Surgical Nutrition

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

Physician Assistant ProgramDepartment of Nutritional Sciences

Is It Still NPO Until Bowel Function Resumes?

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

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

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-S15. .

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.

Pre-Operative Risk Reduction

• Nutritional assessment• Concept of “prehabilitation”• Pre-operative fasting

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 Absent0 Normal Nutritional Requirements

Mild1

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

Mild1

Hip fractureCirrhosis, DM, Benign Cx Hemodialysis, COPD

Mod2

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

25-50% of usual food intake over last weekMod

2Major 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..

Veterans Affairs TPN Study. NEJM. 1991;325:525-532.

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

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..

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.

Post-Operative Ileus

http://melokinex.com/POI.html

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)http://melokinex.com/POI.html

Post-Operative IleusLocation Symptoms Signs Management

Time to Resoluti

on

StomachNausea +++Vomiting +++Abdominal Pain +

Distention +Succussion Splash

NG TubeMetoclopramideErythromycin

12-24hr

Small Bowel

Nausea ++Vomiting ++Abdominal Pain +

Distention ++NG TubeAlvimopan (Entereg)

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-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

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

Banerjee B. Nutritional Management of Digestive Disorders.. 2011.

Vassilyadi F, et al. Nutr Clin Pract.. 2013;28:209-217.

Enteral Nutritional Support• Started 24-48 hour after surgery• Access

Enteral Nutritional Support

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

Enteral Nutritional Support

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

Enteral Nutritional Support

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

Enteral Nutritional Support• Complications– Abdominal distention– Aspiration– Diarrhea– Iatrogenic injury

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Dec3%284%29/Pages/23.aspx

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• 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• More ≠ Better– Accurate caloric intake– Promote nitrogen retention

• Laboratory studies– Acute Phase Reactants ≠ Helpful

NICE Guidelines. Nutritional Support in Adults. 2006

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

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

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

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.

Kristopher R. Maday, MS, PA-C, CNSCEmail: maday@uab.edu

Twitter: @PA_Maday

Thank You For Your Time