Nutrition in Surgical Patients

1. Nutrition in Surgical Patients Nicky Wyer MSc, RD Senior Specialist Dietitian UHCW Nutrition Support Team

2. Areas to cover • Malnutrition and the surgical patient • Identifying patients at risk • ERAS – Nutritional aspects • Routes for nutrition support • Refeeding syndrome

4. Malnutrition does it matter? A malnourished patient will have 3 times the number of complications and 4 times the risk of death from the same surgery compared to a well nourished patient (NICE 2006)

5. There is no universally accepted definition of malnutrition but the following is increasingly being used from RCP 2002: A state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome Definition of Malnutrition ‘Malnutrition’ refers to both under and over-nutrition (but more commonly used for under-nutrition)

6. Under-recognised & under-treated 80% of this expenditure was in England The Extent of ‘The Problem’ [1] Estimated > 3 million people in the UK are at risk of malnutrition at any one time (Elia & Russell, 2009) Public health expenditure on disease-related malnutrition in the UK (2007) > 13 billion per annum (Elia & Russell, 2009) 40% of adult hospital patients are overtly malnourished on admission. 8% categorised as severe.

7. Elderly Chronic ill-health e.g. diabetes, renal, COPD, neuro Cancer Deprivation / poverty GI disorders / post GI surgery Alcoholics Drug Dependency Patients with Altered Nutritional Requirements: Critical care Sepsis Cancer Trauma Surgery Renal Failure Liver Disease GI & pancreatic disorders COPD Pregnancy Who’s at risk?

8. Psychiatric Anhedonia Depression Confusion Anorexia Effects of Undernutrition Renal Reduced Na & H2O excretion Hepatic Fatty Liver Necrosis/ Fibrosis Immunity Increased infection risk Impaired wound healing Cardiac Reduced cardiac output CCF Gut Reduced immunity Reduced integrity Oedema Other Reduced muscle strength Neurological weakness Inability to regulate temperature Respiratory Decreased tidal volumes Reduced muscle bulk Loss of adaptive response to hypoxia ?Micronutrient deficiency

9. ESPEN guidelines for enteral nutrition in surgery • Patients who are significantly malnourished and are due to undergo major surgery should be considered for preoperative nutrition support, this may involve tube feeding for 10-14 days pre-op (ESPEN 2006) • Oral intake should be resumed as soon as possible after surgery, usually within 24hrs, with monitoring • Enteral tube feeding should be given without delay post op for any patient who it is anticipated will be unable to eat for > 7days and for patients who cannot maintain oral intake >60% requirements for >10 days • PN should be reserved for malnourished patients who cannot be fed via the GIT for at least 7 days

10. Nutritional requirements • Typically quoted as 25 – 30kcal / kg calories however Dietitian will assess patients individual needs • Calorie requirements affected by: • Age, Gender, Activity level, Weight, • Degree of stress associated with surgery • Calorific intake from other sources e.g. propofol in ITU

11. Identification: Nutrition Screening

12. Sometimes we miss the obvious

13. Albumin Commonly used by the medical profession as a marker for nutritional state Albumin is not a marker for nutrition Albumin indicates disease state not nutrition Poor nutritional state can coexist with illness but albumin does not indicate malnutrition No single biochemical marker can be used to assess nutrition

14. David Blaine Fast for 44 days He lost 25.5Kg(26.6%) At end BMI = 21.6Kgm-2 Albumin 52.9 gl-1

15. Fashion model BMI = 11.5 Kgm-2 Albumin = 38 gl-1

16. Common Least Common Other causes of Low Albumin • Sepsis - CRP; ALB • Acute & Chronic inflammatory conditions • Cirrhosis/ Liver disease • Nephrotic syndrome • Malabsorption • Malnutrition Hypoalbuminaemia is an important prognostic indicator. The lower the level, the higher the mortality

17. Pre-operative fasting • Typically patients NBM from midnight prior to surgery. Advocated to ensure an empty stomach to  risk of aspiration • ESPEN (2006) and NICE (2006): Safe for patients to eat up to 6 hours prior to surgery and drink fluids up to 2 hours prior to surgery (grade A evidence) • This  the need for IV fluids which helps prevent post op fluid and salt overload which adversely affects the GIT tract and ability to mobilise (Powell-Tuck 2011)

