Nutrition Assessment and Post-Surgical

Advancement

Rebecca Cohen, MS, RD, LDN

Transplant Dietitian

Tulane Transplant Institute

Nutrition and Surgery Reported 40% incidence of malnutrition in

acute hospital setting 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.

Normal Nutrition (EatRight.org)

The Newest Food Guide

Teaches ● 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 and food tracker

Carbohydrates Limited storage capacity, needed for CNS (glucose) function

Yields 3.4 kcal/gm

Recommended 45-65% of total caloric intake

Simple vs Complex

Fats Major endogenous fuel source in healthy adults

Yields 9 kcal/gm

Too little can lead to essential fatty acid (linoleic acid) deficiency and increased risk of infections

Recommended 20-30% of total caloric intake

Protein Needed to maintain anabolic state (match catabolism)

Yields 4 kcal/gm

Must adjust in patients with renal and hepatic failure

Recommended 10-35% of total caloric intake

Normal Nutrition Requirements

HEALTHLY male/female

• Caloric intake= 25-30 kcal/kg/day

• Protein intake= 0.8-1gm/kg/day (max=150gm/day)

• Fluid intake= ~30 ml/kg/day*

*Unless medical state warrants fluid restriction

Reasons for Malnutrition Inadequate nutritional intake Metabolic response Nutrient losses Protein/energy store depletion Prevalence of ileus, anorexia, malabsorption Extraordinary stressors (surgical stress, hypovolemia,

bacteremia, medications) Wound healing

Anabolic state May require appropriate vitamins

Nutrition Comparison

SURGERY PATIENT

Caloric intake *Mild stress

25-30 kcal/kg/day *Moderate stress

30-35 kcal/kg/day *Severe stress

30-40 kcal/kg/day Protein intake

1-2 gm/kg/day Fluid intake

INDIVIDUALIZED

HEALTHLY 70 kg MALE

Caloric intake25-30 kcal/kg/day

Protein intake0.8-1gm/kg/day

Fluid intake30 ml/kg/day

Albumin Synthesized in and catabolized by the liver Normal range: 3.5-5 g/dL Half-life: 20 days

Pros Cons

Ranked as the strongest predictor of surgical outcomes

Lack of specificity due to long half-life

Inverse relationship between postoperative morbidity and mortality compared with preoperative serum albumin levels

Not accurate in pt’s with liver disease (elevated Tbili) or during inflammatory response (elevated WBC or CRP)

Prealbumin Synthesized by the liver and partly catabolized by

the kidneys Normal range:16-40 mg/dL

Values of <16 mg/dL are associated with malnutrition Half-life: 2-3 days

Pros Cons

Shorter half life than albumin More expensive than albumin

More favorable marker of acute change in nutritional status (compared to albumin)

Levels may be increased in the setting of renal dysfunction, corticosteroid therapy, or dehydration

*A baseline prealbumin is useful as part of the initial nutritional assessment if routine monitoring is planned

Over-hydration can decrease prealbumin levels; result in false negative

Nitrogen Balance Measures net changes in body protein mass Nitrogen Balance = protein intake (gm) - (UUN +4)

6.25 Healthy individuals= nitrogen balance (-1 to +1)

Positive Value Negative Value

Found during periods of growth, tissue repair, or pregnancy

Associated with burns, fevers, wasting diseases and other serious injuries, & during periods of fasting

Intake of nitrogen into the body is greater than the loss of nitrogen from the body

Amount of nitrogen excreted from the body is greater than nitrogen intake

Increase in the total body pool of protein

Often seen following major surgery*Patient will likely require extra protein for tissue building

Postoperative Diet Advancement Delay feeds for 24-48 hours until bowel

sounds & function return Begin with clear liquids

Supply fluids and electrolytes Require minimal digestion and stimulation of GI

tract Intended for short-term use due to inadequacy of

nutritional needs

Clear Liquid DietAcceptable food items

Water (plain, carbonated or flavored) Fruit juices without pulp, such as apple or white grape Fruit-flavored beverages, such as fruit punch or lemonade Plain gelatin Tea or coffee without milk or cream Strained tomato or vegetable juice Sports drinks Clear, fat-free broth Hard candy, such as lemon drops or peppermint rounds Ice pops without milk, bits of fruit, seeds or nuts (except red)

http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/clear-liquid-diet/art-20048505

