Update on Surgical Nutrition

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Kristopher R. Maday, MS, PA-C, CNSCUniversity of Alabama at Birmingham

Physician Assistant Program

Objectives• Identify malnourished prior to

surgery• Discuss post-operative diet

advancement• Recognize when nutritional support

needs to implemented– How to choose correct type– How to monitor nutritional support

• Dogmalysis

No Financial Disclosures

Common Dogma of Surgical Nutrition

• NPO at midnight for all surgical procedures

• NPO until bowel function resumes• Clears Full Liquid Soft Regular• Nutrition stresses surgical

anastomosis• TPN early in malnourished patients• No enteral feeding with vasopressors• No enteral feeding with open

abdomen

Prior Research

Studley HO. JAMA. 1936;106:458-460.

Stack JA, et al. Gastroenterologist. 1996;4:S8-S15. .

Prior Research

Grass F, et al. Eur J Clin Nutr. 2011;65(5):642-647. .

80% 20%

Perioperative Timeline

Miller KR, et al. JPEN. 2013;37:39S.

30-60 days 24 hours 1-14 days

Evaluation Preparation and Optimization

Pre-Op OR Post-Op

Assessment Prehabilitation Pre-operative

Pre-operative Risk Reduction

30-60 days 24 hours

Nutritional Assessment

Impaired Nutritional Status Severity of Disease Absent

0 Normal Nutritional Status Absent0 Normal Nutritional Requirements

Weight loss > 5% in 3 months50-75% of usual food intake over last week

Hip fractureCirrhosis, DM, Benign Cx, Hemodialysis, COPD

Weight loss > 5% in 2 monthsBMI 18.5-20.5 with impaired general condition

25-50% of usual food intake over last weekMod2

Major abdominal surgeryStroke, PNA, Malignancy

Severe3

Weight loss of > 5% in 1 monthWeight loss > 15% in 3 months

BMI < 18.5 with impaired general condition0-25% of usual food intake over last week

Severe3

Head injuryBone marrow transplant

ICU admission

Kondrup J, et al. Clinical Nutrition. 2003;22:321-336..

Schiesser M et al. Clin Nutr. 2008;27(4):565-570

Kudsk KA, et al. JPEN. 2003;27:1-9..

Nutritional Risk Screening Tool (NRS 2002)

Pre-operative serum albumin < 3.0 mg/dL

Prehabilitation

Valentijn TM, et al. Surgeon. 2013;11(3):169-176..

Migita K, et al. Gastrointest Surg. 2012;16(9):1659-1665..

Fearon KC, et al. NEJM. 2011;365(6):565-567..

Obese and A1C > 7% Preservation of lean mass

Pre-operative Fasting

Cahill GF. Trans Am Clin Climatol Assoc. 1983;946:1-21..

8-12hr = glycogen

14 hours

Pre-Operative Fasting

2011 ASA Guidelines. Anesthesiology. 2011;114(3):495-511.

2011 American Society of Anesthesiologists Guidelines

2 hoursclear liquids

4 hoursbreast milk

6 hourslight meal

8 hoursregular meal

Pre-Operative Fasting

Fearon KC, et al. Clin Nutr. 2005;24(3):466-477.

Steenhagen E. Nutr Clin Prac. 2016;31(1):18-29.

Enhanced Recovery After Surgery (ERAS) Guidelines

25-50g clear carbohydrate drink

Ljungqvist O. JPEN. 2014;38(5):559-566.

Ljungqvist O. JPEN. 2012;3(4);389-398.

Post-Operative Ileus

Hormones and Neuropeptides

(CCK, CGRP, VIP, IL-1, TNF-ɑ)

Surgical Manipulation

Anesthesthesia

Endogenous opiate release

Inflammation(Macrophage and neutrophil

infiltration, cytokines, inflammatory mediators)

Exogenous opiates

Autonomic nervous system

(sympathetic inhibitory pathways)

Enteric nervous system

(substance P, NO)

