Nutritional Complications in Surgical Patients And Keys toSuccessful Dietary Management Romzi Mohd. Ali Dietitian Hospital Kuala Lumpur
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
• 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).
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
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)
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.
• 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.
• 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
• 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
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
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
Intervention?• Fibre containing product to replace standard formula and protein powder diarrhea resolved temporary for 24 hours and diarrhea restarted the the next day
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
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)
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
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).
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.
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 nonspecificother ‘mechanical’ causes need to be excluded• Gastroenterolgists, surgeons, radiologists & dietitians all have important roles in its diagnosis
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
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.
• 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.
• 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)
• 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
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
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 POD9low stoma output is around 500 ml ,high stoma output : 1L or more. (Khan et.al., 2009)
• 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
• 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 timeThicken the stool
Management:• High calorie, high protein, high fluid diet• High soluble fibre food introduced• Oral nutritional supplement with soluble fibre
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)
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
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
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 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
• Malaysia Guidelines for Preoperative Fasting• The 2-4-6 rule : 2 hrs clear fluids 4 hrs breast milk 6 hrs formula milk & solids
• 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)
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
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).
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
• 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
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..
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
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)
• 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.
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 &.