Nutrition care plan for surgical patients

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Nutrition care plan for surgical patients

• Surgical Nutrition Training Module
• Level 1
• Philippine Society of General Surgeons
• Committee on Surgical Training

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Objectives

• To discuss the process of nutrition management of
  surgical patients
• To discuss the role of the nutrition team

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NUTRITION CARE PLAN FORMULATION
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The surgical nutrition process
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Nutrition Care Plan Form
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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?

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Surgical nutrition pathways Pre-operative phase
Condition When oral or enteral feeding not
possible
ESPEN Guidelines on Parenteral Nutrition (2009)
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Surgical nutrition pathwaysIntra
Post-operative Period
ESPEN Guidelines on Enteral Nutrition (2006) and
Parenteral Nutrition (2009)
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Nutrition Care Plan
Physician, Dietitian, 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

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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?

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Micronutrients

• Electrolytes
• Laboratory values
• 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
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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)

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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
2001643-50 Sullivan MM, et al. J Hosp Infect
200149268-273
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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 gt100 daily requirement Single or combinations
Maximum effect when given at the proper dose
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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

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The surgical nutrition process
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Monitoring issues
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Calorie, protein, fluid balance form
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Nutrient monitor form
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How to implement

• Monitoring everyone is involved

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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 week

Jan Wernermann, ICU Cookbook.Franc-Asia
Workshop, Singapore, 2003
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Nutrition Team
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NST activity
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NST activity/documentation
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Outcomes of adequate intake
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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., Lukes Medical
Center, 2008.
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Thank you