Increased age

Low albumin

Opioid use

Previous abdominal

surgery

Long surgery

Emergency surgery

Blood loss

Bragg D, et al. Clin Nutr. 2015;34(3):367-376

Post-Operative Ileus

Location Symptoms Signs Management Time to Resolution

StomachNausea +++Vomiting +++Abdominal Pain +

Distention +Succussion Splash

NG TubeMetoclopramideErythromycin

12-24hr

Small Bowel

Nausea ++Vomiting ++Abdominal Pain +

Distention ++ NG TubeAlvimopan 6-12hr

ColonNausea +Vomiting +Abdominal Pain ++

Distention +++

NeostigmineDecompress 48-72hr

Johnson MD, et al. Cleveland Clinic Journal of Medicine. 2009;76(11):642

Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125

Oral Post-Operative Diet

Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125Steenhagen E. Nutr Clin Prac. 2016;31(1):18-29.

Start REGULAR diet 24 hours post-op

Oral Post-Operative Diet

Nutritional Support• Indications – Unlikely to take in > 50% PO for next 3-

5 days– Inability to meet physiologic demands

by oral intake• 2 types– Enteral vs Parenteral

NICE Guidelines. Nutritional Support in Adults. 2006 Ukleja A, et al. Nutr Clin Pract. 2010;25:403-414

3500 BC 1598

Enteral Nutritional Support

24-48 hourspost-op

Martindale RG, et al. JPEN. 2013;37(1):5S-20S.

Enteral Nutrition Support

Lewis SJ, et al. BMJ. 2001;323:1-5.

Complications• Distention• Aspiration• Diarrhea• Azotemia• Iatrogenic injury• Volume problems

Total Parenteral Nutrition• Admixture of amino acids, dextrose,

lipids, vitamins, minerals, and electrolytes

• Indications– Non-functional GI tract– Failure of PO/enteral route

Total Parenteral Nutrition

McClave SA, et al. JPEN. 2013;37(S);73s.

Total Parenteral Nutrition• Access– Central Line– Tunneled/Cuffed

Catheter– PICC Line– Ports– Peripheral IV

Total Parenteral Nutrition• Complications– Catheter related bloodstream infections

(CRBSI)– Thrombosis– Hepatosteatosis– Hyper/hypoglycemia– Hyperlipidema– Electrolyte abnormalities

Maroulis J, et al. Clinical Nutrition. 2000;19(5):295-304.

Ukleja A, et al. Gastroenterol Clin N Am. 2007;36:23-46.

Heyland DK, et al. JPEN. 2003;27:355-373

Monitoring Nutritional Support

• Ensuring adequate caloric intake– Estimation• Equations (Ireton-Jones)

–Measure• Indirect calorimetry

• Ensuring adequate protein intake– Estimation• Equations (~1.5g/kg/day)

–Measure• Nitrogen balance

Maday KR. Universal Journal of Clinical Medicine. 2013;1(3):39-43.

Nitrogen Balance• 24 hour urine urea nitrogen (g)– 15.4g

• Add a “fudge factor” for non-urinary losses– Usually around 4

• Calculate 24 hour nitrogen intake– Total protein intake / 6.25

((75g protein)/6.25) – (15.4g + 4) = -7.4

7.4 x 6.25 + 10g = 56.25g protein/day

Weaning Nutritional Support

Continuous Nocturnal Bolus

Supplements for Wound Healing

Stechmiller JK. JPEN. 2010;25(1):61-68

Can You Feed An Open Abdomen?

1. If the gut works, use it2. Start slow and advance

to goal

Powel NJ, et al. JPEN. 2012;27(4):499-506

Moore SM, et al. JPEN. 2016;31(1):9-13

Friese RS, et al. JPEN. 2012;27(4):492-498

Powel NJ, et al. JPEN. 2012;27(4):499-506

Can You Feed On Vasopressors?

Probably

Yang S, et al. JPEN. 2014;29(1):90-96

Bruns BR, et al. JPEN. 2016;31(1):14-17

Wells DL. JPEN. 2012;27(4):521-526

Take Home Points1.Involve your dietician2.Early enteral is best3.Parenteral only in select

cases4.Supplement when needed5.Critical illness is tough

Thank You!

w w w . p a i n e p o d c a s t . c o m

@PA_Madaymaday@uab.edu

Update on Surgical Nutrition

Health & Medicine