Topics on Surgical Nutrition

Topics on Surgical NutritionKristopher R. Maday, MS, PA-C, CNSCUniversity of Alabama at BirminghamDepartment of Nutritional SciencesSurgical Physician Assistant Program

The Beginning3500 BCAncient egyptians would infuse wine, milk, whey, wheat or barley broths, eggs, and brandy through rectal enemas to preserve health, protect inflamed bowel, and treat diarrhea1598Capivacceus reported infusing liquids through a hollow tube placed into the esophagus

Presdient Garfield was treated this way in 1882 q4 x 79d - Continued through 1940s2

The Beginning1930sProtein hydrolysate formulas and automatic feeding pumps were developed1968Dr. Stanley Dudrick - UPennInvented Total Parenteral Nutrition (TPN)

Why Do We Care???1936 Studley et al.Malnourished patients with the same diseases as nourished patients had poorer outcomes1962 Keys et al.Healthy individuals who are deprived of adequate nutrients for a long enough period of time will develop adverse clinical events due to malnutrition

What we are used toNPO after surgery until bowel function resumesPrevent nausea and vomitingProtect surgical anastomosis before being stressed by food

Pre-Operative IssuesLength of starvationWell-nourished person has a 7-10 day energy and protein storeHealthy individual can tolerate up to 12-14 days without adverse effectsMajor surgery or critical illness can shorten to 5-7 daysNutritional StateIdentifying malnutrition

Risk for Malnutrition> 10% loss of usual body weight< 85% of Ideal Body Weight***Obese patients can be malnourished***Serum Albumin2003 - Kudsk et alPre-op Albumin < 3.25 g/dl saw a marked rise in complications and mortality in GI surgery patientsInability to eat for > 7 daysNutritional Risk Index(1.519serum albumin)+(41.7(present weight/usual weight))No Risk - > 100Mild 97.5-100Moderate 83.5-97.5Severe - < 83.5

Nutritional AssessmentAcute Phase ProteinsAlbumin and PrealbuminEnergy NeedsHarris Benedict, Ireton-Jones, Indirect Calorimetry, 22-25kcal/kgPermissive Underfeeding50-70% of caloric goals***only need 400kcal to needing for protein sparing***Indirect CalorimetryProtein Needs0.5-2 g/kg24hr Urine Urea Nitrogen collectionNitrogen Balance

Goals of Nutritional SupportProvide support consistent with the patients medical condition and nutritional statusPrevent or treat macronutrient and micronutrient deficienciesProvide doses of nutrients compatible with existing metabolismAvoid complications related to dietary deliveryImprove patient outcome

Enteral NutritionFeeding via the GI tractTypes of AccessBedsideNG, DobhoffSurgicalG-tube, J-tube, G-J Tube

Benefits of Enteral NutritionIf the gut works.use itPrevent translocation of bacteriaMaintains gut integritySustains closure of the paracellular channels between the intraepithelial cellsStimulate immunoglobulin A and bile salts which coat enteric bacteriaStimulates peristalsis

Benefits of Early Enteral Nutrition

Infectious ComplicationsMortality

Early enteral feeding versus nil by mouth after gastrointestinal surgery: systematic review and meta-analysis of controlled trialsLewis SJ, Egger M, Sylvester PA, Thomas SBMJ 2001;323:775

Mortality - 7% in early feeding group and 13% in control

Starvation reduces the collagen content in anastomotic scar tissue diminishes the quality of healing

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ComplicationsAbdominal DistensionAspirationGastric vs Transpyloric FeedingSignificant reduction if tube is past the Ligament of TrietzDiarrheaHyperosmolar enteral feedingsElemental formula helps preventIatrogenic Injury

Current therapies to shorten postoperative ileusJohnson MD, Walsh RMCleveland Clinic Journal of Medicine 2009;76(11):642

Aspiration Pneumonia

Iatrogenic Complication

Total Parenteral NutritionDeveloped in 1968 as a bridging modality for patients whom the oral route is not feasableAdmixture of amino acids, dextrose, lipids, vitamins, minerals, and electrolytesNot as nutritional complete as enteral formulas

Prior to this patients were essentially condemned to die of malnutrition18

Typical TPN Order2000kcal/20%Amino Acids 10%1000mlDextrose 70%342mlLipids 20%300mlNaCl250mEqNaPO420mmolNaOAc10mLKCl10mEqKPO410mmolKOAc20mEqMgSO416mEqCalcium Gluconate5mgZnSO45mgSterile Water1000mLMVI10mlTrace Elements3ml

IndicationsNon-stressed patient undergoing surgery who has severe protein-calorie malnutritionPatient who has a nonfunctional GI tract Short gut Syndrome, High output fistulae, obstruction, chronic mesenteric ischemiaPatient who fails oral/enteral intakeIntractable vomiting or diarrhea+/- Pancreatitis

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Enterocutaneous Fistula

Access for TPN AdministrationCentral LineGood for short term, inpatient TPNTunneled, Cuffed CathetersHickman, GroshongGood for long term, home TPNPICC LineGood for long-term, home TPNPortsMediport, Port-a-CathGood for long term, hom TPNPeripheral IV***For PPN, not TPN***Osmolarity issues

ComplicationsMechanicalAccess IssuesThrombosisInfectious Catheter associated bacteremia5 cases per 1000 catheter days, 12-25% mortality

