Nutrition

Question 1

Indications for parenteral nutrition

Answer 1

• Prolonged obstruction or ileus (>7d)
• High output fistula
• Short bowel syndrome
• Severe Crohn’s
• Severe malnutrition
• Severe pancreatitis
• Unable to swallow: e.g. oesophageal Ca

Question 2

Nutrition screening

Answer 2

MUST - malnutrition universal screening tool

Question 3

MUST

Answer 3

Low risk - 0 - monitor weekly
Medium risk - 1 - monitor 3 days
High risk - 2 + - refer to dietician

Takes into account:

• BMI
• Unplanned weight loss
• Current intake

Question 4

When to refer to a dietician

Answer 4

NBM for 3+ days 
Pressure ulcer grade 2+ 
Pt request 
Haemodialysis 
TPN

Question 5

Refeeding syndrome

Answer 5

Decreased carb intake → catabolic state with less insulin, fat and protein
catabolism and depletion of intracellular phosphate

• Refeeding → increased insulin in response to carbs and increases cellular PO4 uptake.
• Hypophosphataemia
• Rhabdomyolysis
• Respiratory insufficiency
• Arrhythmias
• Shock
• Seizures

• Enzymes are down regulated so ammonia not sufficiently metabolised causing toxicity

Question 6

Physiological stress effect

Answer 6

Hyper-metabolic state and catabolic response

Question 7

Assessment

Answer 7

All patients admitted to hospital should be screened for malnutrition and have their nutritional state assessed - MUST

Question 8

Nasogastric tube feeding (NGT)

Answer 8

If unable to take sufficient calories orally or dysfunctional swallow

Question 9

Gastrostomy feeding

Answer 9

If oesophagus blocked/dysfunctional

Question 10

Jejunal feeding (jejunostomy)

Answer 10

If stomach inaccessible or outflow obstruction

Question 11

Parenteral nutrition

Answer 11

If jejunum inaccessible or intestinal failure (IF)

Question 12

Should surgery be delayed to optimise nutrition first

Answer 12

No

Question 13

SNAP

Answer 13

Sepsis – Overwhelming infection present must be corrected otherwise feeding will be largely useless

Nutrition – Once the infection is corrected, suitable nutritional support should be provided

Anatomy – Define the anatomy of the GI tract so that surgery can be planned

Procedure – Definitive surgery SN&A

Question 14

Correcting albumin

Answer 14

Treat underlying cause not simply feeding patient more protein

Question 15

Enhanced Recovery After Surgery

Answer 15

• Reduction in ‘Nil By Mouth’ times (clear fluids up to 2 hours pre-surgery)
• Pre-operative carbohydrate loading
• Minimally invasive surgery
• Minimising the use of drains and nasogastric tubes
• Rapid reintroduction of feeding post-operatively
• Early mobilisation

Question 16

Entero-Cutaneous Fistulae

Answer 16

High fistula (jejunal) - may need support with enteral or parenteral nutrition

Low fistulae (ileum/colon) - low fibre diet

Question 17

High Output Stoma treatment factors

Answer 17

Distance From DJ Flexure to Jejunostomy

Distance From DJ Flexure to Colostomy

Question 18

How to reduce stoma output if infection and active disease is excluded (5)

Answer 18

1. Reduction in hypotonic fluids to 500ml/day
2. Reduction in gut motility with high dose loperamide and codeine phosphate
3. Reduction in secretions with high dose PPI bd
4. Use of WHO solution to reduce sodium losses
5. Low fibre diet to reduce intraluminal retention of water

Question 19

Where possible, which of the following feeding routes should be used to optimise a patient’s nutritional status pre-operatively?

Answer 19

Oral feeding