Download Cardiac Transplantation

Nutritional Management of
CHF and Heart Surgery
報告者：臺北醫學大學•市立萬芳醫院 魏賓慧 營養師
報告日期：民國 90 年 9 月 13 日
Contents
* Congestive heart failure (CHF) *
* Cardiac cachexia *
* Cardiac Surgery *
* Congestive heart failure *
 The structure of the heart pump (Figure 33-1 )
 Definitions : A physical inadequacy of the heart in maintaining the
circulation of blood to tissue.
 Characterized by
(1)
Decreased cardiac output with impaired tissue perfusion as well
as systemic
and vascular congestion.
(2)
Breathlessness
(3)
Abnormal sodium and water retention.
 Related Physiology
 heart pumping
less blood circulating to body tissue
congestion in lungs or body circulation
ankle swelling , abdominal pain , ascites
hepatic congestion , jugular vein distention , breathing difficulty
Right CHF : pitting edema of extremities , Fatigue , congestion in the liver,
spleen , other organs
Light CHF : affects the lungs, with pulmonary edema rales , and dyspnea .
 L’t sided heart failure always leads to right-sided failure because of
increased pressure to heart via the pulmonary circuit.
 Decreased renal flow
  the glomercular filtration rate
 the amount of sodium filtered.
 Activated the rennin-angiotensin-aldosterone system of the kidney
 aldosterone , ADH
 tubular resorption of sodium and water
 congestion in the lungs
 SOB
 BUN may be increased
 malnutrition and cardiac cachexia in severe heart failure
(poor circulation to the tissue may deprive the tissue of nutrients)
(symptom : anorexia , fat and muscle wasting , edema )
 Common Symptoms
(1) SOB (shortness of breath)
 dyspnea on exertion
 SOB at rest (orthopnea) or at night
(paroxysmal nocturnal dyspnea)
(2) Inadequate blood supply to the abdominal organs :
 anorexia, nausea , feeling of fullness , constipation ,
abdominal pain , malabsorption , enlarged liver , liver tenderness.
(3) Decreased cranial blood supply
 lead to mental confusion , memory loss, anxiety ,
insomnia , headache.
(4) Cool extremities , sweating , edema in the legs
 Disease Progression of CHF
Compensation for poor cardiac output by
1. increasing the force of contraction
2. increasing in size
3. pumping more often
4. stimulating the kidneys to conserve sodium and water
To maintain near-normal circulation, but eventually the heart can
no longer attain a normal output.
 Classification of heart failure Table 33-1 >
The stage of CHF are categorized by severity of symptoms
<
 The risk of CHF- (The Framingham Study-epidemiologic )
HTN, left ventricular hypertrophy, coronary heart disease, diabetes.
 Potential etiologies for CHF
(1) Elevated thyroid hormones
(2) Beriberi
(3)
(4) HTN
(5)
(6) Cardiac shunt
(7)
(8) Cardiomyopathy
(9)
(10) Pericardical disease
(thyrotoxicosis)
Severe anemia
Valvular stenosis or regurgitation
Ischemic heart disease
Artrial fibrillation
 Treatment
(1) First line of treatment-Restricted activity + moderate sodium-restricted diet
(Early adaptations to mild heart failure show susceptibility
to sodium excess.)
(2) hormone therapy
(3) implanation of a pacemaker
(4) cardiac transplantation
(5) oxygen therapy
(6)
medication and dietary adjustments.
 Nutritional Care
(一)、The goal of dietary management
1. Reduce the workload of the heart
2. Decrease edema of the extremities
3. Improve SOB
4. Management of cardiac cachexia
(二)、Assessment of nutritional status
1. Biochemical markers：
Serum albumin and transferrin 
2.Anthropometrics and diet history
 Calf and thigh circumferences
 mid–upper arm circumference
( sensitive indicators of lean body mass in cardiac patients retaining fluid)
3. Assessment of cardiac cachexia
 especially waiting for surgery.
 Dietary component
1. Energy
(1) 20% -30% above BEE
(ref 3)
(based upon the Harris –Benedict equation)
30-50% above basal level (ref 1)
due to the increased energy expenditure of the heart and lungs.
(2) For cardiac cachexia / underweight/ poor nutritional
status
1.6-1.8×resting energy expenditure for nutritional repletion.
