Nutrition care plan for surgical patients

Surgical Nutrition Training ModuleLevel 1

Philippine Society of General SurgeonsCommittee on Surgical Training

Objectives

• To discuss the process of nutrition management of surgical patients

• To discuss the role of the nutrition team

NUTRITION CARE PLAN FORMULATION

The surgical nutrition process

All admitted patients are nutritionally screened

All nutritionally at risk patients are assessed

All high risk patients are given nutrition care plans

Monitoring of the nutrition process is done

Nutrition care plan modification / Discharge

Nutrition Care Plan

Form

Nutritional status

• Severely malnourished?• Feeding access? Oral, GIT, parenteral,

combinations• Need to build up before surgery?• Is there a need for special nutrients?

malnutritionScheduled• esophageal resection• gastrectomy• pancreaticoduodenectomy

Enteral nutrition for 10-14 days

oral immunonutrition for 6-7 days

Early oral feeding within 7 days

yes no

within 4 days

yes

“Fast Track”

no

Parenteral hypocaloric

Adequate calorie intake within 14 days

Enteral access (NCJ)

yes no

enteral nutrition immunonutrition for 6-7 days

Oral intake of energy requirements

yes no

combined enteral / parenteral

no slight, moderate severe

SURGERY

PRE-OPERATIVE PHASE

POST-OP

EARLY DAY 1 - 14

LATE DAY 14

Oral intake of energy requirements

yesnosupplemental enteral diet

Surgical nutrition pathways: Pre-operative phase

Normal to moderate

malnutrition

SURGERY

Severe Malnutrition • Esophageal resection• Gastrectomy• Pancreaticoduodenectomy

Parenteral nutrition + Omega-3-Fatty Acids + Antioxidants (+ glutamine); 6-7 days

Nutritional Assessment

ESPEN Guidelines on Parenteral Nutrition (2009)

Condition: When oral or enteral feeding not possible

Surgical nutrition pathways:Intra & Post-operative Period

While in the OR ask yourself: “is oral feeding possible within 7 days?”

Yes No

Can I feed within 4 days? Needle catheter jejunostomy

• Enteral nutrition (12 hrs)• Better: immunonutrition

If enteral nutrition is inadequate

Supplemental PN

Yes No

“Fast Track” PN

Transition

ESPEN Guidelines on Enteral Nutrition (2006) and Parenteral Nutrition (2009)

Nutrition Care Plan

Physician, Dietitian, Pharmacist

Total calorie and protein requirement

• Guidelines:– Nutritional status – if severely malnourished

• Calories: 20 to 30 kcal/kg body weight• Use actual body weight if not obese

– Capacity to undergo surgery• Normal or low malnutrition level: immediate surgery

Non-protein calories

• Ratio of glucose to lipid content• Issue regarding type of lipids

– Saturated vs. unsaturated– Long chain vs. medium chain triglycerides– Omega-3 vs. omega-6 PUFA, how about omega-9?

Micronutrients

• Electrolytes– Laboratory values– Drug-nutrient interactions

• Vitamins– Water and fat soluble vitamins

• Trace elements

Nutrition Care Plan

Physician, Dietitian, Pharmacist

Physician, Nurse

Nurse, Dietitian, Pharmacist

Nurse, Dietitian, Physician, Pharmacist

Formulation

• Oral supplementation• Enteral nutrition

– Standard vs. special nutrition– Supplemental vs. meal replacement– Issue of blenderized diets

• Parenteral nutrition– Supplemental vs. total PN– Need to include micronutrients in all solutions– Special nutrients (e.g. pharmaconutrition)

Enteral nutrition issues

Commercial Formulas Blenderized Formulas

Uniform contentsSterile

Low viscosityLactose freeDefined caloric density

Daily nutrient variabilityNon-sterile; high bacterial content and other pathogensHigh viscosityDoes not provide adequate caloric density

Gallagher-Alfred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50

Sullivan MM, et al. J Hosp Infect 2001;49:268-273

Pharmaconutrition

Dose Content in preps

Glutamine 0.4 – 0.5 g/kg 12 – 15 g/L

Arginine ? 4 – 16 g/L

Omega-3-fatty acids (EPA)

2 – 6 g/day 1 – 2 g/L

Antioxidants

Carotenoids

Vitamin C,E

>100% daily requirement

Single or combinations

Maximum effect when given at the proper dose

Access and delivery

• Enteral:– Short term vs. long term– need for enteral pumps

• Parenteral– Peripheral vs. central– Single or multiple lumen catheters– Protocols for maintenance

The surgical nutrition process

All admitted patients are nutritionally screened

All nutritionally at risk patients are assessed

All high risk patients are given nutrition care plans

Monitoring of the nutrition process is done

Nutrition care plan modification / Discharge

The team performs the calorie count and fluid balance

The fluid, calorie, and protein intake are recorded and adequacy of intake

is recorded in the patient’s chart

Monitoring issues

Calorie, protein,

fluid balance

form

Nutrient monitor

form

How to implement• Monitoring: everyone is involved

Monitoring

• Fluid balance – avoid fluid accumulation within 4-5 days post op

• Calorie balance• Gastric retention for enteral nutrition• Blood tests:

– BUN high – dialyze– High triglycerides – lower lipid flow– Hyperglycemia – insulin

• Weight once a weekJan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003

Nutrition TeamDiagnosisManagementOverall plan

ScreeningEnteral nutritionParenteral nutritionMonitoring

Parenteral nutritionMonitoring

Enteral nutritionMonitoring

NST activity

Policies and guidelines

Patient rounds

NST meeting

Reports on outcome

Updates from other studies

compiled and updated

regular like 3x a week

• difficult cases• coordination issues

monthly, yearly

regular

NST activity/documentation

Outcomes of adequate intake

Adequate intake in surgery patients

Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients

nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, 2008.

THANK YOU