Update on Surgical Nutrition
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This document provides an overview of pre- and post-operative nutrition considerations for surgical patients. Key points discussed include identifying malnourished patients prior to surgery, advancing diets post-operatively based on bowel function, and recognizing when nutritional support such as enteral or parenteral nutrition needs to be implemented. Guidelines for pre-operative fasting and resuming oral intake after surgery are reviewed. Complications of different nutritional support methods and strategies for monitoring are also summarized.
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Update on Surgical Nutrition
- 1. Kristopher R. Maday, MS, PA-C, CNSC University of Alabama at Birmingham Physician Assistant Program
- 2. • Identify malnourished prior to surgery • Discuss post-operative diet advancement • Recognize when nutritional support needs to implemented – How to choose correct type – How to monitor nutritional support • Dogmalysis
- 4. • NPO at midnight for all surgical procedures • NPO until bowel function resumes • Clears Full Liquid Soft Regular • Nutrition stresses surgical anastomosis • TPN early in malnourished patients • No enteral feeding with vasopressors • No enteral feeding with open abdomen
- 5. Studley HO. JAMA. 1936;106:458- Stack JA, et al. Gastroenterologist. 1996;4:S8-
- 6. Grass F, et al. Eur J Clin Nutr. 2011;65(5):642-647. . 80% 20%
- 7. 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
- 8. Assessment Prehabilitation Pre-operative 30-60 days 24 hours
- 9. 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.. Schiesser M et al. Clin Nutr. 2008;27(4):565-570Kudsk KA, et al. JPEN. 2003;27:1-9.. Nutritional Risk Screening Tool (NRS 2002) Pre-operative serum albumin < 3.0 mg/dL
- 10. 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.. Obese and A1C > 7% Preservation of lean mass
- 11. Cahill GF. Trans Am Clin Climatol Assoc. 1983;946:1- 21.. 8-12hr = glycogen 14 hours
- 12. 2011 ASA Guidelines. Anesthesiology. 2011;114(3):495- 2011 American Society of Anesthesiologists Guidelines 2 hours clear liquids 4 hours breast milk 6 hours light meal 8 hours regular meal
- 13. Fearon KC, et al. Clin Nutr. 2005;24(3):466-477. Steenhagen E. Nutr Clin Prac. 2016;31(1):18-29. Enhanced Recovery After Surgery (ERAS) Guidelines 25-50g clear carbohydrate drink Ljungqvist O. JPEN. 2014;38(5):559-566.
- 14. Ljungqvist O. JPEN. 2012;3(4);389-398.
- 15. 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
- 16. Increased age Male Low albumin Opioid use Previous abdominal surgery Long surgery Emergency surgery Blood loss Bragg D, et al. Clin Nutr. 2015;34(3):367- Slow Gut
- 17. 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 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
- 18. Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125 Steenhagen E. Nutr Clin Prac. 2016;31(1):18-29. Start REGULAR diet 24 hours post-op
- 20. • 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-
- 23. Martindale RG, et al. JPEN. 2013;37(1):5S- 20S.
- 24. Martindale RG, et al. JPEN. 2013;37(1):5S- 20S.
- 25. Lewis SJ, et al. BMJ. 2001;323:1- 5.
- 26. Complications • Distention • Aspiration • Diarrhea • Azotemia • Iatrogenic injury • Volume problems Martindale RG, et al. JPEN. 2013;37(1):5S- 20S.
- 27. • Admixture of amino acids, dextrose, lipids, vitamins, minerals, and electrolytes • Indications – Non-functional GI tract – Failure of PO/enteral route
- 28. McClave SA, et al. JPEN. 2013;37(S);73s.
- 29. • Access – Central Line – Tunneled/Cuffed Catheter – PICC Line – Ports – Peripheral IV
- 30. • 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.
- 31. Heyland DK, et al. JPEN. 2003;27:355-373
- 32. • Ensuring adequate caloric intake – Estimation • Equations (Ireton-Jones) – Measure • Indirect calorimetry • Ensuring adequate protein intake – Estimation • Equations (~1.5g/kg/day) – Measure • Nitrogen balance Maday KR. Universal Journal of Clinical Medicine.
- 33. • 24 hour urine urea nitrogen (g) – 15.4g • Add a “fudge factor” for non-urinary losses – Usually around 4 • Calculate 24 hour nitrogen intake – Total protein intake / 6.25 ((75g protein)/6.25) – (15.4g + 4) = -7.4 7.4 x 6.25 + 10g = 56.25g protein/day
- 34. Continuous Nocturnal Bolus
- 35. Stechmiller JK. JPEN. 2010;25(1):61-68
- 37. 1. If the gut works, use it 2. Start slow and advance to goal Powel NJ, et al. JPEN. 2012;27(4):499-Moore SM, et al. JPEN. 2016;31(1):9-13 Friese RS, et al. JPEN. 2012;27(4):492-
- 38. Powel NJ, et al. JPEN. 2012;27(4):499- 506
- 40. Probably Yang S, et al. JPEN. 2014;29(1):90-96Bruns BR, et al. JPEN. 2016;31(1):14-17 Wells DL. JPEN. 2012;27(4):521-526
- 41. 1.Involve your dietician 2.Early enteral is best 3.Parenteral only in select cases 4.Supplement when needed 5.Critical illness is tough
- 42. w w w . p a i n e p o d c a s t . c o m @PA_Maday maday@uab.edu
Editor's Notes
- a principle or set of principles laid down by an authority as incontrovertibly true.
- 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
- 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
- 12x increase in surgical ciomplication in obese patients 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
- No glycogen = increase catabolism of lean mass
- Light meal = toast or cereal with clear liquid
- decreased post-op LOS by 3-6 days, preserved lean body mass, and increased insulin sensitivity
- Cholecystokinin (CCK), calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide (VIP), IL-1, TNF-a
- Multiple studies have shown NGT does not limit and may even prolong post-op ileus
- No difference in incidence of N/V, distention, or need for NG tube placement 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
- Calorie counts, supplements, diet options
- 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
- 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
- NFGIT – SGS, high output fistula, obstruction, ischemia, incontinuity, peritonitis Intractable nausea/vomiting, abdominal pain, diarrhea
- 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
- 2003 – Canadian guidelines for nutritional support
- Adjusted body weight 24hr urine urea nitrogen
- Increasing 56g/day will get to a +1.6 nitrogen balance
- Reduced oral intake can be expected if >25% of caloric needs are met via nutritional support
- No well designed RCT Low risk of bowel necrosis on small or stable vasopressor doses