Williams' Basic Nutrition & Diet Therapy 14th Edition Chapter 22 Surgery and Nutrition Support Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 1 Nutrition Support and Methods of Feeding Surgical treatment requires added nutrition support for tissue healing and rapid recovery. To ensure optimal nutrition for surgery patients, diet management may involve enteral and/or parenteral nutrition support. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2 Introduction (p. 447) Clinical signs of malnutrition in: ◦ 38.7% of hospitalized elderly patients ◦ 50.5% of elderly patients in rehabilitation facilities Effective nutrition should: ◦ Reverse malnutrition ◦ Improve prognosis ◦ Speed recovery Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3 Nutrition Needs of General Surgery Patients (p. 447) Nutrition needs are greatly increased in patients undergoing surgery Deficiencies easily develop Pay careful attention to: ◦ Nutritional status before surgery ◦ Individual nutrition needs after surgery Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4 Poor Nutritional Status (p. 447) Has been associated with: ◦ Impaired wound healing ◦ Increased risk of postoperative infection ◦ Reduced quality of life, increased mortality rate ◦ Impaired function of gastrointestinal tract, cardiovascular system, respiratory system ◦ Increased hospital stay, cost Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5 Preoperative Nutrition Care: Nutrient Reserves (p. 448) Nutrient reserves can be built up before elective surgery to fortify a patient Protein deficiencies are common* Sufficient kilocalories are required ◦ Extra carbohydrates maintain glycogen stores Vitamin and mineral deficiencies should be corrected Water balance should be assessed Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6 Immediate Preoperative Period (p. 449) Patients are typically directed not to take anything orally for at least 8 hours before surgery** Before gastrointestinal surgery, a nonresidue diet may be prescribed Nonresidue elemental formulas provide complete diet in liquid form Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 7 Emergency Surgery (p. 449) No time for building up ideal nutrient reserves Reason for maintaining good nutrition status at all times Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 8 Postoperative Nutrition Care: Nutrient Needs for Healing (p. 449) Postoperative nutrient losses are great but food intake is diminished Protein losses occur during surgery from tissue breakdown and blood loss ◦ *controlling edema: when serum protein levels are low, osmotic pressure is lost and edema develops Catabolism usually occurs after surgery (tissue breakdown and loss exceed tissue buildup) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 9 Need for Increased Protein (p. 450) Building tissue for wound healing Controlling edema Controlling shock by maintaining blood volume Healing bone: protein is essential Resisting infection: protein tissues are major components of immune system Transporting lipids: fat is important component of tissue structure Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10 Water (p. 451) To prevent dehydration Water loss may occur through vomiting, hemorrhage, fever, infection or diuresis** Loose sodium and chloride** Elderly require special attention Large water losses possible from various routes IV fluids Oral fluids as soon as possible Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 11 Energy (p. 451) Provide sufficient nonprotein kilocalories for energy to spare protein for tissue building CHO’s spare protein for tissue building and help to avoid liver damage by maintaining glycogen reserves in the liver tissue** Energy needs increased for extensive surgery or burn patients 12 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. Vitamins (p. 451) Vitamin C to build connective tissue** ◦ Sources** B vitamins to metabolize protein and energy B-complex vitamins to build hemoglobin Vitamin K to promote blood clotting **patients treated with antibiotics may have a decreased gut flora and vitamin K synthesis Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 13 Minerals (p. 451) *Tissue catabolism results in cell potassium and phosphorous loss Potassium Phosphorus Sodium, chloride Iron ◦ *iron deficiency anemia may develop from blood loss or inadequate iron absorption* Zinc Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 14 General Dietary Management (p. 452) Routine IV fluids supply hydration and electrolytes, but not energy and nutrients Methods of feeding ◦ Oral ◦ Enteral: Nourishment through regular gastrointestinal route, either by regular oral feedings or by tube feedings ◦ *Parenteral: Nourishment through small peripheral veins or large central vein *risk for hyperglycemia *table 22-2 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 15 Methods of Feeding: Oral (p. 452) Allows more needed nutrients to be added Stimulates normal action of the gastrointestinal tract Early feedings associated with reduced complications Progresses from clear to full liquids, then to a soft or regular diet Routine house diet Assisted oral feeding: try to avoid making patient feel inadequate Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 16 Methods of Feeding: Enteral (p. 454) Used when oral feeding cannot be tolerated Nasogastric tube is most common route **Nasoduodenal or nasojejunal tube more appropriate for patients at risk for aspiration, reflux, or continuous vomiting Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 17 Criteria for selecting a nutrition support method *Enteral *parenteral BOX 22-1 ASSISTED feeding guidelines *Blind client Copyright © 2013, 2009, 2005 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. Methods of Feeding (p. 456) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 19 Alternative Routes (p. 455) Esophagostomy Percutaneous endoscopic gastrostomy Percutaneous endoscopic jejunostomy Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 20 Alternative Route Formulas (p. 456) Generally prescribed by the physician Important to regulate amount and rate of administration Wide variety of commercial formulas available Rate: bolus or continuous Monitoring for complications: diarrhea is most common complication *pureed table food for tube feeding may present these problems ◦ Safety** Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 21 Parenteral Feedings (p. 458) **Definition: any method other than the normal GI route Peripheral parenteral nutrition: less than 5 to 7 days Total parenteral nutrition: for large nutrient needs or longer periods** TPN provides crucial nutrition support from solutions that contain glucose, amino