Nutrition

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Nutrition

• . . . and the surgical patient
• Carli Schwartz, RD,LDN

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Role of Nutrition In Surgical Patients

• Malnutrition may compound the severity of
  complications related to a surgical procedure
• A well-nourished patient usually tolerates major
  surgery better than a severely malnourished
  patient
• Malnutrition is associated with a high incidence
  of operative complications and death.

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Normal Nutrition (EatRight.org)
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The Newest Food Guide Pyramid

• Balancing Calories   ? Enjoy your food, but eat
  less.   ? Avoid oversized portions.    
• Foods to Increase   ? Make half your plate fruits
  and vegetables.   ? Make at least half your
  grains whole grains.   ? Switch to fat-free or
  low-fat (1) milk.    
• Foods to Reduce   ? Compare sodium in foods like
  soup, bread, and frozen meals ? and choose the
  foods with lower numbers.   ? Drink water instead
  of sugary drinks.       
• Website http//www.choosemyplate.gov/
• Includes interactive tools including a
  personalized daily food plan
• Plan, analyze and track diet and physical
  activity.

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Macronutrients

• Carbohydrates
• Converted to glucose, bodys major source of
  energy
• Simple vs. Complex dependent on chemical
  structure
• Yields 3.4 kcal/gm
• Recommended 45-65 total daily calories.
• Fats
• Major endogenous fuel source in healthy adults
• Yields 9 kcal/gm
• Aids body in absorbing vitamins, proper growth
  and development
• Too little can lead to essential fatty acid
  (linoleic acid) deficiency and increased risk of
  infections
• Chose less saturated and trans fats
• Recommended 20-30 of total caloric intake
• Protein
• Needed to maintain anabolic state (match
  catabolism)
• Yields 4 kcal/gm
• Complete versus incomplete
• Build and maintain bones, muscles and skin
• Must adjust in patients with renal and hepatic
  failure
• Recommended 10-35 of total caloric intake.

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Normal Nutrition

• Requirements

• HEALTHLY male/female
• (weight maintenance)
• Caloric intake25-30 kcal/kg/day
• Harris Benedict Equation for Basal Metabolic Rate
  (multiply by activity factor for REE)
• Women BMR 655 ( 4.35 x weight in pounds )
  ( 4.7 x height in inches ) - ( 4.7 x age in years
  )Men BMR 66 ( 6.23 x weight in pounds ) (
  12.7 x height in inches ) - ( 6.8 x age in year )
  
• Protein intake0.8-1gm/kg/day (max150gm/day)
• Fluid intake 30 ml/kg/day or 1 ml/kcal/day

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Nutrition

• Requirements

? SURGICAL PATIENT ?
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Increased Risk of Malnutrition

• Inadequate nutritional intake
• Metabolic response (hypermetabolism from long
  term inflammation or infectious conditions)
• Nutrient losses without proper replenishment
• Protein /energy store depletion
• Diminished nutrient intake (pre/post operative)
• Prevalence of GI obstruction, anorexia,
  malabsorption
• Extraordinary stressors (surgical stress,
  hypovolemia, sepsis, bacteremia, medications)
• Wound healing
• Anabolic state, higher demand for nutrients
  (amino acids, zinc, vitamin A C, arginine)

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Nutrition Needs
HEALTHLY 70 kg MALE Caloric intake 25-30
kcal/kg/day Protein intake 0.8-1gm/kg/day
(max150gm/day) Fluid intake 30 ml/kg/day
SURGERY PATIENT Caloric intake Mild stress,
inpatient 25-30 kcal/kg/day Moderate stress,
ICU patient 30-35 kcal/kg/day Severe stress,
burn patient 30-40 kcal/kg/day Protein
intake 1-2 gm/kg/day Fluid intake INDIVIDUALIZED
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Nutrition Needs for the Mechanically Ventilated
Patient

