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Surgical Nutrition

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A brief summary of surgical nutrition, routes and requirements

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Surgical Nutrition

  1. 1. Brooke Sachs Surgical Teaching April 2018 Resources list plus with the help of lecture notes from Surgical Metabolism subject USYD 2015
  2. 2.  Born April 25 1906, died Sept 17 1991  Wanted to be an artist but his parents did not approve  Obtained a scholarship to the National Academy of Design, training there while completing high school  Went to Medical School to appease his parents – worked at the peak of the Great Depression and struggled to make money  Went back to illustrating in order to make ends meet  Wrote/illustrated over 200 pamphlets and 13 atlases  According to Dr Michael DeBakey, Netter’s contribution to our understanding of anatomy is the greatest advancement since Vesalius in the 16th century  Now has a medical school in Conneticut named after him
  3. 3.  Gain an understanding of surgical metabolism  Understand how to optimise peri-operative nutrition in elective patients  Understand how to optimise metabolic outcomes through nutrition in emergency/non-elective patients  Understand the different feeding methods and their relative risks, benefits and uses in surgical patients  Define and understand re-feeding syndrome
  4. 4.  Body builders  Fitness fanatics  Dieticians and nutritionists  The Paleo Chef  And so on and so on
  5. 5.  Elderly folk  Post-trauma  Cancer patients  Liver disease patients  Burns  And so on, and so on
  6. 6.  37 M presents to hospital with severe epigastric pain  pancreatitis  Diagnosed as severe, has SIRS then MODS response requiring ICU support  Necrotising pancreatitis  BMI 30, no recent weight loss or gain  Doesn’t normally go to the doctor, no known background health conditions  Normally eats meat, pies, doesn’t like fruit or vegetables  Works as a truck driver, smokes 10 cigarettes/day for 20 years  Normally drinks 1 carton of beer/week  12 hours prior to presentation had pain start after celebrating his birthday by drinking a bottle of whiskey
  7. 7.  70 F presented last night with small bowel obstruction and strangulation requiring urgent laparotomy – 20cm bowel resected and re-anastomosed, adhesiolysis  Background previous open cholecystectomy, TAHBSO, AF on warfarin, PVD, HTN  No recent weight loss, BMI 19  Was well prior to the last 24h  Previous smoker 50 pack years, quit 5 years ago, teetotaler, lives in assisted living, normally walks with a 4ww but does her own grocery shopping, able to complete ADLs  What is your nutrition plan?
  8. 8.  Micronutrient deficiencies in the absence of macronutrient deficiency (enough energy, not enough vitamins … all our patients who eat a lot of KFC)  Macronutrient deficiency  Pure starvation  Relative protein deficiency  Micro- and macronutrient deficiencies  Often seen in the developing world  Cachexia  Cytokine mediated  Cancer  INADEQUATE NUTRITION CAN OCCUR IN PEOPLE EATING A NORMAL DIET  SURGICAL PATIENTS ARE IN A CATABOLIC STATE
  9. 9.  Sepsis, surgery, acute and chronic illness predispose individuals to metabolic derangement  This is driven by a pro-inflammatory state  Can occur even when eating ”adequately”  Can be worsened by anorexia promoted by illness  Protein intake is the most important component of macronutrition in these patients  This leads to:  Loss of lean body mass (i.e. muscle)  Structural and functional impairment (muscle wasting, organ impairment)  Dysregulation of energy utilisation pathways  Ineffective antioxidation  build up of toxins  INCREASED COMPLICATIONS AND MORTALITY
  10. 10.  Detsky et al. JPEN 1987  9% of moderately malnourished patients have major complications  42% of severely malnourished patients have major complications  Severely malnourished patients are four-times more likely to suffer post operative complications than well-nourished patients  Hypoalbuminaemia is associated with higher surgical morbidity and mortality  Infectious complications are increased with malnutrition
  11. 11.  Our patients are septic, broken or inflammed  Their endocrine systems are hyperactive (adrenal response, thyroid response)  Surgery may resolve part of their inflammation, however the process of performing surgery is extremely physiologically stressful  Post-operative outcomes are impacted by  Nutrition  pre- and post-operative body composition  Medications  Post operative management
  12. 12. https://thoracickey.com/metabolism-in-surgical-patients/
  13. 13.  Desky et al  Hx  Weight change  Dietary intake change  GI symptoms  Functional capacity  Underlying disease and metabolic demand  Physical exam  Loss of subcutaneous fat  Muscle wasting  Ankle oedema  Sacreal oedema  Ascites  Also consider:  Weight fluctuations – a patient who lost 10% of their BW, then regained 3% is in a better position than someone who lost 7% in the same time frame  Intention – someone intentionally losing weight on a healthy diet is in a better position than someone trying to gain weight but losing it  Previous surgeries/known background GIT issues  Medications
