Nutrition screening and assessment of surgical patients
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Nutrition screening and assessment of surgical patients
Surgical Nutrition Training ModuleLevel 1
Philippine Society of General SurgeonsCommittee on Surgical Training
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Objectives
• To discuss body composition analysis in surgical patients
• To discuss ways to improve body composition and function to improve outcomes in surgery
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Muscle and fat mass, all ages
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Body compartments in health and disease
WATER (60%)
FAT (25%)
PROTEIN (14%)
WATER (72%)
FAT (15%)
PROTEIN (12%)
WATER (70%)
FAT (23%)
PROTEIN (6%)
CARBO + OTHER (1%)
NORMAL STARVATION CRITICAL CARE
WATER (55%)
FAT (30%)
PROTEIN (14%)
OBESE
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Loss of lean body mass = ↑mortality
Loss of Total LBM
Complications Associated Mortality
10% Decreased immunityIncreased infections
10%
20% Decrease in healing, increaseIn weakness, infection
30%
30% Too weak to sit, pressure ulcers,Pneumonia, lack of healing
50%
40% Death, usually from pneumonia 100%
Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9.
LBM=Lean Body Mass
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Principles in surgical nutrition
• Surgery causes cellular damage and metabolic responses that increase energy and nutrient needs
• Immunosuppression increases susceptibility to bacterial and other infectious agent intrusion with their corresponding side effects
• Wound healing requires increased energy and nutrient needs
• Malnutrition affects surgical outcome(s)• Optimum outcome is dependent on preparation,
operative method, and adequate support
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Malnutrition detection toolsNutrition screening Nutritional assessment
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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
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STEP 1: NUTRITION SCREENING
Goal: To identify the nutritionally at risk patients
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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
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Height and weight taken from regularly calibrated instruments
Basic data requirements• Body Mass Index
– <18.5 underweight– 18.5 – 24.9 normal– 25 – 29.9 overweight– 30+ obese
• Severe weight loss– >5% in 1 month– >7.5% in 3 months– >10% in 6 months
• Mid Arm Circumference– Male: <17.6 cm– Female: <17.1 cm
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Nutrition Screening Form for Adult and Geriatric patients
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Nutrition Screening Form for Pediatric patients -
boys
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Nutrition Screening Form for Pediatric patients -
girls
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Outcome: nutrition surveillance
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NUTRITIONAL ASSESSMENT
Goal: To identify the nutritionally HIGH RISK patients
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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
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Nutritional Assessment
and Risk Level Form
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Outcome: complication prediction
Predicting post-operative complications based on surgical nutritional risk level using the SNRAF in colon cancer patients - a Chinese General Hospital & Medical Center experience. Ocampo R B, Kadatuan Y, Torillo MR,
Camarse CM, Malilay RB, Cheu G, Llido LO, Gilbuena AA. Yr 2007.
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A filtering process
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CASE DISCUSSION: NUTRITION SCREENING AND ASSESSMENT
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Gastric CA
• FM, 68 y/o, admitted because of gastric mass and admitted to undergo gastrectomy
• Ht - 1.65m; Wt. 46 kg; BMI=16.9• Previous wt 4 months - 52 kg; % weight loss = 11%• Ancillary procedures:
– Chest Xray: old (?) PTB– ECG: Normal heart– CBC: Hb=10; WBC=6,000; Platelets=250,000; N%=70; L%=10– Electrolytes: Na=130; K=3.2– BUN =25; Creatinine=1.2– Albumin - 3
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Nutrition screening
1. Is the BMI <18.5 or >30? 2. Has the patient lost
weight within the last three (3) months?
3. Did the patient have a reduced dietary intake in the last week?
4. Is the patient severely ill (e.g. in intensive therapy)
1. YES: BMI = 16.92. YES: lost weight (11% in
the last 4 months)3. YES: reduced dietary
intake4. NO: not severely ill
NUTRITION SCREEN RESULT: NUTRITIONALLY AT RISK
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Nutritional assessment/Risk Level
SGA: Weight loss: >10% and gastro symptoms = (grade C) (3 pts) → severe malnutrition
BMI=16.9 (2 pts)Albumin=3 (less than 3: 2 pts)TLC=600 (less than 900: 2 pts)Total Risk Score=9
Nutritional Assessment = Severe malnutritionRisk Level =High Risk of developing nutrition
related complications
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Final decision
• Nutrition build up of this patient is mandatory for at least 5 to 10 days
• Other options:– Do surgery then continuous post-operative nutrition
maintenance and build up– Needs a Nutrition Care Plan
• Rationale: body composition and reserves cannot provide optimum condition for good healing and fast recovery plus reduction of complications (infection, dehiscence, fistula formation)
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THANK YOU