Nutrition Postoperative

8/13/2019 Nutrition Postoperative

1/47

For the Surgical Patient

Kelly Sparks LDN, RD


2/47

Lecture Outline

Energy Sources

Nutrition Requirements

Diet AdvancementMicronutrients for wound healing

Enteral versus Parenteral Nutrition

Case studies


3/47

Energy Sources Carbohydrates

Limited storage capacity, needed for CNS function

Yields 3.4 kcal/gram

Pitfall: too much=lipogenesis and increased CO2 production

Fats

Major endogenous fuel source in healthy adults Yields 9 kcal/gm

Pitfall: too little=essential fatty acid (linoleic acid deficiency-dermatitisand increased risk of infections

Protein

Needed to maintain anabolic state (match catabolism) Yields: 4 kcal/gm

Pitfall: must adjust in patient with renal and hepatic failure

Elevated creatinine, BUN, and/or ammonia


4/47

Nutrition Requirements

Healthy AdultsCalories: 25-35 kcals/kg

Protein: 0.8-1 gm/kg

Fluids: 30 mls/kg Requirement Change for the Surgical Patient

Special ConsiderationsStress

Injury or disease

Surgery

Pre-hospital/pre-surgical nutrition


5/47

Nutrition

The surgical patient

Extraordinary stressors (hypovolemia,

hypervolemia, bacteremia, medications)

Wound Healing

Anabolic state, appropriate vitamins (A, C, Zinc), and

adequate kcals/protein.

Poor Nutrition=Poor OutcomesFor every gram deficit of untreated

hypoalbuminemia there is ~30% increase in

mortality


6/47

Post-Operative Nutrition Requirements

Calories:

Increase to 30-40 kcals/kg

Patient on ventilator usually require less

calories ~20-25 kcal/kg

Protein:

Increase to 1-1.8 grams/kg

Fluids:

Individualized


7/47

Diet Advancement

Traditional Method:

Start clear liquids when signs of bowel function

returns.

Rationale: Clear liquid diets supply fluid andelectrolytes in a form that require minimal digestion

and little stimulation of the GI tract.

Clear liquids are intended for short-term use due toinadequacy


8/47

Diet Advancement

Recent Evidence:

Suggests that liquid diets and slow diet progression

may not be warranted!!

Clinical study:

Looked atearly post-operative feedingusing

regular diets or very fast progression vs. traditional

methods of NPO until bowel function with slow dietprogression and foundno difference in post-

operative complications. (emesis, distention, NGT

reinsertion, LOS,)


9/47

Keep in Mind

Per SLP

When using liquid diets, patients must have

adequate swallowing functions.

Even patients with mild dysphagia often requirethickened liquids.

Therefore, be specific in writing liquid diet orders

for patients with dysphagia


10/47

Micronutrients in Wound Healing

Vitamin Supplementation to promote healing

has been somewhat disputed.

Some studies show no significant effect unless

there is a clinical vitamin deficiency

Serum vitamin levels are not always accurate;

therefore, must use subjective diet history and

clinical judgment to determine deficiency.


11/47

Key Nutrients for Wound Healing

Vitamin A: Cellular differentiation, proliferation, epithelialization,

collagen synthesis, counteract catabolic effect of steroids.

RDA=3333 International Units

Appropriate dose=25,000 IU per day x 10 days in setting of high dosesteroids or deficiency.

Avoid long term supplementation due to high risk of toxicity with fat-soluble vitamins.

No vitamin A with renal failure due to greater potent ional fortoxicity. (Can exceed the binding capacity of retinol binding

protein leading to elevated circulating levels.)


12/47


Vitamin C:Collagen synthesis

RDA=50-90 mg/day

Low levels are common in high risk population (elderly,smokers, cancer, liver disease).

Appropriate dose: 500 mg x 10 days

No vitamin C with renal failure due to risk for renal

oxalate stone formation.


13/47


Zinc:Protein synthesis, cellular replication, collagen formation; large

wounds, chest tubes, and wound drains contribute to further zinc

loses.

Appropriate dose: 220 mg per day of Zinc Sulfate or50 mg of elemental Zinc x 10 days.

Prolonged Zinc supplementation interferes with copper

absorption and can lead to copper deficiency which delays wound

healing by impairing collagen synthesis.

MVI with minerals:1 tablet daily to compensate for any general micronutrient losses.


14/47

What is nutrition support?

An alternate means of providing nutrients to people who cannot eat

any or enough food

When is it needed?

