Nutrition care plan for surgical
patients
Surgical Nutrition Training Module
Level 1
Philippine Society of General Surgeons
Committee on Surgical Training
Objectives
• To discuss the process of nutrition
management of surgical patients
• To discuss the role of the nutrition team
NUTRITION CARE PLAN
FORMULATION
The surgical nutrition process
All admitted patients are nutritionally screened
All nutritionally at risk patients are assessed
All high risk patients are given nutrition care plans
Monitoring of the nutrition process is done
Nutrition care plan modification / Discharge
Nutrition
Care Plan
Form
Nutritional status
• Severely malnourished?
• Feeding access? Oral, GIT, parenteral,
combinations
• Need to build up before surgery?
• Is there a need for special nutrients?
PRE-OPERATIVE PHASE
severe
Scheduled
• esophageal resection
• gastrectomy
• pancreaticoduodenectomy
Enteral nutrition
for 10-14 days
oral immunonutrition
for 6-7 days
malnutrition
no
slight, moderate
SURGERY
Early oral feeding within 7 days
POST-OP
EARLY DAY 1 - 14
no
yes
Enteral access (NCJ)
within 4 days
enteral nutrition
Oral intake of energy requirements
no
yes
immunonutrition for 6-7 days
yes
“Fast Track”
no
Parenteral hypocaloric
combined enteral / parenteral
Adequate calorie intake within 14 days
LATE DAY 14
yes
no
Oral intake of energy requirements
supplemental enteral diet
no
yes
Surgical nutrition pathways:
Pre-operative phase
Condition: When oral or
enteral feeding not possible
Nutritional Assessment
Normal to moderate
malnutrition
Severe Malnutrition
• Esophageal resection
• Gastrectomy
• Pancreaticoduodenectomy
Parenteral nutrition + Omega-3-Fatty Acids +
Antioxidants (+ glutamine); 6-7 days
SURGERY
ESPEN Guidelines on Parenteral Nutrition (2009)
Surgical nutrition pathways:
Intra & Post-operative Period
While in the OR ask yourself: “is oral feeding possible within 7 days?”
Yes
No
Can I feed within 4 days?
Needle catheter jejunostomy
Yes
No
• Enteral nutrition (12 hrs)
• Better: immunonutrition
“Fast Track”
PN
If enteral nutrition is inadequate
Transition
Supplemental PN
ESPEN Guidelines on Enteral Nutrition (2006) and Parenteral Nutrition (2009)
Nutrition Care Plan
Physician, Dietitian, Pharmacist
Total calorie and protein requirement
• Guidelines:
– Nutritional status – if severely malnourished
• Calories: 20 to 30 kcal/kg body weight
• Use actual body weight if not obese
– Capacity to undergo surgery
• Normal or low malnutrition level: immediate surgery
Non-protein calories
• Ratio of glucose to lipid content
• Issue regarding type of lipids
– Saturated vs. unsaturated
– Long chain vs. medium chain triglycerides
– Omega-3 vs. omega-6 PUFA, how about omega-9?
Micronutrients
• Electrolytes
– Laboratory values
– Drug-nutrient interactions
• Vitamins
– Water and fat soluble vitamins
• Trace elements
Nutrition Care Plan
Physician, Dietitian, Pharmacist
Physician, Nurse
Nurse, Dietitian, Pharmacist
Nurse, Dietitian, Physician, Pharmacist
Formulation
• Oral supplementation
• Enteral nutrition
– Standard vs. special nutrition
– Supplemental vs. meal replacement
– Issue of blenderized diets
• Parenteral nutrition
– Supplemental vs. total PN
– Need to include micronutrients in all solutions
– Special nutrients (e.g. pharmaconutrition)
Enteral nutrition issues
Commercial Formulas
Blenderized Formulas
Uniform contents
Sterile
Daily nutrient variability
Non-sterile; high bacterial content
and other pathogens
High viscosity
Does not provide adequate caloric
density
Low viscosity
Lactose free
Defined caloric density
Gallagher-Alfred. Nutrition Supp Svc 1983;
Tanchoco CC, et al. Respirology 2001;6:43-50
Sullivan MM, et al. J Hosp Infect 2001;49:268-273
Pharmaconutrition
Glutamine
Arginine
Omega-3-fatty
acids (EPA)
Antioxidants
Carotenoids
Vitamin C,E
Dose
Content in preps
0.4 – 0.5 g/kg
?
12 – 15 g/L
4 – 16 g/L
2 – 6 g/day
1 – 2 g/L
>100% daily
requirement
Single or
combinations
Maximum effect when given at the proper dose
Access and delivery
• Enteral:
– Short term vs. long term
– need for enteral pumps
• Parenteral
– Peripheral vs. central
– Single or multiple lumen catheters
– Protocols for maintenance
The surgical nutrition process
All admitted patients are nutritionally screened
All nutritionally at risk patients are assessed
All high risk patients are given nutrition care plans
Monitoring of the nutrition process is done
Nutrition care plan modification / Discharge
Monitoring issues
The team performs the calorie count
and fluid balance
The fluid, calorie, and protein intake
are recorded and adequacy of intake
is recorded in the patient’s chart
Calorie,
protein,
fluid
balance
form
Nutrient
monitor
form
How to implement
• Monitoring: everyone is involved
Monitoring
• Fluid balance – avoid fluid accumulation
within 4-5 days post op
• Calorie balance
• Gastric retention for enteral nutrition
• Blood tests:
– BUN high – dialyze
– High triglycerides – lower lipid flow
– Hyperglycemia – insulin
• Weight once a week
Jan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003
Nutrition Team
Diagnosis
Management
Overall plan
Screening
Enteral nutrition
Parenteral nutrition
Monitoring
Enteral nutrition
Monitoring
Parenteral nutrition
Monitoring
NST activity
Policies and guidelines
Patient rounds
NST meeting
compiled and updated
regular like 3x a week
• difficult cases
• coordination issues
Reports on outcome
monthly, yearly
Updates from other
studies
regular
NST activity/documentation
• malnutrition rate
• underweight / obese
• severe weight loss
Screened and
assessed patients
“At Risk” patients
• critically ill
• elderly
• stroke
• cancer
• post-op
complications
• severely malnourished
• poor intake
• effect of nutrition care:
• calorie count
• outcome:
• morbidity
• mortality
• nutraceuticals
• other interventions
• suggestions
• nutrition care
• fluid balance
• access
• formulation
• carried out?
Outcomes of adequate intake
Adequate intake in surgery patients
Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate
energy and protein intake on morbidity and mortality in surgical patients
nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s
Medical Center, 2008.
THANK YOU