Nutritional Complications in Surgical Patients And Keys toSuccessful Dietary Management      Romzi Mohd. Ali          Diet...
No of cases admittedunder surgical dept 2011• Burns ; average 10 /mth• GI tract: 136/mth• Hepatobiliary: 30/mth• Trauma: 7...
• Malnutrition is prevalent in  hospitalised pts• International studies estimating the  prevalence to be 20–42% (Kyle et a...
June 2009:                           At Risk Of Malnutrition• At risk of malnutrition  rate (N=264): 48 %• Surgical pts at...
Impact of malnutrition on surgical pts• Malnutrition – cause of ↑morbidity & ↑ mortality• Severe malnutrition - caused by ...
Lack of NCP/Protocol/       Not well established nutrition         Guidelines/SOP                screening system         ...
• Nutrition screening system• Mentoring system• NCP/Protocol/Guidelines/SOP• Competency & mentoring system• Inter-communic...
NUTRITIONSCREENING
Nutrition Screening  System        Nursing staff      working flow chart   screening tools
CME fornurses &doctors
• Challenging - lack of  enthusiasm, personal bias,   individual practices• One of the key to  successful dietary  managem...
• Multidisciplinary team  approach-ward rounds• Meet their needs-provide useful data & info that cancontributes to achieve...
• Invite physician for a  talk/CME regularly & offer  to sent them the current  relevant articles or journal  especially t...
Inter-dietitianreferral system
Communicating Pre & Post- opFeeding Plan To Patient/Family  members/Nurses/Physician
Easily accessibleNCP/Guidelines/ Protocols/SOP
NCP/Guidelines/    Protocols/SOP• Very important to  analyse the information  gathered and fit it into  the local setting•...
Mentoring System“ To Be Old and Wise You MustFirst Be Young and Stupid “ ?
Mentoring System• Personalized CDE• Gain competency & clinical  expertise + confidence faster• Dietetic Grand Rounds• Ward...
Gastrointestinal (GI) Problems• Nausea - 10 to 20% of patients• Abdominal bloating & cramps from  delayed gastric emptying...
Dietary Management     of Diarrhea
Case Study• 77 years old/ / Malay/Female• Admitted to surgic ward 28/4/2012• For neck exploration, debulking of  thyroid C...
Diet history6/5/12: Referred to Dietitian for Gastrostomy feeding-   tolerated well10/5/12: Pt BOx4 loose stool , & refuse...
Intervention?•   Fibre containing    product to replace    standard formula    and protein    powder diarrhea resolved  t...
Chronology of BO                         • T/O from SW11 to SW 14         9/5                         • T. Ciproflaxocin p...
Management:1. Suggest to change IVD NS 2 Θ to   IVD D5% 2 Θ (200kcal).2. Change bolus feeding to   intermittent feeding pu...
4. Start probiotic b.d during rest hour5. Suggest to con’t ORS – PRN Outcome: Diarrhea resolved within 24 H the plan was m...
GASTOPARESIS• The hallmark: delayed gastric  emptying in the absence of a  mechanical obstruction• commonest causes: - idi...
GASTOPARESIS• Post-op gastroparesis - a result  of gastric, oesophageal and/or  pancreato-duodenal surgery  (interruption ...
GASTOPARESIS• Nausea & vomiting- the predominant symptoms of  gastroparesis (74% & 53% of cases) - abdominal pain (45%), b...
GASTOPARESIS• mild - moderate case : dietary  manipulation plays a key role in  management- simple  adjustment to meal rou...
Dietary management:• Principle aim : to restore & maintain nutritional status,  reduce symptoms. In diabetic pts, added ai...
• Dietetic approaches to pts with gastroparesis  can be complex- essential to have a specialist  dietitian involved from t...
• The main dietary components that need to be  evaluated include particle size, meal size, & fat &  fibre content of the m...
Eletrolyte imbalance
• 68 years old malay man, A  pensioner• Case of DM (on OHA) x 1 year,  HPT x 2 years, IHD,  hypercholesterolemia• MVA ( mo...
Previous diet intake priorto dietitian referral(POD10):• Started on TPN on  POD3• TPN + oral on POD7• Off TPN on POD8 and ...
Stoma output & fluid intake VS POD           1600                              1500           1400                        ...
• Renal profile:Na: 142 mmol/l (N)K:3.8 mmol/l (N)Creatinine:88 mmol/l (↑)Urea: 6.1 mmol/l(N)High creatinine (? dehydratio...