(3) In obese individuals
 hypocaloric diet (1000-1200 kcal/day) will reduce the stress
on the heart and facilitate weight reduction.
 weight loss may lead to sympotomatic relief of SOB.
2. Protein (ref 1)
0.8-1 g protein /kg BW ( if oral intake)
1.5 g/ kg BW (if parenterally)
3. CHO
 Determined by arterial pCO2 and hyperglycemia.
 Hypoperfusion of the pancrease as well as certain medications used
to treat CHF can lead to acute hyperinsulinemia and insulin
resistance.
4. Sodium
(I). Asymptomatic patients with mild heart failure (Class I-II) and no
congestion can retain sodium and water after a high–salt diet
(250 mEq/day ≒ 5.8g Na ≒14.7 g NaCl)
(II) Sodium restriction recommendation depends on the severity of
the heart failure
< ref1 >
 in mild failure , a sodium-restricted diet and bedrest may be
sufficient to improve symptoms.
 For moderate to severe heart failure , 1-2 g Na /day ;
3-4 g /day (if p’t improved)
< ref2 >
 500 mg at first , then progress to 1000 mg as edema subsided.
 Not all patients require the strict limitations;
4-6 g sodium may be satisfactory.
< ref3 >
 Sodium : 1000 -3000 mg /day
depend upon the severity of the heart failure.
 3 g Na for moderate heart failure
 2 g Na for severe heart failure
 For hospitalized p’t , a more restrictive diet(500 mg-1000 mg Na)
may be beneficial in decreasing accumulated extracellular fluid
and reducing cardiac workload. difficulty to compliance
 At discharge , 3 g Na /day should be prescribed to encourage
better compliance.
5. Fluid
(1) 1000-2000 mL fluid/day (severe HF)
(2) No more than 3 L fluid /day
(3) patients with refractory edema should receive only 0.5 mL/ kcal
(4) monitor :
-Obtaining a baseline weight
-urine specific gravity
-serum electrolyte
-clinical signs of edema
(5) Fluid restrictions are discontinued at discharge.
(6) Help patient plan fluid intake over waking hours –
75 % from meals, 25 % with medications and for thirst between
meals.
Sodium-Restricted Diets-5 levels < ref1 >
Levels
No Added Mild sodium Moderate
Salt Diet restriction
sodium
restriction
Daily Sodium
4g
2g
1g
Allowance
(174 mEq) (87mEq) (43mEq)
Table salt /day
< 1/2 t
< 1/4 t
No
* High Na foods Limited
No
No
Moderate Na
Limited
No
foods
* Frozen
No
vegetables
Regular bread and
Limited
backed goods
* Naturally high
Na vegetables
* Animal
protein foods
Drinking water
(Na 40 mg or
2 meq/L)
As discharge
diet
OK
OK
Difficult
Strict
Severe
sodium
Sodium
restriction restriction
500mg
250mg
(22 mEq) (11 mEq)
No
No
No
No
No
No
No
No
Low Na
bread
replace
No
Low-Na
foods
replace
No
Meat
6 oz/day
Distilled
water
Limited
Distilled
water
No.
No.
Used in Rarely used
short period
*High Na foods : Table 33-5
*Frozen vegetable : peas, lima beans, mixed vegetable, corn.
* Naturally high Na vegetables: beets, carrots, kale , spinach , celery , white turnips,
rutabagas , mustard greens , chard , dandelion greens .
*Animal protein foods : meat , eggs , milk , cheese , poultry , fish
 Low-sodium or Low-Salt Syndrome
 The minimum 250 mg (9 mEq) sodium required by the human to
maintain life.
 Result from adrenal insufficiency , marked
vomiting ,diarrhea ,burns
 Symptoms : weakness , lassitude , anorexia, vomiting abdominal
cramps , aching skeletal muscles , metal confusion.
6. Potassium
 A high–potassium diet (because of diuretics use)
 Potassium depletion may lead to digitalis toxicity.
Symptoms : Anorexia , nausea , vomiting , abdominal discomfort ,
hallucinations , depression , drowsiness , cardiac arrhythmias).
7. Supplements
(1) Adequate intake of thiamine ,riboflavin , B6 , B12 , folic acid ,
Vit E
(2) Causion of Ca , Mg : aggravate cardiac arrhythmias.
