Perioperative Nutrition Flashcards
Why is nutrition important in surgery?
Malnourished patients make poor surgical candidates
Why do malnourished patients make poor surgical candidates?
Because surgery causes physiological stress with resultant hyper-metabolic state and catabolic response, which is not favoured in the malnourished patient
Why will a proportion of surgical patients have a degree of malnutrition?
Because their underlying disease process reduces their nutritional reserves in the post-operative period
What is the problem with malnourished patients post-operatively?
They are at increased risk of post-operative complications such as reduced wound healing, infection, and skin breakdown
What should be done regarding nutrition in surgery?
Any patient undergoing elective or semi-elective surgery should be assessed for evidence of malnutrition, and where possible this should be corrected, or nutrition supported both pre and post operatively
What should happen to all patients admitted to hospital, regarding nutrition?
They should be screened for malnutrition, and have their nutritional state assessed
How can screening for malnutrition be achieved?
Using the Malnutrition Universal Screening Tool (MUST)
When might MUST score calculation be unnecessary?
In disease-related cachexia
Why might MUST score be unnecessary in disease-related cachexia?
It is usually obvious with bedside observation
What features of disease-related cachexia may be obvious on bedside examination?
- Muscle wasting
- Loose skin
- Patient’s usual clothes no longer fitting
What may following screening for malnutrition?
Nutritional assessment
What does a nutritional assessment require?
Expert input from a Registered Dietitian
What tools are used to assess nutritional state?
- Weight
- BMI
- Grip strength
- Triceps Skin Fold thickness
- Mid Arm circumference
How is BMI calculated?
Weight (kg) / (height (m)2)
What is the normal range for BMI?
18.5-24.9 kg/m2
What features may be found on examination that suggest disease related cachexia?
- Apthous ulcers
- Angular chelitis
- Pressure sores
What might be appropriate if malnutrition is identified?
Nutritional support
Why is nutritional support important in malnourished surgical patients?
It improves surgical outcomes
What decisions need to be made on a case-by-case basis regarding nutritional support?
- When and how to deliver nutritional support
- The timing of subsequent surgery
Who is involved in the development of an appropriate schedule for nutritional support?
It should be done with the assistance and under the direction of a registered dietician
What does the type of nutritional support that can be offered depend on?
Largely on the pathology present
As a general principle, what is the best way to administered nutrional support?
Best to give enteral nutrition via the oral route wherever possible (this applies to pre- and post-operative nutrition
Why might enteral nutrition via the oral route not be an option?
For many patients, it may not be possible to administered sufficient calories via this route
What should be given if a patient is unable to eat sufficient calories?
Oral nutritional supplements
What should be done if the oesophagus is blocked/dysfunctional?
Gastrostomy feeding (PEG/RIG)
What should be done if the stomach is inaccessible, or there is outflow obstruction?
Jejunal feeding (jejunostomy)
What should be done if the jejenum is inaccessible, or there is intestinal failure?
Parenteral nutrition
Is malnutrition an indication for delaying surgery?
No
What do patients with intestinal failure need?
Often (but not always) parenteral nutrition
What does the acronym SNAP stand for when considering nutrition in intestinal failure?
- Sepsis
- Nutrition
- Anatomy
- Procedure
What does sepsis in the SNAP acronym for intestinal failure nutrition refer to?
Any overwhelming infection present must be corrected, otherwise feeding will be largely useless
What does nutrition in the SNAP acronym for intestinal failure nutrition refer to?
Once the infection is corrected, suitable nutritional support should be provided
What does anatomy in the SNAP acronym for intestinal failure nutrition refer to?
You should define the anatomy of the GI tract so that surgery can be planned
What does procedure in the SNAP acronym for intestinal failure nutrition refer to?
Definitive surgery should be performed once any infection is eradicated, the patient nourished, and the anatomy defined
How is serum albumin involved in nutrition and surgery?
A low serum albumin is associated with poorer surgical outcomes, but it does not reflect nutritional state
What can a low serum albumin reflect?
- Chronic inflammation
- Protein loosing enteropathy
- Proteinuria
- Hepatic dysfunction
What are the tenets of Enhanced Recovery After Surgery (ERAS)?
- Reduction in NBM times
- Pre-operative carbohydrate loading
- Minimally invasive surgery
- Minimising the use of drains and nasogastric tubes
- Rapid reintroduction of feeding post-op
- Early mobilisation
How short can NBM be made?
Fluids can be taken up to 2 hours pre-surgery
What does evidence suggest that early post-operative feeding causes?
A reduction in post-operative complications
How long after an uncomplicated gastrointestinal surgery can patients safely tolerate an enteral diet without increasing the risk of post-operative complications?
24 hours
Is an entero-cutaneous fistulae an absoloute indication for parenteral nutrition?
No, the proportion of ECF that will heal spontaneously with PN is relatively small
What nutritional strategy should be employed in an entero-cutaeous fistulae?
Supporting nutrition prior to a likely surgical repair
What is the modern nutrition management of an entero-cutaneous fistula dependant on?
The level of the fistula
What nutritional support may be needed with a high entero-cutaneous fistula (jejunal)?
Enteral or parenteral nutrition
What nutritional support can be employed with a low entero-cutaneous fistulae (ileum/colon)?
Low fibre diet
What investigation is often critical in deciding how an entero-cutaneous fistula should be managed in terms of nutrition?
Imaging
What is the nutritional support and treatment for a high output stoma dependant on?
- Length of bowel to stoma
- Presence of disease
- Medical management
If the distance from the DJ flexure to jejunostomy is 150-200cm, what are the probable nutritional requirements?
Enteral support
If the distance from the DJ flexure to jejunostomy is 100-150cm, what are the probable nutritional requirements?
Enteral support, with or without IV fluids
If the distance from the DJ flexure to jejunostomy is <100cm, what are the probable nutritional requirements?
Parenteral nutrition
If the distance from the DJ flexure to colostomy is 100-150cm, what are the probable nutritional requirements?
Enteral support
If the distance from the DJ flexure to colostomy is 50-100cm, what are the probable nutritional requirements?
Enteral support with or without IV fluids
If the distance from the DJ flexure to colostomy is <50cm, what are the probable nutritional requirements?
Parenteral nutrition
What can drive stoma output independent of the length of residual bowel?
The presence of persistent disease or systemic infection
How can a reduction in stoma output be achieved once active disease or infection have been excluded?
- Reduction in hypotonic fluids to 500mls/day
- Reduction in gut motility with high dose loperamide and codeine phosphate
- Reduction in secretion with high dose PPIs (twice daily dose)
- Use of WHO solution to reduce sodium losses
- Low fibre diet to reduce intraluminal retention of water