Illness resulting in inability to take in adequate nutrients by

mouth

Illness or surgery that results in malfunctioning gastrointestinal

tract

Two types:

Enteral nutrition

Parenteral nutrition


15/47

Indications for Enteral Nutrition

Malnourished patient expected to be unable to

eat adequately for > 5-7 days

Adequately nourished patient expected to be

unable to eat > 7-9 days

Adaptive phase of short bowel syndrome

Following severe trauma or burns


16/47

Contraindications to Enteral Nutrition Support

Malnourished patient expected to eat within 5-7 days

Severe acute pancreatitis

High output enteric fistula distal to feeding tube Inability to gain access

Intractable vomiting or diarrhea

Aggressive therapy not warranted Expected need less than 5-7 days if malnourished or

7-9 days if normally nourished


17/47

Enteral Access Devices

Nasogastric

Nasoenteric

Gastrostomy

PEG (percutaneous endoscopic gastrostomy)Surgical or open gastrostomy

Jejunostomy

PEJ (percutaneous endoscopic jejunostomy)

Surgical or open jejunostomy

Transgastric Jejunostomy

PEG-J (percutaneous endoscopic gastro-jejunostomy)

Surgical or open gastro-jejunostomy


18/47

Feeding Tube Selection

Can the patient be fed into the stomach, or is

small bowel access required?

How long will the patient need tube feedings?


19/47

Gastric vs. Small Bowel Access

If the stomach empties, use it.

Indications to consider small bowel access:Gastroparesis / gastric ileus

Recent abdominal surgery

Sepsis

Significant gastroesophageal reflux

Pancreatitis

AspirationIleus

Proximal enteric fistula or obstruction


20/47

Short-Term vs. Long-Term

Tube Feeding Access

No standard of care for cut-off time between

short-term and long-term access

However, if patient is expected to require

nutrition support longer than 6-8 weeks, long-

term access should be considered


21/47

Choosing Appropriate Formulas

Categories of enteral formulas:Polymeric (Jevity)

Whole protein nitrogen source, for use in patients with normalor near normal GI function

Monomeric or elemental (Perative, Optimental)Predigested nutrients; most have a low fat content or high % of

MCT oil (medium-chain triglycerides); for use in patients withseverely impaired GI function

Disease specific (Nepro, Nutrahep, Glucerna)

Formulas designed for feeding patients with specific diseasestates

Formulas are available for respiratory disease, diabetes, renalfailure, hepatic failure, and immune compromise

*well-designed clinical trials may or may not be available


22/47

Enteral Nutrition Prescription Guidelines

Gastric feedingContinuous feeding:

Start at rate 30 mL/hour

Advance in increments of 20 mL q 8 hours to goal

Check gastric residuals q 4 hours

Bolus feeding:Start with 100-120 mL bolus

Increase by 60 mL q bolus to goal volume

Typical bolus frequency every 3-8 hours

Small bowel feedingContinuous feeding only; do not bolus due to risk of dumping

syndromeStart at rate 20 mL/hour

Advance in increments of 20 mL q 8 hours to goal

Do not check gastric residuals


23/47

Aspiration Precautions

To prevent aspiration of tube feeding, keep

HOB > 30at all times

Do not use methylene blue to test for

aspiration; regular blue food dye OK but not

proven effective method of detecting

aspiration


24/47

Complications of Enteral Nutrition Support

Nausea and vomiting / delayed gastric

emptying

MalabsorptionCommon manifestations include unexplained weight

loss, steatorrhea, diarrhea

Potential causes include gluten sensitiveenteropathy, Crohns disease, radiation enteritis,

HIV/AIDS-related enteropathy, pancreatic

insufficiency, short gut syndrome


25/47

Enteral Nutrition Case Study

78-year-old woman admitted with new CVA

Significant aspiration detected on bedside swallow

evaluation and confirmed with modified barium

swallow study; speech language pathologistrecommended strict NPO with alternate means of

nutrition

PEG placed for long-term feeding access

Plan of care is to stabilize the patient and transfer her

to a long-term care facility for rehabilitation


26/47

Enteral Nutrition Case Study (continued)

Height: 54 IBW: 120# +/- 10%

Weight: 130# / 59kg 100% IBW

BMI: 22

Usual weight: ~130# no weight change

Estimated needs:

1475-1770 kcal (25-30 kcal/kg)59-71g protein (1-1.2 g/kg)

1770 mL fluid (30 mL/kg)


27/47

Steps to determine the Enteral Nutrition

Prescription

1. Estimate energy, protein, and fluid needs

2. Select most appropriate enteral formula

3. Determine continuous vs. bolus feeding

4. Determine goal rate to meet estimated needs

5. Write/recommend the enteral nutritionprescription


28/47

Enteral Nutrition Prescription

Tube feeding via PEG with full strength

Jevity 1.2

Initiate at 30 mL/hour, advance by 20 mL q 8 hoursto goal

Goal rate = 55 mL/hour continuous infusionAbove goal will provide 1584 kcal, 73g protein, 1069 mL free

H2O

Give additional free H2O 175 mL QID to meet

hydration needs and keep tube patent Check gastric residuals q 4 hours; hold feeds for

residual > 200 mL

Keep HOB > 30at all times


29/47

What is parenteral nutrition?

