Nutrition in Surgical Patients

Nicky Wyer MSc, RDSenior Specialist DietitianUHCW Nutrition Support Team

Learning objectivesTo understand: Who is at risk of malnutrition and how

to identifyThe impact of malnutrition on surgical

plans and outcomesUnderstanding of routes for nutrition

supportHow to address common symptoms in

the surgical patient that impact on nutritional intake

Who to refer to

What is malnutrition?

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)

Malnutrition does it matter?

What is the overall aim of your surgical team?

A malnourished patient will have 3 x higher rate of complications and 4 x greater risk of death from the same surgery compared to a

well nourished patient (NICE 2006)

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

Wound infectionsWound breakdownAnastamotic leak

Hospital acquired pneumoniaRenal failure

Return to theatre for revisional surgeryMorbidityMortality

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.

Who’s at risk?ElderlyChronic ill-health

e.g. diabetes, renal, COPD, neuro

CancerDeprivation /

povertyGI disorders / post GI

surgeryAlcoholics / Drug

Dependency

Patients with AlteredNutritional

Requirements:◦Critical care◦Sepsis◦Cancer◦Trauma◦Surgery◦Renal Failure◦Liver Disease◦GI & pancreatic

disorders◦COPD◦Pregnancy

Identification: Nutrition Screening

Sometimes we miss the obvious

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

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

ESPEN guidelines (2006) for enteral nutrition in surgery Significantly malnourished

pts having elective major surgery should be considered for preoperative nutrition support, this may involve tube feeding for 10-14 days pre-op

Oral intake should be resumed as soon as possible after surgery, usually within 24hrs, with monitoring

Tube feeding (EN) should be given immediately post op for pts anticipated to be unable to eat for > 7days & for pts who cannot maintain oral diet >60% requirements for >10 days

PN should be reserved for malnourished patients who cannot be fed via the GIT for at least 7 days

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

Components of the ERAS multimodal care pathway

http://www.erassociety.org/index.php/eras-care-system/eras-protocol

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

Oral nutrition support – food firstHigh calorie, high protein dietSnacks, puddingsMajority of patients can resume a

normal diet within hours of surgery

Avoid unnecessary restrictions

Oral nutritional supplements

Not all the same!Consideration should be given to what

product best addresses the identified nutritional deficiencies prior to prescribing

Co-morbidities will also affect choice e.g. milk protein allergy, diabetes, fat malabsorption, renal disease, coeliac disease

Not all patients need supplements forever!!

Key symptoms which affect ability for patient to take oral or enteral

nutrition

Nausea

Vomiting or high NG aspirates

Pain

Diarrhoea

Constipation

Altered level of consciousness

Addressing symptomsNausea / vomiting: anti emetics,

prokinetics, ensuring bowels opening

Pain: analgesiaConstipation: laxatives, enemasSwallowing: SALTx, altered

consistency diet/fluids

Feeding routes - enteralGastric

◦ Nasogastric tube: patients at high risk of aspiration, swallowing problems, unconscious. Can be used in addition to oral nutrition. Nasal bridles for some patients

Feeding routes - enteralGastric

◦ PEG / RIG / surgical gastrostomy: the placement of a tube through the abdominal wall directly into the stomach. Long term nutrition support. Prophylactic in H&N cancer

Feeding routes - enteralJejunal

◦Nasojejunal (NJ) tube - jejunal feeding tube passed endoscopically via the nasal passage

◦Surgical jejunostomy – jejunal feeding tube directing through the abdomen into the small bowel

◦Gastroparesis, UGI ◦surgery

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

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

If the gut works, use it! If the gut works a little, use

it a little

ReferralsDietitian – oral nutrition support

(food, supplements), enteral feed rotas (NG, PEG, NJ, jej), other dietary modifications

Nutrition Team – PEG assessments, assessment for nasal bridle, complicated EN, ethical dilemas re feeding route, all PN patients

Case examplesMr X, 75, admitted as emergency

with #NOFPMH HTN, osteoporosisPost operatively: poor intake of

diet

What would you want to know?What would you do?

Mr XPre admission nutritional state –

weight, height, BMI, usual intake, weight history

Symptoms which may be affecting his appetite – nausea/pain/constipation

Nutrition risk score (MUST)

Plan: ONS – food first / supplements, Dietitian, consider NGT

Case examplesOutpatient clinicMrs S has oesophageal cancer,

due for an elective oesophagectomy

PMH Type 2 DMWhat would you want to knowWhat might your plan be?

Mrs SNutritional state: weight, weight

history, BMI, swallowing, current nutritional intake / any impairment, other symptoms. Nutrition risk score: MUST

Consider pre operative nutrition support if malnourished – outpatient / inpatient

Consider post operative feeding tube due to impact that surgery will have on ability to eat – surgical jejunostomy or NJ

Case exampleInpatientMr D. Emergency admission with

severe abdo pain. Emergency laparotomy for ischaemic bowel with stoma formation

What would you want to knowWhat might the plan be?

Mr DNutritional state: weight, BMI,

weight loss, intake prior to admission, symptoms – type/duration. MUST score

How much bowel remaining and site of stoma. Quality of remaining bowel

Nutrition route could be oral +/- enteral tube or equally may need PN for short or long term

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

Nutrition support should be provided for patients identified at risk of malnutrition from nutrition screening aiming for the least invasive route

Treatment of symptoms inhibiting oral or enteral nutrition an important aspect of surgical teams plan

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