Peri-Operative and Post-Operative Care Flashcards
>25% of hospital inpatients may be malnourished
What ways may this have happened?
- Increased nutritional requirements
- (eg sepsis, burns, surgery)
- Increased nutritional losses
- (eg malabsorption, output from stoma)
- Decreased intake
- (eg dysphagia, nausea, sedation, coma)
- Effect of treatment
- (eg nausea, diarrhoea)
- Enforced starvation
- (eg prolonged periods nil by mouth)
- Missing meals through being whisked off, eg for investigations
- Difficulty with feeding
- (eg lost dentures; no one available to assist)
- Unappetizing food
>25% of hospital inpatients maybe malnourished
What should be asked in a Hx to establish this?
- recent weight loss,
- reduced intake,
- diet change,
- N&V,
- pain,
- diarrhoea
>25% of hospital inpatients maybe malnourished.
What maybe seen O/E of a patient who is malnouished/to check if they are?
- hydration,
- malnutrition
- skin hanging off muscles,
- not fat between fold of skin,
- hair rough & wiry,
- pressure sores,
- sores at corner of mouth,
- BMI <20,
- anthropomorphic indices (measurements to infer body composition, growth and development)
Although investigations into malnutrition are generally unhelpful what blood test maybe suggestive of malnutrition?
low albumin is suggestive
How can you prevent malnutrition in hospital?
assess nutrition & weight on admission & regularly after
- ensure meals are uninterrupted when possible
- provide appetizing food
- seek help from dietician
What is the name given to when nutrition is given into the GI tract and what methods of doing this are there?
enteral nutrition
- Nutrition PO where possible (all fluid diet can meet requirements),
- –> early post-op enteral nutrition has been shown to benefit patients & reduce complications
- Naso-enteric feeding:
- Nasogastric (NG - use when possible), naso-duodenal, naso-jejunal (NJ)
- Enterostomy feeding:
- Percutaneous endoscopic gastrostomy (PEG) - surgical opening through abdomen into stomach
- Percutaneous endoscopic jejunostomy (PEJ)
What type of feed is this?
undigested proteins, starched and long chain fatty acids
polymeric feed
What type of feed is this?
individual amino acids, oligo0 & monosaccharides needing minimal digestion
elemental feed
What are the benefits of enteral nutriton over parenteral?
Even if there is GI disease, studies show that enteral nutrition is
- safer,
- cheaper,
- and at least as efficacious
–>as parenteral nutrition in the perioperative period
What is the name given to (nutrition given IV via central venous line (or PICC line - peripherally inserted central catheter)?
When is this used?
parenteral nutrition
NOTE–> paraenteral nutrition has risks…
specialist advice vital; only considered if:
- Pt likely to become malnourished without it
- (i.e. GI tract not functioning e.g. bowel obstruction)
- & is unlikely to function for at least 7d
-
Supplementing other forms of nutrition
- (e.g. short gut syndrome, active Crohn’s)
- or used alone (TNP - total parenteral nutrition)
- Most regimens provide 2000kCal and 10-14g nitrogen in 2–3L
What complications of parenteral nutrition are there?
- Sepsis
- (staph epidermis/aureus, candida, pseudomonas, IE)
- Thrombosis
- (central vein thrombosis can result in PE or SVC obstruction)
- Metabolic imbalance:
- electrolyte abnormalities,
- deranged plasma glucose,
- hyperlipidaemia,
- deficiency syndromes,
- acid-base disturbance
- Mechanical:
- pneumothorax,
- embolism of IV line tip
What is the name of the syndrome that is basically a hypo-phosphataemic state?
& how does it occur
refeeding syndrome!
a life threatening metabolic complication of re-reeding (via ANY route) after a long period of starvation
Pathophysiology:
in starved state = catabolic and so body turns to fat and protein metabolism which means there is decreased circulating insulin and stores of phosphate (serum levels normal)
then when there is refeeding –> increased carbohydrate load so there is increased insulin and cellular intake of phosphate –> <0.5mmol/L within 4d
Refeeding = at risk of, rhabdomyolysis, red & white cell dysfunciton, resp insufficiency, arrhythmias, cardiogenic shock, seizures, sudden death…
who is at risk of hypo-phosphataemic state/refeeding syndrome?
how can you prevent this?
- cancer pts
- anorexia
- alcoholics
- GI surgery
- starvation
To prevent re-feeding syndrome: ID at-risk patients, monitor during re-feeding - check their glucose (as will drop with increased insulin), lipids, na, k phos, ca, mg, zn. Involve a nutritionist
What is the rx of re-feeding syndrome?
parenteral phosphate administration
e. g. 18mmol/d + oral supplementation
* [as pathophysiology of refeeding = STARVED STATE: i.e. catabolic state, body turns to fat & protein metabolism → ↓circulating insulin & ↓stores of phosphate (serum levels normal) –> REFEEDING: ↑carbohydrate load → ↑insulin & ↑cellular uptake of phosphate, hypo-physophataemic state (<0.5mmol/L) (within 4d)]*
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much na/k/cl do you need per day?
1 mmol each
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much energy do you need per day?
2000-2500kCal/d
or 20-40kCal/kg/d
(if over 4000 then => fatty liver)
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much nitrogen do you need per day?
0.2-0.4g
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much protein do you need per day?
0.5g
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much fat do you need per day?
3g
