Nutrition

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Nutrition

• . . . and the surgical patient
• Carli Schwartz, RD/LDN

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Nutrition and Surgery

• Reported 40 incidence of malnutrition in acute
  hospital setting
• Malnutrition may compound the severity of
  complications related to a surgical procedure
• A well-nourished patient usually tolerates major
  surgery better than a severely malnourished
  patient
• Malnutrition is associated with a high incidence
  of operative complications and death.

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Normal Nutrition (EatRight.org)
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The Newest Food Guide Pyramid

• Balancing Calories   ? Enjoy your food, but eat
  less.   ? Avoid oversized portions.    
• Foods to Increase   ? Make half your plate fruits
  and vegetables.   ? Make at least half your
  grains whole grains.   ? Switch to fat-free or
  low-fat (1) milk.    
• Foods to Reduce   ? Compare sodium in foods like
  soup, bread, and frozen meals ? and choose the
  foods with lower numbers.   ? Drink water instead
  of sugary drinks.   
•           
• Website http//www.choosemyplate.gov/
• Includes interactive tools including a
  personalized daily food plan and food tracker

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Macronutrients

• Carbohydrates
• Limited storage capacity, needed for CNS
  (glucose) function
• Yields 3.4 kcal/gm
• Recommended 45-65 total daily calories.
• Fats
• Major endogenous fuel source in healthy adults
• Yields 9 kcal/gm
• Too little can lead to essential fatty acid
  (linoleic acid) deficiency and increased risk of
  infections
• Recommended 20-30 of total caloric intake
• Protein
• Needed to maintain anabolic state (match
  catabolism)
• Yields 4 kcal/gm
• Must adjust in patients with renal and hepatic
  failure
• Recommended 10-35 of total caloric intake.

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Normal Nutrition

• Requirements

• HEALTHLY male/female
• (weight maintenance)
• Caloric intake25-30 kcal/kg/day
• Protein intake0.8-1gm/kg/day (max150gm/day)
• Fluid intake 30 ml/kg/day

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Nutrition

• Requirements

? SURGICAL PATIENT ?
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Special considerations

• Stress
• Injury or disease
• Surgery
• Pre-hospital/pre-surgical nutrition
• Nutrition history

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• The surgical patient . . . .
• Increased risk of malnutrition due to
• Inadequate nutritional intake
• Metabolic response
• Nutrient losses
• Protein /energy store depletion
• Diminished nutrient intake
• Prevalence of GI obstruction, anorexia,
  malabsorption
• Extraordinary stressors (surgical
  stress,hypovolemia, bacteremia, medications)
• Wound healing
• Anabolic state, appropriate vitamins
• Poor nutritionpoor outcomes
• 33 mortality rate associated with weight loss
  greater than 20

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Nutrition
HEALTHLY 70 kg MALE Caloric intake 25-30
kcal/kg/day Protein intake 0.8-1gm/kg/day
(max150gm/day) Fluid intake 30 ml/kg/day
SURGERY PATIENT Caloric intake Mild stress,
inpatient 25-30 kcal/kg/day Moderate stress,
ICU patient 30-35 kcal/kg/day Severe stress,
burn patient 30-40 kcal/kg/day Protein
intake 1-2 gm/kg/day Fluid intake INDIVIDUALIZED
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Serum Nutrition Markers

• Albumin
• Synthesized in and catabolized by the liver
• Pro often ranked as the strongest predictor of
  surgical outcomes- inverse relationship between
  postoperative morbidity and mortality compared
  with preoperative serum albumin levels
• Con lack of specificity due to long half-life
  (approximately 20 days). Not accurate in pts
  with liver disease or during inflammatory
  response
• Normal range 3.5-5 g/dL.

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serum markers (contd)

• Prealbumin (transthyretin) - transport protein
  for thyroid hormone, synthesized by the liver and
  partly catabolized by the kidneys.
• Pro Shorter half life (two to three days) making
  it a more favorable marker of acute change in
  nutritional status. A baseline prealbumin is
  useful as part of the initial nutritional
  assessment if routine monitoring is planned.
• Cons More expensive than albumin. Levels may be
  increased in the setting of renal dysfunction,
  corticosteroid therapy, or dehydration, whereas
  physiological stress, infection, liver
  dysfunction, and over-hydration can decrease
  prealbumin levels.
• Normal range16 to 40 mg/dL values of lt16 mg/dL
  are associated with malnutrition.

