update on surgical nutrition
TRANSCRIPT
Update on Surgical Nutrition
Kristopher R. Maday, MS, PA-C, CNSCUniversity of Alabama at Birmingham
Physician Assistant Program
Objectives• Identify malnourished prior to
surgery• Discuss post-operative diet
advancement• Recognize when nutritional support
needs to implemented– How to choose correct type– How to monitor nutritional support
• Dogmalysis
No Financial Disclosures
Common Dogma of Surgical Nutrition
• NPO at midnight for all surgical procedures
• NPO until bowel function resumes• Clears Full Liquid Soft Regular• Nutrition stresses surgical
anastomosis• TPN early in malnourished patients• No enteral feeding with vasopressors• No enteral feeding with open
abdomen
Prior Research
Studley HO. JAMA. 1936;106:458-460.
Stack JA, et al. Gastroenterologist. 1996;4:S8-S15. .
Prior Research
Grass F, et al. Eur J Clin Nutr. 2011;65(5):642-647. .
80% 20%
Perioperative Timeline
Miller KR, et al. JPEN. 2013;37:39S.
30-60 days 24 hours 1-14 days
Evaluation Preparation and Optimization
Pre-Op OR Post-Op
Assessment Prehabilitation Pre-operative
Pre-operative Risk Reduction
30-60 days 24 hours
Nutritional Assessment
Impaired Nutritional Status Severity of Disease Absent
0 Normal Nutritional Status Absent0 Normal Nutritional Requirements
Mild1
Weight loss > 5% in 3 months50-75% of usual food intake over last week
Mild1
Hip fractureCirrhosis, DM, Benign Cx, Hemodialysis, COPD
Mod2
Weight loss > 5% in 2 monthsBMI 18.5-20.5 with impaired general condition
25-50% of usual food intake over last weekMod2
Major abdominal surgeryStroke, PNA, Malignancy
Severe3
Weight loss of > 5% in 1 monthWeight loss > 15% in 3 months
BMI < 18.5 with impaired general condition0-25% of usual food intake over last week
Severe3
Head injuryBone marrow transplant
ICU admission
Kondrup J, et al. Clinical Nutrition. 2003;22:321-336..
Schiesser M et al. Clin Nutr. 2008;27(4):565-570
Kudsk KA, et al. JPEN. 2003;27:1-9..
Nutritional Risk Screening Tool (NRS 2002)
Pre-operative serum albumin < 3.0 mg/dL
Prehabilitation
Valentijn TM, et al. Surgeon. 2013;11(3):169-176..
Migita K, et al. Gastrointest Surg. 2012;16(9):1659-1665..
Fearon KC, et al. NEJM. 2011;365(6):565-567..
Obese and A1C > 7% Preservation of lean mass
Pre-operative Fasting
Cahill GF. Trans Am Clin Climatol Assoc. 1983;946:1-21..
8-12hr = glycogen
14 hours
Pre-Operative Fasting
2011 ASA Guidelines. Anesthesiology. 2011;114(3):495-511.
2011 American Society of Anesthesiologists Guidelines
2 hoursclear liquids
4 hoursbreast milk
6 hourslight meal
8 hoursregular meal
Pre-Operative Fasting
Fearon KC, et al. Clin Nutr. 2005;24(3):466-477.
Steenhagen E. Nutr Clin Prac. 2016;31(1):18-29.
Enhanced Recovery After Surgery (ERAS) Guidelines
25-50g clear carbohydrate drink
Ljungqvist O. JPEN. 2014;38(5):559-566.
Ljungqvist O. JPEN. 2012;3(4);389-398.
Post-Operative Ileus
Hormones and Neuropeptides
(CCK, CGRP, VIP, IL-1, TNF-ɑ)
Surgical Manipulation
Anesthesthesia
Endogenous opiate release
Inflammation(Macrophage and neutrophil
infiltration, cytokines, inflammatory mediators)
Exogenous opiates
Autonomic nervous system
(sympathetic inhibitory pathways)
Enteric nervous system
(substance P, NO)
Increased age
Male
Low albumin
Opioid use
Previous abdominal
surgery
Long surgery
Emergency surgery
Blood loss
Bragg D, et al. Clin Nutr. 2015;34(3):367-376
Slow
Gut
Post-Operative Ileus
Location Symptoms Signs Management Time to Resolution
StomachNausea +++Vomiting +++Abdominal Pain +
Distention +Succussion Splash
NG TubeMetoclopramideErythromycin
12-24hr
Small Bowel
Nausea ++Vomiting ++Abdominal Pain +
Distention ++ NG TubeAlvimopan 6-12hr
ColonNausea +Vomiting +Abdominal Pain ++
Distention +++
NeostigmineDecompress 48-72hr
Johnson MD, et al. Cleveland Clinic Journal of Medicine. 2009;76(11):642
Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125
Oral Post-Operative Diet
Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125Steenhagen E. Nutr Clin Prac. 2016;31(1):18-29.
