Nutrition screening and assessment of surgical patients

Surgical Nutrition Training ModuleLevel 1

Philippine Society of General SurgeonsCommittee on Surgical Training

Objectives

• To discuss body composition analysis in surgical patients

• To discuss ways to improve body composition and function to improve outcomes in surgery

Muscle and fat mass, all ages

Body compartments in health and disease

WATER (60%)

FAT (25%)

PROTEIN (14%)

WATER (72%)

FAT (15%)

PROTEIN (12%)

WATER (70%)

FAT (23%)

PROTEIN (6%)

CARBO + OTHER (1%)

NORMAL STARVATION CRITICAL CARE

WATER (55%)

FAT (30%)

PROTEIN (14%)

OBESE

Loss of lean body mass = ↑mortality

Loss of Total LBM

Complications Associated Mortality

10% Decreased immunityIncreased infections

10%

20% Decrease in healing, increaseIn weakness, infection

30%

30% Too weak to sit, pressure ulcers,Pneumonia, lack of healing

50%

40% Death, usually from pneumonia 100%

Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9.

LBM=Lean Body Mass

Principles in surgical nutrition

• Surgery causes cellular damage and metabolic responses that increase energy and nutrient needs

• Immunosuppression increases susceptibility to bacterial and other infectious agent intrusion with their corresponding side effects

• Wound healing requires increased energy and nutrient needs

• Malnutrition affects surgical outcome(s)• Optimum outcome is dependent on preparation,

operative method, and adequate support

Malnutrition detection toolsNutrition screening Nutritional assessment

The surgical nutrition process

All admitted patients are nutritionally screened

All nutritionally at risk patients are assessed

All high risk patients are given nutrition care plans

Monitoring of the nutrition process is done

Nutrition care plan modification / Discharge

STEP 1: NUTRITION SCREENING

Goal: To identify the nutritionally at risk patients

The surgical nutrition process

All admitted patients are nutritionally screened

All nutritionally at risk patients are assessed

All high risk patients are given nutrition care plans

Monitoring of the nutrition process is done

Nutrition care plan modification / Discharge

Height and weight taken from regularly calibrated instruments

Basic data requirements• Body Mass Index

– <18.5 underweight– 18.5 – 24.9 normal– 25 – 29.9 overweight– 30+ obese

• Severe weight loss– >5% in 1 month– >7.5% in 3 months– >10% in 6 months

• Mid Arm Circumference– Male: <17.6 cm– Female: <17.1 cm

Nutrition Screening Form for Adult and Geriatric patients

Nutrition Screening Form for Pediatric patients -

boys

Nutrition Screening Form for Pediatric patients -

girls

Outcome: nutrition surveillance

NUTRITIONAL ASSESSMENT

Goal: To identify the nutritionally HIGH RISK patients

The surgical nutrition process

All admitted patients are nutritionally screened

All nutritionally at risk patients are assessed

All high risk patients are given nutrition care plans

Monitoring of the nutrition process is done

Nutrition care plan modification / Discharge

Nutritional Assessment

and Risk Level Form

Outcome: complication prediction

Predicting post-operative complications based on surgical nutritional risk level using the SNRAF in colon cancer patients - a Chinese General Hospital & Medical Center experience. Ocampo R B, Kadatuan Y, Torillo MR,

Camarse CM, Malilay RB, Cheu G, Llido LO, Gilbuena AA. Yr 2007.

A filtering process

CASE DISCUSSION: NUTRITION SCREENING AND ASSESSMENT

Gastric CA

• FM, 68 y/o, admitted because of gastric mass and admitted to undergo gastrectomy

• Ht - 1.65m; Wt. 46 kg; BMI=16.9• Previous wt 4 months - 52 kg; % weight loss = 11%• Ancillary procedures:

– Chest Xray: old (?) PTB– ECG: Normal heart– CBC: Hb=10; WBC=6,000; Platelets=250,000; N%=70; L%=10– Electrolytes: Na=130; K=3.2– BUN =25; Creatinine=1.2– Albumin - 3

Nutrition screening

1. Is the BMI <18.5 or >30? 2. Has the patient lost

weight within the last three (3) months?

3. Did the patient have a reduced dietary intake in the last week?

4. Is the patient severely ill (e.g. in intensive therapy)

1. YES: BMI = 16.92. YES: lost weight (11% in

the last 4 months)3. YES: reduced dietary

intake4. NO: not severely ill

NUTRITION SCREEN RESULT: NUTRITIONALLY AT RISK

Nutritional assessment/Risk Level

SGA: Weight loss: >10% and gastro symptoms = (grade C) (3 pts) → severe malnutrition

BMI=16.9 (2 pts)Albumin=3 (less than 3: 2 pts)TLC=600 (less than 900: 2 pts)Total Risk Score=9

Nutritional Assessment = Severe malnutritionRisk Level =High Risk of developing nutrition

related complications

Final decision

• Nutrition build up of this patient is mandatory for at least 5 to 10 days

• Other options:– Do surgery then continuous post-operative nutrition

maintenance and build up– Needs a Nutrition Care Plan

• Rationale: body composition and reserves cannot provide optimum condition for good healing and fast recovery plus reduction of complications (infection, dehiscence, fistula formation)

THANK YOU