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Surgical Nutrition
Kristopher R. Maday, MS, PA-C, CNSC
University of Alabama at Birmingham
Physician Assistant Program
Department of Nutritional Sciences
Is It Still NPO Until Bowel Function
Resumes?
Objectives
• Identify malnourished patients prior to
surgery to limit complications as a result of
surgery
• Discuss post-operative diet advancement
• Recognize when nutritional support needs to
be implemented and how to choose the
appropriate type
• Evaluate how to monitor nutritional support
and when to stop
Dogma of Nutrition in
Surgery
• NPO at midnight for all surgical procedures
• NPO until bowel function resumes
• Clears  Full Liquid  Soft Diet Regular
Diet
• Nutrition stresses surgical anastomosis
• TPN early in malnourished patients
Prior Research
• Malnourished patients have worse
outcomes
• Healthy individuals, when starved long
enough, will develop adverse clinical
events
• 80% of surgeons agree that nutrition
decreases complications and LOS, but only
20% implement any interventions
Studley HO. JAMA. 1936;106:458-
460.
Stack JA, et al. Gastroenterologist. 1996;4:S8-
S15. .
Grass F, et al. Eur J Clin Nutr. 2011;65(5):642-647. .Stack JA, et al. Gastroenterologist. 1996;4:S8-
Perioperative Timeline
Miller KR, et al. JPEN. 2013;37:39S.
30-60 days 24 hours 1-14 days
Evaluation
Preparation and
Optimization
Pre-
Op
OR Post-Op
Miller KR, et al. JPEN. 2013;37:39S.
Pre-Operative Risk Reduction
• Nutritional assessment
• Concept of “prehabilitation”
• Pre-operative fasting
Nutritional Assessment
• Nutritional Risk Screening (NRS) 2002
• Pre-operative serum albumin < 3.0 mg/dL
Impaired Nutritional Status Severity of Disease
Absent
0
Normal Nutritional Status Absent
0
Normal Nutritional Requirements
Mild
1
Weight loss > 5% in 3 months
50-75% of usual food intake over last week
Mild
1
Hip fracture
Cirrhosis, DM, Benign Cx Hemodialysis, COPD
Mod
2
Weight loss > 5% in 2 months
BMI 18.5-20.5 with impaired general condition
25-50% of usual food intake over last week
Mod
2
Major abdominal surgery
Stroke, PNA, Malignancy
Severe
3
Weight loss of > 5% in 1 month
Weight loss > 15% in 3 months
BMI < 18.5 with impaired general condition
0-25% of usual food intake over last week
Severe
3
Head injury
Bone marrow transplant
ICU admission
Kondrup J, et al. Clinical Nutrition. 2003;22:321-
336..
Veterans Affairs TPN Study. NEJM. 1991;325:525-
532.
Kudsk KA, et al. JPEN. 2003;27:1-9..
Prehabilitation
• 12x increase rate of surgical complications
in obese patients
• Increase rate of post-operative
complications with hemoglobin A1c > 7%
• Decreased morbidity with preservation of
lean body mass stores
Valentijn TM, et al. Surgeon. 2013;11(3):169-
176..
Migita K, et al. Gastrointest Surg. 2012;16(9):1659-
1665..
Fearon KC, et al. NEJM. 2011;365(6):565-
567..
Pre-Operative Fasting
• 8-12 hour fast depletes almost all glycogen
stores
• Updated 2011 American Society of
Anesthesiologists (ASA) Guidelines
• Enhanced Recovery After Surgery (ERAS)
Society Guidelines
Cahill GF. Trans Am Clin Climatol Assoc. 1983;946:1-
21..
2011 ASA Guidelines. Anesthesiology. 2011;114(3):495-511.
Gustafson UO, et al. World J Surg. 2013;37:259-
284.