• Absorb• water• electrolytes (Na, Ca, K)• SCFA• Vitamin synthesized by bacteria  (biotin & Vit K)• moving & storing stool...
• promote absorption of water  and sodium & regulate function  of bowel (Yang et.al., 2005).• Soluble fiber able to absorb...
Management:• High calorie, high protein, high fluid diet• High soluble fibre food introduced• Oral nutritional supplement ...
Management based on anticipatedcomplication – low serum sodium• High salt diet as it is  predicted that serum sodium  may ...
Outcome :• Improved !   By 2 nd day after intervention• Stoma output: 730 ml (loose stool)• Overall appearance: more energ...
stoma output Vs num of FU    1400                       1180 (watery)  1200o      1050 (watery)u  1000t                   ...
Pre- op NBM• Traditional surgical  nutrition practices such as  NBM periods can also  reduce nutrient intake
• Malaysian guidelines  recommend for healthy  adults having an elective  procedure :• Limited solid food may be  taken up...
• Malaysia Guidelines for  Preoperative Fasting• The 2-4-6 rule :  2 hrs clear fluids  4 hrs breast milk  6 hrs formula mi...
• Fasting practices in the Gl  wards of a tertiary-referral  hospital (Royal Prince Alfred  Hospital, Australia) (N=124 )•...
Results:• Pts admitted to the GI  wards spent a mean of  19.95% of their hospital  stay on ‘NBM’ diet• The mean fasting ti...
Results:• The mean fasting time after  major GI surgery was 57:48 h  (SD 31:15), compared to the  recommended 24 h• Pts wi...
REASONS FOR FASTING          %Preparation for tests or other   35non-surgical procedureswhich accounted for 35% ofthe time...
•excessiveamount of timedespite theevidence
• 2007: A prospective study among  ventilated pts in Intensive Care  Unit (ICU) & High Dependency  Ward (HDW) at K. Lumpur...
Outcome:• Before tracheostomy :  Mean NBM time reduced  significantly (17.28 + 18.89)   (8.10 + 16.28) hrs• After tracheo...
Current Applied  Strategy in Burns Ward• Continue EN feeding until an  hour or less before the actual  planned procedure t...
Post-op NBM• Post-op management of GI surgical pts:  traditionally been ‘NBM ’,- would allow time for  the return of norma...
• Issue of mouth care - animportant aspect of patient care inthe general surgical ward & ICUsetting•clinicians should pay ...
ORAL HYGIENE IN     SURG. PTS• Palliative surgical pts -particularly prone  to oral morbidity• Aside from pt discomfort & ...
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Dr romzi md ali nutritional complications in surgical patients and keys to successful dietary management

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Dr romzi md ali nutritional complications in surgical patients and keys to successful dietary management

  1. 1. Nutritional Complications in Surgical Patients And Keys toSuccessful Dietary Management Romzi Mohd. Ali Dietitian Hospital Kuala Lumpur
  2. 2. No of cases admittedunder surgical dept 2011• Burns ; average 10 /mth• GI tract: 136/mth• Hepatobiliary: 30/mth• Trauma: 7-10/mth9 July 2012 Dept of Dietetic & Foodservices, Hospital 2 K. Lumpur
  3. 3. • Malnutrition is prevalent in hospitalised pts• International studies estimating the prevalence to be 20–42% (Kyle et al., 2002; Lazarus & Hamlyn, 2005; Banks et al., 2007).• Pts undergoing surgery for upper GI or colorectal cancer - particularly at risk of malnutrition (Farreras et al 2005)• Pevalence of malnutrition in pts with GI cancer : 22–62% Braga et al., 2002;; Farreras et al., 2005).
  4. 4. June 2009: At Risk Of Malnutrition• At risk of malnutrition rate (N=264): 48 %• Surgical pts at risk of malnutrition N=37 : 52.9 %• A follow on study , only on newly admitted surg pt (N=397): 11.1 %Source: HKL Dietetic Technical Committee
  5. 5. Impact of malnutrition on surgical pts• Malnutrition – cause of ↑morbidity & ↑ mortality• Severe malnutrition - caused by on-going energy deficits in the postoperative period  ↑ risk of infectious complications (Akbarshahi et al. 2008)
  6. 6. Lack of NCP/Protocol/ Not well established nutrition Guidelines/SOP screening system Inappropriate NBMDid not keep up with practice data from current trials Gastrointestinal (GI) intolerance Lack of Metabolic competency & imbalances clinical expertise InappropriatePoor Mentoring Barrier to a Successful transitional Dietary Management feeding system practices Poor Interdepartment/ Inappropriate pre/postop dietitian communication surg nutrition practices.
