SURGERY NUTRITION Flashcards
nutritional challenge in surgery
⦁ Chronically ill ⦁ Diabetes ⦁ Advanced lung disease ⦁ Perioperative ⦁ Advanced age
assess nutritional status in patients through
⦁ History
⦁ PE
⦁ Labs to assess protein status (albumin)
fundamental goals of nutritional support
= to meet the energy requirements for metabolic processes (Basal metabolic rate) & tissue repair
energy source required for certain conditions
⦁ physical activity = 10-50% > basal metabolism
⦁ hospitalized patient = 10-20% > basal metabolism
⦁ Trauma = 10-30% > basal metabolism
⦁ Sepsis = 50-80% > basal metabolism
⦁ Burns = 100-200% > basal metabolism
which condition requires highest energy source
BURNS
need 100-200% energy above basal metabolism rate
the stress of surgery creates a _________ state
hyper-metabolic state (catabolic)
malnutrition consequences after surgery
- Malnutrition consequences ⦁ increased susceptibility to infection ⦁ poor wound healing ⦁ increased frequency of decubitus ulcers ⦁ overgrowth of bacteria in GI tract
PATIENT ASSESSMENT: HISTORY/ROS
-HISTORY ⦁ chronic medical illnesses ⦁ recent hospitalizations ⦁ past surgeries ⦁ medications
- SOCIAL HISTORY
⦁ socioeconomic status
⦁ use of alcohol, tobacco, other drugs - DIET HISTORY
⦁ supplements
⦁ what type of food the pt eats, when they eat during the day - ROS
⦁ any weight loss or weight gain
⦁ GI symptoms: N/V, diarrhea, constipation
PATIENT ASSESSMENT: PE
- height / weight / BMI
- HEENT: temporal wasting, pallor, xerostosis, bleeding gums, dentition, angular cheilosis, dentition
- Neck: thyromegaly (sign of iodine deficiency)
- Extremities: edema, muscle wasting
- Neurologic: peripheral neuropathy (associated with B12 deficiency)
- Skin: Ecchymosis, petechiae, pressure ulcers, pallor (wound healing / signs of wound infection)
- CV: evidence of heart failure
angular cheilosis can be associated with which deficiencies
vitamin B
iron
labs to assess protein status
serum albumin
serum transferrin
serum prealbumin (transthyretin)
- protein status assessment
⦁ Serum Albumin = most frequently used (< 2.2 = predictor of poor outcome)
⦁ Serum transferrin- usually used to assess iron status, but can indicate protein status; can be a more immediate indicator of protein status than albumin
- low indicator of protein status if normal serum iron***
⦁ Serum prealbumin (transthyretin)
⦁ Others = CBC, CMP, vitamin levels as indicated
serum transferrin
- usually used to assess iron status, but can indicate protein status; can be a more immediate indicator of protein status than albumin
*low indicator of protein status if normal serum iron
PRE-OP PATIENTS
- Generally healthy, well-nourished patients who are going in for scheduled surgeries do not need any pre-op nutrition
- Patients with preexisting conditions such as cancer, particularly GI tract cancer, may need pre-op enteral nutrition IF they are significantly malnourished
- If a pre-op patient is mildly malnourished, they may need early nutritional support
⦁ If not on bowel rest and can take PO = need high protein, high calorie nutrition
⦁ If on bowel rest because of bowel surgery / unable to eat for certain number of days = parenteral support is indicated (IV) - earlier if significantly malnourished
why a patient may not be eating post-op
⦁ still nauseous from anesthetic and/or pain meds ⦁ ileus ⦁ start of an infection ⦁ depression ⦁ anorexic because of cancer
with severe malnutrition = may benefit to
may benefit to have the surgery delayed in order to get either enteral or parenteral nutrition, depending on the situation
enteral vs parenteral nutrition
Enteral: Nutrition via intestinal route
Parenteral: Nutrition per IV solution
why the gut is not working
⦁ obstruction
⦁ ileus
⦁ GI ischemia
⦁ persistent vomiting
BENEFITS TO ENTERAL FEEDING
⦁ leads to a more rapid advancement of PO feedings
⦁ fewer infections
⦁ lower costs
⦁ shorter hospital stays
⦁ more physiologic way to provide nutrition (not as hard on the digestive system)
enteral nutrition
- nutrition via intestinal route
calories, protein, electrolytes, vitamins, minerals & fluids are given either orally or via a feeding tube (nasogastric, gastrostomy, jejunostomy, etc); wide variety of supplements
short term (< 30 days) enteral nutrition
- Nasogastric or nasoenteric tubes are preferred over gastrostomy or jejunostomy tubes
- tubes are placed in the 3rd portion of the duodenum (past the ligament of treitz) and are associated with less risk of aspiration
- Intermittent (bolus) gravity feeding is usually done, but continual infusions can be done for jejunal feedings or to reduce reflux
most common enteral nutrition route
nasogastric
NASOGASTRIC NUTRITION
- most common
- can accept high volume/rapid rate feeds
- simple to insert
- usually short-term
NASOJEJUNAL NUTRITION
- short term use
- reduces GERD*
- for use with impaired stomach motility or increased risk of aspiration (the further the tube goes, the lower the risk of aspiration)
- more difficult to place than NG
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)
- may be used for extended periods of time (lasts 12-24 months)
- indications = Stroke, Parkinson’s, Esophageal cancer
- inserted through stomach wall either endoscopically or surgically
indications for PEG
stroke
Parkinson’s
esophageal cancer
PERCUTANEOUS JEJUNOSTOMY TUBES
- used for early post-operative feedings or patients at risk of reflux
- difficult & more complications
COMPLICATIONS OF TUBE FEEDING
- aspiration (prevention = nasojejunal tube)
- diarrhea (multiple causes) ⦁ meds ⦁ composition of the feeding ⦁ infusion rate ⦁ physiological disturbances
- Metabolic disturbances (pay careful attention to fluid & electrolyte management)
summary of enteral feeding access sites
- NG tube = short-term use, but higher aspiration risk
- Nasoduodenal / nasojejunal = for short term use, & less aspiration risk (reduced by 25% compared to NG)
- PEG = need endoscopy to insert; lasts 12-24 months; aspiration risk
- Jejunostomy = surgical feeding tube (early post-op feedings or pts at risk of reflux)
FEEDING INTOLERANCE = “dumping syndrome”
“DUMPING SYNDROME” - can follow the rapid infusion of feeds via jejunal tubes or rapid gastric bolus feeds
- Symptoms = faintness, palpitations, diaphoresis, pallor, tachycardia, hypoglycemia
- Treatment = slow rate of feeding, or change formula to one with more complex carbs
generally give _________ solutions through parenteral nutrition
HYPERTONIC
PARENTERAL NUTRITION
- nutrition via IV solution
- necessary when the oral route cannot be used
- generally give HYPERTONIC solutions
⦁ infused into a large central vein to reduce the risk of intimal damage from the catheter & infusate
⦁ the catheter tip has to be in a blood vessel with high blood flow
⦁ “central” locations = SVC, RA, IVC, NOT the internal jugular, external jugular, subclavian or axillary veins - want parenteral nutrition for as short time as possible; as soon as oral feeding is possible, switch over!
what are the central locations for parenteral nutrition catheter placement
SVC
IVC
RA
