Download SURGICAL NUTRITION

SURGICAL NUTRITION
Professor Magdy Amin RIAD
Professor of Otolaryngology.
Ain shames University
Senior Lecturer in Otolaryngology
University of Dundee
Nutritional assessment
• Clinical assessment
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Weight loss
10% =mild malnutrition
30% = severe malnutrition
Body mass index
• Anthropometric assessment
– Triceps skin fold thickness
– Mid arm circumference
– Hand grip strength
• Blood indices
– Reduced serum albumin, prealbumin or transferrin
– Lymphocyte count
• No index of nutritional assessment shown to be superior
to clinical assessment
Methods of nutritional support
• Use gastrointestinal tract if available
• Prolonged post-operative starvation is
probably not required
• Early enteral nutrition reduced postoperative morbidity
Enteral feeding
• Prevents intestinal mucosal atrophy
• Supports gut associated immunological
shield
• Attenuates hypermetabolic response to
injury and surgery
• Cheaper than TPN and has fewer
complications
Polymeric liquid diet
• Short peptides, medium chain triglycerides
and polysaccharides
• Vitamins and trace elements
Elemental diet
• L-amino acids, simple sugars
• Expensive and unpalatable
• High osmolarity can cause diarrhoea
Enteral feed
• Enteral feed can be taken orally or by NGT
Nasoenteral tube - usually fine bore
• Long term feeding can be by:
• Surgical gastrostomy, jejunostomy
• Percutaneous endoscopic gastrostomy
• Needle catheter jejunostomy
• Rate of infusion – often started at low rate
and increased
• Strength of initial feed – often diluted and
strength gradually increased
Complications of enteral feeding
• Malposition and blockage of tube
• Gastrooesophageal reflux
• Feed intolerance
Enteral Therapy
1. Continuous: delivery of formula at a
designated rate over a 24-hour period via
an enteral feeding pump.
2. Interval: delivery of a designated volume
of formula 6 times per 24-hour period via
an enteral feeding pump at 300 cc per
hour
EQUIPMENT
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1. Enteral feeding set with bag
2. Formula
3. Graduated cylinder
4. Irrigation container
5. 60 cc syringe with catheter adaptor
6. Enteral feeding pump
PROCEDURE
• 1. Clamp nasogastric tube as ordered by
physician. This will be done when bowel sounds
are present.
• 2. Assess for complaints of nausea. If nausea
occurs, unclamp the tube and attempt to
aspirate gastric contents to prevent vomiting.
Reclamp when nausea subsides. The tube
should be clamped and the patient free of
nausea 1 hour before initiating a feeding.
PROCEDURE
• 3. After all feeding tube placements and/or
adjustments, a radiograph is usually obtained to
verify proper location of tube prior to initiating
feedings. Verification must be approved by
physician.
• 4. Explain procedure to patient. Elevate head of
bed to a sitting position (45°). Maintain upright
position during continuous and interval feedings
and for 30 minutes after interval feedings.
• 5. Wash hands thoroughly.
Prior to feedings:
a. Confirm that a radiograph has been
reviewed to verify proper placement of
tube before initiating feeding.
b. For subsequent feedings, assess tube
position (eg, absence of coiling in mouth,
length of tube from nose to inlet).
Initiation and progression of
feedings:
a. Initiate feedings with D5W at 100 cc per hour x 2 hours
per feeding pump. Wait 1 hour and assess residual. If
>100 cc, recheck in 1 hour. Repeat as needed.
b. If feeding tolerated, start full-strength isotonic formula at
50 cc per hour per feeding pump. NOTE: If hypertonic
formula is used, refer to Precautions, Considerations and
Observations for information concerning initiation and
advancement of feeding.
