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Nutrition
. . . and the surgical patient
Carli Schwartz, RD,LDN
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.
Normal Nutrition
(EatRight.org)
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.
Macronutrients



Carbohydrates

Converted to glucose, body’s 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.
Normal Nutrition

Requirements
HEALTHLY male/female
(weight maintenance)
• Caloric intake=25-30 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 intake=0.8-1gm/kg/day (max=150gm/day)
• Fluid intake=~ 30 ml/kg/day or 1 ml/kcal/day
Nutrition

Requirements
? SURGICAL PATIENT ?
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)
Nutrition Needs
HEALTHLY 70 kg MALE
Caloric intake
25-30 kcal/kg/day
Protein intake
0.8-1gm/kg/day
(max=150gm/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
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 >40
11-14 kcal/kg actual body weight per day.
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 pt’s with
liver disease or during inflammatory response
Normal range: 3.5-5 g/dL.
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 range:16 to 40 mg/dL; values of <16 mg/dL are associated with
malnutrition.
**Expect an increase of .1 mg/dL per day if adequate protein is being provided. **
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.
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
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



Start clear liquids when signs of bowel function
returns
Rationale


Wait for return of bowel sounds or passage of flatus.
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
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.
Diet Advancement

Advance diet to full liquids followed by solid
foods, depending on patient’s tolerance.

Consider the patient’s disease state and any
complications that may have come about since
surgery.

Ex: steroid-induced diabetes in a post-kidney
transplant patient.
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
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, Crohn’s 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.
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.
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
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
Patients who cannot eat . . . ?
Consider Nutrition Support!
Nutrition Support

Length of time a patient can remain NPO
after surgery without complications is
unknown, however depends on:



Severity of operative stress
Patient’s 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)
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
Nutrition Support

Enteral Nutrition Support

Parenteral Nutrition support
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.
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 > 75% of needs with
po intake.
 Malnourished patient expected to be unable
to eat adequately for > 5-7 days
 Adequately nourished patient expected to be
unable to eat > 10 days
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 < 60 mmHg
Need for high dose pressors/vasoactives
Intractable vomiting, diarrhea or high gastric residuals
Septic shock, persons requiring massive fluid resucitation
Feeding Tube Access
www.medscape.com
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
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, longterm access should be considered (PEG tube
placement)
Tulane Enteral Nutrition
Product Formulary
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
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.
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.
Indications for Parenteral
Nutrition Support



Malnourished patient expected to be unable
to eat > 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
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 < 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
Tulane Daily Parenteral
Nutrition Order Form
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 >250-400 mg/dL, lipid infusion should be significantly reduced or
discontinued

~100 grams fat per week is needed to prevent essential fatty acid deficiency
Check LFT’s weekly

If LFT’s significantly elevated as a result of TPN, then minimize lipids to < 1
g/kg/day and cycle TPN/PPN over 12 hours to rest the liver

If Bilirubin > 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
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
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
Parenteral Nutrition
Prescription

Important to consider:



Glucose infusion rate should be < 5 mg/kg/minute
(maximum tolerated by the liver) to prevent
hepatic steatosis
Lipid infusion should be < 0.1 g/kg/hour (ideally <
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.
Benefits of Enteral Nutrition
over parenteral nutrition

Cost



Maintains integrity of the gut



Tube feeding cost ~ $10-20 per day
TPN cost ~ $100 or more per day!
Tube feeding preserves intestinal function; it is more
physiologic
TPN may be associated with gut atrophy
Less infection


Tube feeding—very small risk of infection and may
prevent bacterial translocation across the gut wall
TPN—high risk/incidence of line infection and sepsis
Nutrition support: Clinical
Decision Algorithm
AAFP.org
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 >
7-10 days)
Physiologic and metabolic sequelae may include:




EKG changes, hypotension, arrhythmia, cardiac arrest
Weakness, paralysis
Respiratory depression
Ketoacidosis / metabolic acidosis
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
Consequences of Overfeeding

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
Patient Handouts and Nutrition
Education




Nutrition Care Manual- Nutrition resources
from The Academy of Nutrition and Dietetics
(AND, formerly ADA)
NutritionCareManual.org
Username: [email protected]
Passoword: Tulane1
Questions
Contact Information:
Carli Schwartz, RD/LDN
Dietitian, Tulane Abdominal Transplant Institute
(504) 988-1176
[email protected]
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.