  7. 7. • Nutrition screening system• Mentoring system• NCP/Protocol/Guidelines/SOP• Competency & mentoring system• Inter-communication system• Gastrointestinal (GI) intolerance• Eletrolite imbalance
  8. 8. NUTRITIONSCREENING
  9. 9. Nutrition Screening System Nursing staff working flow chart screening tools
  10. 10. CME fornurses &doctors
  11. 11. • Challenging - lack of enthusiasm, personal bias, individual practices• One of the key to successful dietary management• Symbiotic relationship• View your recommend. as those of a consultant-, some will be accepted & some not.
  12. 12. • Multidisciplinary team approach-ward rounds• Meet their needs-provide useful data & info that cancontributes to achievement oftreatment goals & plan-Organized in form of writtencommunications & documentationto relay this need-to-knowinformation•Take the initiative -Don’t rely onphysicians to read recommend. forchanges in the treatment plan.Contact them by pager, phone toensure recom. received
  13. 13. • Invite physician for a talk/CME regularly & offer to sent them the current relevant articles or journal especially those obviously not implementing current evidence surgical nutrition practice• A chance for open interdepartmental communication on setting up a way of practice or system
  14. 14. Inter-dietitianreferral system
  15. 15. Communicating Pre & Post- opFeeding Plan To Patient/Family members/Nurses/Physician
  16. 16. Easily accessibleNCP/Guidelines/ Protocols/SOP
  17. 17. NCP/Guidelines/ Protocols/SOP• Very important to analyse the information gathered and fit it into the local setting• This needs some critical thinking, experience & practice
  18. 18. Mentoring System“ To Be Old and Wise You MustFirst Be Young and Stupid “ ?
  19. 19. Mentoring System• Personalized CDE• Gain competency & clinical expertise + confidence faster• Dietetic Grand Rounds• Ward rounds- learn from doctors Clinical Audit
  20. 20. Gastrointestinal (GI) Problems• Nausea - 10 to 20% of patients• Abdominal bloating & cramps from delayed gastric emptying• Diarrhea - 30% in medic/surgic wards - 60% in ICU - Nutrient, fluid, electrolyte losses - Infected pressure sores & pt distress• Constipation
  21. 21. Dietary Management of Diarrhea
  22. 22. Case Study• 77 years old/ / Malay/Female• Admitted to surgic ward 28/4/2012• For neck exploration, debulking of thyroid Ca, tracheostomy & gastrostomy• Known case of HPT
  23. 23. Diet history6/5/12: Referred to Dietitian for Gastrostomy feeding- tolerated well10/5/12: Pt BOx4 loose stool , & refused feeding11/5: nurse called to review due to diarrhea Step 3: 300cc (6 scps Ensure + ½ scp Myotein), 30 cc flushing, 3 hourly, 8x/day FULL FEEDING
  24. 24. Intervention?• Fibre containing product to replace standard formula and protein powder diarrhea resolved temporary for 24 hours and diarrhea restarted the the next day
  25. 25. Chronology of BO • T/O from SW11 to SW 14 9/5 • T. Ciproflaxocin prescribed 10/5 • BOx4 , loose stool, large amount • BOx5, watery stool 11/5 • Refused for feeding • BOx1, loose stool 12/4 • Loperamide prescribed • Loperamide off 13/5 • BOx5 – IVD Hartman 1 • Refused for feeding Jevity prescribed to replace Ensure+Myotein  diarrhea resolvedtemporary for 24 hoursand diarrhea restarted the the next day Graphic by: Nik Nurizzati
  26. 26. Management:1. Suggest to change IVD NS 2 Θ to IVD D5% 2 Θ (200kcal).2. Change bolus feeding to intermittent feeding pump feeding & restart feeding with predigested formula until diarrhea improved. (KIV for high fibre formula later)3. Dietary regimen planed in two step only (Fast step up) at rate 60 cc/h- 120 cc/h (full feeding)
  27. 27. 4. Start probiotic b.d during rest hour5. Suggest to con’t ORS – PRN Outcome: Diarrhea resolved within 24 H the plan was made for transitition back to bolus feeding & discharge  Successfully overcome diarrhea and correct electrolyte imbalance, fluids inadequacy and dehydration
  28. 28. GASTOPARESIS• The hallmark: delayed gastric emptying in the absence of a mechanical obstruction• commonest causes: - idiopathic(36–49%) -diabetes mellitus (25–29%) -post-surgical (7–13%) (Feldman et al., 1979).