Diet Advancement cont. Advance diet to full liquids

Middle step Meet daily calorie and protein needs

Acceptable food items Coffee, tea, cream, carbonated beverages Fruit and vegetable juices Milk & Milkshakes Nutritional supplements Custard-style yogurt, pudding, custard Plain ice cream, sherbet, sorbet Jell-o (any flavor) Cream soups, strained, cream of wheat, cream of rice, grits Pureed soups & Tomato puree Gravy, margarine Sugar, syrup, jelly, honey

http://www.upmc.com/patients-visitors/education/nutrition/pages/full-liquid-diet-facts.aspx

Diet Advancement cont. Advance diet to solid foods Appropriate to introduce solids as soon as the

GI tract is functioning & liquids are tolerated Diets available:

Regular Pediatric Heart healthy ADA/Diabetic Renal Low sodium (2 gm) Bland/Soft/Low residue

Key considerations Condition of the GI tract Disease state Complications that may have resulted from surgery

Ex: diabetes in a post-kidney transplant patient. Why?

For liquid diets, patients must have adequate swallowing functions, as determined by SLP Mechanical soft Pureed Thicken liquids

Must be specific in writing liquid diet orders for patients with dysphagia

Nutrition Support Options

Length of time a patient can remain NPO without complications is unknown Tulane Protocol: NPO > 4 days

Two types of nutritional support Enteral Parenteral

Enteral Nutrition Liquid mixture designed to meet nutrient needs

Goal rates are individidualized

Given through a tube in the stomach or small intestine Nasogastric tube Nasoduodenal tube Nasojejunal tube Gastrostomy/Jejunostomy

Continuous or Bolus feeds Specialized formulas for select disease states

Glucerna Suplena Nepro Elemental formulas

Indications Contraindications

Functioning GI tract Severe acute pancreatitis

Adaptive phase of short bowel syndrome

High output enteric fistula distal to feeding tube

Following severe trauma or burns

Inability to gain access

Intractable vomiting or diarrhea

Aggressive therapy not warranted

Gastric vs. Small Bowel

“If you don’t use it, you lose it.”

Indications to consider small bowel access: Gastroparesis Recent abdominal surgery Sepsis Significant gastroesophageal reflux (GERD) Aspiration risk Mild ileus Proximal enteric fistula or obstruction

No standard of care for cut-off time between short-term and long-term access

Long-term access should be considered if the patient is expected to require nutrition support longer than 6-8 weeks

NG tubes can be used for long term enteral nutrition

However, complications can include: Non-elective extubation Tube misplacement Occasional need to check position of the tube

Short-term vs Long-term

Choosing Appropriate Formulas

Polymeric Monomeric/elemental

Disease specific

Basic Info: Uses whole proteins as nitrogen source

Predigested nutrients; most have a low fat content or high % of MCT

Specific formulas for•Respiratory disease•Diabetes•Renal failure•Hepatic failure•Immune compromise

Consider for patients with:

Normal or near normal GI function

Impaired GI function Specific disease states

Tulane Enteral Nutrition Product Formulary

Enteral Nutrition Guidelines Gastric feeding

Small bowel feeding Continuous feeding only; do not bolus due to risk of

dumping syndrome Start slowly @ 20 mL/hour Advance in increments of 20 mL q 8 hours to goal Do not check gastric residuals

Continuous feeding Bolus feeding• Start at rate 30 mL/hour• Advance in increments of 20 mL

q 8 hours to goal• Check gastric residuals q 4 hour

• Start with 120 mL bolus• Increase by 60 mL q bolus to

goal volume• Every 3-8 hours

Complications of Enteral Nutrition Support

Access Administration GI complications Metabolic complications

Enteral Nutrition Case Study

78-year-old woman admitted with new CVA

Significant aspiration detected on bedside swallow evaluation SLP recommends strict NPO with alternate means of

nutrition

PEG placed for long-term feeding access

Plan: stabilize the patient and transfer her to a long-term care facility for rehabilitation

Enteral Nutrition Case Study (continued)

Height: 5’4” Weight: 130# / 59kg BMI: 22 IBW: 120# +/- 10% Usual weight: 130# Estimated needs:

Calories? Protein? Fluid?

Enteral Nutrition Prescription Jevity 1.2 (via PEG)

Initiate at 30 mL/hour, advance by 20 mL q 8 hours to goal

Goal rate = 55 mL/hour 1584 kcal 73g protein 1069 mL free H2O, additional ~515mL needed

Check residuals q 4 hours hold feeds for residual > 200 mL

Aspiration precautions

What is parenteral nutrition?