Post-Operative Ileus
http://melokinex.com/POI.html
Hormones and
Neuropeptides
(CCK, CGRP, VIP, IL-1, TNF-ɑ)
Surgical
Manipulation
Anesthesthesi
a
Endogenous opiate
release
Inflammation
(Macrophage and neutrophil
infiltration, cytokines,
inflammatory mediators)
Exogenous opiates
Autonomic nervous
system
(sympathetic inhibitory
pathways)
Enteric nervous
system
(substance P, NO)
http://melokinex.com/POI.html
Post-Operative Ileus
Location Symptoms Signs Management
Time to
Resolution
Stomach
Nausea +++
Vomiting +++
Abdominal Pain +
Distention +
Succussion
Splash
NG Tube
Metoclopramide
Erythromycin
12-24hr
Small Bowel
Nausea ++
Vomiting ++
Abdominal Pain +
Distention ++
NG Tube
Alvimopan
(Entereg)
6-12hr
Colon
Nausea +
Vomiting +
Abdominal Pain
++
Distention +++
Neostigmine
Decompress
48-72hr
Johnson MD, et al. Cleveland Clinic Journal of Medicine. Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125
Oral Post-Op Diet
• Clear liquid diet < Regular
Diet
• No difference in incidence of
N/V, distention, or need for
NG tube placement
• Start 24 hours after surgery
Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125
Nutritional Support
• Indications
– Unlikely to take in > 50% PO for next 3-5 days
– Inability to meet physiologic demands by oral
intake
• 2 types
– Enteral vs Parenteral
NICE Guidelines. Nutritional Support in Adults. 2006 Ukleja A, et al. Nutr Clin Pract. 2010;25:403-414
Banerjee B. Nutritional Management of Digestive
Disorders.. 2011.
Vassilyadi F, et al. Nutr Clin Pract.. 2013;28:209-217.
Enteral Nutritional
Support
• Started 24-48 hour after surgery
• Access
Enteral Nutritional
Support
Martindale RG, et al. JPEN. 2013;37(1):5S-
20S.
Enteral Nutritional
Support
Martindale RG, et al. JPEN. 2013;37(1):5S-
20S.
Enteral Nutritional
Support
Lewis SJ, et al. BMJ. 2001;323:1-5.
Enteral Nutritional
Support
• Complications
– Abdominal distention
– Aspiration
– Diarrhea
– Iatrogenic injury
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrar
y/2006/Dec3%284%29/Pages/23.aspx
Total Parenteral Nutrition
• Admixture of amino acids, dextrose, lipids,
vitamins, minerals, and electrolytes
• Indications
– Non-functional GI tract
– Failure of PO/enteral route
Total Parenteral Nutrition
• Access
– Central Line
– Tunneled/Cuffed Catheter
– PICC Line
– Ports
– Peripheral IV
Total Parenteral Nutrition
• Complications
– Catheter related bloodstream infections
(CRBSI)
– Thrombosis
– Hepatosteatosis
– Hyper/hypoglycemia
– Hyperlipidema
– Electrolyte abnormalities
Maroulis J, et al. Clinical Nutrition. 2000;19(5):295-304.Ukleja A, et al. Gastroenterol Clin N Am. 2007;36:23-46.
Heyland DK, et al. JPEN. 2003;27:355-373
Monitoring Nutritional
Support
• More ≠ Better
– Accurate caloric intake
– Promote nitrogen retention
• Laboratory studies
– Acute Phase Reactants ≠ Helpful
NICE Guidelines. Nutritional Support in Adults. 2006
Weaning Nutritional Support
• Parenteral
– Stop once 60% of energy needs are met by
oral/enteral route
• Enteral
– Continuous  Nocturnal  Bolus
– Stop once 75% of energy needs are met by
oral route
Take Home Points
• Identification of malnourished patients
and prehabilitation prior to surgery
• If the gut works, use it after 24 hours post-
op
• Enteral > Parenteral
Dogmalysis of Surgical
Nutrition
• Carbohydrate load 2 hours
before surgery
• Regular diet after POD#1
• Early enteral nutrition is safe
and reduces complications,
hospital LOS, and overall
mortality
• TPN only in a very select few
If I Had to Pick Three…
• Ukleja A, et al. Standards for Nutrition
Support: Adult Hospitalized Patients. Nutr
Clin Pract. 2010;25(4):403-414.
• McClave SA, et al. Summary Points and
Consensus Recommendations from the North
American Surgical Nutrition Summit. JPEN.