• Support the Immune system, facilitate wound
  healing, prevent muscle breakdown and
  malnutrition
• Important NOT to overfeed! Permissive
  underfeeding is recommended if adequate protein
  is provided.
• Overfeeding total (not just carbohydrate)
  calories can exacerbate hyperglycemia, cause
  fatty liver, increase CO2 production, and burden
  the system by forcing it to deal with the excess
  caloric load.
• Respiratory quotient value 1 when the organism
  is burning chiefly carbohydrates, near 0.7 when
  mainly fats, and near 0.8 when primarily burning
  protein
• Prolonged underfeeding may lead to excessive loss
  of lean body mass and prevent muscle breakdown.
  Providing adequate protein can help prevent this
  (1.5-2gm/kg non-obese, 2-2.5 gm/kg IBW for obese)
  
• To prevent over-feeding, use Penn State Equation
  (BEE obtained from Harris Benedict Equation)
• Obese critically ill vent dependent patients
• REE BEE (1.1) VE (32) Tmax (140)-5340
• Non-obese critically ill patients
• REE BEE(0.85) VE(33) Tmax (175)-6433
• Mechanically ventillated Patients who are
  morbidly Obese with BMI gt40
• 11-14 kcal/kg actual body weight per day.

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Nutritional Labs

• Albumin
• Synthesized in and catabolized by the liver
• Pro often ranked as the strongest predictor of
  surgical outcomes- inverse relationship between
  postoperative morbidity and mortality compared
  with preoperative serum albumin levels
• Con lack of specificity due to long half-life
  (approximately 20 days). Not accurate in pts
  with liver disease or during inflammatory
  response
• Normal range 3.5-5 g/dL.

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Nutritional Labs

• Prealbumin (transthyretin) - transport protein
  for thyroid hormone, synthesized by the liver and
  partly catabolized by the kidneys.
• Pro Shorter half life (two to three days) making
  it a more favorable marker of acute change in
  nutritional status. A baseline prealbumin is
  useful as part of the initial nutritional
  assessment if routine monitoring is planned.
• Cons More expensive than albumin. Levels may be
  increased in the setting of renal dysfunction,
  corticosteroid therapy, or dehydration, whereas
  physiological stress, infection, liver
  dysfunction, and over-hydration can decrease
  prealbumin levels.
• Normal range16 to 40 mg/dL values of lt16 mg/dL
  are associated with malnutrition.
• Expect an increase of .1 mg/dL per day if
  adequate protein is being provided.

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Nutritional Labs

• Markers of Inflammation- WBC and CRP
• If elevated, PAB and Albumin not a good measure
  of nutrition status due to suppression of
  production during inflammatory response.

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Nitrogen Balance

• Protein intake (gm)/6.25 - (UUN 4) balance in
  grams
• Nitrogen balance measures net changes in body
  protein mass
• Positive value found during periods of growth,
  tissue repair or pregnancy. This means that the
  intake of nitrogen into the body is greater than
  the loss of nitrogen from the body, so there is
  an increase in the total body pool of protein.
• Negative value can be associated with burns,
  fevers, wasting diseases and other serious
  injuries and during periods of fasting. This
  means that the amount of nitrogen excreted from
  the body is greater than the amount of nitrogen
  ingested.
• Nitrogen Equilibrium Expected in Healthy
  Individuals
• Requires 24 hour urine collection
• Can determine minimum adequate protein with
  losses through hypermetabolism.
• Complex determination of balance, measures of
  losses difficult and limited utility in clinical
  setting

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Postoperative Nutritional Care

• Traditional Method Diet advancement
• Introduction of solid food depends on the
  condition of the GI tract.
• Oral feeding delayed for 24-48 hours after
  surgery
• Wait for return of bowel sounds or passage of
  flatus.
• Start clear liquids when signs of bowel function
  returns
• Rationale
• Clear liquid diets supply fluid and electrolytes
  that require minimal digestion and little
  stimulation of the GI tract
• Clear liquids are intended for short-term use due
  to inadequacy

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Things to Consider

• For liquid diets, patients must have adequate
  swallowing functions
• Even patients with mild dysphagia often require
  thickened liquids.
• Must be specific in writing liquid diet orders
  for patients with dysphagia
• There is no physiological reason for solid foods
  not to be introduced as soon as the GI tract is
  functioning and a few liquids are being
  tolerated. Multiple studies show patients can be
  fed a regular solid-food diet after surgery
  without initiation of liquid diets.