8. Caffeine -- limited
 its potential to increase heart rate and cause dysrhythmia.
 At first , no caffeine
latter , limited to 4-5 cups of coffee /day
9. Other meal plan
(1) Small, frequent meals (5-6 meals/day )
Decrease the cardiac workload
Meeting nutritional requirements
(2) Bland , low roughage foods
Lessen heartburn , distention , flatulence
Noted : avoid overintake of beans , cabbage , onions , cauliflower ,
Brussels sprounts
(3) Soft textures food
 Reduce the amount of chewing .
(4) Add soluble fiber  Ex. apples , oat bran.
(5) Multivitamin supplementation
需補充族群:
exhibit anorexia , malnutrition , poor intake below 1200 kcal / day
(6) Allow rest before and after meals.
(7) Avoid Alcohol
 How to achieve requirement
 Affecting nutritional status factors: anorexia , early satiety , ascites,
altered taste , and labored efforts to eat
 Nutritional support include:
1.Nutrients-dense liquid supplements
2.Try duodenal tube feeding, if oral feeding didn’t meet enough.
 Initiated feeding rate 30 ml/hr , then increased gradually
 Formula selection: 2 kcal/cc, Na content
3. Parenteral therapy, if enteral feeding fail.
 Starting infusion volume: 1500 cc/day
 For cachetic patient:
Infusion rates : 600 cc/day to avoid
metabolically stressing the patient.
4. Avoid overly aggressive feeding
(because of worsen CHF , resulting in pulmonary edema. )
5.Nutritional rehabilitation takes a minimum of 3 weeks to achieve.
……………………………………………………………………………
1. Krause’s Food, Nutrition, and Diet Therapy /9th edition / L.Kathleen
Maban ; Sylvia Escott-Stump
Ch23 / nutrition in cardiovascular disease.
P.547-548.
Ch33/ nutritional care in heart failure and transplant. P.737-748
2. Nutrition and Diagnosis-related care / Forth edition /
Sylavia Escott-Stump
P.219-220 , 234-236 (CHF)
P.237-238 (cardiac cachexia)
P.574-575 ( open heart surgery (CABG or valve replacement))
3. 張仙平.
P. 511-513 (Nutrition management following cardiac surgery)
p.515-517(Nutrition management of CHF)
* Cardiac cachexia *
 Definitions
 Patient with CHF(moderate to servere ) or some valvular heart disease
cannot eat adequately to maintain weight.
 35-50% of patient with moderate to severe heart failure have
malnutrition known as cardiac cachexia.
 Symptoms :
 Increased total body fluid
(which occurs in an effort to improve heart function)
 Marked loss of lean body mass and adipose tissue
( supraclavicular and temporal muscle wasting )
 Weight loss
 Anorexia
 Malabsorption with steatorrhea or diarrhea.
 A loss of myocardial mass with reduced heart rate and oxygen
consumption , eventually occurs in cardiac cachexia.
 The cachectic p’t who must undergo cardiac surgery is at high risk
of greater morbidity and mortality, delayed wound healing,
increased time for weaning ventilator, and susceptibility to
postoperative acute renal failure.
 Nutritional support and rehabilitation should begin before surgery.
 Factors in the development of
cardiac cachexia
< Table 33-2 >
 Dietary and Nutritional recommendations.
 Calorie : calculated at 1.5* BEE
 Protein : increasing or decreasing ,dependent on renal or hepatic status
(1) calorie : nitrogen ratio of 150 : 1
(2) 1-1.5 g/kg BW
 Sodium : restricted to 1-2 g daily
 Modify potassium intake as appropriate for serums levels.
 High folate, thiamine, Vitamin B6 , Vitamin B12 , Vitamins E
 Increasing magnesium , zinc , iron ( dependent on serum levels).
 Provide small , frequent meals
 prevent overloading with high glucose or with rapid fat infusion.
 supplements between meals to improve total calorie intake,
Ex: sherbet shakes.
 Provide as preferred foods as feasible to improve appetite and intake.
Nutrition Management Following Cardiac Surgery
(一)、Percutaneous transluminal coronary angioplasty (PTCA)
 Uses balloon to break up plaque deposits in an occluded artery
 Procedure is done under local anesthesia in a cardiac catheterization lab
 Recovery is quicker than with bypass surgery.
