Nutrition in Surgical Patients

Nicky Wyer MSc, RDSenior Specialist DietitianUHCW Nutrition Support Team

Areas to coverMalnutrition and the surgical

patientIdentifying patients at riskERAS – Nutritional aspectsRoutes for nutrition supportRefeeding syndrome

Malnutrition does it matter?A malnourished patient will have 3 times the number of complications

and 4 times the risk of death from the

same surgery compared to a well

nourished patient (NICE 2006)

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)

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

surgeryAlcoholicsDrug Dependency

Patients with AlteredNutritional

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

disorders◦COPD◦Pregnancy

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

ESPEN guidelines for enteral nutrition in surgery

Patients who are significantly malnourished and are due to undergo major surgery should be considered for preoperative nutrition support, this may involve tube feeding for 10-14 days pre-op (ESPEN 2006)

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

Enteral tube feeding should be given without delay post op for any patient who it is anticipated will be unable to eat for > 7days and for patients who cannot maintain oral intake >60% requirements for >10 days

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

Nutritional requirements

Typically quoted as 25 – 30kcal / kg calories however Dietitian will assess patients individual needs

Calorie requirements affected by:◦Age, Gender, Activity level, Weight, ◦Degree of stress associated with

surgery◦Calorific intake from other sources

e.g. propofol in ITU

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

David BlaineFast for 44 daysHe lost 25.5Kg(26.6%)At end BMI = 21.6Kgm-2Albumin 52.9 gl-1

Fashion modelBMI = 11.5 Kgm-2

Albumin = 38 gl-1

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

Pre-operative fastingTypically patients NBM from midnight

prior to surgery. Advocated to ensure an empty stomach to risk of aspiration

ESPEN (2006) and NICE (2006): Safe for patients to eat up to 6 hours prior to surgery and drink fluids up to 2 hours prior to surgery (grade A evidence)

This the need for IV fluids which helps prevent post op fluid and salt overload which adversely affects the GIT tract and ability to mobilise (Powell-Tuck 2011)

Surgery & Fasting

Catabolism

Hyperglycaemia

Insulin resistance

Loss of fat & muscle stores

Components of the ERAS multimodal care pathway

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

Preoperative carb loadingpreOp (Nutricia) and preload

(Vitaflo)4 x 200ml evening pre surgery,

2 x 200ml up to 2hrs pre anaesthesia. 100kcal, 25g (4.2g sugar) carbohydrate per carton

Creates a non starved metabolism

Moderates metabolic response to surgery

Pre op carbohydrate loadingDecreased catabolismDecreased hyperglycaemiaPreserved muscle massImproved grip strengthReduced LOSReduced Anxiety

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

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 supportHigh 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!Patient preferences keyConsideration should be given to what

product best addresses the identified nutritional deficiencies prior to prescribing

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

Ongoing monitoring of patients is essential to establish when nutritional goals have been met and nutritional support can be stopped

Not all patients need supplements forever!!

Addressing symptomsNausea / vomiting: anti emetics,

prokinetics, dilatation, ensuring bowels opening

Pain: analgesiaConstipation: laxatives, enemasSwallowing: SALTx, altered

consistency diet/fluids

Puree diet example

Breakfast: Porridge & Cup of tea (all)

Mid Morning: Cup of Coffee & Squash

Lunch: Beef Casserole meal (all) Crème Caramel (all)Orange Juice

Mid Afternoon: Squash

Evening Meal: Salmon Bake Meal (all)Raspberry Mousse (all)Squash

Supper: Cup of tea

What do you think of this intake??

Puree diet example

Total: 1270kcal 52.5g protein 1135ml fluid

This will be inadequate for most post operative patients

Be aware that patients can have difficulty achieving adequate intakes on altered consistency diet and fluid as choices are more limited and less nutrient rich

Require additional snacks or puddings and many require oral nutritional supplements when on this texture

Enteral feedingEnteral feeding refers to the

delivery of nutritionally complete feed containing protein, carbohydrate, fat, water, minerals and vitamins directly into the stomach, duodenum or jejunum.