2013;27(S1):99S-105S.
• Miller KR, et al. An Evidence-Based Approach
to Perioperative Nutrition Support in the
Elective Surgery Patient. JPEN.
2013;37(S1):39S-50S.
Kristopher R. Maday, MS, PA-C, CNSC
Email: maday@uab.edu
Twitter: @PA_Maday
Thank You For Your Time

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Surgical Nutrition

  • 1. Surgical Nutrition Kristopher R. Maday, MS, PA-C, CNSC University of Alabama at Birmingham Physician Assistant Program Department of Nutritional Sciences Is It Still NPO Until Bowel Function Resumes?
  • 2. Objectives • Identify malnourished patients prior to surgery to limit complications as a result of surgery • Discuss post-operative diet advancement • Recognize when nutritional support needs to be implemented and how to choose the appropriate type • Evaluate how to monitor nutritional support and when to stop
  • 3. Dogma of Nutrition in Surgery • NPO at midnight for all surgical procedures • NPO until bowel function resumes • Clears  Full Liquid  Soft Diet Regular Diet • Nutrition stresses surgical anastomosis • TPN early in malnourished patients
  • 4. Prior Research • Malnourished patients have worse outcomes • Healthy individuals, when starved long enough, will develop adverse clinical events • 80% of surgeons agree that nutrition decreases complications and LOS, but only 20% implement any interventions Studley HO. JAMA. 1936;106:458- 460. Stack JA, et al. Gastroenterologist. 1996;4:S8- S15. . Grass F, et al. Eur J Clin Nutr. 2011;65(5):642-647. .Stack JA, et al. Gastroenterologist. 1996;4:S8-
  • 5. Perioperative Timeline Miller KR, et al. JPEN. 2013;37:39S. 30-60 days 24 hours 1-14 days Evaluation Preparation and Optimization Pre- Op OR Post-Op Miller KR, et al. JPEN. 2013;37:39S.
  • 6. Pre-Operative Risk Reduction • Nutritional assessment • Concept of “prehabilitation” • Pre-operative fasting
  • 7. Nutritional Assessment • Nutritional Risk Screening (NRS) 2002 • Pre-operative serum albumin < 3.0 mg/dL Impaired Nutritional Status Severity of Disease Absent 0 Normal Nutritional Status Absent 0 Normal Nutritional Requirements Mild 1 Weight loss > 5% in 3 months 50-75% of usual food intake over last week Mild 1 Hip fracture Cirrhosis, DM, Benign Cx Hemodialysis, COPD Mod 2 Weight loss > 5% in 2 months BMI 18.5-20.5 with impaired general condition 25-50% of usual food intake over last week Mod 2 Major abdominal surgery Stroke, PNA, Malignancy Severe 3 Weight loss of > 5% in 1 month Weight loss > 15% in 3 months BMI < 18.5 with impaired general condition 0-25% of usual food intake over last week Severe 3 Head injury Bone marrow transplant ICU admission Kondrup J, et al. Clinical Nutrition. 2003;22:321- 336.. Veterans Affairs TPN Study. NEJM. 1991;325:525- 532. Kudsk KA, et al. JPEN. 2003;27:1-9..
  • 8. Prehabilitation • 12x increase rate of surgical complications in obese patients • Increase rate of post-operative complications with hemoglobin A1c > 7% • Decreased morbidity with preservation of lean body mass stores Valentijn TM, et al. Surgeon. 2013;11(3):169- 176.. Migita K, et al. Gastrointest Surg. 2012;16(9):1659- 1665.. Fearon KC, et al. NEJM. 2011;365(6):565- 567..
  • 9. Pre-Operative Fasting • 8-12 hour fast depletes almost all glycogen stores • Updated 2011 American Society of Anesthesiologists (ASA) Guidelines • Enhanced Recovery After Surgery (ERAS) Society Guidelines Cahill GF. Trans Am Clin Climatol Assoc. 1983;946:1- 21.. 2011 ASA Guidelines. Anesthesiology. 2011;114(3):495-511. Gustafson UO, et al. World J Surg. 2013;37:259- 284.