  29. 29. GASTOPARESIS• Post-op gastroparesis - a result of gastric, oesophageal and/or pancreato-duodenal surgery (interruption of the vagus nerve)• The obesity epidemic increasing trends for bariatric surgery, is also likely to be associated with an increase in the incidence of post-operative gastroparesis in the future.
  30. 30. GASTOPARESIS• Nausea & vomiting- the predominant symptoms of gastroparesis (74% & 53% of cases) - abdominal pain (45%), bloating (31%), wt loss (30%), - post-prandial fullness (23%) & early satiety (29%)• Risk of malnutrition lead oral intake, including reduced macronutrient intake, weight loss & dehydration, as well as mineral & vitamin deficiency (Ogorek et al., 1991).• These symptoms nonspecificother ‘mechanical’ causes need to be excluded• Gastroenterolgists, surgeons, radiologists & dietitians all have important roles in its diagnosis
  31. 31. GASTOPARESIS• mild - moderate case : dietary manipulation plays a key role in management- simple adjustment to meal routines & diets can lead to an improvement in symptoms• More severe cases-alternative feeding routes play an important role Keld et al. 2011. Pathogenesis, investigation and dietary and medical management of gastroparesis. Review. J Hum Nutr Diet, 24, pp. 421–430
  32. 32. Dietary management:• Principle aim : to restore & maintain nutritional status, reduce symptoms. In diabetic pts, added aim of improving glycaemic control• Moderate to severe disease- dietary management becomes more challenging – EN/PN nutrition support may be needed• Limited evidence base for dietetic management strategies because controlled studies are scarce• Majority of recommendations are based on clinical experience.
  33. 33. • Dietetic approaches to pts with gastroparesis can be complex- essential to have a specialist dietitian involved from the beginning of assessment (multidisciplinary team mx)• Need to get a detailed history of symptom frequency & timing, focus on the type & consistency of foods tolerated, & the timing, content & size of meals.• Evaluation of nutritional & fluid status (including weight & anthropometric measurements), glycaemic control & the presence of any vitamin & mineral deficiency is also needed.
  34. 34. • The main dietary components that need to be evaluated include particle size, meal size, & fat & fibre content of the meal.• Alcohol & carbonated drinks are discouraged• The overall dietary advice -diet of frequent, small, low-fibre & low fat meals with increased liquid nutrient intake (or a pureed or liquid diet• NJ rather than NG route is recommended by the National Institute for Health and Clinical Excellence (NICE, 2006)
  35. 35. Eletrolyte imbalance
  36. 36. • 68 years old malay man, A pensioner• Case of DM (on OHA) x 1 year, HPT x 2 years, IHD, hypercholesterolemia• MVA ( motorbike VS car) on 21/2/2012• Dx: Post MVA day 15 with 0 intestinal obstruction 2 rd th traumatic ileus, right 3 -9 ribs fracture, HAP• POD 10 Exploratory laparotomy + transverse colostomy + appendicectomy
  37. 37. Previous diet intake priorto dietitian referral(POD10):• Started on TPN on POD3• TPN + oral on POD7• Off TPN on POD8 and on soft diet only
  38. 38. Stoma output & fluid intake VS POD 1600 1500 1400 1300 o i u 1200 n 1030 (↑) 1050 (↑) t t 1000 900 p fluid intake a u 800 750 (↑) k t stoma output e 600 ( m 400 & l ) 200 52 0 0 POD6 POD7 POD8 POD9low stoma output is around 500 ml ,high stoma output : 1L or more. (Khan et.al., 2009)
  39. 39. • Renal profile:Na: 142 mmol/l (N)K:3.8 mmol/l (N)Creatinine:88 mmol/l (↑)Urea: 6.1 mmol/l(N)High creatinine (? dehydration )Electrolyte:Corrected Ca: 1.95 (↓)Mg: 0.66 (N)
  40. 40. • Absorb• water• electrolytes (Na, Ca, K)• SCFA• Vitamin synthesized by bacteria (biotin & Vit K)• moving & storing stool• Transverse colostomy may affect hydration status, electrolyte balance & cause watery stool
  41. 41. • promote absorption of water and sodium & regulate function of bowel (Yang et.al., 2005).• Soluble fiber able to absorb excess liquid in colon & forming gel which prevent the rapid transmit timeThicken the stool
  42. 42. Management:• High calorie, high protein, high fluid diet• High soluble fibre food introduced• Oral nutritional supplement with soluble fibre
