Nutrition Assessment and Post-Surgical Advancement

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Nutrition Assessment and Post-Surgical
Advancement

• Rebecca Cohen, MS, RD, LDN
• Transplant Dietitian
• Tulane Transplant Institute

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Nutrition and Surgery

• Reported 40 incidence of malnutrition in acute
  hospital setting
• 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.

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Normal Nutrition (EatRight.org)
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The Newest Food Guide

• Teaches ? 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 and food tracker

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Carbohydrates

• Limited storage capacity, needed for CNS
  (glucose) function
• Yields 3.4 kcal/gm
• Recommended 45-65 of total caloric intake
• Simple vs Complex

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Fats

• Major endogenous fuel source in healthy adults
• Yields 9 kcal/gm
• Too little can lead to essential fatty acid
  (linoleic acid) deficiency and increased risk of
  infections
• Recommended 20-30 of total caloric intake

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Protein

• Needed to maintain anabolic state (match
  catabolism)
• Yields 4 kcal/gm
• Must adjust in patients with renal and hepatic
  failure
• Recommended 10-35 of total caloric intake

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Normal Nutrition Requirements

• HEALTHLY male/female
• Caloric intake 25-30 kcal/kg/day
• Protein intake 0.8-1gm/kg/day (max150gm/day)
• Fluid intake 30 ml/kg/day

Unless medical state warrants fluid restriction
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Reasons for Malnutrition

• Inadequate nutritional intake
• Metabolic response
• Nutrient losses
• Protein/energy store depletion
• Prevalence of ileus, anorexia, malabsorption
• Extraordinary stressors (surgical stress,
  hypovolemia, bacteremia, medications)
• Wound healing
• Anabolic state
• May require appropriate vitamins

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Nutrition Comparison
SURGERY PATIENT Caloric intake Mild
stress 25-30 kcal/kg/day Moderate
stress 30-35 kcal/kg/day Severe stress 30-40
kcal/kg/day Protein intake 1-2 gm/kg/day Fluid
intake INDIVIDUALIZED
HEALTHLY 70 kg MALE Caloric intake 25-30
kcal/kg/day Protein intake 0.8-1gm/kg/day Fluid
intake 30 ml/kg/day
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Albumin

• Synthesized in and catabolized by the liver
• Normal range 3.5-5 g/dL
• Half-life 20 days

Pros Cons
Ranked as the strongest predictor of surgical outcomes Lack of specificity due to long half-life
Inverse relationship between postoperative morbidity and mortality compared with preoperative serum albumin levels Not accurate in pts with liver disease (elevated Tbili) or during inflammatory response (elevated WBC or CRP)
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Prealbumin

• Synthesized by the liver and partly catabolized
  by the kidneys
• Normal range16-40 mg/dL
• Values of lt16 mg/dL are associated with
  malnutrition
• Half-life 2-3 days

Pros Cons
Shorter half life than albumin More expensive than albumin
More favorable marker of acute change in nutritional status (compared to albumin) Levels may be increased in the setting of renal dysfunction, corticosteroid therapy, or dehydration
A baseline prealbumin is useful as part of the initial nutritional assessment if routine monitoring is planned Over-hydration can decrease prealbumin levels result in false negative
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Nitrogen Balance

• Measures net changes in body protein mass
• Nitrogen Balance protein intake (gm) - (UUN 4)
  
• 6.25
• Healthy individuals nitrogen balance (-1 to 1)

Positive Value Negative Value
Found during periods of growth, tissue repair, or pregnancy Associated with burns, fevers, wasting diseases and other serious injuries, during periods of fasting
Intake of nitrogen into the body is greater than the loss of nitrogen from the body Amount of nitrogen excreted from the body is greater than nitrogen intake
Increase in the total body pool of protein Often seen following major surgery Patient will likely require extra protein for tissue building
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Postoperative Diet Advancement

• Delay feeds for 24-48 hours until bowel sounds
  function return
• Begin with clear liquids
• Supply fluids and electrolytes
• Require minimal digestion and stimulation of GI
  tract
• Intended for short-term use due to inadequacy of
  nutritional needs

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Clear Liquid Diet

• Acceptable food items
• Water (plain, carbonated or flavored)
• Fruit juices without pulp, such as apple or white
  grape
• Fruit-flavored beverages, such as fruit punch or
  lemonade
• Plain gelatin
• Tea or coffee without milk or cream
• Strained tomato or vegetable juice
• Sports drinks
• Clear, fat-free broth
• Hard candy, such as lemon drops or peppermint
  rounds
• Ice pops without milk, bits of fruit, seeds or
  nuts (except red)

http//www.mayoclinic.org/healthy-living/nutrition
-and-healthy-eating/in-depth/clear-liquid-diet/art
-20048505
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Diet Advancement cont.