Initiation and progression of
feedings:
c. Advance the rate of feeding 25 cc per hour
every 12 hours as tolerated until desired rate is
achieved (usually 75 to 100 cc per hour). Do not
exceed desired rate recommended by dietitian.
d. Convert to interval feedings 48 hours after
desired continuous rate is achieved. Establish
interval feeding schedule by dividing 24-hour
volume into 6 feedings. Administer interval
feeding per feeding pump at 300 cc per hour
8. Gastric residual should be assessed
every 4 hours (see 2 under Precautions,
Considerations and Observations).
9. Dilute medications with 30 cc water and
administer a few minutes apart if patient is
taking more than 1 medication
Flush the feeding tube to clear formula and
medications from the tube and ensure
patency:
a. Flush with 50 cc tap water prior to
administration of medications or interval
feedings.
a. Flush with 50 cc tap water after
medication administration or interval
feedings.
c. Flush with 50 cc tap water every 4 hours
before hanging new formula with
continuous feeding.
d. The dietitian will make recommendations
for additional water requirements as
indicated.
specific intolerance problems: a.
Nausea, vomiting, fullness, or
cramping:
(1) Continuous feeding: stop feeding for 1
hour. Resume feeding at the last tolerated
rate for the next 12 hours and then
increase.
(2) Interval feeding: stop feeding and hold
until next scheduled feeding.
Heartburn:
• (1) Do not stop feeding.
• (2) Contact physician for antacid order
(preferably Maalox).
Flatulence:
• (1) Do not stop feeding.
• (2) Increase physical activity/ambulation.
Liquid stools (3 or more totaling
500 cc or greater per 24 hours):
(1) If diarrhea occurs within 48 hours after
feedings are initiated:
(a) Change to sterile water at 50 cc per hour for
12 hours, then resume formula feeding at 50
cc per hour and advance per protocol.
(b) If no improvement within 24 hours, consult
physician/dietitian for further
recommendations.
Liquid stools (3 or more totaling
500 cc or greater per 24 hours):
(2) If diarrhea occurs after 48 hours from initiation
of feedings, consult physician for antidiarrheal
medication:
(a) Imodium (loperamide) 4 mg initially, followed by
2 mg after each unformed stool (maximum 16
mg per day) or
(b) Lomotil (diphenoxylate with atropine sulfate) 5
mg, 3 to 4 times per day
(c) If no improvement within 24 to 48 hours,
consult physician/dietitian for further
recommendations.
• The most reliable indicator of proper tube
placement is a radiograph, followed by pH
and aspirate color, with auscultation a poor
fourth. Auscultation alone is unreliable;
sounds may be heard with lung
placement, as well as esophageal, gastric,
or intestinal placement
Check gastric residual if feeding
intolerance occurs
(nausea/fullness):
• a. Continuous feedings: (1) If residual is greater
than 2 hours of present rate, hold the feeding
and recheck in 1 hour. Resume feeding when
amount is less than 2 hours of present rate,
otherwise continue to check hourly. (2) When the
desired volume of feeding is achieved,
discontinue checking residual unless feeding
intolerance occurs.
Check gastric residual if feeding
intolerance occurs
(nausea/fullness):
• b. Interval feedings:
• (1) If more than 100 cc of the previous feeding is
aspirated, hold the feeding and recheck in 1
hour. If aspirate remains more than 100 cc, hold
feeding until next scheduled time. (2) When
residuals are less than 100 cc for 24 hours,
discontinue checking residual unless intolerance
occurs.
• Formula feedings should be out of refrigeration
no longer than 4 hours.
• 4. This procedure primarily pertains to gastric
feedings. For duodenal or jejunal feedings,
consult the dietitian to determine formula
selection and maintain continuous administration
rate.
• 5. If the patient is starting on interval feedings
and shows any signs of intolerance, consider
returning to continuous feedings.
• 6. Avoid stopping continuous feedings
during bathing, ambulation, or while
assisting patient to bathroom.
• 7. Consult physician and dietitian to
establish insulin dose and dietary
requirements for diabetic patients.
