1. Surgical Nutrition
Kristopher R. Maday, MS, PA-C, CNSC
University of Alabama at Birmingham
Physician Assistant Program
Department of Nutritional Sciences
Is It Still NPO Until Bowel Function
Resumes?
2. Objectives
• Identify malnourished patients prior to
surgery to limit complications as a result of
surgery
• Discuss post-operative diet advancement
• Recognize when nutritional support needs to
be implemented and how to choose the
appropriate type
• Evaluate how to monitor nutritional support
and when to stop
3. Dogma of Nutrition in
Surgery
• NPO at midnight for all surgical procedures
• NPO until bowel function resumes
• Clears Full Liquid Soft Diet Regular
Diet
• Nutrition stresses surgical anastomosis
• TPN early in malnourished patients
4. Prior Research
• Malnourished patients have worse
outcomes
• Healthy individuals, when starved long
enough, will develop adverse clinical
events
• 80% of surgeons agree that nutrition
decreases complications and LOS, but only
20% implement any interventions
Studley HO. JAMA. 1936;106:458-
460.
Stack JA, et al. Gastroenterologist. 1996;4:S8-
S15. .
Grass F, et al. Eur J Clin Nutr. 2011;65(5):642-647. .Stack JA, et al. Gastroenterologist. 1996;4:S8-
5. 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
Miller KR, et al. JPEN. 2013;37:39S.
7. Nutritional Assessment
• Nutritional Risk Screening (NRS) 2002
• Pre-operative serum albumin < 3.0 mg/dL
Impaired Nutritional Status Severity of Disease
Absent
0
Normal Nutritional Status Absent
0
Normal Nutritional Requirements
Mild
1
Weight loss > 5% in 3 months
50-75% of usual food intake over last week
Mild
1
Hip fracture
Cirrhosis, DM, Benign Cx Hemodialysis, COPD
Mod
2
Weight loss > 5% in 2 months
BMI 18.5-20.5 with impaired general condition
25-50% of usual food intake over last week
Mod
2
Major abdominal surgery
Stroke, PNA, Malignancy
Severe
3
Weight loss of > 5% in 1 month
Weight loss > 15% in 3 months
BMI < 18.5 with impaired general condition
0-25% of usual food intake over last week
Severe
3
Head injury
Bone marrow transplant
ICU admission
Kondrup J, et al. Clinical Nutrition. 2003;22:321-
336..
Veterans Affairs TPN Study. NEJM. 1991;325:525-
532.
Kudsk KA, et al. JPEN. 2003;27:1-9..
8. Prehabilitation
• 12x increase rate of surgical complications
in obese patients
• Increase rate of post-operative
complications with hemoglobin A1c > 7%
• Decreased morbidity with preservation of
lean body mass stores
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..
9. Pre-Operative Fasting
• 8-12 hour fast depletes almost all glycogen
stores
• Updated 2011 American Society of
Anesthesiologists (ASA) Guidelines
• Enhanced Recovery After Surgery (ERAS)
Society Guidelines
Cahill GF. Trans Am Clin Climatol Assoc. 1983;946:1-
21..
2011 ASA Guidelines. Anesthesiology. 2011;114(3):495-511.
Gustafson UO, et al. World J Surg. 2013;37:259-
284.
10. Post-Operative Ileus
http://melokinex.com/POI.html
Hormones and
Neuropeptides
(CCK, CGRP, VIP, IL-1, TNF-ɑ)
Surgical
Manipulation
Anesthesthesi
a
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)
http://melokinex.com/POI.html
11. Post-Operative Ileus
Location Symptoms Signs Management
Time to
Resolution
Stomach
Nausea +++
Vomiting +++
Abdominal Pain +
Distention +
Succussion
Splash
NG Tube
Metoclopramide
Erythromycin
12-24hr
Small Bowel
Nausea ++
Vomiting ++
Abdominal Pain +
Distention ++
NG Tube
Alvimopan
(Entereg)
6-12hr
Colon
Nausea +
Vomiting +
Abdominal Pain
++
Distention +++
Neostigmine
Decompress
48-72hr
Johnson MD, et al. Cleveland Clinic Journal of Medicine. Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125
12. Oral Post-Op Diet
• Clear liquid diet < Regular
Diet
• No difference in incidence of
N/V, distention, or need for
NG tube placement
• Start 24 hours after surgery
Warren J, et al. Nutr Clin Pract. 2011;26(2):115-125
13. 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
14. Banerjee B. Nutritional Management of Digestive
Disorders.. 2011.
Vassilyadi F, et al. Nutr Clin Pract.. 2013;28:209-217.
