LECTURE 5 NUTRITION CARE PLAN FOR SURGICAL PATIENTS...

LECTURE 5 – NUTRITION CARE PLAN FOR SURGICAL PATIENTS

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Nutrition care plan for surgical patients

Surgical Nutrition Training ModuleLevel 1

Philippine Society of General SurgeonsCommittee on Surgical Training

In this session we will discuss the most important component of the surgical nutrition process – the NUTRITION CARE PLAN

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Objectives

• To discuss the process of nutrition management of surgical patients

• To discuss the role of the nutrition team

The objectives are: • To discuss the process and mechanics of the nutrition care plan for surgical patients • To discuss the role of the nutrition team in formulating and carrying out the nutrition care

plan


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NUTRITION CARE PLAN FORMULATION

How is the nutrition care plan designed, formulated, and carried out?


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The surgical nutrition process

All admitted patients are nutritionally screened

All nutritionally at risk patients are assessed

All high risk patients are given nutrition care plans

Monitoring of the nutrition process is done

Nutrition care plan modification / Discharge

The NUTRITION CARE PLAN is the third step in the surgical nutrition process: • Nutrition screening is the first step – all patients are screened to identify the “nutritionally

at risk” • Nutrition assessment is the second step – all identified “nutritionally at risk” will be

classified as mild, moderate, or high risk • The third step is the NUTRITION CARE PLAN which consists of three main components:

• Designing • Formulating – implementation part • Carrying out – implementation part

• The fourth step is the monitoring process of the nutrition care plan implementation • The fifth step is the reassessment of the nutrition care delivery process and revision of the

nutrition care plan if needed


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Nutrition Care Plan

Form

This is the nutrition care plan form. It contains all the components of the nutrition management for the surgery process.


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Nutritional status

• Severely malnourished?

• Feeding access? Oral, GIT, parenteral, combinations

• Need to build up before surgery?

• Is there a need for special nutrients?

These are the initial components of the nutrition care plan – to design the nutrition regimen based on the nutritional status of the patient and the magnitude of surgery. These are the issues: • Is the patient severely malnourished? • Is there a need for a feeding access? Oral, GIT, parenteral, combinations? • Is there a need to build up the patient before surgery? • Is there a need for special nutrients?


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malnutrition

Scheduled• esophageal resection• gastrectomy• pancreaticoduodenectomy

Enteral nutrition for 10-14 days

oral immunonutrition for 6-7 days

Early oral feeding within 7 days

yes no

within 4 days

yes

“Fast Track”

no

Parenteral hypocaloric

Adequate calorie intake within 14 days

Enteral access (NCJ)

yes no

enteral nutrition immunonutrition for 6-7 days

Oral intake of energy requirements

yes no

combined enteral / parenteral

no slight, moderate severe

SURGERY

PRE-OPERATIVE PHASE

POST-OP

EARLY DAY 1 - 14

LATE DAY 14

Oral intake of energy requirements

yesnosupplemental enteral diet

This is the clinical nutrition decision making process designed for surgery as recommended in the guidelines for surgery by the European Society of Clinical Nutrition and Metabolism in year 2009 (formerly ESPEN). • Please note that in the identified major surgeries nutrition build up with supplementation of

immunonutrition is recommended even if the patients are nutritionally assessed to be normal.

• The postoperative phase is characterized by the following: • Emphasis on early feeding • Placement of access for feeding (jejunostomy) when oral intake recovery is not

expected beyond one to two weeks • Supplemental parenteral nutrition when the patient’s actual intake falls below 60%


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Surgical nutrition pathways: Pre-operative phase

Normal to moderate malnutrition

SURGERY

Severe Malnutrition • Esophageal resection• Gastrectomy• Pancreaticoduodenectomy

Parenteral nutrition + Omega-3-Fatty Acids + Antioxidants (+ glutamine); 6-7 days

Nutritional Assessment

ESPEN Guidelines on Parenteral Nutrition (2009)

Condition: When oral or enteral feeding not possible

This is the decision making process when the patient cannot have oral or enteral feeding pre-operatively. Note that the parenteral nutrition regimen contains all macro and micronutrients and pharmaconutrients

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Surgical nutrition pathways:Intra & Post-operative Period

While in the OR ask yourself: “is oral feeding possible within 7 days?”

