Transcript Nutrition in Surgical Patients

Nutrition in Surgical Patients
Nicky Wyer MSc, RD
Senior Specialist Dietitian
UHCW Nutrition Support Team
Areas to cover
Malnutrition and the surgical patient
 Identifying patients at risk
 ERAS – Nutritional aspects
 Routes for nutrition support
 Refeeding syndrome
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Malnutrition does it matter?
A malnourished patient will have 3
times the number of complications and
4 times the risk of death from the same
surgery compared to a well nourished
patient (NICE 2006)
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)
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?
Elderly
 Chronic ill-health e.g.
diabetes, renal, COPD,
neuro
 Cancer
 Deprivation / poverty
 GI disorders / post GI
surgery
 Alcoholics
 Drug Dependency
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Patients with Altered
Nutritional Requirements:
◦ Critical care
◦ Sepsis
◦ Cancer
◦ Trauma
◦ Surgery
◦ Renal Failure
◦ Liver Disease
◦ GI & pancreatic disorders
◦ COPD
◦ Pregnancy
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
Cardiac
Reduced cardiac output
CCF
Renal
Reduced Na & H2O excretion
Other
Reduced muscle strength
Neurological weakness
Inability to regulate temperature
ESPEN guidelines for enteral
nutrition in surgery
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Patients who are significantly malnourished and are due
to undergo major surgery should be considered for
preoperative nutrition support, this may involve tube
feeding for 10-14 days pre-op (ESPEN 2006)
Oral intake should be resumed as soon as possible after
surgery, usually within 24hrs, with monitoring
Enteral tube feeding should be given without delay post
op for any patient who it is anticipated will be unable to
eat for > 7days and for patients who cannot maintain oral
intake >60% requirements for >10 days
PN should be reserved for malnourished patients who
cannot be fed via the GIT for at least 7 days
Nutritional requirements
Typically quoted as 25 – 30kcal / kg
calories however Dietitian will assess
patients individual needs
 Calorie requirements affected by:
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◦ Age, Gender, Activity level, Weight,
◦ Degree of stress associated with surgery
◦ Calorific intake from other sources e.g.
propofol in ITU
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
David Blaine
Fast for 44 days
He lost 25.5Kg(26.6%)
At end BMI = 21.6Kgm-2
Albumin 52.9 gl-1
Fashion model
BMI = 11.5 Kgm-2
Albumin = 38 gl-1
Other causes of Low Albumin
Common
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Sepsis - CRP; ALB
Acute & Chronic inflammatory
conditions
Cirrhosis/ Liver disease
Nephrotic syndrome
Malabsorption
Malnutrition
Least
Common
Hypoalbuminaemia is an important prognostic
indicator. The lower the level, the higher the mortality
Pre-operative fasting
Typically patients NBM from midnight prior
to surgery. Advocated to ensure an empty
stomach to  risk of aspiration
 ESPEN (2006) and NICE (2006): Safe for
patients to eat up to 6 hours prior to
surgery and drink fluids up to 2 hours prior
to surgery (grade A evidence)
 This  the need for IV fluids which helps
prevent post op fluid and salt overload
which adversely affects the GIT tract and
ability to mobilise (Powell-Tuck 2011)
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Surgery & Fasting
Catabolism
Insulin
resistance
Hyperglycaemia
Loss of fat &
muscle stores
Components of the ERAS multimodal
care pathway
http://www.erassociety.org/index.php/eras-care-system/eras-protocol
Preoperative carb loading
preOp (Nutricia) and preload (Vitaflo)
 4 x 200ml evening pre surgery,
2 x 200ml up to 2hrs pre anaesthesia.
100kcal, 25g (4.2g sugar) carbohydrate
per carton
 Creates a non starved metabolism
 Moderates metabolic response
to surgery
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Pre op carbohydrate loading
Decreased catabolism
 Decreased hyperglycaemia
 Preserved muscle mass
 Improved grip strength
 Reduced LOS
 Reduced Anxiety
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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
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
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!
Patient preferences key
Consideration should be given to what product
best addresses the identified nutritional
deficiencies prior to prescribing
 Co-morbidities will also affect choice e.g. CMP
allergy, diabetes, fat malabsorption, renal disease,
coeliac disease
 Ongoing monitoring of patients is essential to
establish when nutritional goals have been met
and nutritional support can be stopped
 Not all patients need supplements forever!!
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Addressing symptoms
Nausea / vomiting: anti emetics,
prokinetics, dilatation, ensuring bowels
opening
 Pain: analgesia
 Constipation: laxatives, enemas
 Swallowing: SALTx, altered consistency
diet/fluids
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Puree diet example
Breakfast:
Porridge & Cup of tea (all)
Mid Morning:
Cup of Coffee & Squash
Lunch:
Beef Casserole meal (all)
Crème Caramel (all)
Orange Juice
Mid Afternoon:
Squash
Evening Meal:
Salmon Bake Meal (all)
Raspberry Mousse (all)
Squash
Supper:
Cup of tea
What do you think of this intake??
