Transcript Document 7420314

For the Surgical Patient
Kelly Sparks LDN, RD
Lecture Outline
Energy Sources
Nutrition Requirements
Diet Advancement
Micronutrients for wound healing
Enteral versus Parenteral Nutrition
Case studies
Energy Sources
 Carbohydrates
 Limited storage capacity, needed for CNS function
 Yields 3.4 kcal/gram
 Pitfall: too much=lipogenesis and increased CO2 production
 Fats
 Major endogenous fuel source in healthy adults
 Yields 9 kcal/gm
 Pitfall: too little=essential fatty acid (linoleic acid deficiency-dermatitis
and increased risk of infections
 Protein
 Needed to maintain anabolic state (match catabolism)
 Yields: 4 kcal/gm
 Pitfall: must adjust in patient with renal and hepatic failure
 Elevated creatinine, BUN, and/or ammonia
Nutrition Requirements
Healthy Adults
Calories: 25-35 kcals/kg
Protein: 0.8-1 gm/kg
Fluids: 30 mls/kg
 Requirement Change for the Surgical Patient
 Special Considerations
Stress
 Injury or disease
 Surgery
 Pre-hospital/pre-surgical nutrition
Nutrition
The surgical patient…
Extraordinary stressors (hypovolemia,
hypervolemia, bacteremia, medications)
Wound Healing
Anabolic state, appropriate vitamins (A, C, Zinc), and
adequate kcals/protein.
Poor Nutrition=Poor Outcomes
For every gram deficit of untreated
hypoalbuminemia there is ~30% increase in
mortality
Post-Operative Nutrition Requirements
Calories:
Increase to 30-40 kcals/kg
Patient on ventilator usually require less
calories ~20-25 kcal/kg
Protein:
Increase to 1-1.8 grams/kg
Fluids:
Individualized
Diet Advancement
Traditional Method:
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
inadequacy
Diet Advancement
Recent Evidence:
Suggests that liquid diets and slow diet progression
may not be warranted!!
Clinical study:
Looked at early post-operative feeding using
regular diets or very fast progression vs. traditional
methods of NPO until bowel function with slow diet
progression and found no difference in postoperative complications. (emesis, distention, NGT
reinsertion, LOS,)
Keep in Mind…
Per SLP
When using liquid diets, patients must have
adequate swallowing functions.
Even patients with mild dysphagia often require
thickened liquids.
Therefore, be specific in writing liquid diet orders
for patients with dysphagia
Micronutrients in Wound Healing
Vitamin Supplementation to promote healing
has been somewhat disputed.
Some studies show no significant effect unless
there is a clinical vitamin deficiency
Serum vitamin levels are not always accurate;
therefore, must use subjective diet history and
clinical judgment to determine deficiency.
Key Nutrients for Wound Healing
 Vitamin A:
 Cellular differentiation, proliferation, epithelialization,
collagen synthesis, counteract catabolic effect of steroids.
 RDA=3333 International Units
 Appropriate dose=25,000 IU per day x 10 days in setting of high dose
steroids or deficiency.
 Avoid long term supplementation due to high risk of toxicity with fatsoluble vitamins.
 No vitamin A with renal failure due to greater potent ional for
toxicity. (Can exceed the binding capacity of retinol binding
protein leading to elevated circulating levels.)
Key Nutrients for Wound Healing
Vitamin C:
Collagen synthesis
RDA=50-90 mg/day
Low levels are common in high risk population (elderly,
smokers, cancer, liver disease).
Appropriate dose: 500 mg x 10 days
No vitamin C with renal failure due to risk for renal
oxalate stone formation.
Key Nutrients for Wound Healing
Zinc:
 Protein synthesis, cellular replication, collagen formation; large
wounds, chest tubes, and wound drains contribute to further zinc
loses.
 Appropriate dose: 220 mg per day of Zinc Sulfate or
50 mg of elemental Zinc x 10 days.
 Prolonged Zinc supplementation interferes with copper
absorption and can lead to copper deficiency which delays wound
healing by impairing collagen synthesis.
MVI with minerals:
 1 tablet daily to compensate for any general micronutrient losses.
What is 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
Indications for 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
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
Enteral Access Devices
 Nasogastric
 Nasoenteric
 Gastrostomy
PEG (percutaneous endoscopic gastrostomy)
Surgical or open gastrostomy
 Jejunostomy
PEJ (percutaneous endoscopic jejunostomy)
Surgical or open jejunostomy
 Transgastric Jejunostomy
PEG-J (percutaneous endoscopic gastro-jejunostomy)
Surgical or open gastro-jejunostomy
Feeding Tube Selection
Can the patient be fed into the stomach, or is
small bowel access required?
How long will the patient need tube feedings?
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
Short-Term vs. Long-Term
Tube Feeding Access
No standard of care for cut-off time between
short-term and long-term access
However, if patient is expected to require
nutrition support longer than 6-8 weeks, longterm access should be considered
Choosing Appropriate Formulas
 Categories of enteral formulas:
Polymeric (Jevity)
 Whole protein nitrogen source, for use in patients with normal
or near normal GI function
Monomeric or elemental (Perative, Optimental)
 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)
 Formulas designed for feeding patients with specific disease
states
 Formulas are available for respiratory disease, diabetes, renal
failure, hepatic failure, and immune compromise
*well-designed clinical trials may or may not be available
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
Bolus feeding:
 Start with 100-120 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
 Advance in increments of 20 mL q 8 hours to goal
 Do not check gastric residuals
Aspiration Precautions
To prevent aspiration of tube feeding, keep
HOB > 30° at all times
Do not use methylene blue to test for
aspiration; regular blue food dye OK but not
proven effective method of detecting
aspiration
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, Crohn’s disease, radiation enteritis,
HIV/AIDS-related enteropathy, pancreatic
insufficiency, short gut syndrome
Enteral Nutrition Case Study
 78-year-old woman admitted with new CVA
 Significant aspiration detected on bedside swallow
evaluation and confirmed with modified barium
swallow study; speech language pathologist
recommended strict NPO with alternate means of
nutrition
 PEG placed for long-term feeding access
 Plan of care is to 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
Usual weight: ~130#
Estimated needs:
IBW: 120# +/- 10%
100% IBW
no weight change
1475-1770 kcal (25-30 kcal/kg)
59-71g protein (1-1.2 g/kg)
1770 mL fluid (30 mL/kg)
Steps to determine the Enteral Nutrition
Prescription
1.
