Nicky Wyer MSc, RD
Senior Specialist Dietitian
UHCW Nutrition Support Team






Malnutrition and the surgical patient
Identifying patients at risk
ERAS – Nutritional aspects
Routes for nutrition support
Refeeding syndrome

A malnourished patient will have 3 times the number of complications and
4 times the risk of death from the same surgery compared to a well nourished patient (NICE 2006)

There is no universally accepted definition of malnutrition but the following is increasingly being used from RCP 2002:
A state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome
‘Malnutrition’ refers to both under and over-nutrition
(but more commonly used for under-nutrition)

Estimated > 3 million people in the UK are at risk of malnutrition at any one time (Elia & Russell, 2009)
Under-recognised & under-treated
Public health expenditure on disease-related malnutrition in the UK (2007) > 13 billion per annum
(Elia & Russell, 2009)
80% of this expenditure was in England
40% of adult hospital patients are overtly malnourished on admission. 8% categorised as severe.








Elderly
Chronic ill-health e.g. diabetes, renal, COPD, neuro
Cancer
Deprivation / poverty
GI disorders / post GI surgery
Alcoholics
Drug Dependency
Patients with Altered
Nutritional Requirements:
◦
◦ Critical care
Sepsis
◦
◦
◦ Cancer
Trauma
Surgery
◦
◦
◦
◦
◦ Renal Failure
Liver Disease
GI & pancreatic disorders
COPD
Pregnancy

Psychiatric
Anhedonia
Depression
Confusion
Anorexia
?Micronutrient deficiency
Immunity
Increased infection risk
Impaired wound healing
Respiratory
Decreased tidal volumes
Reduced muscle bulk
Loss of adaptive response to hypoxia
Cardiac
Reduced cardiac output
CCF
Hepatic
Fatty Liver
Necrosis/ Fibrosis
Renal
Reduced Na & H2O excretion
Gut
Reduced immunity
Reduced integrity
Oedema
Other
Reduced muscle strength
Neurological weakness
Inability to regulate temperature





Patients who are significantly malnourished and are due to undergo major surgery should be considered for preoperative nutrition support, this may involve tube feeding for 10-14 days pre-op (ESPEN 2006)
Oral intake should be resumed as soon as possible after surgery, usually within 24hrs, with monitoring
Enteral tube feeding should be given without delay post op for any patient who it is anticipated will be unable to eat for > 7days and for patients who cannot maintain oral intake >60% requirements for >10 days
PN should be reserved for malnourished patients who cannot be fed via the GIT for at least 7 days



Typically quoted as 25 – 30kcal / kg calories however Dietitian will assess patients individual needs
Calorie requirements affected by:
◦ Age, Gender, Activity level, Weight,
◦ Degree of stress associated with surgery
◦ Calorific intake from other sources e.g. propofol in ITU






Commonly used by the medical profession as a marker for nutritional state
Albumin is not a marker for nutrition
Albumin indicates disease state not nutrition
Poor nutritional state can coexist with illness but albumin does not indicate malnutrition
No single biochemical marker can be used to assess nutrition

David Blaine
Fast for 44 days
He lost 25.5Kg(26.6%)
At end BMI = 21.6Kgm-2
Albumin 52.9 gl-1

Fashion model
BMI = 11.5 Kgm -2
Albumin = 38 gl -1







Sepsis - CRP; ALB
Acute & Chronic inflammatory conditions
Cirrhosis/ Liver disease
Nephrotic syndrome
Malabsorption
Malnutrition
Common
Least
Common
Hypoalbuminaemia is an important prognostic indicator. The lower the level, the higher the mortality




Typically patients NBM from midnight prior to surgery. Advocated to ensure an empty stomach to  risk of aspiration
ESPEN (2006) and NICE (2006): Safe for patients to eat up to 6 hours prior to surgery and drink fluids up to 2 hours prior to surgery (grade A evidence)
This  the need for IV fluids which helps prevent post op fluid and salt overload which adversely affects the GIT tract and ability to mobilise (Powell-Tuck 2011)