18. Surgery & Fasting Catabolism Insulin resistance Hyperglycaemia Loss of fat & muscle stores

19. Components of the ERAS multimodal care pathway http://www.erassociety.org/index.php/eras-care-system/eras-protocol

20. Preoperative carb loading • preOp (Nutricia) and preload (Vitaflo) • 4 x 200ml evening pre surgery, 2 x 200ml up to 2hrs pre anaesthesia. 100kcal, 25g (4.2g sugar) carbohydrate per carton • Creates a non starved metabolism • Moderates metabolic response to surgery

21. Pre op carbohydrate loading • Decreased catabolism • Decreased hyperglycaemia • Preserved muscle mass • Improved grip strength • Reduced LOS • Reduced Anxiety

22. Elective Emergency Nutrition screen on admission Nutrition screening in OPC +/-ERAS protocol High Risk Low Risk High Risk Low Risk Post operative nutrition support Rescreen weekly Pre-op nutrition support & goal setting

23. Options for nutrition support • Oral nutrition support • Enteral tube feeding • Nasogastric • Nasojejunal • PEG / RIG • Jejunostomy • Parenteral feeding Aim for the least invasive method required to achieve goals

24. Oral nutrition support • High calorie, high protein diet • Snacks, puddings • Majority of patients can resume a normal diet within hours of surgery • Avoid unnecessary restrictions

25. Oral nutritional supplements • Not all the same! • Patient preferences key • Consideration should be given to what product best addresses the identified nutritional deficiencies prior to prescribing • Co-morbidities will also affect choice e.g. CMP allergy, diabetes, fat malabsorption, renal disease, coeliac disease • Ongoing monitoring of patients is essential to establish when nutritional goals have been met and nutritional support can be stopped • Not all patients need supplements forever!!

26. Addressing symptoms • Nausea / vomiting: anti emetics, prokinetics, dilatation, ensuring bowels opening • Pain: analgesia • Constipation: laxatives, enemas • Swallowing: SALTx, altered consistency diet/fluids

27. Puree diet example Breakfast: Porridge & Cup of tea (all) Mid Morning: Cup of Coffee & Squash Lunch: Beef Casserole meal (all) Crème Caramel (all) Orange Juice Mid Afternoon: Squash Evening Meal: Salmon Bake Meal (all) Raspberry Mousse (all) Squash Supper: Cup of tea What do you think of this intake??

28. Puree diet example Total: 1270kcal 52.5g protein 1135ml fluid This will be inadequate for most post operative patients Be aware that patients can have difficulty achieving adequate intakes on altered consistency diet and fluid as choices are more limited and less nutrient rich Require additional snacks or puddings and many require oral nutritional supplements when on this texture

29. Enteral feeding • Enteral feeding refers to the delivery of nutritionally complete feed containing protein, carbohydrate, fat, water, minerals and vitamins directly into the stomach, duodenum or jejunum. NICE 2006

30. Enteral feeding For those unable to take orally for >7 days or are unable to take sufficient amounts (>60%) and for whom more invasive nutritional support is an appropriate part of the treatment plan ESPEN 2006 • Polymeric feeds first line, reflects normal dietary intake • Specialist feeds for use in certain conditions e.g. renal, malabsorption, sodium or fluid restriction • Various “core” feeds available • fibre and fibre free versions • 0.8-2kcal / ml • Nutritionally complete in set amount of calories • Gluten & lactose free majority of products • Contain milk protein except Soya based feeds • Vegetarian issue – carminic acid – in ONS, fish oils. • Depends on company / product used, Dietitian will advise

31. Nasogastric - indications • Patients at high risk of aspiration, swallowing problems, unconscious. • Supplementary to oral nutrition – poor appetite, increased nutritional requirements. • Supplementary to parenteral nutrition.

32. Nasal Bridal • A nasal bridal is a device to secure a NG or NJ tube to the nasal septum • 2 high grade magnets are inserted via each nostril these connect around the nasal septum allowing the looping of a thin strip of gauze/tape around the nasal septum which is then fixed to the NG / NJ tube with a clip.

