Transcript Nutrition in Surgical Patients

Nutrition in Surgical Patients
Nicky Wyer MSc, RD
Senior Specialist Dietitian
UHCW Nutrition Support Team
Learning objectives
To understand:
 Who is at risk of malnutrition and how to
identify
 The impact of malnutrition on surgical plans and
outcomes
 Understanding of routes for nutrition support
 How to address common symptoms in the
surgical patient that impact on nutritional intake
 Who to refer to
What is malnutrition?
Definition of Malnutrition
There is no universally accepted definition of malnutrition but the
following is increasingly being used from RCP 2002:
A state of nutrition in which a deficiency or
excess (or imbalance) of energy, protein, and
other nutrients causes measurable adverse
effects on tissue/body form (body shape, size
and composition) and function, and clinical
outcome
‘Malnutrition’ refers to both under and over-nutrition
(but more commonly used for under-nutrition)
Malnutrition does it matter?
What is the overall aim of
your surgical team?
A malnourished patient will have 3 x higher
rate of complications and 4 x greater risk of
death from the same surgery compared to a
well nourished patient (NICE 2006)
Effects of Undernutrition
Psychiatric
Anhedonia
Depression
Confusion
Anorexia
?Micronutrient
deficiency
Respiratory
Decreased tidal volumes
Reduced muscle bulk
Loss of adaptive response to
hypoxia
Hepatic
Fatty Liver
Necrosis/ Fibrosis
Gut
Reduced immunity
Reduced integrity
Oedema
Immunity
Increased infection risk
Impaired wound healing
Wound infections
Cardiac
Wound breakdown
Reduced cardiac output
Anastamotic leak
CCF
Hospital acquired pneumonia
Renal failure
Return to theatre for revisional surgery
Morbidity
Renal
Reduced Na & H2O excretion
Mortality
Other
Reduced muscle strength
Neurological weakness
Inability to regulate temperature
The Extent of ‘The Problem’ [1]
Estimated > 3 million people in the UK are at risk of
malnutrition at any one time (Elia & Russell, 2009)
Under-recognised & under-treated
Public health expenditure on disease-related
malnutrition in the UK (2007) > 13 billion per annum
(Elia & Russell, 2009)
80% of this expenditure was in England
40% of adult hospital patients are overtly malnourished on
admission. 8% categorised as severe.
Who’s at risk?
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Elderly
Chronic ill-health e.g.
diabetes, renal, COPD,
neuro
Cancer
Deprivation / poverty
GI disorders / post GI
surgery
Alcoholics / Drug
Dependency
Patients with Altered
Nutritional Requirements:
◦ Critical care
◦ Sepsis
◦ Cancer
◦ Trauma
◦ Surgery
◦ Renal Failure
◦ Liver Disease
◦ GI & pancreatic disorders
◦ COPD
◦ Pregnancy
Identification: Nutrition Screening
Sometimes we miss the obvious
Albumin
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Commonly used by the medical profession as a
marker for nutritional state
Albumin is not a marker for nutrition
Albumin indicates disease state not nutrition
Poor nutritional state can coexist with illness
but albumin does not indicate malnutrition
No single biochemical marker can be used to
assess nutrition
Other causes of Low Albumin
Common
Sepsis - CRP; ALB
 Acute & Chronic inflammatory
conditions
 Cirrhosis/ Liver disease
 Nephrotic syndrome
 Malabsorption
 Malnutrition
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Least
Common
Hypoalbuminaemia is an important prognostic
indicator. The lower the level, the higher the mortality
ESPEN guidelines (2006) for enteral
nutrition in surgery
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Significantly malnourished pts
having elective major surgery
should be considered for
preoperative nutrition support,
this may involve tube feeding for
10-14 days pre-op
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Oral intake should be resumed as
soon as possible after surgery,
usually within 24hrs, with
monitoring
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Tube feeding (EN) should be
given immediately post op for pts
anticipated to be unable to eat
for > 7days & for pts who cannot
maintain oral diet >60%
requirements for >10 days
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PN should be reserved for
malnourished patients who
cannot be fed via the GIT for at
least 7 days
Elective
Emergency
Nutrition screening
in OPC
Nutrition screen
on admission
+/-ERAS
protocol
High
Risk
Low
Risk
Pre-op nutrition
support & goal setting
High
Risk
Post operative
nutrition support
Low
Risk
Rescreen
weekly
Components of the ERAS multimodal
care pathway
http://www.erassociety.org/index.php/eras-care-system/eras-protocol
Options for nutrition support
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Oral nutrition support
Enteral tube feeding
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Nasogastric
Nasojejunal
PEG / RIG
Jejunostomy
Parenteral feeding
Aim for the least invasive method required to
achieve goals
Oral nutrition support – food first
High calorie, high protein diet
 Snacks, puddings
 Majority of patients can resume a normal
diet within hours of surgery
 Avoid unnecessary restrictions
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Oral nutritional supplements
Not all the same!
Consideration should be given to what product
best addresses the identified nutritional
deficiencies prior to prescribing
 Co-morbidities will also affect choice e.g. milk
protein allergy, diabetes, fat malabsorption, renal
disease, coeliac disease
 Not all patients need supplements forever!!