Start REGULAR diet 24 hours post-op
Oral Post-Operative Diet
Nutritional Support• Indications – Unlikely to take in > 50% PO for next 3-
5 days– Inability to meet physiologic demands
by oral intake• 2 types– Enteral vs Parenteral
NICE Guidelines. Nutritional Support in Adults. 2006 Ukleja A, et al. Nutr Clin Pract. 2010;25:403-414
3500 BC 1598
1882
1968
Enteral Nutritional Support
24-48 hourspost-op
Enteral Nutritional Support
Martindale RG, et al. JPEN. 2013;37(1):5S-20S.
Enteral Nutritional Support
Martindale RG, et al. JPEN. 2013;37(1):5S-20S.
Enteral Nutrition Support
Lewis SJ, et al. BMJ. 2001;323:1-5.
Enteral Nutritional Support
Complications• Distention• Aspiration• Diarrhea• Azotemia• Iatrogenic injury• Volume problems
Martindale RG, et al. JPEN. 2013;37(1):5S-20S.
Total Parenteral Nutrition• Admixture of amino acids, dextrose,
lipids, vitamins, minerals, and electrolytes
• Indications– Non-functional GI tract– Failure of PO/enteral route
Total Parenteral Nutrition
McClave SA, et al. JPEN. 2013;37(S);73s.
Total Parenteral Nutrition• Access– Central Line– Tunneled/Cuffed
Catheter– PICC Line– Ports– Peripheral IV
Total Parenteral Nutrition• Complications– Catheter related bloodstream infections
(CRBSI)– Thrombosis– Hepatosteatosis– Hyper/hypoglycemia– Hyperlipidema– Electrolyte abnormalities
Maroulis J, et al. Clinical Nutrition. 2000;19(5):295-304.
Ukleja A, et al. Gastroenterol Clin N Am. 2007;36:23-46.
Heyland DK, et al. JPEN. 2003;27:355-373
Monitoring Nutritional Support
• Ensuring adequate caloric intake– Estimation• Equations (Ireton-Jones)
–Measure• Indirect calorimetry
• Ensuring adequate protein intake– Estimation• Equations (~1.5g/kg/day)
–Measure• Nitrogen balance
Maday KR. Universal Journal of Clinical Medicine. 2013;1(3):39-43.
Nitrogen Balance• 24 hour urine urea nitrogen (g)– 15.4g
• Add a “fudge factor” for non-urinary losses– Usually around 4
• Calculate 24 hour nitrogen intake– Total protein intake / 6.25
((75g protein)/6.25) – (15.4g + 4) = -7.4
7.4 x 6.25 + 10g = 56.25g protein/day
Weaning Nutritional Support
Continuous Nocturnal Bolus
Supplements for Wound Healing
Stechmiller JK. JPEN. 2010;25(1):61-68
Can You Feed An Open Abdomen?
Can You Feed An Open Abdomen?
1. If the gut works, use it2. Start slow and advance
to goal
Powel NJ, et al. JPEN. 2012;27(4):499-506
Moore SM, et al. JPEN. 2016;31(1):9-13
Friese RS, et al. JPEN. 2012;27(4):492-498
Powel NJ, et al. JPEN. 2012;27(4):499-506
Can You Feed On Vasopressors?
Can You Feed On Vasopressors?
Probably
Yang S, et al. JPEN. 2014;29(1):90-96
Bruns BR, et al. JPEN. 2016;31(1):14-17
Wells DL. JPEN. 2012;27(4):521-526
Take Home Points1.Involve your dietician2.Early enteral is best3.Parenteral only in select
cases4.Supplement when needed5.Critical illness is tough