• Advance diet to full liquids
• Middle step
• Meet daily calorie and protein needs
• Acceptable food items
• Coffee, tea, cream, carbonated beverages
• Fruit and vegetable juices
• Milk Milkshakes
• Nutritional supplements
• Custard-style yogurt, pudding, custard
• Plain ice cream, sherbet, sorbet
• Jell-o (any flavor)
• Cream soups, strained, cream of wheat, cream of
  rice, grits
• Pureed soups Tomato puree
• Gravy, margarine
• Sugar, syrup, jelly, honey

http//www.upmc.com/patients-visitors/education/nu
trition/pages/full-liquid-diet-facts.aspx
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Diet Advancement cont.

• Advance diet to solid foods
• Appropriate to introduce solids as soon as the GI
  tract is functioning liquids are tolerated
• Diets available
• Regular
• Pediatric
• Heart healthy
• ADA/Diabetic
• Renal
• Low sodium (2 gm)
• Bland/Soft/Low residue

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Key considerations

• Condition of the GI tract
• Disease state
• Complications that may have resulted from surgery
• Ex diabetes in a post-kidney transplant patient.
  Why?
• For liquid diets, patients must have adequate
  swallowing functions, as determined by SLP
• Mechanical soft
• Pureed
• Thicken liquids
• Must be specific in writing liquid diet orders
  for patients with dysphagia

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Nutrition Support Options

• Length of time a patient can remain NPO without
  complications is unknown
• Tulane Protocol NPO gt 4 days
• Two types of nutritional support
• Enteral
• Parenteral

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Enteral Nutrition

• Liquid mixture designed to meet nutrient needs
• Goal rates are individidualized
• Given through a tube in the stomach or small
  intestine
• Nasogastric tube
• Nasoduodenal tube
• Nasojejunal tube
• Gastrostomy/Jejunostomy
• Continuous or Bolus feeds
• Specialized formulas for select disease states
• Glucerna
• Suplena
• Nepro
• Elemental formulas

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Indications Contraindications
Functioning GI tract Severe acute pancreatitis
Adaptive phase of short bowel syndrome High output enteric fistula distal to feeding tube
Following severe trauma or burns Inability to gain access
Intractable vomiting or diarrhea
Aggressive therapy not warranted
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Gastric vs. Small Bowel

• If you dont use it, you lose it.
• Indications to consider small bowel access
• Gastroparesis
• Recent abdominal surgery
• Sepsis
• Significant gastroesophageal reflux (GERD)
• Aspiration risk
• Mild ileus
• Proximal enteric fistula or obstruction

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Short-term vs Long-term

• No standard of care for cut-off time between
  short-term and long-term access
• Long-term access should be considered if the
  patient is expected to require nutrition support
  longer than 6-8 weeks
• NG tubes can be used for long term enteral
  nutrition
• However, complications can include
• Non-elective extubation
• Tube misplacement
• Occasional need to check position of the tube

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Choosing Appropriate Formulas
Polymeric Monomeric/elemental Disease specific
Basic Info Uses whole proteins as nitrogen source Predigested nutrients most have a low fat content or high of MCT Specific formulas for Respiratory disease Diabetes Renal failure Hepatic failure Immune compromise
Consider for patients with Normal or near normal GI function Impaired GI function Specific disease states
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Tulane Enteral Nutrition Product Formulary
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Enteral Nutrition Guidelines

• Gastric feeding
• Small bowel feeding
• Continuous feeding only do not bolus due to risk
  of dumping syndrome
• Start slowly _at_ 20 mL/hour
• Advance in increments of 20 mL q 8 hours to goal
• Do not check gastric residuals

Continuous feeding Bolus feeding
Start at rate 30 mL/hour Advance in increments of 20 mL q 8 hours to goal Check gastric residuals q 4 hour Start with 120 mL bolus Increase by 60 mL q bolus to goal volume Every 3-8 hours
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Complications of Enteral Nutrition Support

• Access
• Administration
• GI complications
• Metabolic complications

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Enteral Nutrition Case Study

• 78-year-old woman admitted with new CVA
• Significant aspiration detected on bedside
  swallow evaluation
• SLP recommends strict NPO with alternate means of
  nutrition
• PEG placed for long-term feeding access
• Plan stabilize the patient and transfer her to a
  long-term care facility for rehabilitation

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Enteral Nutrition Case Study (continued)

• Height 54
• Weight 130 / 59kg BMI 22
• IBW 120 /- 10
• Usual weight 130
• Estimated needs
• Calories?
• Protein?
• Fluid?

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Enteral Nutrition Prescription

• Jevity 1.2 (via PEG)
• Initiate at 30 mL/hour, advance by 20 mL q 8
  hours to goal
• Goal rate 55 mL/hour
• 1584 kcal
• 73g protein
• 1069 mL free H2O, additional 515mL needed
• Check residuals q 4 hours
• hold feeds for residual gt 200 mL
• Aspiration precautions

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What is parenteral nutrition?

