Perioperative Care - ERAS and nutrition in surgical patient Flashcards
Nutrition in the surg
Gatric cancer? How would they present?
- Haematemesis
- Early satiety
- Upper GI meleana
- Low Hb (anaemic)
- Iron Deficieny anaemia
- GORD
- Weight loss- Unintentional weight loss - Significant
- Upper GI discomfort
What are the ALARM symptoms ?
What are the ALARM signs for red flags for upper GI?
- 1) Nodal spread supraclavicular
- Signs of weight loss - Muscle wasting
- Feel abdo - for masses,
- Feeling Neck nodes
- Metastatic gastric - goes to umbilicus
What would his blood look like?
How can we assess his nutrition?
- NG tube
2.
What are signs of wasting in GI malignancy?
- Temporal fossa wasting
- Clavicular fossa wasting
- anorexia
What is definition of Malnutrition?
What is cachexia?
What is the diagnostic criteria for it? (what are the things we need to measure)
What is Protein energy Undernutrition?
What are the clinical features of this?
What is sarcopenia?
How do we apply nutrition to surgery or critical illnesses?
What does it improve? (list 5)
Is it preventable? (yes) Modifiable
What patients are at risk??? List 6
(think patients at risk of starvation or decreased food uptake)
- Starvation
- bariatric surgery
- cancer
- autoimmune disease
- Acute processes: Burns, head injury, sepsis
4 Different pathologies - 4 different implications for management
1) GI Malignancy
2)
Why is nutrtion important in surgery? (list 4 reasons)
- Hypermetabolic response, release of stress hormones, and inflammatory mediators
- Catabolism lead to increased breakdown
3.
What are the consequences of poor nutrition in the surgical patient?
List 5 consequences Clinically;
ADD NG tube for this patient!!!
answer following
What are ALARM symptoms
What are the 3 major macronutrients?
What are 4 major micronutrients?
Why are they important?
(never want to overfeed a patient especially ICU patient)
What is Indirect calorimetry? (gold standard for measuring caloric need)
What are the general recommendations for protein? Glucose/carbs? lipids?
What about patients with High BMI? low BMI? (need to adjust caloric intake specific to pts needs)
What are 2 different important nutrional screening tools?(MST, MUST)
When should it occur? (and when should it be reassessed?)
How do you assess nutrional status?
Pmhx? Weight history? Medications? Dietary intake/hisotry? GI symptoms? Functional capacity (ADLS), Physical examination!
What is subjective global assesssment? (GOLD standard for diagnosing malnutrition WW, QLD uses)
Nutrition assessments? (list 3 important ones)
Whats important of the SGA?
Whats the SGA classification?
Outline physical exam for malnutrition?
Outline 8 implications for malnutrtion for patients?
What are risk factors for malnutrition?
- Physiological
- social
- psychological
Now, How do we support a patients nutrition when undergoing surgery?
When should we intervene and offer nutritonal support?
nutrtional delivery? (resource 2.0) (eneteral feeding always best)!!
- What important patient considerations do you have to consider?
- What different nutriton options do we have?
What about enteral nutrition? What are the different types? (when are they used)
What is naosjejunal feeding? (also known as post stomach feeds)
What is gastronomy - PEG - Used in Head and neck cancer (e.g swallowing difficulties, support during treatment)
PEJ?
RIG?
What do we need to consider with Enteral feeding?
What are risks associated with NG tubes?
How long should we use a Naso-enteric tube?
What are risks of them?
What are benefits (e.g bolus feeds) - able to disconnect from tubes
What are risks of long term feeding options?
1) Skin irratation around site
2) need to teach patient
What are different eneteral feed options? (when is each better)
What is TPN? When is it used? Where does it insert (SVC)?, How is it most commonly given
What are the major constituents of TPN?
Indications for TPN? (think crohns -SB resection)
- Impaird absorption
- inadequate GI function (Bowel obstruction)
- Enteral feeding cannot be established
- Post op anastomosis leak
- GI fistula
- prolonged bowel rest
- bowel obstruction
- severe malnutrition (where EN is not possible)
What are risks associated with TPN? (think - needs a central venous catheter)
What are metabolic abnormalities/risks you need to consider when starting TPN?
needs to be done in continous fashing! (cannot bolus feed TPN)
How do we manage a patient on TPN?
(what must we monitor -U+Ecs, CMP, BSL, eGFR, LFTS, fluid status(BP, HR,)
What must we calculate? (nitrogen balance)
What is refeeding syndrome?
When does it occur? What happens to insulin?
What do we need to monitor on bloods? (phosphate very important, +Mg
What are risk factors for having a refeeding syndrome?? (who is at highest risk)
What is the management of refeeding syndrome?
What is ERAS? What does it involve?
What does ERAS ultimately help?
ERAS benefits?
What are the different methods of implementing ERAS in the following settings?
1) preadmission
2) Pre-operative
3) intraoperative
4) post operative
Pre: Preadmission support, smoking cessation, control Etoh intake,
What are the different strategies for implementing ERAS (different stages of surgery)
What other considerations are important around surgery (ERAS)?
What are some miscellaneous consideration with feeding different patients?
