Surgical Nutrition

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Surgical Nutrition
Surgical Nutrition Support Team Dr. Sawyer, Dr.
Schirmer Kate Willcutts, Kelly ODonnell, Kate
Lewis
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Nutrition why do we care?

• Malnutrition
• Defined any disorder of nutrition status,
  including disorders resulting from a deficiency
  of nutrient intake, impaired nutrient metabolism,
  or over-nutrition
• Why avoid it?
• associated with increased mortality and morbidity
• delays wound healing, increases length and cost
  of stay

JPEN 26(1S)1-138S, 2002
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Malnutrition

• Prevalence 30-55 of hospitalized patients.
• Do you know it when you see it?

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Physical Exam

• obesity, cachexia, dry mucous membranes,
  petechiae, ecchymosis, poorly healing wounds,
  glossitis, stomatitis, edema, hair loss, ascites
  or cheilosis
• Wasting temporalis muscle, deltoids, etc.

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Question

• What is cheilosis?
• Thin, spoon nails associated with vitamin or
  mineral deficiency.
• Cracking at the corner of the mouth due to
  riboflavin deficiency.
• Form of dermatitis associated with niacin
  deficiency.
• Visual changes associated with vitamin A
  deficiency.

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Laboratory values and nutrition

• Which of the following is true?
• The half life of pre-albumin is 21 days.
• Albumin as an acute phase reactant and increased
  in sepsis.
• Pre-albumin and albumin levels directly correlate
  with nutritional status.
• Albumin and pre-albumin are poor indicators of
  nutritional status in most hospitalized patients.

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Laboratory values

• Albumin (t1/221 days)
• Hypoalbuminemia associated with mortality and
  post-op complications.

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Laboratory values

• Albumin (t1/221 days)
• Hypoalbuminemia associated with mortality and
  post-op complications.
• Poor indicator of nutritional status (can be
  normal in malnourished states and low in
  well-nourished states)

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Serum Albumin - Variation
Example of an actual patients labs
Admit date 9/28 4.0 mg/dl 9/30 2.9 mg/dl
11/5 2.7 mg/dl 11/6 3.4 mg/dl
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Laboratory values

• Albumin (t1/221 days)
• Hypoalbuminemia associated with mortality and
  post-op complications.
• Poor indicator of nutritional status (can be
  normal in malnourished states and low in
  well-nourished states)
• Transferrin (t1/29 days)
• Has not been extensively studied
• Affected by iron metabolism
• Pre-albumin (t1/2 2-3 days)
• Increased in renal failure, steroids decreased
  in liver failure, infection (negative acute phase
  reactant)

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Subjective Global Assessment

• Recognition is often difficult
• Subjective Global Assessment clinical tool
  developed by surgeons that combines history and
  physical exam to identify malnourished patients.
  Most heavily weighted factors are weight loss,
  poor dietary intake and muscle wasting.
• History involuntary loss
• 10 body weight within 6 months or
• 5 within one month
• Detsky AS et al. What is subjective global
  assessment of nutritional status? JPEN
  1987118-13.

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So now what?

• Using physical exam and subjective global
  assessment and not labs, youve identified a
  malnourished pre or post surgery patient.

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Preoperative Nutrition Support

• Malnourished patients are at increased risk of
  perioperative mortality/morbidity
• Unclear causal relationship
• Clinical Trials
• Heterogeneous population
• Varying definitions of malnutrition
• Various routes of administration

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Preoperative Nutrition Support

• Severely malnourished patients (10 loss of body
  weight) if surgery can be postponed 7-10 days
• Reduces postoperative morbidity
• Enteral route superior to parenteral route
• Immune-enhancing formulas- Pre-op in GI cancer
  pts.

JPEN. 2002 Jan-Feb
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What about post-op?
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Case

• EM 55 yo male
• POD 1 s/p open cholecystectomy
• Otherwise healthy. No weight loss prior to admit
• What do you want to know to decide re diet
  initiation?
• After you start the diet, how would you advance
  it?

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Post-operative Nutrition

• Traditional approach NPO until return of bowel
  function
• Possibly leaving in NGT for decompression of the
  stomach.
• After bowel function returns, ice chips or clear
  liquid diet is started. Then advance as
  tolerated.
• Rationale concern about aspiration and/or
  anastomotic breakdown or dehiscence.

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How slow do we need to go?

• After laparoscopic surgery, diets are advanced
  within 24-48 hours regardless of bowel function.
• Clinical trials have assessed early postoperative
  feeding following open procedures.
• The majority of trials have shown
• early removal of NG tubes
• earlier initiation of oral diet
• quicker progression to regular diet
• RESULTS IN shorter LOS and reduced hospital
  without an increase in complications nausea,
  vomiting, anastomotic leaks, aspiration, wound
  dehiscence, mortality or hospital readmission.

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Exceptions to the rule

• Patients who
• had emergent GI surgery
• required longer and more complicated surgeries
• and/or lost large amounts of blood during
  surgery.

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If oral diet not possible

• If well-nourished, can wait 5-7 days for return
  of bowel function.
• If anticipate inability to take oral diet within
  5-7 days and catabolic OR severely malnourished,
  start nutrition support.
• ASPEN guidelines feeding within 24-48 hrs of
  hemodynamic stability in ICU pts
• Lowers mortality and infectious episodes (10
  level 2 studies)
• How are we going to feed?