Puree diet example
Total: 1270kcal
52.5g protein
1135ml fluid
This will be inadequate for most post operative patients
Be aware that patients can have difficulty achieving
adequate intakes on altered consistency diet and fluid
as choices are more limited and less nutrient rich
Require additional snacks or puddings and many
require oral nutritional supplements when on this
texture
Enteral feeding
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Enteral feeding refers to the delivery of
nutritionally complete feed containing
protein, carbohydrate, fat, water, minerals
and vitamins directly into the stomach,
duodenum or jejunum.
NICE 2006
Enteral feeding
For those unable to take orally for >7 days or are
unable to take sufficient amounts (>60%) and for
whom more invasive nutritional support is an
appropriate part of the treatment plan ESPEN 2006
Polymeric feeds first line, reflects normal dietary intake
 Specialist feeds for use in certain conditions e.g. renal, malabsorption,
sodium or fluid restriction
 Various “core” feeds available
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fibre and fibre free versions
0.8-2kcal / ml
Nutritionally complete in set amount of calories
Gluten & lactose free majority of products
Contain milk protein except Soya based feeds
Vegetarian issue – carminic acid – in ONS, fish oils.
Depends on company / product used, Dietitian will advise
Nasogastric - indications
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Patients at high risk of aspiration,
swallowing problems, unconscious.
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Supplementary to oral nutrition – poor
appetite, increased nutritional
requirements.
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Supplementary to parenteral nutrition.
Nasal Bridal
A nasal bridal is a
device to secure a
NG or NJ tube to
the nasal septum
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2 high grade magnets are inserted via each
nostril these connect around the nasal
septum allowing the looping of a thin strip of
gauze/tape around the nasal septum which is
then fixed to the NG / NJ tube with a clip.
Gastrostomy feeding
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The placement of a tube through the abdominal
wall directly into the stomach for either
temporary or permanent delivery of enteral feed
(Payne-James et al 2001).
PEG, RIG, Surgical gastrostomy – be clear on
what type of tube it is
 Head & Neck cancer
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Indications / contraindications
Indications
Contraindications
 Long term nutrition
Absolute
support required
 Total gastrectomy
 Swallowing impairment  Portal hypertension
with gastric varices
Relative
 Unfit for procedure
 Partial gastrectomy
 PD
 Ascites
 Active gastric ulcer
Jejunal Feeding
Placement of a tube into the small bowel,
either via the nasal cavity (NJ), surgically
placed (surgical jejunostomy), or
occasionally via PEG tube (PEJ). It is a
method of feeding patients who are unable
to maintain or improve their nutritional
status by oral intake and in whom gastric
feeding is contraindicated or has been
unsuccessful.
Indications for jejunal feeding
Previously documented gastroparesis
Gastric stasis due to paralysing agents
required for ventilation
 Persisting delayed gastric emptying despite
medical management
 Severe acute pancreatitis
 Upper GI surgery
 Pancreatic or duodenal injury
 Hepato-biliary surgery
 Cancer of the oesophagus or stomach
where NG or gastrostomy feeding is
inappropriate
 Upper GI fistula
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Complications of EN
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Nausea and vomiting
Abdominal distension
Diarrhoea
Constipation
Oesophagitis
Aspiration
Blocked tube
Complications during tube insertion
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
Indications
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Short bowel
syndrome
Prolonged paralytic
ileus (>7/7)
Bowel obstruction or
pseudo-obstruction
Motility disorders e.g.
scleroderma
Gastrointestinal
fistulae
Adhesions
Anastamotic leak
Radiation
gastroenteritis
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Mucositis, oesophagitis or
intractable vomiting
secondary to
chemotherapy
Severe acute
inflammatory bowel
disease
GI perforation
Severe acute pancreatitis
Post op extensive bowel
surgery
Parenteral Nutrition
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Bags made up by aseptic
lab
Mixture of glucose, lipid,
amino acids, electrolytes,
fluid, vitamins, minerals
and trace elements
Modifications can be made
if clinically indicated
If EN commences can
reduce PN gradually as
EN increases
Refeeding syndrome
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Patients who have had a prolonged period with
little/no nutrition >10/7, low BMI, >10% unintentional
wt loss, electrolyte disturbances, alcoholics pose risk
of refeeding syndrome when any feeding commenced
Severe electrolyte & metabolic abnormalities can
occur as a result of feeding but difficult to separate
from abnormalities associated with critical illness
Prevent by slow feeding, vitamin supplementation and
electrolyte correction
Ensure patients are assessed by a dietitian to
ascertain risk level and appropriate plan is made
Pathophysiology of refeeding
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
 Increasing use of ERAS protocols and cessation of
prolonged fasting pre-op improves outcomes
 Nutrition support should be provided for patients
identified at risk of malnutrition from nutrition
screening aiming for the least invasive route
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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