  14. 14.  Occurs when a patient has been under-nourished or not nourished at all for a period of time, then switched suddenly to adequate/excess calories  Precipitates an insulin surge  Metabolic rate increases, therefore the O2 consumption and CO2 production increase  Insulin stimulates shift of phosphate, potassium and magnesium from serum into cells, resulting in electrolyte imbalances  The whole-body stores of these electrolytes are likely to already be low  Critically low serum levels can precipitate cardiac/neuromuscular compromise leading to arrhythmias, CHF, acute respiratory failure and death  Thiamine deficiency contributes to adverse outcomes
  15. 15.  Take baseline EUC, CMP, lipid studies  Repeat these at least BD for the first few days in most patients at risk  Involve a dietician in management  Replace electrolytes, aiming for K>4, Mg >1, Phosphate >1  Add thiamine and multivitamin to the diet/IV administration  Slowly increase calories to the patient’s calculated requirements
  16. 16.  Oral  Water  Clear fluids  Free fluids  Light diet  Full diet  NGT/OGT/NDT/ODT/NJT/OJT/PEG (percutaneous endoscopic gastrostomy)/PEJ  Enteral feed formula  TPN/parenteral nutrition  Central for long term feeds  Peripheral for short term feeds  Both can be supplementary to any of the above options
  17. 17.  Clear fluid diets – about 400-500 kcal/day  Free fluids – 900-1000kcal/day  Energy requirements are 25-35 kcal/kg/day  With 1.5g/kg/day ideal body weight of protein  Protein: Fat: Glucose ratio 20:30:50% of daily calories
  18. 18.  Our GIT is designed for digestion and absorption  Enteral feeds promote immunocompetence and maintenance of the integrity of tissues  Non-utilisation of the GIT leads to complications in critical care and geriatric patients, even when for short periods  It is cost effective compared to TPN, and does not have the risk of line sepsis
  19. 19.  To avoid periods of starvation within 24-72 h with oral/enteral feeds will be INSUFFICIENT to achieve adequate intake in moderate-severely malnourished patients  When unable to use the GIT  Intestinal obstruction  Short bowel/intestinal failure/malabsorption  High output enterocutaneous fistula(e)  Non-functioning GIT  Ischaemic bowel  Severe shock with impaired splanchnic perfusion  ESPEN Guidelines on Parenteral Nutrition
  20. 20.  37 M presents to hospital with severe epigastric pain  pancreatitis  Diagnosed as severe, has SIRS then MODS response requiring ICU support  Necrotising pancreatitis  BMI 30, no recent weight loss or gain  Doesn’t normally go to the doctor, no known background health conditions  Normally eats meat, pies, doesn’t like fruit or vegetables  Works as a truck driver, smokes 10 cigarettes/day for 20 years  Normally drinks 1 carton of beer/week  12 hours prior to presentation had pain start after celebrating his birthday by drinking a bottle of whiskey
  21. 21.  http://espen.info/documents/Acutepancreatitis.pdf  Mild to moderate pancreatitis  No evidence that enteral vs paerenteral has a beneficial effect  Nutritional therapy to be considered if refeding is delayed  Usually fast for 2-5 days, treat cause, replace fluids and electrolytes, analgese, then commence oral feeds from day 3-7) with a carbohydrate-rich, moderate-protein, moderate-fat diet prior to normal diet  Severe pancreatitis  Essential to have nutritional support  Parenteral vs enteral based on patient tolerance. ENTERAL FEEDS should be attempted in all patients  some patients will require a combination  Some authorities suggest early jejunal feeds, some suggest parental with small enteral based on tolerance  IV lipids safe with hypertriglyceridaemia is avoided  Feeds of any kind reduce the hypercatabolic state seen in severe pancreatitis
  22. 22.  70 F presented last night with small bowel obstruction and strangulation requiring urgent laparotomy – 20cm bowel resected and re-anastomosed, adhesiolysis  Background previous open cholecystectomy, TAHBSO, AF on warfarin, PVD, HTN  No recent weight loss, BMI 19  Was well prior to the last 24h  Previous smoker 50 pack years, quit 5 years ago, teetotaler, lives in assisted living, normally walks with a 4ww but does her own grocery shopping, able to complete ADLs  What is your nutrition plan?
  23. 23.  It is helpful to give epidural analgesia peri-operatively to decrease opioid requirements, reduce effects on peristalsis, and improve post-operative cognitive functions  Anaesthetic guidelines have changed in many centres to allow clear fluids until 2h pre-op (though not in this lady’s case) – pre operative glucose reduces insulin resistance  Aim would be to commence enteral feeds within hours of completing surgery  NG/NJ vs oral dependent on patient status post operatively  Oral is preferable – decreased length of stay associated with consuming orally vs having a tube  Consideration of TPN only if patient is not expected to meet >50% of required caloric intake within 7 days of operation
  24. 24.  Surgical nutrition is complicated  It’s not something you do on your own – involve the dietician, the patient and the nursing staff  It’s easy to make a big difference with small tweaks, even in the absence of allied health input  Always think about the little things you can do to optimise your patients  Good peri-operative nutrition reduces cost and complications acutely as well as improving survival at 5 years in oncological surgeries  Educate  Educate  Educate

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