33. Gastrostomy feeding • The placement of a tube through the abdominal wall directly into the stomach for either temporary or permanent delivery of enteral feed (Payne-James et al 2001). • PEG, RIG, Surgical gastrostomy – be clear on what type of tube it is • Head & Neck cancer

34. Indications / contraindications Indications • Long term nutrition support required • Swallowing impairment Contraindications Absolute • Total gastrectomy • Portal hypertension with gastric varices Relative • Unfit for procedure • Partial gastrectomy • PD • Ascites • Active gastric ulcer

35. Jejunal Feeding Placement of a tube into the small bowel, either via the nasal cavity (NJ), surgically placed (surgical jejunostomy), or occasionally via PEG tube (PEJ). It is a method of feeding patients who are unable to maintain or improve their nutritional status by oral intake and in whom gastric feeding is contraindicated or has been unsuccessful.

36. Indications for jejunal feeding • Previously documented gastroparesis • Gastric stasis due to paralysing agents required for ventilation • Persisting delayed gastric emptying despite medical management • Severe acute pancreatitis • Upper GI surgery • Pancreatic or duodenal injury • Hepato-biliary surgery • Cancer of the oesophagus or stomach where NG or gastrostomy feeding is inappropriate • Upper GI fistula

37. Complications of EN Nausea and vomiting Abdominal distension Diarrhoea Constipation Oesophagitis Aspiration Blocked tube Complications during tube insertion

38. Parenteral nutrition (PN) • Administration of nutrients, fluids and electrolytes directly into a central or peripheral vein • Traditionally associated with  complications • However PN used appropriately, with close attention to glycaemic control and avoidance of overfeeding can safely deliver adequate nutrition

39. Who needs it? • Patients who are malnourished or who are likely to become malnourished and where the GI tract is not fully functional or is inaccessible (NICE 2006) • PN anticipated to be needed >7/7 • TPN should be avoided where aggressive nutritional support not indicated or where the risks outweigh the benefits

40. If the gut works, use it! If the gut works a little, use it a little

41. Indications • Short bowel syndrome • Prolonged paralytic ileus (>7/7) • Bowel obstruction or pseudo-obstruction • Motility disorders e.g. scleroderma • Gastrointestinal fistulae • Adhesions • Anastamotic leak • Radiation gastroenteritis • Mucositis, oesophagitis or intractable vomiting secondary to chemotherapy • Severe acute inflammatory bowel disease • GI perforation • Severe acute pancreatitis • Post op extensive bowel surgery

42. Parenteral Nutrition • Bags made up by aseptic lab • Mixture of glucose, lipid, amino acids, electrolytes, fluid, vitamins, minerals and trace elements • Modifications can be made if clinically indicated • If EN commences can reduce PN gradually as EN increases

43. Refeeding syndrome • Patients who have had a prolonged period with little/no nutrition >10/7, low BMI, >10% unintentional wt loss, electrolyte disturbances, alcoholics pose risk of refeeding syndrome when any feeding commenced • Severe electrolyte & metabolic abnormalities can occur as a result of feeding but difficult to separate from abnormalities associated with critical illness • Prevent by slow feeding, vitamin supplementation and electrolyte correction • Ensure patients are assessed by a dietitian to ascertain risk level and appropriate plan is made

44. Pathophysiology of refeeding

45. Conclusion • Malnutrition significantly affects outcomes from surgery • Identification of malnourished patients enables appropriate treatments to be initiated to promote the rapid recovery and discharge of surgical patients • Increasing use of ERAS protocols and cessation of prolonged fasting pre-op improves outcomes • Nutrition support should be provided for patients identified at risk of malnutrition from nutrition screening aiming for the least invasive route

46. References • Anderson MR, O’Connor M, Mayer P, O’Mahony D, Woodward J, Kane,K. (2003). The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high- risk dysphagia stroke patients. Clinical Nutrition. Vol 23. No 4 • ERAS society guidelines (joint publications with ESPEN): http://www.erassociety.org/index.php/eras-guidelines • ESPEN (2006). Guidelines on enteral nutrition: surgery including organ transplantation. Clinical Nutrition 25: 224 – 244 • ESPEN (2009). Guidelines on parenteral nutrition: surgery. Clinical Nutrition 28: 378 - 386 • Gustafsson UO, Nygren J, Thorell A, Soop M, Hellström PM, Ljungqvist O, Hagström-Toft E. (2008). Pre-operative carbohydrate loading on postoperative hyperglycaemia in hip fracture patients: A randomised control clinical study. ActaAnaesthesiol Scand. 2008 Aug;52(7):946-51 • NICE (2006) Nutrition Support in Adults: oral supplements, enteral and parenteral feeding. NICE • Powell-Tuck et al. (2011) British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP). BAPEN