It is a special liquid mixture given into the blood via a catheter in a vein

Contains all the, carbohydrates, protein, fat, vitamins, minerals, and other nutrients needed

Light sensitive, always covered in a light resistant bag

Indications for TPN Two criteria, need both

Malnourished patient expected to be unable to eat > 5-7 days Failed enteral nutrition trial per SLP Appropriate tube placement

EN is contraindicated or severe GI dysfunction is present Ex: paralytic ileus, mesenteric ischemia, small bowel

obstruction, enteric fistula distal to enteral access sites

TPN (total parenteral nutrition)

PPN(peripheral parenteral nutrition)

High glucose concentration (15-25% final dextrose concentration)

Similar nutrient components as TPN, but lower concentration (5%-10% final dextrose concentration)

Provides a hyperosmolar formulation (1300-1800 mOsm/L)

Osmolarity < 900 mOsm/L (maximum tolerated by a peripheral vein)

Must be delivered into a large-diameter vein

May be delivered into a peripheral vein

Large fluid volumes needed to meet same calorie and protein dose as TPN (because lower in concentration)

Often used with other MNT and for a short period of time

Parenteral Access Devices

Peripheral venous access Catheter placed percutaneouly into a peripheral

vessel

Central venous access (catheter tip in SVC) Percutaneous jugular, femoral, or subclavian

catheter Implanted ports (surgically placed) PICC (peripherally inserted central catheter)

Writing TPN prescriptions

1. Determine total volume of formulation based on individual patient fluid needs

1. Determine amino acid content

2. Determine dextrose content

3. Determine lipid content

4. Check to make sure desired formulation will fit in the total volume indicated

Tulane TPN Order Form

Parenteral Nutrition Monitoring Check electrolytes daily and adjust TPN/PPN

additives accordingly

Check accu-check glucose q 6 hours

Check triglyceride level within 24 hours of starting TPN/PPN and weekly while patient remains on it

Parenteral Nutrition Monitoring (continued)

Check LFT’s weekly

Check pre-albumin weekly

Acid/base balance Increase/decrease chloride as needed Bicarbonate is unstable in TPN/PPN prep Precursor—acetate—is used

Complications of TPN/PPN Hepatic steatosis

Usually benign in patients on short-term PN

Resolves in 10-15 days

Limiting fat content of PN to control steatosis in long-term use

Complications of TPN/PPN (continued)

Cholestasis

Due to no intestinal nutrients to stimulate hepatic bile flow

Gastrointestinal atrophy

Trophic enteral feeding to minimize/prevent GI atrophy

TPN/PPN Case Study 55-year-old male admitted with small bowel

obstruction

Complicated cholecystecomy 1 month ago. Since, poor po intake and 20 # weight loss

NPO for 3 days since admitright subclavian central line was placed

Plan: start TPN since patient is expected to be NPO for at least 1-2 weeks

TPN/PPN Case Study(continued)

Height: 6’0” Weight: 155# / 70kg BMI: 21 IBW: 178# +/- 10% Usual wt: 175# Estimated needs:

Calories? Protein? Fluid?

TPN/PPN PrescriptionAmino acid 4.5% (or 45 g/liter)

Dextrose 17.5% (or 175 g/liter)

Lipid 20% 285 mL over 24 hours

2120 kcal, 90g protein (2 liters/24 hrs)

GIR: 3.5 mg/kg/minute

Enteral Parenteral

Cost $10-20 per day $100 or more per day

Gut Preserves intestinal function

May be associated with gut atrophy

Infection Very small risk of infection

High risk/incidence of infection and sepsis

Enteral Nutrition > Parenteral Nutrition

Miscellaneous Thoughts

• Transitional feeds• PNEN• PN/EN oral feeds

• Refeeding syndrome • Caused by intracellular movement when energy is

provided after a period of starvation (usually > 7-10 days)• Hypomagnesaemia, hypokalemia, hypophosphatemia• Close monitoring of electrolytes• Initiate feeds slowly, work towards goal rate

Miscellaneous Thoughts

Under-feeding Over-feeding

Depressed ventilatory drive Hyperglycemia

Decreased respiratory muscle function

Hepatic dysfunction from fatty infiltration

Impaired immune function Respiratory acidosis from increased CO2 production

Increased infection Difficulty weaning from the ventilator

Questions

Contact Information:

Rebecca Cohen, MS, RD, LDNTransplant Dietitian, Tulane Transplant Institute(504) 988-1176Rebecca.Cohen@hcahealthcare.com

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, Dec;88(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 July;222(1):73-7.

Ross, R. Micronutrient recommendations for wound healing. Support Line. 2004(4): 4.

Krause’s 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.