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Other measures of protein status

• Nitrogen balance measures net changes in body
  protein mass
• Protein 16 nitrogen
• Protein intake (gm)/6.25 - (UUN 4) balance in
  grams
• Positive value found during periods of growth,
  tissue repair or pregnancy. This means that the
  intake of nitrogen into the body is greater than
  the loss of nitrogen from the body, so there is
  an increase in the total body pool of protein.
• Negative value can be associated with burns,
  fevers, wasting diseases and other serious
  injuries and during periods of fasting. This
  means that the amount of nitrogen excreted from
  the body is greater than the amount of nitrogen
  ingested. Often seen following major surgery-
  person likely will require extra protein for
  tissue building.
• Healthy Humans Nitrogen Equilibrium
• Complex determination of balance, measures of
  losses difficult and limited utility in clinical
  setting

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Postoperative Nutritional Care

• Traditional Method Diet advancement
• Introduction of solid food depends on the
  condition of the GI tract.
• Oral feeding delayed for 24-48 hours after
  surgery
• Wait for return of bowel sounds or passage of
  flatus.
• Start clear liquids when signs of bowel function
  returns
• Rationale
• Clear liquid diets supply fluid and electrolytes
  that require minimal digestion and little
  stimulation of the GI tract
• Clear liquids are intended for short-term use due
  to inadequacy

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Things to Consider

• For liquid diets, patients must have adequate
  swallowing functions
• Even patients with mild dysphagia often require
  thickened liquids.
• Must be specific in writing liquid diet orders
  for patients with dysphagia
• There is no physiological reason for solid foods
  not to be introduced as soon as the GI tract is
  functioning and a few liquids are being
  tolerated. Multiple studies show patients can be
  fed a regular solid-food diet after surgery
  without initiation of liquid diets.

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Diet Advancement

• Advance diet to full liquids followed by solid
  foods, depending on patients tolerance.
• Consider the patients disease state and any
  complications that may have come about since
  surgery.
• Ex steroid-induced diabetes in a post-kidney
  transplant patient.

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Patients who cannot eat . . . ?
Consider Nutrition Support!
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Nutrition Support

• Length of time a patient can remain NPO after
  surgery without complications is uknown, however
  depends on
• Severity of operative stress
• Patients preexisting nutritional status
• Nature and severity of illness
• Two types of nutritional support
• Enteral
• Parenteral

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What is enteral nutrition?

• Enteral Nutrition
• Also called "tube feeding," enteral nutrition is
  a liquid mixture of all the needed nutrients.
• Consistency is sometimes similar to a milkshake.
• It is given through a tube in the stomach or
  small intestine.
• If oral feeding is not possible, or an extended
  NPO period is anticipated, an access devise for
  enteral feeding should be inserted at the time of
  surgery.

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Indications for Enteral Nutrition

• Malnourished patient expected to be unable to eat
  adequately for gt 5-7 days
• Adequately nourished patient expected to be
  unable to eat gt 7-9 days
• Adaptive phase of short bowel syndrome
• Following severe trauma or burns

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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

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Enteral Access Devices

• Nasogastric/nasoenteric
• Nasoduodenal, Nasojejunal
• 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

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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?

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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
• Aspiration
• Ileus
• Proximal enteric fistula or obstruction

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Short-Term vs. Long-Term Tube Feeding Access

• No standard of care for cut-off time between
  short-term and long-term access
• If the patient is expected to require nutrition
  support longer than 6-8 weeks, long-term access
  should be considered
• NG tubes have been used successfully for long
  term enteral nutrition.
• -Not deal for long term feeding due to risk of
  non-elective extubation, tube misplacement, and
  ccasional need to check position of the tube
  by x ray

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Choosing Appropriate Formulas

• Categories of enteral formulas
• Polymeric
• Whole protein nitrogen source, for use in
  patients with normal or near normal GI function
• Monomeric or elemental
• Predigested nutrients most have a low fat
  content or high of MCT for use in patients
  with severely impaired GI function
• Disease specific
• Formulas designed for feeding patients with
  specific disease states
• Formulas are available for respiratory disease,
  diabetes, renal failure, hepatic failure, and
  immune compromise
• well-designed clinical trials may or may
  not be available

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Tulane Enteral Nutrition Product Formulary
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Enteral Nutrition Prescription Guidelines

• Gastric feeding
• Continuous 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 120 mL bolus
• Increase by 60 mL q bolus to goal volume
• Typical bolus frequency every 3-8 hours
• Small bowel feeding
• Continuous feeding only do not bolus due to risk
  of dumping syndrome
• Start at rate 20 mL/hour
• Advance in increments of 20 mL q 8 hours to goal
• Do not check gastric residuals

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Aspiration Precautions

• To prevent aspiration of tube feeding, keep HOB gt
  30 at all times
• Use of blue dye to test for aspiration is
  controversial and has been discontinued in
  practice. (FDA Public Health Advisory 2003)
• Lacks sensitivity
• Falsely positive reading on guaiac tests
• Several adverse events reported including ,
  including gastric bacterial colonization and
  diarrhea, systemic dye absorption, and death
  (especially in septic patients)

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Complications of Enteral Nutrition Support

• Issues with access, administration, GI
  complications, metabolic complications. These
  include
• Nausea, vomitting, diarrhea, delayed gastric
  emptying, malabsorption, refeeding syndrome,
  hyponatremia, microbial contamination, tube
  obstruction, leakage from ostomy/stoma site,
  micronutrient deficiencies (if patient not at
  goal).