  43. 43. Management based on anticipatedcomplication – low serum sodium• High salt diet as it is predicted that serum sodium may be reduced- Add ¼ tsp of NaCl to mixed porridge- Allow liberal soy sauce in softboiled egg during breakfast- soy sauce (liberal)
  44. 44. Outcome :• Improved ! By 2 nd day after intervention• Stoma output: 730 ml (loose stool)• Overall appearance: more energetic, alert and able to ambulate slowly with assistant, fair hydration• Serum sodium essentially remain normal
  45. 45. stoma output Vs num of FU 1400 1180 (watery) 1200o 1050 (watery)u 1000t 800 (soft)p 800 730 (loose)ut 600 stoma output(m 400l 200) 0 1st visit 1st FU 2nd Fu 3rd FU Num of FU
  46. 46. Pre- op NBM• Traditional surgical nutrition practices such as NBM periods can also reduce nutrient intake
  47. 47. • Malaysian guidelines recommend for healthy adults having an elective procedure :• Limited solid food may be taken up to 6 h prior to anaesthesia &• clear fluids totalling not more than 200 ml per hr may be taken up to 2 h prior to anaesthesia
  48. 48. • Malaysia Guidelines for Preoperative Fasting• The 2-4-6 rule : 2 hrs clear fluids 4 hrs breast milk 6 hrs formula milk & solids
  49. 49. • Fasting practices in the Gl wards of a tertiary-referral hospital (Royal Prince Alfred Hospital, Australia) (N=124 )• The amount of time on ‘Nil By Mouth’ or fluid diets & reasons for these orders• NBM: no oral, EN, PN• Inadequate diet: either NBM or receiving oral clear flds only (<2000KJ/day)
  50. 50. Results:• Pts admitted to the GI wards spent a mean of 19.95% of their hospital stay on ‘NBM’ diet• The mean fasting time for all procedures performed within the endoscopy dept. : 14:23 h (SD 12:36) compared to the official requirement of 6 h
  51. 51. Results:• The mean fasting time after major GI surgery was 57:48 h (SD 31:15), compared to the recommended 24 h• Pts with mild-to-moderate malnutrition(SGA B) spend significantly more time fasting than severely malnourished pts (SGA C).
  52. 52. REASONS FOR FASTING %Preparation for tests or other 35non-surgical procedureswhich accounted for 35% ofthe time spent fasting.Fasting for surgery 25Fasting to aid symptom 17managementPost-operative fasting 14No reason was recorded 9
  53. 53. •excessiveamount of timedespite theevidence
  54. 54. • 2007: A prospective study among ventilated pts in Intensive Care Unit (ICU) & High Dependency Ward (HDW) at K. Lumpur Hospital (N=54)• Standards to achieve : NBM Time Less than 6 hrs before & after procedures• protocol on NBM was introduced with a letter from letter on Standards for NBM time from Head of Anesthesiology and Intensive Care Department , Source : Mages et al. 2007. HKL QA study
  55. 55. Outcome:• Before tracheostomy : Mean NBM time reduced significantly (17.28 + 18.89)  (8.10 + 16.28) hrs• After tracheostomy: fasting time was also reduced significantly (10.85 + 7.17)  (7.04 + 8.08) hrs..
  56. 56. Current Applied Strategy in Burns Ward• Continue EN feeding until an hour or less before the actual planned procedure time, then aspirate the gastric content out - avoid prolong NBM as usually the procedure time is not always punctual• Feeding continuation after post op for wound debridement• Appropriate feeding transition practices from EN to oral
  57. 57. Post-op NBM• Post-op management of GI surgical pts: traditionally been ‘NBM ’,- would allow time for the return of normal gut motility, preventing post- op vomiting & nausea.• Recent literature recommends that oral or EN should recommence within the 1 st day of major surgery-improves outcomes (Fearon et al. 2005)• Post-operative nausea is more prevalent in pts that had been fasted for a prolonged period preoperatively ( Diks et al. 2005)
  58. 58. • Issue of mouth care - animportant aspect of patient care inthe general surgical ward & ICUsetting•clinicians should pay moreattention : simple measure canalter surgical outcome• If neglected leading toreluctance in commencing ormaintaining an adequate dietaryintake Ford 2008.
  59. 59. ORAL HYGIENE IN SURG. PTS• Palliative surgical pts -particularly prone to oral morbidity• Aside from pt discomfort & general well- being, oral hygiene in ICU is important to prevent of ventilator assoc. pneumonia• Tooth brushing- ideal method of promoting oral hygiene.• Simple antiseptic mouthwashes (Chlorhexidine 0.2%) is widely used &.
  60. 60. THANK YOU FOR LISTENING

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