Nutrition Assessment and Post-Surgical Advancement Rebecca Cohen, MS, RD, LDN Transplant Dietitian...
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Transcript of Nutrition Assessment and Post-Surgical Advancement Rebecca Cohen, MS, RD, LDN Transplant Dietitian...
Nutrition Assessment and Post-Surgical
Advancement
Rebecca Cohen, MS, RD, LDN
Transplant Dietitian
Tulane Transplant Institute
Nutrition and Surgery Reported 40% incidence of malnutrition in
acute hospital setting Malnutrition may compound the severity of
complications related to a surgical procedure A well-nourished patient usually tolerates
major surgery better than a severely malnourished patient Malnutrition is associated with a high incidence of
operative complications and death.
Normal Nutrition (EatRight.org)
The Newest Food Guide
Teaches ● Balancing Calories ● Enjoy your food, but eat less ● Avoid oversized portions
Foods to Increase ● Make half your plate fruits and vegetables ● Make at least half your grains whole grains ● Switch to fat-free or low-fat (1%) milk
Foods to Reduce ● Compare sodium in foods like soup, bread, and frozen meals and choose the foods with lower numbers ● Drink water instead of sugary drinks
Website: http://www.choosemyplate.gov/ Includes interactive tools including a personalized daily food plan and food tracker
Carbohydrates Limited storage capacity, needed for CNS (glucose) function
Yields 3.4 kcal/gm
Recommended 45-65% of total caloric intake
Simple vs Complex
Fats Major endogenous fuel source in healthy adults
Yields 9 kcal/gm
Too little can lead to essential fatty acid (linoleic acid) deficiency and increased risk of infections
Recommended 20-30% of total caloric intake
Protein Needed to maintain anabolic state (match catabolism)
Yields 4 kcal/gm
Must adjust in patients with renal and hepatic failure
Recommended 10-35% of total caloric intake
Normal Nutrition Requirements
HEALTHLY male/female
• Caloric intake= 25-30 kcal/kg/day
• Protein intake= 0.8-1gm/kg/day (max=150gm/day)
• Fluid intake= ~30 ml/kg/day*
*Unless medical state warrants fluid restriction
Reasons for Malnutrition Inadequate nutritional intake Metabolic response Nutrient losses Protein/energy store depletion Prevalence of ileus, anorexia, malabsorption Extraordinary stressors (surgical stress, hypovolemia,
bacteremia, medications) Wound healing
Anabolic state May require appropriate vitamins
Nutrition Comparison
SURGERY PATIENT
Caloric intake *Mild stress
25-30 kcal/kg/day *Moderate stress
30-35 kcal/kg/day *Severe stress
30-40 kcal/kg/day Protein intake
1-2 gm/kg/day Fluid intake
INDIVIDUALIZED
HEALTHLY 70 kg MALE
Caloric intake25-30 kcal/kg/day
Protein intake0.8-1gm/kg/day
Fluid intake30 ml/kg/day
Albumin Synthesized in and catabolized by the liver Normal range: 3.5-5 g/dL Half-life: 20 days
Pros Cons
Ranked as the strongest predictor of surgical outcomes
Lack of specificity due to long half-life
Inverse relationship between postoperative morbidity and mortality compared with preoperative serum albumin levels
Not accurate in pt’s with liver disease (elevated Tbili) or during inflammatory response (elevated WBC or CRP)
Prealbumin Synthesized by the liver and partly catabolized by
the kidneys Normal range:16-40 mg/dL
Values of <16 mg/dL are associated with malnutrition Half-life: 2-3 days
Pros Cons
Shorter half life than albumin More expensive than albumin
More favorable marker of acute change in nutritional status (compared to albumin)
Levels may be increased in the setting of renal dysfunction, corticosteroid therapy, or dehydration
*A baseline prealbumin is useful as part of the initial nutritional assessment if routine monitoring is planned
Over-hydration can decrease prealbumin levels; result in false negative
Nitrogen Balance Measures net changes in body protein mass Nitrogen Balance = protein intake (gm) - (UUN +4)
6.25 Healthy individuals= nitrogen balance (-1 to +1)
Positive Value Negative Value
Found during periods of growth, tissue repair, or pregnancy
Associated with burns, fevers, wasting diseases and other serious injuries, & during periods of fasting
Intake of nitrogen into the body is greater than the loss of nitrogen from the body
Amount of nitrogen excreted from the body is greater than nitrogen intake
Increase in the total body pool of protein
Often seen following major surgery*Patient will likely require extra protein for tissue building
Postoperative Diet Advancement Delay feeds for 24-48 hours until bowel
sounds & function return Begin with clear liquids
Supply fluids and electrolytes Require minimal digestion and stimulation of GI