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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 pathologist
  recommended 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

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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)

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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 nutrition prescription

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Enteral Nutrition Prescription

• Tube feeding via PEG with full strength
• Jevity 1.2
• Initiate at 30 mL/hour, advance by 20 mL q 8
  hours to goal
• Goal rate 55 mL/hour continuous infusion
• Above 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 gt 200 mL
• Keep HOB gt 30 at all times

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What is parenteral nutrition?

• Parenteral Nutrition
• also called "total parenteral nutrition," "TPN,"
  or "hyperalimentation."
• It is a special liquid mixture given into the
  blood via a catheter in a vein.
• The mixture contains all the protein,
  carbohydrates, fat, vitamins, minerals, and other
  nutrients needed.

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Indications for Parenteral Nutrition Support

• Malnourished patient expected to be unable to eat
  gt 5-7 days AND enteral 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

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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
• PPN (peripheral parenteral nutrition)
• Similar nutrient components as TPN, but lower
  concentration (5-10 final dextrose
  concentration)
• Osmolarity lt 900 mOsm/L (maximum tolerated by a
  peripheral vein)
• May be delivered into a peripheral vein
• Because of lower concentration, large fluid
  volumes are needed to provide a comparable
  calorie and protein dose as TPN
• Often used in conjunction with other nutrition
  therapy and for short period of time.

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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)

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Writing TPN prescriptions

• Determine total volume of formulation based on
  individual patient fluid needs
• Determine amino acid (protein) content
• Adequate to meet patients estimated needs
• Determine dextrose (carbohydrate) content
• 70-80 of non-protein calories or 45-65 total
  calories
• Determine lipid (fat) content
• 20-30 non-protein calories
• Determine electrolyte needs
• Determine acid/base status
• Check to make sure desired formulation will fit
  in the total volume indicated

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Tulane Daily Parenteral Nutrition Order Form
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Parenteral Nutrition Monitoring

• Check daily electrolytes and adjust TPN/PPN
  electrolyte additives accordingly
• Check accu-check glucose q 6 hours (regular
  insulin may be added to TPN/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 the same
  manner until target glucose is reached
• IDDM start with 0.1 units regular insulin per
  gram of dextrose in TPN/PPN, then increase daily
  by half of the previous days sliding scale
  insulin requirement
• Check triglyceride level within 24 hours of
  starting TPN/PPN
• If TG gt250-400 mg/dL, lipid infusion should be
  significantly reduced or discontinued
• Consider adding carnitine 1 gram daily to TPN/PPN
  to improve lipid metabolism
• 100 grams fat per week is needed to prevent
  essential fatty acid deficiency

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Parenteral Nutrition Monitoring (continued)

• Check LFTs weekly
• If LFTs significantly elevated as a result of
  TPN, then minimize lipids to lt 1 g/kd/day and
  cycle TPN/PPN over 12 hours to rest the liver
• If Bilirubin gt 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

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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

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Complications of Parenteral Nutrition

• Hepatic steatosis
• May occur within 1-2 weeks after starting PN
• May be associated with fatty liver infiltration
• Usually 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

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Complications of Parenteral Nutrition Support
(continued)

• Cholestasis
• May occur 2-6 weeks after starting PN
• Indicated by progressive increase in TBili and an
  elevated serum alkaline phosphatase
• Occurs because there are no intestinal nutrients
  to stimulate hepatic bile flow
• Trophic enteral feeding to stimulate the
  gallbladder can be helpful in reducing/preventing
  cholestasis
• Gastrointestinal atrophy
• Lack of enteral stimulation is associated with
  villus hypoplasia, colonic mucosal atrophy,
  decreased gastric function, impaired GI immunity,
  bacterial overgrowth, and bacterial translocation
• Trophic enteral feeding to minimize/prevent GI
  atrophy

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Parenteral Nutrition Case Study

• 55-year-old male admitted with small bowel
  obstruction
• History of complicated cholecystecomy 1 month
  ago. Since then patient has had poor appetite
  and 20-pound weight loss
• Patient has been NPO for 3 days since admit
• Right subclavian central line was placed and plan
  noted to start TPN since patient is expected to
  be NPO for at least 1-2 weeks

