Nutrition care plan for surgical patients

1. Nutrition care plan for surgical patients Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training

2. Objectives • To discuss the process of nutrition management of surgical patients • To discuss the role of the nutrition team

3. NUTRITION CARE PLAN FORMULATION

4. The surgical nutrition process All admitted patients are nutritionally screened All nutritionally at risk patients are assessed All high risk patients are given nutrition care plans Monitoring of the nutrition process is done Nutrition care plan modification / Discharge

5. Nutrition Care Plan Form

6. Nutritional status • Severely malnourished? • Feeding access? Oral, GIT, parenteral, combinations • Need to build up before surgery? • Is there a need for special nutrients?

7. PRE-OPERATIVE PHASE • Scheduled • esophageal resection • gastrectomy • pancreaticoduodenectomy malnutrition no slight, moderate severe oral immunonutrition for 6-7 days Enteral nutrition for 10-14 days SURGERY Early oral feeding within 7 days POST-OP EARLY DAY 1 - 14 Enteral access (NCJ) no yes within 4 days enteral nutrition immunonutrition for 6-7 days Oral intake of energy requirements yes no yes no “Fast Track” Parenteral hypocaloric combined enteral / parenteral Adequate calorie intake within 14 days Oral intake of energy requirements LATE DAY 14 yes no supplemental enteral diet yes no

8. Surgical nutrition pathways: Pre-operative phase Nutritional Assessment Condition: When oral or enteral feeding not possible Normal to moderate malnutrition Severe Malnutrition • Esophageal resection • Gastrectomy • Pancreaticoduodenectomy Parenteral nutrition + Omega-3-Fatty Acids + Antioxidants (+ glutamine); 6-7 days SURGERY ESPEN Guidelines on Parenteral Nutrition (2009)

9. Surgical nutrition pathways:Intra & Post-operative Period While in the OR ask yourself: “is oral feeding possible within 7 days?” Yes No Can I feed within 4 days? Needle catheter jejunostomy • Enteral nutrition (12 hrs) • Better: immunonutrition Yes No If enteral nutrition is inadequate “Fast Track” PN Transition Supplemental PN ESPEN Guidelines on Enteral Nutrition (2006) and Parenteral Nutrition (2009)

10. Nutrition Care Plan Physician, Dietitian, Pharmacist

11. Total calorie and protein requirement • Guidelines: • Nutritional status – if severely malnourished • Calories: 20 to 30 kcal/kg body weight • Use actual body weight if not obese • Capacity to undergo surgery • Normal or low malnutrition level: immediate surgery

12. Non-protein calories • Ratio of glucose to lipid content • Issue regarding type of lipids • Saturated vs. unsaturated • Long chain vs. medium chain triglycerides • Omega-3 vs. omega-6 PUFA, how about omega-9?

13. Micronutrients • Electrolytes • Laboratory values • Drug-nutrient interactions • Vitamins • Water and fat soluble vitamins • Trace elements

14. Nutrition Care Plan Physician, Dietitian, Pharmacist Physician, Nurse Nurse, Dietitian, Pharmacist Nurse, Dietitian, Physician, Pharmacist

15. Formulation • Oral supplementation • Enteral nutrition • Standard vs. special nutrition • Supplemental vs. meal replacement • Issue of blenderized diets • Parenteral nutrition • Supplemental vs. total PN • Need to include micronutrients in all solutions • Special nutrients (e.g. pharmaconutrition)

16. Enteral nutrition issues Gallagher-Alfred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50 Sullivan MM, et al. J Hosp Infect 2001;49:268-273

17. Pharmaconutrition Maximum effect when given at the proper dose

18. Access and delivery • Enteral: • Short term vs. long term • need for enteral pumps • Parenteral • Peripheral vs. central • Single or multiple lumen catheters • Protocols for maintenance

19. The surgical nutrition process All admitted patients are nutritionally screened All nutritionally at risk patients are assessed All high risk patients are given nutrition care plans Monitoring of the nutrition process is done Nutrition care plan modification / Discharge

20. The team performs the calorie count and fluid balance The fluid, calorie, and protein intake are recorded and adequacy of intake is recorded in the patient’s chart Monitoring issues

21. Calorie, protein, fluid balance form

22. Nutrient monitor form

23. How to implement • Monitoring: everyone is involved

24. Monitoring • Fluid balance – avoid fluid accumulation within 4-5 days post op • Calorie balance • Gastric retention for enteral nutrition • Blood tests: • BUN high – dialyze • High triglycerides – lower lipid flow • Hyperglycemia – insulin • Weight once a week Jan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003

25. Nutrition Team Diagnosis Management Overall plan Screening Enteral nutrition Parenteral nutrition Monitoring Enteral nutrition Monitoring Parenteral nutrition Monitoring

26. NST activity Policies and guidelines compiled and updated Patient rounds regular like 3x a week • difficult cases • coordination issues NST meeting Reports on outcome monthly, yearly Updates from other studies regular

27. NST activity/documentation • malnutrition rate • underweight / obese • severe weight loss Screened and assessed patients • severely malnourished • poor intake • effect of nutrition care: • calorie count • outcome: • morbidity • mortality • nutraceuticals • other interventions • “At Risk” patients • critically ill • elderly • stroke • cancer • post-op complications • suggestions • nutrition care • fluid balance • access • formulation • carried out?

28. Outcomes of adequate intake

29. Adequate intake in surgery patients Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, 2008.

30. Thank you