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
3.
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
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.
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
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-
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-
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
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
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