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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)

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Parenteral Nutrition Prescription

• TPN via right-SC line
• 2 L total volume x 24 hours
• Amino acid 4.5 (or 45 g/liter)
• Dextrose 17.5 (or 175 g/liter)
• Lipid 20 285 mL over 24 hours
• Above will provide 2120 kcal, 90g protein,
  glucose infusion rate 3.5 mg/kg/minute, lipid 0.9
  g/kg/day

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Parenteral Nutrition Prescription

• Important items to consider
• Glucose infusion rate should be lt 5 mg/kg/minute
  (maximum tolerated by the liver) to prevent
  hepatic steatosis
• Lipid infusion should be lt 0.1 g/kg/hour
  (ideally lt 0.4 g/kg/day to minimize/prevent
  TPN-induced liver dysfunction)
• Initiate TPN at ½ of goal rate/concentration and
  gradually increase to goal over 2-3 days to
  optimize serum glucose control

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Benefits of Enteral Nutritionover parenteral
nutrition

• Cost
• Tube feeding cost 10-20 per day
• TPN cost 100 or more per day!
• Maintains integrity of the gut
• Tube feeding preserves intestinal function it is
  more physiologic
• TPN may be associated with gut atrophy
• Less infection
• Tube feedingvery small risk of infection and may
  prevent bacterial translocation across the gut
  wall
• TPNhigh risk/incidence of infection and sepsis

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TPN research/controversy

• Lipid source often cited for being
  pro-inflammatory and causing impaired immune
  defenses
• No safeguards developed against TPN complications
  yet.
• Lipid source alteration may improve outcomes ex
  replacing LCT (soybean oil derivative) with
  monounsaturated fatty acids (olive oil, fish
  oil), MCT (coconut oil) or MCT/LCT mix
• Not yet available in U.S. (omegaven)
• Studies show mixed evidence of efficacy. Some
  show reduced mortality and antibiotic use with
  omega 3 fat source.

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Transitional Feedings

• Parenteral to enteral feedings
• Introduce a minimal amount of enteral feeding at
  a low rate (30-40 ml/hr) to establish tolerance.
• Decrease PN level slowly to keep nutrient levels
  at same prescribed amount
• As enteral rate is increased by 25-30 ml/hr
  increments every 8-24 hrs, parenteral can be
  reduced
• Discontinue PN solution if 75 of nutrient needs
  met by enteral route.
• Parenteral/Enteral to oral feedings
• Ideally accomplished by monitoring oral intake
  and concomitantly decreasing rate of nutrition
  support until 75 of needs are met.
• Oral supplements are useful if needs not met 100
  by diet. Ex (Nepro, Glucerna, Boost, Ensure).

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Refeeding Syndrome

• the metabolic and physiologic consequences of
  depletion, repletion, compartmental shifts, and
  interrelationships of phosphorus, potassium, and
  magnesium
• Severe drop in serum electrolyte levels resulting
  from intracellular electrolyte movement when
  energy is provided after a period of starvation
  (usually gt 7-10 days)
• Physiologic and metabolic sequelae may include
• EKG changes, hypotension, arrhythmia, cardiac
  arrest
• Weakness, paralysis
• Respiratory depression
• Ketoacidosis / metabolic acidosis

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Refeeding Syndrome(continued)

• Prevention and Therapy
• Correct electrolyte abnormalities before starting
  nutrition support
• Continue to monitor serum electrolytes after
  nutrition support 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

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Consequences of Over-feeding

• Risks associated with over-feeding
• Hyperglycemia
• Hepatic dysfunction from fatty infiltration
• Respiratory acidosis from increased CO2
  production
• Difficulty weaning from the ventilator
• Risks associated with under-feeding
• Depressed ventilatory drive
• Decreased respiratory muscle function
• Impaired immune function
• Increased infection

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Questions

• Contact Information
• Carli Schwartz, RD/LDN
• Dietitian, Tulane Abdominal Transplant Institute
• [phone]
• Carli.Schwartz_at_hcahealthcare.com

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• References
• 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
  of Surgery. 2001, Dec88(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
  of Surgery.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 oral
  feeding safe after elective colorectal surgery? A
  prospective randomized trial. Annals of Surgery.
  1995 July222(1)73-7.
• Ross, R. Micronutrient recommendations for wound
  healing. Support Line. 2004(4) 4.
• Krauses Food, Nutrition Diet Therapy, 11th Ed.
  Mahan, K., Stump, S. Saunders, 2004.
• American Society for Parenteral and Enteral
  Nutrition. The Science and Practice of Nutrition
  Support. 2001.