TPN ComplicationsMetabolicOverfeedingHyperglycemiaHyperlipidemiaCan precipitate pancreatitisRefeeding SyndromeHypophosphatemiaElectrolyte AbnormalitesHypermanganesemia, HyposelenemiaGastrointestinalIntestinal atrophy, gastroparesis

Cardiac/RenalRisk for volume overloadHepatobiliaryCholestasis in children, Steatosis in adultsAcalculous/Calculous cholecystitisNPO reduces CCK releaseInfectious Higher % than NPOIncreased risk for fungemia

Special ConsiderationsDiabetic patientsObese patientsTrauma/BurnEEN, hypermetabolic demandsRenal DiseaseLimit protein 2o elevated BUNIncreased protein requirements for dialysisLiver DiseaseTPN can worsen liver function

PregnancyHIV/AIDSIncreased energy demandsDrugs, oral lesionsCancerSite of cancer, mucositisTransplant patientsPancreas, small bowelPost-transplant obesity

Diabetes treat malnutrition, gastroparesisHIV increased energy requirement, drugs alter metabolism, oral lesions and PO intakeCancer mucositis from radiation/chemoTrasnplant pancreas 3-5 days, SB 1-2 weeks, post-transplant obesity steroids, 25

Monitoring Nutritional SupportAvoid over/underfeedingMore BetterPromote nitrogen retentionAvoid protein overload

Calorie CountsActual amount infusedABGNitrogen Balance24hr Urine Urea Nitrogen

Laboratory StudiesAlbumin, Pre-albumin, BMP, Mg, Ca, PO4,LFT Intake vs Output

Weaning Nutritional SupportTPNWeaned until 60% of energy needs are met by oral intakeReduced oral intake can be expected if >25% of caloric needs are met via TPNEnteral NutritionTransition from continuous to nocturnal feeding or bolus feedingWeaned until 75% of energy needs are met by oral intake

Putting it all togetherObtaining nutritional assessment as part of pre-op workupIdentifying at risk patients prior to surgeryNutritionally optimize patients before elective surgeryDelay inpatient cases to outpatientAdd procedures to case while in OREstimate nutritional needs for post-op managementAllow for early identification of potential problems

Putting it all togetherEarly PO IntakePost-op ileus resolve earlier than commonly practicedGastric Ileus 24-48 hoursSmall Bowel Ileus 4-8 hoursColonic Ileus 3-5 daysHelps prevent anastomotic dehisenceNutrient intake associated with significant collagen deposition and reversal of mucosal atrophy at anastomosisDecrease mortality, infectious complications, and hospital length of stay

9505Patient NameAge57GenderMaleBEEProtein RequirementHeight168SCI or TBINoIreton-Jones195597Weight6325kCal/Kg1575IBW64.9Harris-Benedict2120kCal : N2 RatioBMI22.3126TEN FormulakCal/cckCal RateProtein/ccTotal Protein InCarbohydrate/ccFat/ccOsmolarity% WaterOsmolite1.5550.0627830.20360.049152576.2Oxepa1.5550.0627830.10530.093853578.5Pulmocare1.5550.0626830.10570.093347578.5Glucerna 1.51.5550.08251090.13310.07587576Peptamen1.2700.07561270.1070.054839081.1Nepro1.8450.081870.16680.09658572.5Pivot 1.51.5550.0941240.1720.05159576Promote1800.0631210.1380.02838083DateAlbuminPre-AlbuminUUNTotal cc of TENN2 BalanceChanges

9501Patient NameAge57GenderMaleBEEProtein RequirementHeight168InjuryTraumaIreton-Jones195597Weight63% TBSA25kCal/Kg1575IBW64.9Head InjuryNoHarris-Benedict2120BMI22.3SCINoCurreriNACarbohydratesProteinFatRequirement316Requirement97kCal needed550cc of D70451cc of AA970cc of Lipid306Total kCal1075Total kCal330ElectrolytesGuidelinesVolumeLast LabsLast DoseDose NeededAdjusted DoseTotal VolumeSodium60-120 mEqNaCl4 mEq/cc804311Potassium40-120 mEqKCl2 mEq/cc602111Acetate10-40 mEqNaOAc2 mEq/cc105KOAc2 mEq/cc105Phosphate10-40 mEqNaPO43 mMol/cc207KPO43 mMol/cc207ElectrolytesMgSO410-20 mEq4.06 mEq/cc164Ca Gluc5-15 mg0.465 mEq/cc511ZnSO41-15 mg1mg/cc1515Vitamin C1000 mg50mg/cc100020Folate1mg5mg/cc11g/kg%Total TPN Volume18374.9Carbohydrates55kCal : N2 Ratio24hr Fluid Requirement23601.5Protein17126Sterile Water Addition5230.9Fat28

ResourcesAmerican Society for Parenteral and Enteral Nutrition (ASPEN)2009 Clinical GuidelinesCharney P, Malone A, ADA Pocket Guide to Nutrition Assessment. Published by: American Dietetic Association (2004)

ContactKristopher R. Maday, MS, PA-C, CNSCAssistant ProfessorUniversity of Alabama at BirminghamSurgical Physician Assistant Program1530 3rd Ave South, SHPB 466Birmingham, AL 35294-1212Telephone: 205-996-2656maday@uab.edu

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