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Diet Advancement

• Advance diet to full liquids followed by solid
  foods, depending on patients tolerance.
• Consider the patients disease state and any
  complications that may have come about since
  surgery.
• Ex steroid-induced diabetes in a post-kidney
  transplant patient.

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Special Dietary Restrictions

• General GI surgery
• Manage nausea/vomiting/diarrhea
• Avoid foods high in sugar and high in fiber
• Have protein foods at every meal
• Eat small and frequent meals (5-6 meals/day)
• Avoid foods high in fat, fried foods, spicy foods
• Have drinks between and not during meals
• Choose soft and well cooked foods
• Utilize Nutrition Care Manual for education
  handouts!

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Special Dietary Restrictions

• Low Fiber Diet (Low Residue)
• There is no scientifically acceptable definition
  of residue. The amount of residue produced by
  digestion of various foods cannot be estimated
  from widely available sources. Data documenting
  the efficacy of a low residue diet are
  unavailable in the literature. The low fiber diet
  is the preferred alternative to the low residue
  diet because the amount of fiber in the diet can
  be estimated from food composition tables.
• Intended to reduce the frequency and volume of
  stools
• Appropriate for new ileostomy/colostomy, s/p
  recent GI surgery, Crohns disease, ulcerative
  colitis, diverticulitis, radiation therapy to
  bowel or pelvis.
• Includes white and refined breads/pasta, well
  cooked fruits and vegetables (without pulp or
  skins), meats, seafood, oils, dairy if tolerated.

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Special Dietary Considerations

• Elemental Diet
• Also referred to as chemically defined diet
• Amino acid based, low residue, for patients with
  chronically impaired GI function. Avoids whole or
  partial proteins and provides fat in small
  quantities.
• Often used as treatment during flare up of IBD or
  after major bowel resection when pt is not
  tolerating p.o. diet.
• Helps to manage inflammation and symptoms of GI
  intolerance. Improves absorption of nutrients.
• Requires specifically tailored Nutritional
  supplement meant for oral or enteral feeding.
  Vital AF or Vivonex products used.
• NO other food is allowed on an elemental diet.
  Elemental does NOT mean low residue, low fat or
  low fiber.
• Elemental diets are often poorly tolerated when
  given by mouth due to poor taste of supplement.
  Some patients prefer diet to be given enterally.

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Nutrition and Wound Healing

• Adequate intake of fat, carbohydrates and protein
  needed for wound healing to take place.
• Physiologic stress caused by wounds can increase
  need for dietary sources of conditionally
  essential amino acids (arginine and Glutamine)
• Encourage RDA recommendations for micronutrients.
  
• Consider MVI, vitamin C, Vitamin A and Zinc
  supplementation
• Nutritional drinks to help patients meet
  nutritional needs.
• Glucose control important with diabetics

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Nutrition Involvement in Wound Healing

• Vitamin A enhances early inflammatory phase,
  promotes epithelial cell differentiation
• Protein prevent prolonging inflammatory phase.
  Protein deficiency inhibits wound remodeling.
  Wound repair and immune function associated with
  glutamine and arginine supplementation.
• Vitamin C enhances neutrophil migration and
  lymphocyte transformation, necessary for collagen
  synthesis, proper immune function and tissue
  antioxidant.
• Zinc required for DNA synthesis, cell division,
  and protein synthesis

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Patients who cannot eat . . . ?
Consider Nutrition Support!
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Nutrition Support