24. Monitoring Nutritional
Support
• More ≠ Better
– Accurate caloric intake
– Promote nitrogen retention
• Laboratory studies
– Acute Phase Reactants ≠ Helpful
NICE Guidelines. Nutritional Support in Adults. 2006
25. Weaning Nutritional Support
• Parenteral
– Stop once 60% of energy needs are met by
oral/enteral route
• Enteral
– Continuous Nocturnal Bolus
– Stop once 75% of energy needs are met by
oral route
26. Take Home Points
• Identification of malnourished patients
and prehabilitation prior to surgery
• If the gut works, use it after 24 hours post-
op
• Enteral > Parenteral
27. Dogmalysis of Surgical
Nutrition
• Carbohydrate load 2 hours
before surgery
• Regular diet after POD#1
• Early enteral nutrition is safe
and reduces complications,
hospital LOS, and overall
mortality
• TPN only in a very select few
28. If I Had to Pick Three…
• Ukleja A, et al. Standards for Nutrition
Support: Adult Hospitalized Patients. Nutr
Clin Pract. 2010;25(4):403-414.
• McClave SA, et al. Summary Points and
Consensus Recommendations from the North
American Surgical Nutrition Summit. JPEN.
2013;27(S1):99S-105S.
• Miller KR, et al. An Evidence-Based Approach
to Perioperative Nutrition Support in the
Elective Surgery Patient. JPEN.
2013;37(S1):39S-50S.
29. Kristopher R. Maday, MS, PA-C, CNSC
Email: maday@uab.edu
Twitter: @PA_Maday
Thank You For Your Time
Notas del editor
1936 – Studley et al Well-nourished, non-stressed patient has 7-10 protein/energy stores 3-5 for major surgery
Pre-habiliation – preparing the patient for the upcoming insult and major metabolic stress – lean muscle preservation and weight loss in Obese patients
ONLY TRULE VALIDATED SCREENING TOOL IN SURGICAL PATIENTS
Choose variable with the highest score Albumin < 3.25 saw marked increase in mortality and complications in elective GI surgery
Add the 2 scores NOT RECOMMENDED TO TREND IN THE HOSPITAL
Age > 70 add 1 point to adjust for frailty of elderly
If age corrected total > 3, start nutritional support
Metabolic tune up of at least 30 days Obesity is malnutrition of chronic disease with inflammation
Weight loss prior to elective surgery glucose control 30-60d pre-op exercise program prior elective surgery with cancer
2hr for clear, 4hr for milk, 6hr for light meal, >8hr normal meal AVERAGE NPO TIME IS 14hr
25-50g CHO 2-3hr before general anesthesias – decreased post-op LOS by 3-6 days, preserved lean body mass, and increased insulin sensitivity
Glutamine enriched CHO formulas showed no difference versus CHO alone
Multiple studies have shown NGT does not limit and may even prolong post-op ileus
CLD has always been initial diet of choice post-op. Max – 1100 kcal and no protein. Increase risk of aspiration due to low viscosity
RD has 2500kcal and 115g protein
Maintains gut integrity
Sustains closure of the paracellular channels between the intraepithelial cells
Stimulate immunoglobulin A and bile salts which coat enteric bacteria
Stimulates peristalsis
3500 BC
Ancient egyptians would infuse wine, milk, whey, wheat or barley broths, eggs, and brandy through rectal enemas to preserve health, protect inflamed bowel, and treat diarrhea
1598
Capivacceus reported infusing liquids through a hollow tube placed into the esophagus
1882
President Garfield keep alive for 79 days with whiskey and beef broth enemas
1930s
Protein hydrolysate formulas and automatic feeding pumps were developed
1968
Dr. Stanley Dudrick - UPenn
Invented Total Parenteral Nutrition (TPN)
11 studies, 837 patients overall mortality – 7% in feeding, 13% in control
Nutrient intake associated with significant collagen deposition and reversal of mucosal atrophy at anastomosis
Central Line
Good for short term, inpatient TPN
Tunneled, Cuffed Catheters
Hickman, Groshong
Good for long term, home TPN
PICC Line
Good for long-term, home TPN
Ports
Mediport, Port-a-Cath
Good for long term, home TPN
Peripheral IV
***For PPN, not TPN***
Osmolarity issues
Bacteria and fungi are common. 5 cases/1000 days with 12-25% mortality with each case Most common cause of UE DVT
2003 – Canadian guidelines for nutritional support
Avoid under/over feeding – Prenal azotemia
24hr UUN, BUN
Calorie counts, actual amount infused electrolytes for refeeding, ABG for overfeeding
Reduced oral intake can be expected if >25% of caloric needs are met via nutritional support