Yes No

Can I feed within 4 days? Needle catheter jejunostomy

• Enteral nutrition (12 hrs)• Better: immunonutrition

If enteral nutrition is inadequate

Supplemental PN

Yes No

“Fast Track” PN

Transition

ESPEN Guidelines on Enteral Nutrition (2006) and Parenteral Nutrition (2009)

These are the surgical access decision making process one has to make before closing up the patient. It is recommended that the question of gut recovery for feeding and the need for special access be addressed while in the operating room.


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Nutrition Care Plan

Physician, Dietitian, Pharmacist

These are the components of the nutrition care plan: • Total calorie requirement for the day – this is based on the discussions made earlier

especially based on guidelines of the major nutrition societies globally (ASPEN, ESPEN, PHILSPEN) – from the macronutrients (carbohydrates, fat, protein)

• Total protein requirement for the day (protein) • Electrolytes • Vitamins – water and fat soluble vitamins • Trace elements • Pharmaconutrients – includes glutamine, fish oils, antioxidants, and arginine The choices come hand in hand with the recommended standard values or specific

requirements for the patient (“tailor fit”) The nutrition team responsible for these decision making values are: • Physician • Dietitian • Nurse • Pharmacist


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Total calorie and protein requirement

• Guidelines:

– Nutritional status – if severely malnourished

• Calories: 20 to 30 kcal/kg body weight

• Use actual body weight if not obese

– Capacity to undergo surgery

• Normal or low malnutrition level: immediate surgery

For total calorie and protein requirement these are the guidelines: • Nutritional status – if severely malnourished

• Calories: 20 to 30 kcal/kg body weight • Use actual body weight if not obese

• Capacity to undergo surgery • Normal or low malnutrition level: immediate surgery guidelines:


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Non-protein calories

• Ratio of glucose to lipid content

• Issue regarding type of lipids

– Saturated vs. unsaturated

– Long chain vs. medium chain triglycerides

– Omega-3 vs. omega-6 PUFA, how about omega-9?

For the non-protein calories (=responsible for the main energy provision), these are the issues that need deciding on: • Ratio of glucose to lipid content – glucose preference for trauma and more lipid preference

for sepsis • Issue regarding type of lipids

• Saturated vs. unsaturated – energy priority (MCT) or immunomodulation (EPA/DHA) • Long chain vs. medium chain triglycerides (LCT is needed for cellular function; faster

delivery and utilization in the tissues for MCT) • Omega-3 vs. omega-6 PUFA, how about omega-9? (less inflammatory or pro-

inflammatory?)


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Micronutrients

• Electrolytes

– Laboratory values

– Drug-nutrient interactions

• Vitamins

– Water and fat soluble vitamins

• Trace elements

Micronutrient delivery • Electrolytes

• Laboratory values: Na, K, Cl, Mg, P • Drug-nutrient interactions

• Vitamins • Water and fat soluble vitamins

• Trace elements


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Nutrition Care Plan

Physician, Dietitian, Pharmacist

Physician, Nurse

Nurse, Dietitian, Pharmacist

Nurse, Dietitian, Physician, Pharmacist

These are the rest of the nutrition care plan: • Formulation – do you prepare a special diet? Do you need oral supplementation, enteral or

parenteral formulation? (=the physician, dietitian, and pharmacist are involved here) • Access route: (=it is the physician or nurse who are the point persons here)

• Enteral: oral, tube fed (gastrostomy? Jejunostomy?) • Parenteral: peripheral? Central?

• Method of delivery: (=the nurse, dietitian, or pharmacist are involved here) • Enteral nutrition - Bolus or gravity drip feeding? Pump driven? • Parenteral nutrition – preferably infusion pump driven

• How do you monitor the nutrition delivery process? (all the members of the nutrition team are involved here)

• Fluid balance especially accumulated fluid balance – zero balance or increasingly positive?