Parenteral Nutrition

also called "total parenteral nutrition," "TPN," or

"hyperalimentation."

It is a special liquid mixture given into the blood viaa catheter in a vein.

The mixture contains all the protein, carbohydrates,

fat, vitamins, minerals, and other nutrients needed.


30/47

Indications for Parenteral Nutrition Support

Malnourished patient expected to be unable to

eat > 5-7 daysANDenteral nutrition is

contraindicated

Patient failed enteral nutrition trial with

appropriate tube placement (post-pyloric)

Enteral nutrition is contraindicated or severe

GI dysfunction is present

Paralytic ileus, mesenteric ischemia, small bowel

obstruction, enteric fistula distal to enteral access

sites


31/47

PPN vs. TPN

TPN (total parenteral nutrition)High glucose concentration (15%-25% final dextrose

concentration)

Provides a hyperosmolar formulation (1300-1800 mOsm/L)

Must be delivered into a large-diameter vein through centralline.

PPN (peripheral parenteral nutrition)Similar nutrient components as TPN, but lower concentration

(5%-10% final dextrose concentration)

Osmolarity < 900 mOsm/L (maximum tolerated by aperipheral vein)

May be delivered into a peripheral vein

Because of lower concentration, large fluid volumes areneeded to provide a comparable calorie and protein dose as

TPN


32/47

Parenteral Access Devices

Peripheral venous access

Catheter placed percutaneously 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)


33/47

Writing TPN prescriptions

1. Determine total volume of formulation based on individualpatient fluid needs

2. Determine amino acid (protein) contentAdequate to meet patients estimated needs

3. Determine dextrose (carbohydrate) content~70-80% of non-protein calories

4. Determine lipid (fat) content~20-30% non-protein calories

5. Determine electrolyte needs6. Determine acid/base status

7. Check to make sure desired formulation will fit in the totalvolume indicated


34/47

Parenteral Nutrition Monitoring

Check daily electrolytes and adjust TPN/PPN electrolyteadditives accordingly

Check accu-check glucose q 6 hours (regular insulin may be added toTPN/PPN bag for glucose control as needed)

Non-diabetics or NIDDM: start with half of the previous days sliding

scale insulin requirement in TPN/PPN bag and increase daily in thesame manner until target glucose is reached

IDDM: start with 0.1 units regular insulin per gram of dextrose inTPN/PPN, then increase daily by half of the previous days slidingscale insulin requirement

Check triglyceride level within 24 hours of starting TPN/PPN

If TG >250-400 mg/dL, lipid infusion should be significantly reducedor discontinued

Consider adding carnitine 1 gram daily to TPN/PPN to improve lipidmetabolism

~100 grams fat per week is needed to prevent essential fatty aciddeficiency


35/47

Parenteral Nutrition Monitoring (continued)

Check LFTs weekly

If LFTs significantly elevated as a result of TPN, then

minimize lipids to < 1 g/kd/day and cycle TPN/PPN over 12

hours to rest the liver

If Bilirubin > 5-10 mg/dL due to hepatic dysfunction, then

discontinue trace elements due to potential for toxicity of

manganese and copper

Check pre-albumin weekly

Adjust amino acid content of TPN/PPN to reach normal pre-

albumin 18-35 mg/dL

Adequate amino acids provided when there is an increase in

pre-albumin of ~1 mg/dL per day


36/47

Parenteral Nutrition Monitoring(continued)

Acid/base balance

Adjust TPN/PPN anion concentration to maintain

proper acid/base balance

Increase/decrease chloride content as needed

Since bicarbonate is unstable in TPN/PPN

preparations, the precursoracetateis used; adjust

acetate content as needed


37/47

Complications of Parenteral Nutrition

Hepatic steatosis

May occur within 1-2 weeks after starting PN

May be associated with fatty liver infiltrationUsually is benign, transient, and reversible in

patients on short-term PN and typically resolves in

10-15 days

Limiting fat content of PN and cycling PN over 12

hours is needed to control steatosis in long-term PN

patients


38/47

Complications of Parenteral Nutrition Support(continued)

CholestasisMay occur 2-6 weeks after starting PN

Indicated by progressive increase in TBili and an elevated serumalkaline phosphatase