NICE 2006

Enteral feedingFor those unable to take orally for >7 days or are unable to take sufficient amounts (>60%) and for whom more invasive nutritional support is an appropriate part of the treatment plan ESPEN 2006

Polymeric feeds first line, reflects normal dietary intake Specialist feeds for use in certain conditions e.g. renal,

malabsorption, sodium or fluid restriction Various “core” feeds available

◦ fibre and fibre free versions◦ 0.8-2kcal / ml◦ Nutritionally complete in set amount of calories◦ Gluten & lactose free majority of products◦ Contain milk protein except Soya based feeds◦ Vegetarian issue – carminic acid – in ONS, fish oils. ◦ Depends on company / product used, Dietitian will advise

Nasogastric - indicationsPatients at high risk of aspiration,

swallowing problems, unconscious.

Supplementary to oral nutrition – poor appetite, increased nutritional requirements.

Supplementary to parenteral nutrition.

Nasal Bridal

A nasal bridal is a device to secure a NG or NJ tube to the nasal septum

2 high grade magnets are inserted via each nostril these connect around the nasal septum allowing the looping of a thin strip of gauze/tape around the nasal septum which is then fixed to the NG / NJ tube with a clip.

Gastrostomy feedingThe placement of a tube through the

abdominal wall directly into the stomach for either temporary or permanent delivery of enteral feed (Payne-James et al 2001).

PEG, RIG, Surgical gastrostomy – be clear on what type of tube it is

Head & Neck cancer

Indications / contraindications

IndicationsLong term

nutrition support required

Swallowing impairment

ContraindicationsAbsoluteTotal gastrectomyPortal hypertension

with gastric varices

RelativeUnfit for procedurePartial gastrectomyPDAscitesActive gastric ulcer

Jejunal Feeding

Placement of a tube into the small bowel,

either via the nasal cavity (NJ), surgically

placed (surgical jejunostomy), or occasionally via PEG tube (PEJ). It is a method of feeding patients who are

unable to maintain or improve their

nutritional status by oral intake and in whom

gastric feeding is contraindicated or has been unsuccessful.

Indications for jejunal feedingPreviously documented gastroparesisGastric stasis due to paralysing agents

required for ventilationPersisting delayed gastric emptying

despite medical managementSevere acute pancreatitisUpper GI surgeryPancreatic or duodenal injuryHepato-biliary surgeryCancer of the oesophagus or stomach

where NG or gastrostomy feeding is inappropriate

Upper GI fistula

Complications of EN

Nausea and vomitingAbdominal distensionDiarrhoeaConstipationOesophagitisAspirationBlocked tubeComplications during tube insertion

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

IndicationsShort bowel

syndromeProlonged paralytic

ileus (>7/7)Bowel obstruction or

pseudo-obstructionMotility disorders e.g.

sclerodermaGastrointestinal

fistulaeAdhesionsAnastamotic leakRadiation

gastroenteritis

Mucositis, oesophagitis or intractable vomiting secondary to chemotherapy

Severe acute inflammatory bowel disease

GI perforationSevere acute

pancreatitisPost op extensive

bowel surgery

Parenteral Nutrition Bags made up by

aseptic labMixture of glucose,

lipid, amino acids, electrolytes, fluid, vitamins, minerals and trace elements

Modifications can be made if clinically indicated

If EN commences can reduce PN gradually as EN increases

Refeeding syndromePatients who have had a prolonged period

with little/no nutrition >10/7, low BMI, >10% unintentional wt loss, electrolyte disturbances, alcoholics pose risk of refeeding syndrome when any feeding commenced

Severe electrolyte & metabolic abnormalities can occur as a result of feeding but difficult to separate from abnormalities associated with critical illness

Prevent by slow feeding, vitamin supplementation and electrolyte correction

Ensure patients are assessed by a dietitian to ascertain risk level and appropriate plan is made

Pathophysiology of refeeding

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

Increasing use of ERAS protocols and cessation of prolonged fasting pre-op improves outcomes

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

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