2.
3.
4.
5.
Estimate energy, protein, and fluid needs
Select most appropriate enteral formula
Determine continuous vs. bolus feeding
Determine goal rate to meet estimated needs
Write/recommend the enteral nutrition
prescription
Enteral Nutrition Prescription
 Tube feeding via PEG with full strength
Jevity 1.2
 Initiate at 30 mL/hour, advance by 20 mL q 8 hours
to goal
 Goal rate = 55 mL/hour continuous infusion
Above goal will provide 1584 kcal, 73g protein, 1069 mL free
H2O
 Give additional free H2O 175 mL QID to meet
hydration needs and keep tube patent
 Check gastric residuals q 4 hours; hold feeds for
residual > 200 mL
 Keep HOB > 30° at all times
What is 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.
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
PPN vs. TPN
 TPN (total parenteral nutrition)
High glucose concentration (15%-25% final dextrose
concentration)
Provides a hyperosmolar formulation (1300-1800 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
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)
Writing TPN prescriptions
1.
2.
Determine total volume of formulation based on individual
patient fluid needs
Determine amino acid (protein) content
Adequate to meet patient’s estimated needs
3.
Determine dextrose (carbohydrate) content
~70-80% of non-protein calories
4.
Determine lipid (fat) content
~20-30% non-protein calories
5.
6.
7.
Determine electrolyte needs
Determine acid/base status
Check to make sure desired formulation will fit in the total
volume indicated
Parenteral Nutrition Monitoring
 Check daily electrolytes and adjust TPN/PPN electrolyte
additives accordingly
 Check accu-check 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 >250-400 mg/dL, lipid infusion should be significantly reduced
or discontinued
 Consider adding carnitine 1 gram daily to TPN/PPN to improve lipid
metabolism
 ~100 grams fat per week is needed to prevent essential fatty acid
deficiency
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 prealbumin 18-35 mg/dL
Adequate amino acids provided when there is an increase in
pre-albumin of ~1 mg/dL per day
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
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
10-15 days
Limiting fat content of PN and cycling PN over 12
hours is needed to control steatosis in long-term PN
patients
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
Parenteral Nutrition Case Study
55-year-old male admitted with small bowel
obstruction
History of complicated cholecystecomy 1
month ago. Since then patient has had poor
appetite and 20-pound weight loss
Patient has been NPO for 3 days since admit
Right subclavian central line was placed and
plan noted to start TPN since patient is
expected to be NPO for at least 1-2 weeks
Parenteral Nutrition Case Study
(continued)
Height: 6’0”
Weight: 155# / 70kg
BMI: 21
Usual wt: 175#
Estimated needs:
IBW: 178# +/- 10%
87% IBW
11% wt loss x 1 mo.
2100-2450 kcal
(30-35 kcal/kg)
84-98g protein
(1.2-1.4 g/kg)
2100-2450 mL fluid (30-35 mL/kg)
Parenteral Nutrition Prescription
 TPN via right-SC line
 2200 mL total volume x 24 hours
 Amino acid: 45 g/liter=
 45g x 2.2 L= 99 grams x 4 kcals/gram =369 kcals
 Dextrose 175 g/liter=
 175g x 2.2 L= 385 grams x 3.4 kcals/gram= 1309 kcals
 Lipid 20% 285 mL over 24 hours
 285 mls x 2= 570 kcals
 Above will provide 2275 kcal, 99g protein,
 DIR=(385 g dex/ 70 kg /1440 minute in a day)*1000=
3.8mg/kg/min
 LIR= (285 mls lipid * 20%)/ 70 kg=0.8 g/kg/day
Parenteral Nutrition Prescription
Important items to consider:
Dextrose infusion rate should be < 4 mg/kg/minute
(maximum tolerated by the liver) to prevent hepatic
steatosis
Lipid infusion rate should be less than 1 g/kg/day to
minimize/prevent TPN-induced liver dysfunction
You may need to adjust/eliminate lipids if patient is
on propofol. (1 ml propofol =1.1 kcal)
Ex. Propofol @ 10 ml/hr would provide 264 kcals
(10 ml/hr x 1.1 kcal/ml, x 24 hrs)
Initiate TPN at ~½ of goal rate/concentration and
gradually increase to goal over 2-3 days to optimize
serum glucose control
Benefits of Enteral Nutrition
Over Parenteral Nutrition
 Cost
 Tube feeding cost ~ $10-20 per day
 TPN costs up to $1000 or more per day!
 Maintains integrity of the gut
 Tube feeding preserves intestinal function; it is more physiologic
 TPN may be associated with gut atrophy
 Less infection
Enteral feeding—very small risk of infection and may
prevent bacterial translocation across the gut wall
 TPN—high risk/incidence of infection and sepsis
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 > 7-10
days)
 Physiologic and metabolic sequelae may include:
EKG changes, hypotension, arrhythmia, cardiac arrest
Weakness, paralysis
Respiratory depression
Ketoacidosis / metabolic acidosis
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
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
Questions
 Reference:
 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 patientcontrolled 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.