Occurs because there are no intestinal nutrients to stimulatehepatic bile flow

Trophic enteral feeding to stimulate the gallbladder can behelpful in reducing/preventing cholestasis

Gastrointestinal atrophy Lack of enteral stimulation is associated with villus hypoplasia,

colonic mucosal atrophy, decreased gastric function, impaired GIimmunity, bacterial overgrowth, and bacterial translocation

Trophic enteral feeding to minimize/prevent GI atrophy


39/47

Parenteral Nutrition Case Study

55-year-old male admitted with small bowelobstruction

History of complicated cholecystecomy 1

month ago. Since then patient has had poorappetite and 20-pound weight loss

Patient has been NPO for 3 days since admit

Right subclavian central line was placed andplan noted to start TPN since patient isexpected to be NPO for at least 1-2 weeks


40/47

Parenteral Nutrition Case Study(continued)

Height: 60 IBW: 178# +/- 10%

Weight: 155# / 70kg 87% IBW

BMI: 21

Usual wt: 175# 11% wt loss x 1 mo.

Estimated needs:

2100-2450 kcal (30-35 kcal/kg)

84-98g protein (1.2-1.4 g/kg)

2100-2450 mL fluid (30-35 mL/kg)


41/47

Parenteral Nutrition Prescription

TPN via right-SC line 2200 mL total volume x 24 hours

Amino acid: 45 g/liter= 45g x 2.2 L= 99 grams x 4 kcals/gram =369 kcals

Dextrose 175 g/liter= 175g x 2.2 L= 385 grams x 3.4 kcals/gram= 1309 kcals

Lipid 20% 285 mL over 24 hours 285 mls x 2= 570 kcals

Above will provide 2275 kcal, 99g protein,

DIR=(385 g dex/ 70 kg /1440 minute in a day)*1000=3.8mg/kg/min

LIR= (285 mls lipid * 20%)/ 70 kg=0.8 g/kg/day


42/47

Parenteral Nutrition Prescription

Important items to consider:Dextrose infusion rate should be < 4 mg/kg/minute

(maximum tolerated by the liver) to prevent hepaticsteatosis

Lipid infusion rate should be less than 1 g/kg/day tominimize/prevent TPN-induced liver dysfunction

You may need to adjust/eliminate lipids if patient ison propofol. (1 ml propofol =1.1 kcal)

Ex. Propofol @ 10 ml/hr would provide 264 kcals(10 ml/hr x 1.1 kcal/ml, x 24 hrs)

Initiate TPN at ~ of goal rate/concentration andgradually increase to goal over 2-3 days to optimize

serum glucose control


43/47

Benefits of Enteral NutritionOver Parenteral Nutrition

Cost

Tube feeding cost ~ $10-20 per day

TPN costs up to $1000 or more per day!

Maintains integrity of the gut

Tube feeding preserves intestinal function; it is more physiologicTPN may be associated with gut atrophy

Less infection

Enteral feedingvery small risk of infection and may

prevent bacterial translocation across the gut wallTPNhigh risk/incidence of infection and sepsis


44/47

Refeeding Syndrome

the metabolic and physiologic consequences ofdepletion, repletion, compartmental shifts, andinterrelationships of phosphorus, potassium, andmagnesium

Severe drop in serum electrolyte levels resulting fromintracellular electrolyte movement when energy isprovided after a period of starvation (usually > 7-10days)

Physiologic and metabolic sequelae may include:EKG changes, hypotension, arrhythmia, cardiac arrest

Weakness, paralysis

Respiratory depression

Ketoacidosis / metabolic acidosis


45/47

Refeeding Syndrome (continued)

Prevention and Therapy

Correct electrolyte abnormalities before starting

nutrition support

Continue to monitor serum electrolytes after nutritionsupport begins and replete aggressively

Initiate nutrition support at low rate/concentration

(~ 50% of estimated needs) and advance to goal

slowly in patients who are at high risk


46/47

Consequences of Over-feeding

Risks associated with over-feeding:Hyperglycemia

Hepatic dysfunction from fatty infiltration

Respiratory acidosis from increased CO2production

Difficulty weaning from the ventilator

Risks associated with under-feeding:Depressed ventilatory drive

Decreased respiratory muscle function

Impaired immune function

Increased infection


47/47

Questions

Reference: 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 ofSurgery.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 ofSurgery.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 oralfeeding safe after elective colorectal surgery? A prospective randomized trial.Annals ofSurgery.1995 July;222(1):73-7.

Ross, R. Micronutrient recommendations for wound healing. Support Line.2004(4): 4.

Nutrition Postoperative

Documents

Transcript of Nutrition Postoperative