Surgery & Fasting
Hyperglycaemia
Catabolism
Loss of fat & muscle stores
Insulin resistance

http://www.erassociety.org/index.php/eras-care-system/eras-protocol




 preOp (Nutricia) and preload (Vitaflo)
4 x 200ml evening pre surgery,
2 x 200ml up to 2hrs pre anaesthesia.
100kcal, 25g (4.2g sugar) carbohydrate per carton
Creates a non starved metabolism
Moderates metabolic response to surgery







Decreased catabolism
Decreased hyperglycaemia
Preserved muscle mass
Improved grip strength
Reduced LOS
Reduced Anxiety

Elective
Nutrition screening in OPC
High
Risk
Low
Risk
Pre-op nutrition support & goal setting
+/-ERAS protocol
Emergency
Nutrition screen on admission
High
Risk
Low
Risk
Post operative nutrition support
Rescreen weekly




Oral nutrition support
Enteral tube feeding
◦ Nasogastric
◦ Nasojejunal
◦ PEG / RIG
◦ Jejunostomy
Parenteral feeding
Aim for the least invasive method required to achieve goals





High calorie, high protein diet
Snacks, puddings
Majority of patients can resume a normal diet within hours of surgery
Avoid unnecessary restrictions







Not all the same!
Patient preferences key
Consideration should be given to what product best addresses the identified nutritional deficiencies prior to prescribing
Co-morbidities will also affect choice e.g. CMP allergy, diabetes, fat malabsorption, renal disease, coeliac disease
Ongoing monitoring of patients is essential to establish when nutritional goals have been met and nutritional support can be stopped
Not all patients need supplements forever!!





Nausea / vomiting: anti emetics, prokinetics, dilatation, ensuring bowels opening
Pain: analgesia
Constipation: laxatives, enemas
Swallowing: SALTx, altered consistency diet/fluids

Breakfast:
Mid Morning:
Lunch:
Porridge & Cup of tea (all)
Cup of Coffee & Squash
Beef Casserole meal (all)
Crème Caramel (all)
Orange Juice
Mid Afternoon:
Evening Meal:
Supper:
Squash
Salmon Bake Meal (all)
Raspberry Mousse (all)
Squash
Cup of tea
What do you think of this intake??

Total: 1270kcal 52.5g protein 1135ml fluid
This will be inadequate for most post operative patients
Be aware that patients can have difficulty achieving adequate intakes on altered consistency diet and fluid as choices are more limited and less nutrient rich
Require additional snacks or puddings and many require oral nutritional supplements when on this texture


Enteral feeding refers to the delivery of nutritionally complete feed containing protein, carbohydrate, fat, water, minerals and vitamins directly into the stomach, duodenum or jejunum.
NICE 2006

For those unable to take orally for >7 days or are unable to take sufficient amounts (>60%) and for whom more invasive nutritional support is an appropriate part of the treatment plan ESPEN 2006



Polymeric feeds first line, reflects normal dietary intake
Specialist feeds for use in certain conditions e.g. renal, malabsorption, sodium or fluid restriction
Various “core” feeds available
◦ fibre and fibre free versions
◦ 0.8-2kcal / ml
◦ Nutritionally complete in set amount of calories
◦ Gluten & lactose free majority of products
◦ Contain milk protein except Soya based feeds
◦ Vegetarian issue – carminic acid – in ONS, fish oils.
◦ Depends on company / product used, Dietitian will advise


Patients at high risk of aspiration, swallowing problems, unconscious.

Supplementary to oral nutrition – poor appetite, increased nutritional requirements.

Supplementary to parenteral nutrition.


A nasal bridal is a device to secure a
NG or NJ tube to the nasal septum

2 high grade magnets are inserted via each nostril these connect around the nasal septum allowing the looping of a thin strip of gauze/tape around the nasal septum which is then fixed to the NG / NJ tube with a clip.


The placement of a tube through the abdominal wall directly into the stomach for either temporary or permanent delivery of enteral feed
(Payne-James et al 2001).


