding –Vitamin A and zinc for optimal immune function –Thiamin, riboflavin, and niacin for increased energy and protein metabolism –Serum Calcium-phosphorus ratios should be monitored

52. Nutritional Care for Burns: Stage 2, Part 3 – Dietary Management Enteral or parenteral feeding may be needed Enteral or parenteral feeding may be needed Oral feedings with added protein or amino acids (commercial formulas) Oral feedings with added protein or amino acids (commercial formulas) Solid foods based on preferences Solid foods based on preferences Oral intake may be inadequate Oral intake may be inadequate

53. Nutritional Care for Burns: Stage 3 – Follow-up Reconstruction Continued nutritional support Continued nutritional support Maintain tissue strength for successful skin grafting or plastic surgery Maintain tissue strength for successful skin grafting or plastic surgery Encouragement and support are critical Encouragement and support are critical