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Altered level of
consciousness
Nausea
Diarrhoea
Key symptoms which
affect ability for patient
to take oral or enteral
nutrition
Vomiting or
high NG
aspirates
Pain
Constipation
Addressing symptoms
Nausea / vomiting: anti emetics,
prokinetics, ensuring bowels opening
 Pain: analgesia
 Constipation: laxatives, enemas
 Swallowing: SALTx, altered consistency
diet/fluids
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Feeding routes - enteral
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Gastric
◦ Nasogastric tube: patients at high risk of
aspiration, swallowing problems, unconscious.
Can be used in addition to oral nutrition.
Nasal bridles for some patients
Feeding routes - enteral
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Gastric
◦ PEG / RIG / surgical gastrostomy: the
placement of a tube through the abdominal
wall directly into the stomach. Long term
nutrition support. Prophylactic in H&N
cancer
Feeding routes - enteral
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Jejunal
◦ Nasojejunal (NJ) tube - jejunal feeding tube
passed endoscopically via the nasal passage
◦ Surgical jejunostomy – jejunal feeding tube
directing through the abdomen into the small
bowel
◦ Gastroparesis, UGI
◦ surgery
Parenteral nutrition (PN)
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Administration of nutrients, fluids and
electrolytes directly into a central or
peripheral vein
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Traditionally associated with
complications
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However PN used appropriately, with
close attention to glycaemic control
and avoidance of overfeeding can safely
deliver adequate nutrition
Who needs it?
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Patients who are malnourished or who are likely
to become malnourished and where the GI tract
is not fully functional or is inaccessible (NICE
2006)
PN anticipated to be needed >7/7
TPN should be avoided where aggressive
nutritional support not indicated or where the
risks outweigh the benefits
Referrals
Dietitian – oral nutrition support (food,
supplements), enteral feed rotas (NG,
PEG, NJ, jej), other dietary modifications
 Nutrition Team – PEG assessments,
assessment for nasal bridle, complicated
EN, ethical dilemas re feeding route, all
PN patients
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Case examples
Mr X, 75, admitted as emergency with
#NOF
 PMH HTN, osteoporosis
 Post operatively: poor intake of diet
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What would you want to know?
 What would you do?
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Mr X
Pre admission nutritional state – weight,
height, BMI, usual intake, weight history
 Symptoms which may be affecting his
appetite – nausea/pain/constipation
 Nutrition risk score (MUST)
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Plan: ONS – food first / supplements,
Dietitian, consider NGT
Case examples
Outpatient clinic
 Mrs S has oesophageal cancer, due for an
elective oesophagectomy
 PMH Type 2 DM
 What would you want to know
 What might your plan be?
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Mrs S
Nutritional state: weight, weight history, BMI,
swallowing, current nutritional intake / any
impairment, other symptoms. Nutrition risk
score: MUST
 Consider pre operative nutrition support if
malnourished – outpatient / inpatient
 Consider post operative feeding tube due to
impact that surgery will have on ability to eat –
surgical jejunostomy or NJ
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Case example
Inpatient
 Mr D. Emergency admission with severe
abdo pain. Emergency laparotomy for
ischaemic bowel with stoma formation
 What would you want to know
 What might the plan be?
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Mr D
Nutritional state: weight, BMI, weight loss,
intake prior to admission, symptoms –
type/duration. MUST score
 How much bowel remaining and site of
stoma. Quality of remaining bowel
 Nutrition route could be oral +/- enteral
tube or equally may need PN for short or
long term
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Conclusion
Malnutrition significantly
affects outcomes from
surgery
 Identification of malnourished patients enables
appropriate treatments to be initiated to
promote the rapid recovery and discharge of
surgical patients
 Nutrition support should be provided for patients
identified at risk of malnutrition from nutrition
screening aiming for the least invasive route
 Treatment of symptoms inhibiting oral or enteral
nutrition an important aspect of surgical teams
plan
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References
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Anderson MR, O’Connor M, Mayer P, O’Mahony D, Woodward J, Kane,K.
(2003). The nasal loop provides an alternative to percutaneous endoscopic
gastrostomy in high- risk dysphagia stroke patients. Clinical Nutrition. Vol
23. No 4
ERAS society guidelines (joint publications with ESPEN):
http://www.erassociety.org/index.php/eras-guidelines
ESPEN (2006). Guidelines on enteral nutrition: surgery including organ
transplantation. Clinical Nutrition 25: 224 – 244
ESPEN (2009). Guidelines on parenteral nutrition: surgery. Clinical
Nutrition 28: 378 - 386
Gustafsson UO, Nygren J, Thorell A, Soop M, Hellström PM, Ljungqvist O,
Hagström-Toft E. (2008). Pre-operative carbohydrate loading on
postoperative hyperglycaemia in hip fracture patients: A randomised
control clinical study. Acta Anaesthesiol Scand. 2008 Aug;52(7):946-51
NICE (2006) Nutrition Support in Adults: oral supplements, enteral and
parenteral feeding. NICE
Powell-Tuck et al. (2011) British Consensus Guidelines on Intravenous
Fluid Therapy for Adult Surgical Patients (GIFTASUP). BAPEN