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


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  • 1. Nutritional Complications in Surgical Patients And Keys toSuccessful Dietary Management Romzi Mohd. Ali Dietitian Hospital Kuala Lumpur
  • 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. • 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. 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. 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. 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. • Nutrition screening system• Mentoring system• NCP/Protocol/Guidelines/SOP• Competency & mentoring system• Inter-communication system• Gastrointestinal (GI) intolerance• Eletrolite imbalance
  • 9. Nutrition Screening System Nursing staff working flow chart screening tools
  • 10. CME fornurses &doctors
  • 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. • 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. • 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. Inter-dietitianreferral system
  • 15. Communicating Pre & Post- opFeeding Plan To Patient/Family members/Nurses/Physician
  • 16. Easily accessibleNCP/Guidelines/ Protocols/SOP
  • 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. Mentoring System“ To Be Old and Wise You MustFirst Be Young and Stupid “ ?
  • 19. Mentoring System• Personalized CDE• Gain competency & clinical expertise + confidence faster• Dietetic Grand Rounds• Ward rounds- learn from doctors Clinical Audit
  • 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. Dietary Management of Diarrhea
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. • 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. • 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. Eletrolyte imbalance
  • 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. 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. 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, 2009)
  • 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. • 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. • promote absorption of water and sodium & regulate function of bowel (Yang, 2005).• Soluble fiber able to absorb excess liquid in colon & forming gel which prevent the rapid transmit timeThicken the stool
  • 42. Management:• High calorie, high protein, high fluid diet• High soluble fibre food introduced• Oral nutritional supplement with soluble fibre
  • 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. 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. 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. Pre- op NBM• Traditional surgical nutrition practices such as NBM periods can also reduce nutrient intake
  • 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. • Malaysia Guidelines for Preoperative Fasting• The 2-4-6 rule : 2 hrs clear fluids 4 hrs breast milk 6 hrs formula milk & solids
  • 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. 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. 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. 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. •excessiveamount of timedespite theevidence
  • 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. 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. 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. 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. • 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. 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 &.