• Length of time a patient can remain NPO after
  surgery without complications is unknown, however
  depends on
• Severity of operative stress
• Patients preexisting nutritional status
• Nature and severity of illness
• In uncomplicated cases, well nourished patients
  tolerate up to 10 days of starvation with no
  medical complications. Moderately or severely
  malnourished patients usually require nutritional
  support earlier. (A.S.P.E.N Nutrition Support
  Practice Manual 2nd Ed)

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Goals of Nutrition Support post-surgery

• Decrease surgical mortality
• Decrease surgical complications and infection
• Reduce the catabolic state and restore anabolism
• Support the depleted patient throughout the
  catabolic phase of recovery
• Decrease hospital LOS
• Speed the healing/recovery process
• Ensure the prompt return of GI function to resume
  standard oral intake as soon as possible

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Nutrition Support

• Enteral Nutrition Support
• Parenteral Nutrition support

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What is enteral nutrition?

• Enteral Nutrition
• Also called "tube feeding," enteral nutrition is
  a liquid mixture of all the needed macro and
  micronutrients.
• Consistency is sometimes similar to a milkshake.
• It is given through a tube in the stomach or
  small intestine.
• Can be sole or partial source of nutrition
• If oral feeding is not possible, or an extended
  NPO period is anticipated, an access devise for
  enteral feeding should be inserted at the time of
  surgery.

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Indications for Enteral Nutrition

• When the GI tract is functional or partially
  functional and..
• Patient has inability to consume or absorb
  adequate nutrients.
• Patient is not meeting gt 75 of needs with po
  intake.
• Malnourished patient expected to be unable to eat
  adequately for gt 5-7 days
• Adequately nourished patient expected to be
  unable to eat gt 10 days

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Contraindications to Enteral Nutrition Support

• Expected need less than 5-7 days if malnourished
  or 7-9 days if normally nourished
• Severe acute pancreatitis (NPO required)
• Small bowel obstruction, ileus or high output
  enteric fistula distal to feeding tube
• Inability to gain or maintain access
• Hemodynamic instability/poor profusion MAP
  consistently lt 60 mmHg
• Need for high dose pressors/vasoactives
• Intractable vomiting, diarrhea or high gastric
  residuals
• Septic shock, persons requiring massive fluid
  resucitation

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Feeding Tube Access
www.medscape.com
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Gastric vs. Small Bowel Access

• If the stomach empties, use it.
• Indications to consider small bowel access
• Gastroparesis / gastric ileus
• Recent abdominal surgery
• Sepsis
• Significant gastroesophageal reflux
• Pancreatitis
• Aspiration
• Ileus
• Proximal enteric fistula or obstruction

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Short-Term vs. Long-Term Tube Feeding Access

• No standard of care for cut-off time between
  short-term and long-term access
• However, if patient is expected to require
  nutrition support longer than 6-8 weeks,
  long-term access should be considered (PEG tube
  placement)

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Tulane Enteral Nutrition Product Formulary
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Choosing Appropriate Formulas

• Categories of enteral formulas
• Polymeric
• Whole protein nitrogen source, for use in
  patients with normal or near normal GI function
• Monomeric or elemental
• Predigested nutrients most have a low fat
  content or high of MCT and peptide or amino
  acid based for use in patients with severely
  impaired GI function
• Disease specific
• Formulas designed for feeding patients with
  specific disease states
• Formulas are available for respiratory disease,
  diabetes, renal failure, hepatic failure, and
  immune compromise
• Concentrated Formulas for patients who are
  volume-sensitive (1.2, 1.5, 2 cal/ml)
• well-designed clinical trials may or may
  not be available

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Complications of Enteral Nutrition Support

• Issues with access, administration, GI
  complications, metabolic complications. These
  include
• Nausea, vomitting, diarrhea, delayed gastric
  emptying, malabsorption, refeeding syndrome,
  hyponatremia, microbial contamination, tube
  obstruction, leakage from ostomy/stoma site,
  micronutrient deficiencies.

