update on surgical nutrition
TRANSCRIPT
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Update on Surgical Nutrition
Kristopher R. Maday, MS, PA-C, CNSCUniversity of Alabama at Birmingham
Physician Assistant Program
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Objectives• 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
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No Financial Disclosures
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Common Dogma of Surgical Nutrition
• 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
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Prior Research
Studley HO. JAMA. 1936;106:458-460.
Stack JA, et al. Gastroenterologist. 1996;4:S8-S15. .
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Prior Research
Grass F, et al. Eur J Clin Nutr. 2011;65(5):642-647. .
80% 20%
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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
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Assessment Prehabilitation Pre-operative
Pre-operative Risk Reduction
30-60 days 24 hours
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Nutritional Assessment
Impaired Nutritional Status Severity of Disease Absent
0 Normal Nutritional Status Absent0 Normal Nutritional Requirements
Mild1
Weight loss > 5% in 3 months50-75% of usual food intake over last week
Mild1
Hip fractureCirrhosis, DM, Benign Cx, Hemodialysis, COPD
Mod2
Weight loss > 5% in 2 monthsBMI 18.5-20.5 with impaired general condition
25-50% of usual food intake over last weekMod2
Major abdominal surgeryStroke, PNA, Malignancy
Severe3
Weight loss of > 5% in 1 monthWeight loss > 15% in 3 months
BMI < 18.5 with impaired general condition0-25% of usual food intake over last week
Severe3
Head injuryBone marrow transplant
ICU admission
Kondrup J, et al. Clinical Nutrition. 2003;22:321-336..
Schiesser M et al. Clin Nutr. 2008;27(4):565-570
Kudsk KA, et al. JPEN. 2003;27:1-9..
Nutritional Risk Screening Tool (NRS 2002)
Pre-operative serum albumin < 3.0 mg/dL
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Prehabilitation
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
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Pre-operative Fasting
Cahill GF. Trans Am Clin Climatol Assoc. 1983;946:1-21..
8-12hr = glycogen
14 hours
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Pre-Operative Fasting
2011 ASA Guidelines. Anesthesiology. 2011;114(3):495-511.
2011 American Society of Anesthesiologists Guidelines
2 hoursclear liquids
4 hoursbreast milk
6 hourslight meal
8 hoursregular meal
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Pre-Operative Fasting
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.
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Ljungqvist O. JPEN. 2012;3(4);389-398.
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Post-Operative Ileus
Hormones and Neuropeptides
(CCK, CGRP, VIP, IL-1, TNF-ɑ)
Surgical Manipulation
Anesthesthesia
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)
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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):367-376
Slow
Gut
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Post-Operative Ileus
Location Symptoms Signs Management Time to Resolution
StomachNausea +++Vomiting +++Abdominal Pain +
Distention +Succussion Splash
NG TubeMetoclopramideErythromycin
12-24hr
Small Bowel
Nausea ++Vomiting ++Abdominal Pain +
Distention ++ NG TubeAlvimopan 6-12hr
ColonNausea +Vomiting +Abdominal Pain ++
Distention +++
NeostigmineDecompress 48-72hr
Johnson MD, et al. Cleveland Clinic Journal of Medicine. 2009;76(11):642
Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125
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Oral Post-Operative Diet
Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125Steenhagen E. Nutr Clin Prac. 2016;31(1):18-29.
Start REGULAR diet 24 hours post-op
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Oral Post-Operative Diet
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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
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3500 BC 1598
1882
1968
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Enteral Nutritional Support
24-48 hourspost-op
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Enteral Nutritional Support
Martindale RG, et al. JPEN. 2013;37(1):5S-20S.
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Enteral Nutritional Support
Martindale RG, et al. JPEN. 2013;37(1):5S-20S.
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Enteral Nutrition Support
Lewis SJ, et al. BMJ. 2001;323:1-5.
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Enteral Nutritional Support
Complications• Distention• Aspiration• Diarrhea• Azotemia• Iatrogenic injury• Volume problems
Martindale RG, et al. JPEN. 2013;37(1):5S-20S.
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Total Parenteral Nutrition• Admixture of amino acids, dextrose,
lipids, vitamins, minerals, and electrolytes
• Indications– Non-functional GI tract– Failure of PO/enteral route
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Total Parenteral Nutrition
McClave SA, et al. JPEN. 2013;37(S);73s.
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Total Parenteral Nutrition• Access– Central Line– Tunneled/Cuffed
Catheter– PICC Line– Ports– Peripheral IV
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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.
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Heyland DK, et al. JPEN. 2003;27:355-373
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Monitoring Nutritional Support
• 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. 2013;1(3):39-43.
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Nitrogen Balance• 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
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Weaning Nutritional Support
Continuous Nocturnal Bolus
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Supplements for Wound Healing
Stechmiller JK. JPEN. 2010;25(1):61-68
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Can You Feed An Open Abdomen?
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Can You Feed An Open Abdomen?
1. If the gut works, use it2. Start slow and advance
to goal
Powel NJ, et al. JPEN. 2012;27(4):499-506
Moore SM, et al. JPEN. 2016;31(1):9-13
Friese RS, et al. JPEN. 2012;27(4):492-498
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Powel NJ, et al. JPEN. 2012;27(4):499-506
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Can You Feed On Vasopressors?
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Can You Feed On Vasopressors?
Probably
Yang S, et al. JPEN. 2014;29(1):90-96
Bruns BR, et al. JPEN. 2016;31(1):14-17
Wells DL. JPEN. 2012;27(4):521-526
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Take Home Points1.Involve your dietician2.Early enteral is best3.Parenteral only in select
cases4.Supplement when needed5.Critical illness is tough