tract Intended for short-term use due to inadequacy of
nutritional needs
Clear Liquid DietAcceptable food items
Water (plain, carbonated or flavored) Fruit juices without pulp, such as apple or white grape Fruit-flavored beverages, such as fruit punch or lemonade Plain gelatin Tea or coffee without milk or cream Strained tomato or vegetable juice Sports drinks Clear, fat-free broth Hard candy, such as lemon drops or peppermint rounds Ice pops without milk, bits of fruit, seeds or nuts (except red)
http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/clear-liquid-diet/art-20048505
Diet Advancement cont. Advance diet to full liquids
Middle step Meet daily calorie and protein needs
Acceptable food items Coffee, tea, cream, carbonated beverages Fruit and vegetable juices Milk & Milkshakes Nutritional supplements Custard-style yogurt, pudding, custard Plain ice cream, sherbet, sorbet Jell-o (any flavor) Cream soups, strained, cream of wheat, cream of rice, grits Pureed soups & Tomato puree Gravy, margarine Sugar, syrup, jelly, honey
http://www.upmc.com/patients-visitors/education/nutrition/pages/full-liquid-diet-facts.aspx
Diet Advancement cont. Advance diet to solid foods Appropriate to introduce solids as soon as the
GI tract is functioning & liquids are tolerated Diets available:
Regular Pediatric Heart healthy ADA/Diabetic Renal Low sodium (2 gm) Bland/Soft/Low residue
Key considerations Condition of the GI tract Disease state Complications that may have resulted from surgery
Ex: diabetes in a post-kidney transplant patient. Why?
For liquid diets, patients must have adequate swallowing functions, as determined by SLP Mechanical soft Pureed Thicken liquids
Must be specific in writing liquid diet orders for patients with dysphagia
Nutrition Support Options
Length of time a patient can remain NPO without complications is unknown Tulane Protocol: NPO > 4 days
Two types of nutritional support Enteral Parenteral
Enteral Nutrition Liquid mixture designed to meet nutrient needs
Goal rates are individidualized
Given through a tube in the stomach or small intestine Nasogastric tube Nasoduodenal tube Nasojejunal tube Gastrostomy/Jejunostomy
Continuous or Bolus feeds Specialized formulas for select disease states
Glucerna Suplena Nepro Elemental formulas
Indications Contraindications
Functioning GI tract Severe acute pancreatitis
Adaptive phase of short bowel syndrome
High output enteric fistula distal to feeding tube
Following severe trauma or burns
Inability to gain access
Intractable vomiting or diarrhea
Aggressive therapy not warranted
Gastric vs. Small Bowel
“If you don’t use it, you lose it.”
Indications to consider small bowel access: Gastroparesis Recent abdominal surgery Sepsis Significant gastroesophageal reflux (GERD) Aspiration risk Mild ileus Proximal enteric fistula or obstruction
No standard of care for cut-off time between short-term and long-term access
Long-term access should be considered if the patient is expected to require nutrition support longer than 6-8 weeks
NG tubes can be used for long term enteral nutrition
However, complications can include: Non-elective extubation Tube misplacement Occasional need to check position of the tube
Short-term vs Long-term
Choosing Appropriate Formulas
Polymeric Monomeric/elemental
Disease specific
Basic Info: Uses whole proteins as nitrogen source
Predigested nutrients; most have a low fat content or high % of MCT
Specific formulas for•Respiratory disease•Diabetes•Renal failure•Hepatic failure•Immune compromise
Consider for patients with:
Normal or near normal GI function
Impaired GI function Specific disease states
Tulane Enteral Nutrition Product Formulary
Enteral Nutrition Guidelines Gastric feeding
Small bowel feeding Continuous feeding only; do not bolus due to risk of
dumping syndrome Start slowly @ 20 mL/hour Advance in increments of 20 mL q 8 hours to goal Do not check gastric residuals
Continuous feeding Bolus feeding• Start at rate 30 mL/hour• Advance in increments of 20 mL
q 8 hours to goal• Check gastric residuals q 4 hour
• Start with 120 mL bolus• Increase by 60 mL q bolus to
goal volume• Every 3-8 hours
Complications of Enteral Nutrition Support
Access Administration GI complications Metabolic complications
Enteral Nutrition Case Study
78-year-old woman admitted with new CVA
Significant aspiration detected on bedside swallow evaluation SLP recommends strict NPO with alternate means of
nutrition
PEG placed for long-term feeding access
Plan: 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 IBW: 120# +/- 10% Usual weight: 130# Estimated needs:
Calories? Protein? Fluid?