PEG, RIG, Surgical gastrostomy – be clear on what type of tube it is
Head & Neck cancer

Indications


Long term nutrition support required
Swallowing impairment
Contraindications
Absolute

Total gastrectomy

Portal hypertension with gastric varices
Relative

Unfit for procedure


Partial gastrectomy
PD


Ascites
Active gastric ulcer

Placement of a tube into the small bowel, either via the nasal cavity (NJ), surgically placed (surgical jejunostomy), or occasionally via PEG tube (PEJ). It is a method of feeding patients who are unable to maintain or improve their nutritional status by oral intake and in whom gastric feeding is contraindicated or has been unsuccessful.










Previously documented gastroparesis
Gastric stasis due to paralysing agents required for ventilation
Persisting delayed gastric emptying despite medical management
Severe acute pancreatitis
Upper GI surgery
Pancreatic or duodenal injury
Hepato-biliary surgery
Cancer of the oesophagus or stomach where NG or gastrostomy feeding is inappropriate
Upper GI fistula









Nausea and vomiting
Abdominal distension
Diarrhoea
Constipation
Oesophagitis
Aspiration
Blocked tube
Complications during tube insertion


Administration of nutrients, fluids and electrolytes directly into a central or peripheral vein

Traditionally associated with  complications

However PN used appropriately, with close attention to glycaemic control and avoidance of overfeeding can safely deliver adequate nutrition




Patients who are malnourished or who are likely to become malnourished and where the GI tract is not fully functional or is inaccessible (NICE
2006)
PN anticipated to be needed >7/7
TPN should be avoided where aggressive nutritional support not indicated or where the risks outweigh the benefits









Short bowel syndrome
Prolonged paralytic ileus (>7/7)
Bowel obstruction or pseudo-obstruction
Motility disorders e.g. scleroderma
Gastrointestinal fistulae
Adhesions
Anastamotic leak
Radiation gastroenteritis





Mucositis, oesophagitis or intractable vomiting secondary to chemotherapy
Severe acute inflammatory bowel disease
GI perforation
Severe acute pancreatitis
Post op extensive bowel surgery





Bags made up by aseptic lab
Mixture of glucose, lipid, amino acids, electrolytes, fluid, vitamins, minerals and trace elements
Modifications can be made if clinically indicated
If EN commences can reduce PN gradually as
EN increases





Patients who have had a prolonged period with little/no nutrition >10/7, low BMI, >10% unintentional wt loss, electrolyte disturbances, alcoholics pose risk of refeeding syndrome when any feeding commenced
Severe electrolyte & metabolic abnormalities can occur as a result of feeding but difficult to separate from abnormalities associated with critical illness
Prevent by slow feeding, vitamin supplementation and electrolyte correction
Ensure patients are assessed by a dietitian to ascertain risk level and appropriate plan is made





Malnutrition significantly affects outcomes from surgery
Identification of malnourished patients enables appropriate treatments to be initiated to promote the rapid recovery and discharge of surgical patients
Increasing use of ERAS protocols and cessation of prolonged fasting pre-op improves outcomes
Nutrition support should be provided for patients identified at risk of malnutrition from nutrition screening aiming for the least invasive route








Anderson MR, O’Connor M, Mayer P, O’Mahony D, Woodward J, Kane,K.
(2003). The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high- risk dysphagia stroke patients. Clinical Nutrition. Vol
23. No 4
ERAS society guidelines (joint publications with ESPEN): http://www.erassociety.org/index.php/eras-guidelines
ESPEN (2006). Guidelines on enteral nutrition: surgery including organ transplantation. Clinical Nutrition 25: 224 – 244
ESPEN (2009). Guidelines on parenteral nutrition: surgery. Clinical
Nutrition 28: 378 - 386
Gustafsson UO, Nygren J, Thorell A, Soop M, Hellström PM, Ljungqvist O,
Hagström-Toft E. (2008). Pre-operative carbohydrate loading on postoperative hyperglycaemia in hip fracture patients: A randomised control clinical study. Acta Anaesthesiol Scand. 2008 Aug;52(7):946-51
NICE (2006) Nutrition Support in Adults: oral supplements, enteral and parenteral feeding. NICE
Powell-Tuck et al. (2011) British Consensus Guidelines on Intravenous
Fluid Therapy for Adult Surgical Patients (GIFTASUP). BAPEN