• 8. Surgical patients on tube feedings
should be weighed daily through
postoperative day 5, then 3 times a week.
• 9. Consult the dietitian for special
formulas, electrolyte imbalance,
signs/symptoms of dehydration or
intolerance to formula feedings.
• 10. Enteral feeding sets are changed
every 24 hours. Label with date and time
opened and the patient’s name.
• 11. Interval feeding bags should be rinsed
after each feeding.
• 12. Change enteral irrigation sets every 24
hours and change water in set every 8
hours.
• 13. Patients on enteral feedings will be
evaluated by the dietitian for free water
requirements, protein, and calorie needs.
• 14. If hypertonic formula is administered:
• a. Initiate half-strength formula at 25 cc
per hour. b. Increase strength every 12
hours until full strength is achieved (ie, half
strength, three-quarters strength, full
strength).
• c. After full strength is achieved, increase
rate 25 cc per hour every 12 hours until
desired rate is met.
• 15. If a patient has been taking a diet by mouth,
it is not necessary to initiate feeding with D5W.
• 16. If tube feedings are withheld for reasons
other than general anesthesia (eg, diagnostic
tests), full-strength feedings may be resumed
without the need for gradual progression of
feeding.
• 17. When a patient is discharged on tube
feedings, adjust schedule to 5 interval feedings
per day by gravity drip
Parenteral nutrition
• Intestinal failure = ‘A reduction in
functioning gut mass below the minimal
necessary for adequate digestion and
absorption of nutrients’
• Useful concept for assessing need for
TPN
• Can be given by either a peripheral or
central line
Indications for total parenteral
nutrition
• Absolute indications
– Enterocutaneous fistulae
• Relative indications
– Moderate or severe malnutrition
– Acute pancreatitis
– Abdominal sepsis
– Prolonged ileus
– Major trauma and burns
– Severe inflammatory bowel disease
Peripheral parenteral nutrition
• Hyperosmotic solution
• Significant problem with thrombophlebitis
• Need to change cannulas every 24- 48
hours
• No evidence to support it as a clinically
important therapy
• Composition - 12g nitrogen, 2000 Calories
Central parenteral nutrition
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Hyperosmolar, low pH and irritant to vessel walls
Typical feed contains the following in 2.5L
14g nitrogen as L amino acids
250g glucose
500 ml 20% lipid emulsion
100 mmol Na+
100 mmol K+
150 mmol Cl15 mmol Mg2+
13 mmol Ca2+
30 mmol PO420.4 mmol Zn2+
Water and fat soluble vitamins
Trace elements
Complications of subclavian and jugular
central venous lines
• 10% of central lines develop significant complications
• Problems of insertion
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Failure to cannulate
Pneumothorax
Haemothorax
Arterial puncture
Brachial plexus injury
Mediastinal haematoma
Thoracic duct injury
• Problems of care
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Line and systemic sepsis
Air embolus
Thrombosis
Catheter breakage
Monitoring of parenteral nutrition
• Feeding lines should only be used for that purpose
• Drugs and blood products should be given via separate
peripheral line
• 5% patients on TPN develop metabolic derangement
• Nutrition should be monitored:
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Clinically – Weight
Biochemically twice weekly
FBC, U+Es, LFTs,
Mg2+, Ca2+, PO42-, Zn2+
Nitrogen balance
• Blood cultures on any sign of sepsis
Metabolic complications of parenteral
nutrition
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Hyponatraemia
Hypokalaemia
Hyperchloraemia
Trace element and folate deficiency
Deranged LFTs
Linoleic acid deficiency
Approximate indications for an 80 kg patient
after surgery
• Dosage: 25 - 30 kcal/kg KG/day
• Polytrauma, sepsis, Burns < 40% :
30 - 35kcal/kg/day
Polytrauma with complications, prolonged
sepsis, Burns > 40%
: 35 - 45 kcal/kg/day