• It is a special liquid mixture given into the
  blood via a catheter in a vein
• Contains all the, carbohydrates, protein, fat,
  vitamins, minerals, and other nutrients needed
• Light sensitive, always covered in a light
  resistant bag

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Indications for TPN

• Two criteria, need both
• Malnourished patient expected to be unable to eat
  gt 5-7 days
• Failed enteral nutrition trial per SLP
• Appropriate tube placement
• EN is contraindicated or severe GI dysfunction is
  present
• Ex paralytic ileus, mesenteric ischemia, small
  bowel obstruction, enteric fistula distal to
  enteral access sites

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TPN (total parenteral nutrition) PPN (peripheral parenteral nutrition)
High glucose concentration (15-25 final dextrose concentration) Similar nutrient components as TPN, but lower concentration (5-10 final dextrose concentration)
Provides a hyperosmolar formulation (1300-1800 mOsm/L) Osmolarity lt 900 mOsm/L (maximum tolerated by a peripheral vein)
Must be delivered into a large-diameter vein May be delivered into a peripheral vein
Large fluid volumes needed to meet same calorie and protein dose as TPN (because lower in concentration)
Often used with other MNT and for a short period of time
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Parenteral Access Devices

• Peripheral venous access
• Catheter placed percutaneouly into a peripheral
  vessel
• Central venous access (catheter tip in SVC)
• Percutaneous jugular, femoral, or subclavian
  catheter
• Implanted ports (surgically placed)
• PICC (peripherally inserted central catheter)

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Writing TPN prescriptions

• Determine total volume of formulation based on
  individual patient fluid needs
• Determine amino acid content
• Determine dextrose content
• Determine lipid content
• Check to make sure desired formulation will fit
  in the total volume indicated

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Tulane TPN Order Form
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Parenteral Nutrition Monitoring

• Check electrolytes daily and adjust TPN/PPN
  additives accordingly
• Check accu-check glucose q 6 hours
• Check triglyceride level within 24 hours of
  starting TPN/PPN and weekly while patient remains
  on it

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Parenteral Nutrition Monitoring (continued)

• Check LFTs weekly
• Check pre-albumin weekly
• Acid/base balance
• Increase/decrease chloride as needed
• Bicarbonate is unstable in TPN/PPN prep
• Precursoracetateis used

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Complications of TPN/PPN

• Hepatic steatosis
• Usually benign in patients on short-term PN
• Resolves in 10-15 days
• Limiting fat content of PN to control steatosis
  in long-term use

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Complications of TPN/PPN (continued)

• Cholestasis
• Due to no intestinal nutrients to stimulate
  hepatic bile flow
• Gastrointestinal atrophy
• Trophic enteral feeding to minimize/prevent GI
  atrophy

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TPN/PPN Case Study

• 55-year-old male admitted with small bowel
  obstruction
• Complicated cholecystecomy 1 month ago. Since,
  poor po intake and 20 weight loss
• NPO for 3 days since admit?right subclavian
  central line was placed
• Plan start TPN since patient is expected to be
  NPO for at least 1-2 weeks

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TPN/PPN Case Study(continued)

• Height 60
• Weight 155 / 70kg BMI 21
• IBW 178 /- 10
• Usual wt 175
• Estimated needs
• Calories?
• Protein?
• Fluid?

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TPN/PPN Prescription

• Amino acid 4.5 (or 45 g/liter)
• Dextrose 17.5 (or 175 g/liter)
• Lipid 20 285 mL over 24 hours
• 2120 kcal, 90g protein (2 liters/24 hrs)
• GIR 3.5 mg/kg/minute

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Enteral Nutrition gt Parenteral Nutrition
Enteral Parenteral
Cost 10-20 per day 100 or more per day
Gut Preserves intestinal function May be associated with gut atrophy
Infection Very small risk of infection High risk/incidence of infection and sepsis
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Miscellaneous Thoughts

• Transitional feeds
• PN?EN
• PN/EN? oral feeds
• Refeeding syndrome
• Caused by intracellular movement when energy is
  provided after a period of starvation (usually gt
  7-10 days)
• Hypomagnesaemia, hypokalemia, hypophosphatemia
• Close monitoring of electrolytes
• Initiate feeds slowly, work towards goal rate

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Miscellaneous Thoughts
Under-feeding Over-feeding
Depressed ventilatory drive Hyperglycemia
Decreased respiratory muscle function Hepatic dysfunction from fatty infiltration
Impaired immune function Respiratory acidosis from increased CO2 production
Increased infection Difficulty weaning from the ventilator
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Questions

• Contact Information
• Rebecca Cohen, MS, RD, LDN
• Transplant Dietitian, Tulane Transplant Institute
• [phone]
• Rebecca.Cohen_at_hcahealthcare.com

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• 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, Dec88(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 July222(1)73-7.
• Ross, R. Micronutrient recommendations for wound
  healing. Support Line. 2004(4) 4.
• Krauses 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.