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What is parenteral nutrition?

• Parenteral Nutrition
• also called "total parenteral nutrition," "TPN,"
  or "hyperalimentation."
• It is a special liquid mixture given into the
  blood via a catheter in a vein.
• The mixture contains all the protein,
  carbohydrates, fat, vitamins, minerals, and other
  nutrients needed.

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Indications for Parenteral Nutrition Support

• Malnourished patient expected to be unable to eat
  gt 5-7 days AND enteral nutrition is
  contraindicated
• Patient failed enteral nutrition trial with
  appropriate tube placement (post-pyloric)
• Enteral nutrition is contraindicated or severe GI
  dysfunction is present
• Paralytic ileus, mesenteric ischemia, small bowel
  obstruction, enteric fistula distal to enteral
  access sites

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PPN vs. TPN

• TPN (total parenteral nutrition)
• High glucose concentration (15-25 final
  dextrose concentration)
• Provides a hyperosmolar formulation (1300-1800
  mOsm/L)
• Must be delivered into a large-diameter vein
• PPN (peripheral parenteral nutrition)
• Similar nutrient components as TPN, but lower
  concentration (5-10 final dextrose
  concentration)
• Osmolarity lt 900 mOsm/L (maximum tolerated by a
  peripheral vein)
• May be delivered into a peripheral vein
• Because of lower concentration, large fluid
  volumes are needed to provide a comparable
  calorie and protein dose as TPN

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Tulane Daily Parenteral Nutrition Order Form
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Parenteral Nutrition Monitoring

• Electrolytes -adjust TPN/PPN electrolyte
  additives daily according to labs
• Check accu-check glucose q 6 hours
• Regular insulin may be added to TPN/PPN bag for
  glucose control as needed
• Check triglyceride level within 24 hours of
  starting TPN/PPN
• If TG gt250-400 mg/dL, lipid infusion should be
  significantly reduced or discontinued
• 100 grams fat per week is needed to prevent
  essential fatty acid deficiency
• Check LFTs weekly
• If LFTs significantly elevated as a result of
  TPN, then minimize lipids to lt 1 g/kg/day and
  cycle TPN/PPN over 12 hours to rest the liver
• If Bilirubin gt 5-10 mg/dL due to hepatic
  dysfunction, then discontinue trace elements due
  to potential for toxicity of manganese and copper
• Check pre-albumin weekly
• Adjust amino acid content of TPN/PPN to reach
  normal pre-albumin 18-35 mg/dL
• Adequate amino acids provided when there is an
  increase in pre-albumin of 1 mg/dL per day

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Complications of Parenteral Nutrition

• Hepatic steatosis (fatty liver disease)
• Thought to be related to excessive dextrose
  administration due to storage of glucose in the
  liver
• May occur within 1-2 weeks after starting PN
• Usually is benign, transient, and reversible in
  patients on short-term PN and typically resolves
  in 10-15 days

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Complications of Parenteral Nutrition Support
(continued)

• Cholestasis
• May occur 2-6 weeks after starting PN
• Indicated by progressive increase in TBili and an
  elevated serum alkaline phosphatase
• Occurs because there are no intestinal nutrients
  to stimulate hepatic bile flow, causing
  disruption or blockage
• Trophic enteral feeding to stimulate the
  gallbladder can be helpful in reducing/preventing
  cholestasis
• Gastrointestinal atrophy
• Lack of enteral stimulation is associated with
  villus hypoplasia, colonic mucosal atrophy,
  decreased gastric function, impaired GI immunity,
  bacterial overgrowth, and bacterial translocation
• Trophic enteral feeding to minimize/prevent GI
  atrophy

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Parenteral Nutrition Prescription

• Important to consider
• Glucose infusion rate should be lt 5 mg/kg/minute
  (maximum tolerated by the liver) to prevent
  hepatic steatosis
• Lipid infusion should be lt 0.1 g/kg/hour
  (ideally lt 0.4 g/kg/day to minimize/prevent
  TPN-induced liver dysfunction)
• Hyperglycemia and re-feeding syndrome. Initiate
  TPN slowly if patient is severely malnourished or
  diabetic.

