nutrition in surgical patients
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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Nutrition in Surgical Patients
Nicky Wyer MSc, RDSenior Specialist DietitianUHCW Nutrition Support Team
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Areas to coverMalnutrition and the surgical
patientIdentifying patients at riskERAS – Nutritional aspectsRoutes for nutrition supportRefeeding 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)
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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)
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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
The Extent of ‘The Problem’ [1]
40% of adult hospital patients are overtly malnourished on admission. 8% categorised as severe.
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Who’s at risk?ElderlyChronic ill-health
e.g. diabetes, renal, COPD, neuro
CancerDeprivation /
povertyGI disorders / post GI
surgeryAlcoholicsDrug Dependency
Patients with AlteredNutritional
Requirements:◦Critical care◦Sepsis◦Cancer◦Trauma◦Surgery◦Renal Failure◦Liver Disease◦GI & pancreatic
disorders◦COPD◦Pregnancy
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ImmunityIncreased infection riskImpaired wound healing
OtherReduced muscle strengthNeurological weaknessInability to regulate temperature
PsychiatricAnhedoniaDepressionConfusionAnorexia
?Micronutrient deficiency
CardiacReduced cardiac outputCCF
HepaticFatty LiverNecrosis/ Fibrosis
RenalReduced Na & H2O excretion
GutReduced immunityReduced integrityOedema
RespiratoryDecreased tidal volumesReduced muscle bulkLoss of adaptive response to hypoxia
Effects of Undernutrition
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ESPEN guidelines for enteral nutrition in surgery
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
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Nutritional requirements
Typically quoted as 25 – 30kcal / kg calories however Dietitian will assess patients individual needs
Calorie requirements affected by:◦Age, Gender, Activity level, Weight, ◦Degree of stress associated with
surgery◦Calorific intake from other sources
e.g. propofol in ITU
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Identification: Nutrition Screening
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Sometimes we miss the obvious
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AlbuminCommonly 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
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David BlaineFast for 44 daysHe lost 25.5Kg(26.6%)At end BMI = 21.6Kgm-2Albumin 52.9 gl-1
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Fashion modelBMI = 11.5 Kgm-2
Albumin = 38 gl-1
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Other causes of Low Albumin
Sepsis - CRP; ALBAcute & Chronic inflammatory
conditionsCirrhosis/ Liver diseaseNephrotic syndromeMalabsorptionMalnutrition
Hypoalbuminaemia is an important prognostic indicator. The lower the level, the higher the mortality
Common
Least Common
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Pre-operative fastingTypically 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
Hyperglycaemia
Insulin resistance
Loss of fat & muscle stores
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Components of the ERAS multimodal care pathway
http://www.erassociety.org/index.php/eras-care-system/eras-protocol
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Preoperative carb loadingpreOp (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 loadingDecreased catabolismDecreased hyperglycaemiaPreserved muscle massImproved grip strengthReduced LOSReduced Anxiety
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Elective
Nutrition screening in OPC
High Risk
Low Risk
Pre-op nutrition support & goal
setting
Emergency
Nutrition screen on admission
Post operative nutrition support
High Risk
Low Risk
Rescreen weekly
+/-ERAS protocol
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Options for nutrition supportOral nutrition supportEnteral tube feeding
◦Nasogastric◦Nasojejunal◦PEG / RIG◦Jejunostomy
Parenteral feeding
Aim for the least invasive method required
to achieve goals
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Oral nutrition supportHigh calorie, high protein dietSnacks, puddingsMajority 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 keyConsideration 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 symptomsNausea / vomiting: anti emetics,
prokinetics, dilatation, ensuring bowels opening
Pain: analgesiaConstipation: laxatives, enemasSwallowing: 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??
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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
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Enteral feedingEnteral 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
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Enteral feedingFor 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
◦ 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
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Nasogastric - indicationsPatients at high risk of aspiration,
swallowing problems, unconscious.
Supplementary to oral nutrition – poor appetite, increased nutritional requirements.
Supplementary to parenteral nutrition.
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Nasal Bridal
A nasal bridal is a device to secure a NG or NJ tube to the nasal septum
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.
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Gastrostomy feedingThe 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
IndicationsLong term
nutrition support required
Swallowing impairment
ContraindicationsAbsoluteTotal gastrectomyPortal hypertension
with gastric varices
RelativeUnfit for procedurePartial gastrectomyPDAscitesActive gastric ulcer
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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.
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Indications for jejunal feedingPreviously documented gastroparesisGastric stasis due to paralysing agents
required for ventilationPersisting delayed gastric emptying
despite medical managementSevere acute pancreatitisUpper GI surgeryPancreatic or duodenal injuryHepato-biliary surgeryCancer of the oesophagus or stomach
where NG or gastrostomy feeding is inappropriate
Upper GI fistula
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Complications of EN
Nausea and vomitingAbdominal distensionDiarrhoeaConstipationOesophagitisAspirationBlocked tubeComplications during tube insertion
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Parenteral nutrition (PN)
Administration of nutrients, fluids and electrolytes directly into a central or peripheral vein
Traditionally associated with complications
However PN used appropriately, with close attention to glycaemic control and avoidance of overfeeding can safely deliver adequate nutrition
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Who needs it?
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 >7/7TPN should be avoided where
aggressive nutritional support not indicated or where the risks outweigh the benefits
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If the gut works, use it! If the gut works a little, use
it a little
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IndicationsShort bowel
syndromeProlonged paralytic
ileus (>7/7)Bowel obstruction or
pseudo-obstructionMotility disorders e.g.
sclerodermaGastrointestinal
fistulaeAdhesionsAnastamotic leakRadiation
gastroenteritis
Mucositis, oesophagitis or intractable vomiting secondary to chemotherapy
Severe acute inflammatory bowel disease
GI perforationSevere acute
pancreatitisPost op extensive
bowel surgery
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Parenteral Nutrition Bags made up by
aseptic labMixture 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
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Refeeding syndromePatients 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
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Pathophysiology of refeeding
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ConclusionMalnutrition 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 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