Enteral Nutrition Prescription Jevity 1.2 (via PEG)
Initiate at 30 mL/hour, advance by 20 mL q 8 hours to goal
Goal rate = 55 mL/hour 1584 kcal 73g protein 1069 mL free H2O, additional ~515mL needed
Check residuals q 4 hours hold feeds for residual > 200 mL
Aspiration precautions
What is parenteral nutrition?
It is a special liquid mixture given into the blood via a catheter in a vein
Contains all the, carbohydrates, protein, fat, vitamins, minerals, and other nutrients needed
Light sensitive, always covered in a light resistant bag
Indications for TPN Two criteria, need both
Malnourished patient expected to be unable to eat > 5-7 days Failed enteral nutrition trial per SLP Appropriate tube placement
EN is contraindicated or severe GI dysfunction is present Ex: paralytic ileus, mesenteric ischemia, small bowel
obstruction, enteric fistula distal to enteral access sites
TPN (total parenteral nutrition)
PPN(peripheral parenteral nutrition)
High glucose concentration (15-25% final dextrose concentration)
Similar nutrient components as TPN, but lower concentration (5%-10% final dextrose concentration)
Provides a hyperosmolar formulation (1300-1800 mOsm/L)
Osmolarity < 900 mOsm/L (maximum tolerated by a peripheral vein)
Must be delivered into a large-diameter vein
May be delivered into a peripheral vein
Large fluid volumes needed to meet same calorie and protein dose as TPN (because lower in concentration)
Often used with other MNT and for a short period of time
Parenteral Access Devices
Peripheral venous access Catheter placed percutaneouly 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. Determine total volume of formulation based on individual patient fluid needs
1. Determine amino acid content
2. Determine dextrose content
3. Determine lipid content
4. Check to make sure desired formulation will fit in the total volume indicated
Tulane TPN Order Form
Parenteral Nutrition Monitoring Check electrolytes daily and adjust TPN/PPN
additives accordingly
Check accu-check glucose q 6 hours
Check triglyceride level within 24 hours of starting TPN/PPN and weekly while patient remains on it
Parenteral Nutrition Monitoring (continued)
Check LFT’s weekly
Check pre-albumin weekly
Acid/base balance Increase/decrease chloride as needed Bicarbonate is unstable in TPN/PPN prep Precursor—acetate—is used
Complications of TPN/PPN Hepatic steatosis
Usually benign in patients on short-term PN
Resolves in 10-15 days
Limiting fat content of PN to control steatosis in long-term use
Complications of TPN/PPN (continued)
Cholestasis
Due to no intestinal nutrients to stimulate hepatic bile flow
Gastrointestinal atrophy
Trophic enteral feeding to minimize/prevent GI atrophy
TPN/PPN Case Study 55-year-old male admitted with small bowel
obstruction
Complicated cholecystecomy 1 month ago. Since, poor po intake and 20 # weight loss
NPO for 3 days since admitright subclavian central line was placed
Plan: start TPN since patient is expected to be NPO for at least 1-2 weeks
TPN/PPN Case Study(continued)
Height: 6’0” Weight: 155# / 70kg BMI: 21 IBW: 178# +/- 10% Usual wt: 175# Estimated needs:
Calories? Protein? Fluid?
TPN/PPN PrescriptionAmino acid 4.5% (or 45 g/liter)
Dextrose 17.5% (or 175 g/liter)
Lipid 20% 285 mL over 24 hours
2120 kcal, 90g protein (2 liters/24 hrs)
GIR: 3.5 mg/kg/minute
Enteral Parenteral
Cost $10-20 per day $100 or more per day
Gut Preserves intestinal function
May be associated with gut atrophy
Infection Very small risk of infection
High risk/incidence of infection and sepsis
Enteral Nutrition > Parenteral Nutrition
Miscellaneous Thoughts
• Transitional feeds• PNEN• PN/EN oral feeds
• Refeeding syndrome • Caused by intracellular movement when energy is
provided after a period of starvation (usually > 7-10 days)• Hypomagnesaemia, hypokalemia, hypophosphatemia• Close monitoring of electrolytes• Initiate feeds slowly, work towards goal rate
Miscellaneous Thoughts
Under-feeding Over-feeding
Depressed ventilatory drive Hyperglycemia
Decreased respiratory muscle function
Hepatic dysfunction from fatty infiltration
Impaired immune function Respiratory acidosis from increased CO2 production
Increased infection Difficulty weaning from the ventilator
Questions
Contact Information:
Rebecca Cohen, MS, RD, LDNTransplant Dietitian, Tulane Transplant Institute(504) [email protected]
References
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 patient-controlled 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.
Krause’s Food, Nutrition & Diet Therapy, 11th Ed. Mahan, K., Stump, S. Saunders, 2004.
American Society for Parenteral and Enteral Nutrition. The Science and Practice of Nutrition Support. 2001.