• Calorie and protein balance? Are the goals met? • Electrolytes: Na, K, Mg, Ca, P (=checking for “refeeding syndrome”) • Weight once a week? • Serum albumin, prealbumin, nitrogen balance


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Formulation

• Oral supplementation

• Enteral nutrition– Standard vs. special nutrition

– Supplemental vs. meal replacement

– Issue of blenderized diets

• Parenteral nutrition– Supplemental vs. total PN

– Need to include micronutrients in all solutions

– Special nutrients (e.g. pharmaconutrition)

Issues on formulation: • Oral supplementation – is this needed or is this enough to increase total intake for the day? • Enteral nutrition - this is always the priority as stated in the algorithm

– Standard vs. special nutrition – Supplemental vs. meal replacement – Issue of blenderized diets

• Parenteral nutrition – Supplemental vs. total PN – Need to include micronutrients in all solutions – Special nutrients (e.g. pharmaconutrition)rmulation:


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Enteral nutrition issues

Commercial Formulas Blenderized Formulas

Uniform contents

Sterile

Low viscosity

Lactose free

Defined caloric density

Daily nutrient variability

Non-sterile; high bacterial content

and other pathogens

High viscosity

Does not provide adequate caloric

density

Gallagher-Alfred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50

Sullivan MM, et al. J Hosp Infect 2001;49:268-273

Here is the issue on blenderized diets: • Contents of commercially-prepared formulas are uniform. In contrast, content can vary

considerably in blenderized formulas, depending on the basic ingredients. • Commercial formulas are prepared in an aseptic environment and are sterile. They are sold

in liquid form, ready to administer, which greatly reduces the risk of contamination. Blenderized formulas, on the other hand, are produced within the institution which increases the risk of bacterial contamination. If the formula becomes contaminated, the patient often suffers diarrhea and other GI symptoms.

• Blenderized formulas also have the disadvantage of being more viscous, increasing the risk of tube clogging.

• They may also contain lactose, which is contraindicated in some patients. Therefore, the use of commercially-prepared formulas is generally safer and more cost-effective.

Gallagher-Allred. Nutrition Supp Svc 1983 Tanchoco CC, et al. Respirology 2001;6:43-50 Sullivan MM, et al. J Hosp Infect 2001;49:268-273


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Pharmaconutrition

Dose Content in preps

Glutamine 0.4 – 0.5 g/kg 12 – 15 g/L

Arginine ? 4 – 16 g/L

Omega-3-fatty

acids (EPA)

2 – 6 g/day 1 – 2 g/L

Antioxidants

Carotenoids

Vitamin C,E

>100% daily

requirement

Single or

combinations

Maximum effect when given at the proper dose

Please take note of the doses of these pharmaconutrients: • Glutamine is usually given as part of the total protein requirement • Arginine is always needed especially for immune function and perfusion • Omega-3-fatty acid dose may reach as high as 15 g/day and usually this is delivered by

intravenous infusion • Antioxidants are needed daily and increased in dose when energy expenditures increase


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Access and delivery

• Enteral:

– Short term vs. long term

– need for enteral pumps

• Parenteral

– Peripheral vs. central

– Single or multiple lumen catheters

– Protocols for maintenance

These are the access and delivery issues: • Enteral:

• Short term vs. long term (cut off from NGT to PEG access = 3 weeks?) • Need for enteral pumps (=jejunostomy feeding is better with enteral pumps)

• Parenteral • Peripheral vs. central (=one week of PN? More than 2-3 weeks?) • Single or multiple lumen catheters (=at least two lumen catheters are recommended

to ensure continuous parenteral nutrition delivery) • Protocols for maintenance


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The surgical nutrition process

All admitted patients are nutritionally screened

All nutritionally at risk patients are assessed

All high risk patients are given nutrition care plans

Monitoring of the nutrition process is done

Nutrition care plan modification / Discharge

The details of the monitoring process will be discussed in the following slides

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The team performs the calorie count and fluid balance

The fluid, calorie, and protein intake are recorded and adequacy of intake

is recorded in the patient’s chart

Monitoring issues

These are the people, equipment, and forms involved in the monitoring process.


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Calorie, protein,

fluid balance

form

The main source of the monitoring information is the patient’s intake and output record. The data from this record is modified and placed in the calorie, protein, and fluid balance form.