  • 10. Post-Operative Ileus http://melokinex.com/POI.html Hormones and Neuropeptides (CCK, CGRP, VIP, IL-1, TNF-ɑ) Surgical Manipulation Anesthesthesi a Endogenous opiate release Inflammation (Macrophage and neutrophil infiltration, cytokines, inflammatory mediators) Exogenous opiates Autonomic nervous system (sympathetic inhibitory pathways) Enteric nervous system (substance P, NO) http://melokinex.com/POI.html
  • 11. Post-Operative Ileus Location Symptoms Signs Management Time to Resolution Stomach Nausea +++ Vomiting +++ Abdominal Pain + Distention + Succussion Splash NG Tube Metoclopramide Erythromycin 12-24hr Small Bowel Nausea ++ Vomiting ++ Abdominal Pain + Distention ++ NG Tube Alvimopan (Entereg) 6-12hr Colon Nausea + Vomiting + Abdominal Pain ++ Distention +++ Neostigmine Decompress 48-72hr Johnson MD, et al. Cleveland Clinic Journal of Medicine. Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125
  • 12. Oral Post-Op Diet • Clear liquid diet < Regular Diet • No difference in incidence of N/V, distention, or need for NG tube placement • Start 24 hours after surgery Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125
  • 13. Nutritional Support • Indications – Unlikely to take in > 50% PO for next 3-5 days – Inability to meet physiologic demands by oral intake • 2 types – Enteral vs Parenteral NICE Guidelines. Nutritional Support in Adults. 2006 Ukleja A, et al. Nutr Clin Pract. 2010;25:403-414
  • 14. Banerjee B. Nutritional Management of Digestive Disorders.. 2011. Vassilyadi F, et al. Nutr Clin Pract.. 2013;28:209-217.
  • 15. Enteral Nutritional Support • Started 24-48 hour after surgery • Access
  • 16. Enteral Nutritional Support Martindale RG, et al. JPEN. 2013;37(1):5S- 20S.
  • 17. Enteral Nutritional Support Martindale RG, et al. JPEN. 2013;37(1):5S- 20S.
  • 18. Enteral Nutritional Support Lewis SJ, et al. BMJ. 2001;323:1-5.
  • 19. Enteral Nutritional Support • Complications – Abdominal distention – Aspiration – Diarrhea – Iatrogenic injury http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrar y/2006/Dec3%284%29/Pages/23.aspx
  • 20. Total Parenteral Nutrition • Admixture of amino acids, dextrose, lipids, vitamins, minerals, and electrolytes • Indications – Non-functional GI tract – Failure of PO/enteral route
  • 21. Total Parenteral Nutrition • Access – Central Line – Tunneled/Cuffed Catheter – PICC Line – Ports – Peripheral IV
  • 22. Total Parenteral Nutrition • Complications – Catheter related bloodstream infections (CRBSI) – Thrombosis – Hepatosteatosis – Hyper/hypoglycemia – Hyperlipidema – Electrolyte abnormalities Maroulis J, et al. Clinical Nutrition. 2000;19(5):295-304.Ukleja A, et al. Gastroenterol Clin N Am. 2007;36:23-46.
  • 23. Heyland DK, et al. JPEN. 2003;27:355-373
  • 24. Monitoring Nutritional Support • More ≠ Better – Accurate caloric intake – Promote nitrogen retention • Laboratory studies – Acute Phase Reactants ≠ Helpful NICE Guidelines. Nutritional Support in Adults. 2006
  • 25. Weaning Nutritional Support • Parenteral – Stop once 60% of energy needs are met by oral/enteral route • Enteral – Continuous  Nocturnal  Bolus – Stop once 75% of energy needs are met by oral route
  • 26. Take Home Points • Identification of malnourished patients and prehabilitation prior to surgery • If the gut works, use it after 24 hours post- op • Enteral > Parenteral
  • 27. Dogmalysis of Surgical Nutrition • Carbohydrate load 2 hours before surgery • Regular diet after POD#1 • Early enteral nutrition is safe and reduces complications, hospital LOS, and overall mortality • TPN only in a very select few
  • 28. If I Had to Pick Three… • Ukleja A, et al. Standards for Nutrition Support: Adult Hospitalized Patients. Nutr Clin Pract. 2010;25(4):403-414. • McClave SA, et al. Summary Points and Consensus Recommendations from the North American Surgical Nutrition Summit. JPEN. 2013;27(S1):99S-105S. • Miller KR, et al. An Evidence-Based Approach to Perioperative Nutrition Support in the Elective Surgery Patient. JPEN. 2013;37(S1):39S-50S.