 Candidate for PTCA ：No more than two occluded arteries
 The common problem： restenosis of artery
 Nutritional medical therapy：Step-II diet
(二)、Coronary artery bypass graft (CABG)
 Narrowed or blocked arteries are bypassed.
The donor vein comes from the leg or artery from the chest.
 Operation takes 4-5 hours.
 Candidate for CABG：more than two occluded arteries
 Complication：
(1) The new grafts are susceptible to atherogenesis , restenosis .
(2) At risk of for developing cardiac cachexia
 Nutritional medical therapy：Step-II diet to stop progression.
(三)、Valve replacement
Replacing the damaged valve with mechanical prosthesis or a
biological tissue valve.
(四)、Atherectomy and Repair of congenital heart defects
 Objectives
1.Preoperative
(1) Monitor serum electrolytes , albumin , glucose, Ca , Mg , P ,
lipid profile (TC , TG , HDL-C , LDL-C)
PS：Lipid values are considered inaccurate in myocardial infarction .
(2) Provide diet as ordered- example:Sodium or cholesterol restricted diet
(3) Provide ample amount of glycogen for stores.
(4) Use PN support as needed for malnourished cardiac patients.
2、 Postoperative
(1) Promote wound healing
(2) Restore normal fluid and electrolyte balance
(3) Promote weight control
(4) Wean from ventilator support when possible
(5) Prevent HHNK coma , sepsis, atelectasis , renal failure , cardiac
tamponade , or wound dehiscence.
(6) maintain comfort and educate regarding follow-up.
 Dietary and Nutritional Recommendations
1. Provide adequate protein and calories for wound healing,
(1) severe heart failure - 20-30% increase in calories
( for increased cardiac and pulmonary expenditure)
(2) Protein needs：
During the catabolic post operative phase： 1.2 g/ kg BW
Following the immediate recovery period： 0.8 g/ kg BW(？)
2. Provide adequate Zn and Vitamins A , C , K. for wound healing
3. Control fluid intake
 measuring previous day’s output plus 500 CC for insensible losses.
4. Control Na and K intake, edema , measuring BP
 monitoring serum Na and K levels
 Modified sodium intake：
Commonly prescribed : 2-3 g
Na Needed by adults : 2 g
at home , 2-4 g Na is reasonable
5. Control cholesterol and SFA intake
(1) Low cholesterol and SFA diet is recommended 4-6 weeks following
CABG surgery since initial emphasis is placed on healing .
(2) NCEP , AHA stages I or II diet
 NCEP’s Step-I diet ( at discharge )
 NCEP’s Step-II Diet is suggested
(If serum cholesterol levels have not been reduced to the desired
level by 3 months following surgery.)
 Note : Serum cholesterol levels recheck 4-6 weeks post-surgery then
again 3 months following surgery.
7. Small-frequent meals
8. The diet is advanced from liquid to solid foods as tolerated.
9. Use TF or TPN if severely malnourished
Note: (1) replete slowly
(2) keep the head of the bed elevated 30° to prevent worsening
of CHF.
 Commonly used drugs in CHF that affect nutritional status
(Table 33-3)
Cardiac Transplantation
 Table 33-11 Nutrition Care For Cardiac Transplant Patients
(Three Phase: Pretransplant , Immediately post-transplantation ,
Long-term post-transplant)

Pretransplant goals -- For transplant candidates
(1) BW at 90-110% of IBW
(2) Positive nitrogen balance of 3-4g / day
(3) Sodium intake of 2g / day
(4) 1-1.2 g protein / kg BW
1.5-2 g protein /kg BW (poor nutritional status)
(5) 30 kcal / kg BW
35-40 kcal / kg BW (poor nutritional status)
 Immediately post-transplantation goals
- High caloric and protein for catabolic period
(1) High caloric (1.5-1.75 * BEE)
(2) 1.2 - 1.5 g protein /kg BW
(3) Diet progression : CLD SD ( Small, frequent meals)
 Long-term post-transplant
(1) Problem: immunosuppressive drugs
Result in weight gain and hyperlipidemia.
 Factors related to developing hypercholesterolemia after
transplantation : prednisone dose , baseline cholesterol level ,
blood glucose , weight gain.
(2) The discharge recommendation
 Normalize blood lipids (Step-II-Diet)
 2-4 g sodium /day
 Achieve and maintain IBW
 Increasing activity level