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Nutrient monitor

form

The nutrient monitoring form will summarize the total calorie and protein requirement, the details of the sources of calorie and protein taken by the patient and finally the percentage of the actual intake which will indicate whether the patient has adequate or inadequate intake.


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How to implement

• Monitoring: everyone is involved

Here is a sample of the completed nutrient monitor form. Note the values.


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Monitoring

• Fluid balance – avoid fluid accumulation within 4-5 days post op

• Calorie balance

• Gastric retention for enteral nutrition

• Blood tests:– BUN high – dialyze

– High triglycerides – lower lipid flow

– Hyperglycemia – insulin

• Weight once a weekJan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003

Finally these are the key monitoring variables of the nutrition care plan: • Fluid balance – avoid fluid accumulation within 4-5 days post op • Calorie balance • Gastric retention for enteral nutrition (=currently the value for slowing or stopping the

feeding for 30 minutes to one hour is 150 to 200 ml ) • Blood tests:

• BUN high – dialyze • High triglycerides – lower lipid flow • Hyperglycemia – insulin

• Weight once a week (weigh daily if accumulated fluid balance is high @2 liters)


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Nutrition TeamDiagnosisManagementOverall plan

ScreeningEnteral nutritionParenteral nutritionMonitoring

Parenteral nutritionMonitoring

Enteral nutritionMonitoring

We now focus on the nutrition team. It is the gold standard for achieving adequate nutrition management for the surgical patient in the hospital setting. The main reason is the team utilizes all the special skills of its specific members – from the physician who is the team leader to the rest of the team: clinical dietitian, nurse, and pharmacist – to delivery optimum nutrition to the patient.


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NST activity

Policies and guidelines

Patient rounds

NST meeting

Reports on outcome

Updates from other

studies

compiled and updated

regular like 3x a week

• difficult cases

• coordination issues

monthly, yearly

regular

The team activity essentially covers the whole nutrition delivery and reporting of outcomes for the whole department or hospital. These are: • Policies and guidelines are initially formulated for the delivery of the clinical nutrition

process • Once guidelines are in place the team goes on patient rounds at least 3x a week • For difficult patients a nutrition team meeting has to be called • All nutrition management data are encoded and compiled for the weekly or monthly

reports; this includes study data for research purposes • Regular updates on clinical nutrition practices are done either locally or abroad


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NST activity/documentation

Screened and

assessed patients

“At Risk” patients

• critically ill

• elderly

• stroke

• cancer

• post-op

complications

• malnutrition rate

• underweight / obese

• severe weight loss

• severely malnourished

• poor intake

• effect of nutrition care:

• calorie count

• outcome:

• morbidity

• mortality

• nutraceuticals

• other interventions

• suggestions

• nutrition care

• fluid balance

• access

• formulation

• carried out?

In essence these are the outcome data that can be reported from the clinical nutrition process: • From the screened and assessed patients

• Malnutrition rate (underweight and obese) • Severe weight loss profile for patients

• From the nutritionally at risk patients • Severely malnourished surgical patients • Who are the patients with poor intake – effect of nutrition care • Outcome (=morbidity, mortality) correlated with adequate intake, use of

pharmaceuticals • Are the suggestions carried out by the attending physicians? (=suggestions on early

feeding, fluid management, access and formulation)


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Outcomes of adequate intake

This study on reduction of mortality in critical care patients was achieved: • when calories delivered reached 1000 kcal and more • when protocols on feeding for the ICU were developed and carried out by a nutrition team • The key process was the nutrition team monitoring system of the nutrition care delivery

process


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Adequate intake in surgery patients

Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate

energy and protein intake on morbidity and mortality in surgical patients

nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s

Medical Center, 2008.

Our local data shows a similar outcome: when adequate intake was achieved in both energy and protein there was no difference in mortality outcome. Most of the high risk patients had critical care status during their periods of treatment. • Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein

intake on morbidity and mortality in surgical patients nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, 2008. Accessed in: www.philspenonline.com.ph/Surg_Intake_ppr_slmc2.pdf

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THANK YOU

LECTURE 5 NUTRITION CARE PLAN FOR SURGICAL PATIENTS...

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