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Benefits of Enteral Nutritionover parenteral
nutrition

• Cost
• Tube feeding cost 10-20 per day
• TPN cost 100 or more per day!
• Maintains integrity of the gut
• Tube feeding preserves intestinal function it is
  more physiologic
• TPN may be associated with gut atrophy
• Less infection
• Tube feedingvery small risk of infection and may
  prevent bacterial translocation across the gut
  wall
• TPNhigh risk/incidence of line infection and
  sepsis

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Nutrition support Clinical Decision Algorithm
AAFP.org
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Refeeding Syndrome

• Defined as the metabolic and physiologic
  consequences of depletion, repletion,
  compartmental shifts, and interrelationships of
  phosphorus, potassium, and magnesium
• Severe drop in serum electrolyte levels (K, PO4,
  Mg) resulting from intracellular electrolyte
  movement when energy is provided after a period
  of starvation (usually gt 7-10 days)
• Physiologic and metabolic sequelae may include
• EKG changes, hypotension, arrhythmia, cardiac
  arrest
• Weakness, paralysis
• Respiratory depression
• Ketoacidosis / metabolic acidosis

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Refeeding Syndrome(continued)

• Prevention and Therapy
• Correct electrolyte abnormalities before starting
  nutrition support
• Continue to monitor serum electrolytes after
  nutrition support begins and replete aggressively
• Initiate nutrition support at low
  rate/concentration ( 50 of estimated needs) and
  advance to goal slowly over 2-3 days in patients
  who are at high risk

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Consequences of Over-feeding

• Risks associated with over-feeding
• Hyperglycemia
• Hepatic dysfunction from fatty infiltration
• Respiratory acidosis from increased CO2
  production
• Difficulty weaning from the ventilator in
  mechanically ventilated patients
• Risks associated with under-feeding
• Depressed ventilatory drive
• Decreased respiratory muscle function
• Impaired immune function
• Increased infection
• Loss of lean body mass and malnutrition if
  chronic

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Patient Handouts and Nutrition Education

• Nutrition Care Manual- Nutrition resources from
  The Academy of Nutrition and Dietetics (AND,
  formerly ADA)
• NutritionCareManual.org
• Username Member_at_tuhc.com
• Passoword Tulane1

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Questions

• Contact Information
• Carli Schwartz, RD/LDN
• Dietitian, Tulane Abdominal Transplant Institute
• [phone]
• Carli.Schwartz_at_hcahealthcare.com

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• References
• American Society for Parenteral and Enteral
  Nutrition. The Science and Practice of Nutrition
  Support. 2001.
• Han-Geurts, I.J, Jeekel,J.,Tilanus H.W,
  Brouwer,K.J., Randomized clinical trial of
  patient-controlled versus fixed regimen feeding
  after elective abdominal surgery. British Journal
  of Surgery. 2001, Dec88(12)1578-82
• Jeffery K.M., Harkins B., Cresci, G.A.,
  Marindale, R.G., The clear liquid diet is no
  longer a necessity in the routine postoperative
  management of surgical patients. American Journal
  of Surgery.1996 Mar 62(3)167-70
• Reissman.P., Teoh, T.A., Cohen S.M., Weiss, E.G.,
  Nogueras, J.J., Wexner, S.D. Is early oral
  feeding safe after elective colorectal surgery? A
  prospective randomized trial. Annals of Surgery.
  1995 July222(1)73-7.
• Ross, R. Micronutrient recommendations for wound
  healing. Support Line. 2004(4) 4.
• Krauses Food, Nutrition Diet Therapy, 11th Ed.
  Mahan, K., Stump, S. Saunders, 2004.
• American Society for Parenteral and Enteral
  Nutrition. The Science and Practice of Nutrition
  Support. 2001.