acids, electrolytes* Must be discussed with patient and/or family first *complications of TPN: metabolic, rebound hypoglycemia, hyperglycemia and infections, phlebitis *start infusion slowly Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 22 Propofol and lipids in nutrition support Lipid emulsion contributes 1.1 kcal per ml, enteral or parenteral nutrition solutions must provide reduced calories from fat to compensate for those that are provided with propofol ◦ *energy metabolism generates CO2 production Copyright © 2013, 2009, 2005 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. Peripheral Parenteral Feeding (p. 459) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 24 Total Parenteral Nutrition (p. 460) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 25 Total Parenteral Nutrition (cont’d) (p. 460) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 26 Total Parenteral Nutrition (cont’d) (p. 460) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 27 Nutrition Support Related to GI Surgery Nutrition problems related to GI surgery require diet modifications because of the surgery’s effect on normal food passage. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 28 Special Nutrition Needs after Gastrointestinal Surgery (p. 460) Gastrointestinal surgery requires special nutrition attention Nutrition therapy varies depending on the surgery site Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 29 Mouth, Throat, and Neck Surgery (p. 462) Requires modification in the mode of eating Patients cannot chew or swallow normally Oral liquid feedings ensure adequate nutrition Mechanical soft diet may be optimal* Enteral feedings required for radical neck or facial surgery when the client is debilitated, tube feedings may be indicated* Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 30 Gastric Surgery (p. 462) Because the stomach is the first major food reservoir in the gastrointestinal tract, stomach surgery poses special problems in maintaining adequate nutrition Problems may develop immediately after surgery or after regular diet resumes Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 31 Gastrectomy (p. 462) Increased gastric fullness and distention may result if gastric resection involved a vagotomy (cutting of the vagus nerve) Weight loss is common Patient may be fed by jejunostomy* Frequent small, simple oral feedings are resumed according to patient’s tolerance* ◦ *small, bland meals, low in bulk Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 32 Dumping Syndrome (p. 462) Common complication of extensive gastric resection in which readily soluble carbohydrates rapidly “dump” into small intestine **Symptoms include: ◦ ◦ ◦ ◦ Cramping, full feeling Rapid pulse Wave of weakness, cold sweating, dizziness Nausea, vomiting, diarrhea terminates the event Occurs 30 to 60 minutes after meal when readily soluble CHO’s enter or dump into the small intestine ◦ Ex: cookies, if simple CHO’s were eaten, late dumping ~2 hours after eating would occur* ◦ When water is drawn from the circulatory system into the intestine, shift in water rapidly shrinks the vascular fluid volume, causing shock* Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 33 Bariatric Surgery (p. 463) Typical deficiencies in several micronutrients Progress from clear liquid to regular diet over about 6 weeks Thereafter limited to about 1 cup of food Subject to dumping syndrome Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 34 Gallbladder Surgery (p. 463) *Cholecystectomy is removal of the gallbladder Surgery is minimally invasive Some moderation in dietary fat is usually indicated after surgery Depending on individual tolerance and response, a relatively low-fat diet may be needed over a period of time *function is to concentrate and store bile which helps with the absorption and digestion of fat* Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 35 Gallbladder Surgery (cont’d) (p. 465) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 36 Intestinal Surgery (p. 464) Intestinal resections are required in cases involving tumors, lesions, or obstructions When most of the small intestine is removed, total parenteral nutrition is used with small allowance of oral feeding Stoma may be created for elimination of fecal waste (ileostomy, colostomy)* Ileostomy-food may be fairly liquid in the GI tract and more problems are encountered with management* Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 37 Intestinal Surgery (cont’d) (p. 466) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 38 Intestinal Surgery (cont’d) (p. 466) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 39 Rectal Surgery (p. 466) Clear fluid or nonresidue diet may be indicated after surgery to reduce painful elimination and allow healing. Return to a regular diet is usually rapid. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 40 Special Nutrition Needs for Patients with Burns (p. 466) Tremendous nutritional challenge Plan of care influenced by: ◦ Age ◦ Health condition ◦ Burn severity** *superficial, second degree, third degree Plan constantly adjusted Critical attention paid to amino acid needs Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 41 Special Nutrition Needs for Patients with Burns (cont’d) (p. 466) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 42 Stages of Nutrition Care of Burn Patients (p. 466) Burn shock or ebb phase ◦ Massive edema at burn site ◦ Loss of heat, water, electrolytes, protein ◦ Immediate IV fluid therapy with salt solution or lactated Ringer’s solution ** **replaces water and electrolytes and prevent shock ◦ After 12 hours, albumin solutions or plasma ◦ MNT not a priority at this time Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 43 Stages of Nutrition Care of Burn Patients (p. 467) Acute or flow phase ◦ Sudden diuresis indicates initial therapy success ◦ Constant attention to fluid intake and output ◦ Around the end of first week, bowel function returns and rigorous MNT begins Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 44 Medical Nutrition Therapy (p. 467) High protein intake High energy intake ◦ Caloric needs based on total BSA burned ◦ Liberal portion of kilocalories from carbohydrates ◦ Avoid overfeeding High vitamin and mineral intake Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 45 Stages of Nutrition Care of Burn Patients (p. 468) Dietary management ◦ Careful intake record ◦ Oral feedings preferred ◦ Enteral or parenteral route may be used if oral intake deficient Follow-up reconstruction ◦ Nutrition support for skin grafting, reconstructive surgery ◦ Personal support to rebuild will and spirit Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 46