  • 29. Kristopher R. Maday, MS, PA-C, CNSC Email: maday@uab.edu Twitter: @PA_Maday Thank You For Your Time

Editor's Notes

  1. 1936 – Studley et al Well-nourished, non-stressed patient has 7-10 protein/energy stores  3-5 for major surgery
  2. Pre-habiliation – preparing the patient for the upcoming insult and major metabolic stress – lean muscle preservation and weight loss in Obese patients
  3. ONLY TRULE VALIDATED SCREENING TOOL IN SURGICAL PATIENTS Choose variable with the highest score Albumin < 3.25 saw marked increase in mortality and complications in elective GI surgery Add the 2 scores NOT RECOMMENDED TO TREND IN THE HOSPITAL Age > 70 add 1 point to adjust for frailty of elderly If age corrected total > 3, start nutritional support
  4. Metabolic tune up of at least 30 days Obesity is malnutrition of chronic disease with inflammation Weight loss prior to elective surgery glucose control 30-60d pre-op exercise program prior elective surgery with cancer
  5. 2hr for clear, 4hr for milk, 6hr for light meal, >8hr normal meal AVERAGE NPO TIME IS 14hr 25-50g CHO 2-3hr before general anesthesias – decreased post-op LOS by 3-6 days, preserved lean body mass, and increased insulin sensitivity Glutamine enriched CHO formulas showed no difference versus CHO alone
  6. Cholecystokinin (CCK), calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide (VIP), IL-1, TNF-a
  7. Multiple studies have shown NGT does not limit and may even prolong post-op ileus
  8. CLD has always been initial diet of choice post-op. Max – 1100 kcal and no protein. Increase risk of aspiration due to low viscosity RD has 2500kcal and 115g protein Maintains gut integrity Sustains closure of the paracellular channels between the intraepithelial cells Stimulate immunoglobulin A and bile salts which coat enteric bacteria Stimulates peristalsis
  9. 3500 BC Ancient egyptians would infuse wine, milk, whey, wheat or barley broths, eggs, and brandy through rectal enemas to preserve health, protect inflamed bowel, and treat diarrhea 1598 Capivacceus reported infusing liquids through a hollow tube placed into the esophagus 1882 President Garfield keep alive for 79 days with whiskey and beef broth enemas 1930s Protein hydrolysate formulas and automatic feeding pumps were developed 1968 Dr. Stanley Dudrick - UPenn Invented Total Parenteral Nutrition (TPN)
  10. 11 studies, 837 patients overall mortality – 7% in feeding, 13% in control Nutrient intake associated with significant collagen deposition and reversal of mucosal atrophy at anastomosis
  11. Aspiration – trasnpyloric tube, sitting up Diarrhea – banana flakes, elemental formulas
  12. NFGIT – SGS, high output fistula, obstruction, ischemia, incontinuity, peritonitis Intractable nausea/vomiting, abdominal pain, diarrhea
  13. Central Line Good for short term, inpatient TPN Tunneled, Cuffed Catheters Hickman, Groshong Good for long term, home TPN PICC Line Good for long-term, home TPN Ports Mediport, Port-a-Cath Good for long term, home TPN Peripheral IV ***For PPN, not TPN*** Osmolarity issues
  14. Bacteria and fungi are common. 5 cases/1000 days with 12-25% mortality with each case Most common cause of UE DVT
  15. 2003 – Canadian guidelines for nutritional support
  16. Avoid under/over feeding – Prenal azotemia 24hr UUN, BUN Calorie counts, actual amount infused electrolytes for refeeding, ABG for overfeeding
  17. Reduced oral intake can be expected if >25% of caloric needs are met via nutritional support