Nutrition 2004 20843848.
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Enteral Vs. Parenteral

• Enteral
• Decreased risk for infectious complications
• Physiologic presentation of nutrients
• Maintains gut mucosa/stimulates gut associated
  lymphoid tissue (GALT)
• Less expensive

• Parenteral
• Greater potential for infectious, metabolic and
  fluid complications
• Does not provide all known nutrients
• Fiber
• Glutamine
• Carnitine
• SCFAs
• Expensive
• 4 times cost of enteral

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• Enteral feeding in STBICU
• Trauma patients, mechanically ventilated for 24
  hrs
• 20 TBSA burns or with head/neck, facial burns
• Other patients, mechanically ventilated for 48
  hrs

• Parenteral Feeding
• Ischemic bowel
• Fistula- possibly
• Chylous leak -possibly
• Short gut
• Bowel obstruction
• Malnourished, unlikely to meet caloric goals
  enterally in 5 days (burns 2 days)
• Well nourished, unlikely to meet goals in 7-10
  days.

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Tube Feeding Formulas

• Promote ( fiber)
• house formula, high protein, intact protein
• 1 kcal/ml, 62.5 gm protein/1000 kcal
• Jevity 1.5
• contains fiber
• 1.5 kcal/ml, 42 gm protein/1000 kcals
• Osmolite 1.5
• no fiber

• Nepro
• low in K, Mg, Phos, protein
• 1.8 kcal/ml, 45 gm protein/1000 kcals
• Nestle FAA
• Predigested nutrients, low in fat.
• Expensive

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Total Parenteral Nutrition

• Lipids
• 2 kcal/ml in 20 lipids
• 1.1 kcal/ml in 10 lipids
• Given once a day as a piggyback
• Or as 3-in-1 admixture
• Protein (4 kcal/g)
• Nonessential/essential amino acids
• 3-20 stock solution
• Carbohydrates (3.4 kcal/g)
• 5-70 dextrose stock solution
• Peripheral less concentrated than central

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Other names for TPN

• Hyperalimentation or hyperal
• CPN Central Parenteral Nutrition
• PPN Peripheral Parenteral Nutrition
• TNA Total Nutrient Admixture

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TPN Components

• Multivitamin preparation
• 13 vitamins including Vitamin K
• Trace Elements (ATES-5)
• Copper, chromium, manganese, selenium, zinc (no
  iron)
• Electrolytes
• Sodium, potassium, chloride, phosphorus,
  magnesium, calcium, acetate
• Medications insulin, Famotidine

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Nasogastric
Nasoduodenal
Nasojejunal
Tube can be inserted via the mouth instead of the
nose.
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Gastrostomy
Jejunostomy
Percutaneous Endoscopic Gastrostomy (PEG) or
surgical gastrostomy
Percutaneous Endoscopic Jejunostomy (PEJ) or
surgical jejunostomy
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Nasoenteric
Naso-Gastric Tube This is called an NG tube
(naso-gastric).  It is inserted through the
nostril and down into the stomach.  Very annoying
to the nostrils, can cause some permanent
"flaring" if used for prolonged periods of time.
Also irritating to the back of the throat,
sometimes aggravating the oral aversions that
have already begun.                            
              
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X-ray done prior to initiating feeding
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PEG tube
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Percutaneous gastrojejunostomy (PEG/J)
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Types of feeding tubes

• Soft, polyurethane or silicon tubes with weighted
  or non-weighted tips.
• Different lengths 30-55
• Different diameters French sizeouter diameter.
• Each unit of French size 0.33 mm
• 12 French 3.96 mm

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Salem sump 18 French
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Tube designed for feeding only
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Tubes

• Smaller diameter more comfortable and more
  likely to clog
• Larger diameter less likely to clog and less
  comfortable.
• PEG larger diameter 24 French
• Long tubes also more likely to clog

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When would you choose..

• Naso or oral gastric?
• Nasoduodenal or nasojejunal?
• Gastrostomy?
• Jejunostomy?
• PEG/J?

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Route of Administration

• Gastric vs. Post-pyloric tube
• Initiation of nutrition in ICU should not be
  postponed significantly if tip is in stomach and
  patient can be placed with HOB 30º
  (contraindications recent intra-abd. surgery,
  intra-abd. infection, h/o reflux or witnessed
  aspiration)

JPEN 27355373, 2003 Curr Opin Crit Care
11461467, 2005
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Assessing Needs

• 200 equations for assessing calorie needs.
• At UVa we use kcals/kg.
• Range 15-40 kcals/kg.
• Take into account age, BMI, risk of refeeding
  syndrome, sedation, wounds, infection, stage of
  acute illness
• Protein needs for most surgical pts start at 1.5
  gm/kg.

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Nitrogen Balance

• Method of measuring protein status of an
  individual.
• In clinical settings, collect 24hr urine for this
  study.

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Nitrogen balance

• 9 gms nitrogen on TUN or Total Urinary Nitrogen
• Add 2 gms for other N losses.
• Convert gms protein in to gms nitrogen by
  dividing by 6.25.
• Compare in to out.

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Negative Nitrogen Balance

• Less nitrogen consumed than is excreted.
• Body is breaking down more protein than it is
  building.
• During inadequate calorie intake, illness,
  critical illness.
• Net catabolism

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Positive Nitrogen Balance

• More nitrogen is consumed than is excreted.
• Body is building more tissue than it is breaking
  down.
• During growth, healing, pregnancy.
• Net anabolism.