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NATIONAL SURGICAL TEACHING SOCIETY FY Survival Guide (Pre and) Post-Operative Nutrition 21/09/2023Name: Dr Claire Crewe Current job: Senior Undergraduate Clinical Teaching Fellow 2020 – graduated from Newcastle University 2020 – 2022 – Foundation programme in Cumbria 2022 – present – clinical teaching fellow in Cumbria, working with Newcastle students 2023 (hopefully) – Core surgical trainingKEY LEARNING OBJECTIVES ▯ Identify patients in need of nutritional optimisation, especially pertaining to BMI, serum albumin, frailty or triceps skin fold thickness. ▯ List the physiological effects of protein–calorie malnutrition ▯ Identify the different types of nutritional support – oral, nasogastric, gastro/jejunostomy and parenteral. ▯ Describe what total parenteral nutrition (TPN) entails, its associated risks, and the additional and particular parameters of care for these patients.Why is this so important? ▯ Specifically in a surgical environment, why do we need to identify these patients in need of nutritional optimisation? ▯ https://www.menti.com/alvuawm75kp6 ▯ Code: 8221039Why is this so important? ▯ At risk of deteriorating ▯ NBM, N&V, surgery (high stress state) ▯ Wound healing ▯ Immune response ▯ Impact activity levels therefore recovery ▯ Independent risk factor for morbidity & mortalityWhy is this so important? ▯ Any surgical situations/conditions that may put people at risk? https://www.menti.com/alvuawm75kp6 Code: 8221039Surgical conditions putting people at higher risk ▯ Burns ▯ Sepsis ▯ Fistulas ▯ Immunosuppression ▯ Malignancy ▯ Resections/stomas esp. ileostomy ▯ ALL increase nutritional requirements ▯ Increased metabolic demands, reduced absorption, excessive catabolismIdentifying those in need of nutritional optimisationPoll Which of these is not a form of assessing nutritional status? - BMI - Triceps skinfold thickness - Grip strength - Serum albumin - Serum transferrinMUST Score Step 1 – Obtain a BMI score. If unable to obtain height and weight, use the alternative procedures shown in this guide. weight loss.e percentage unplanned Step 3 - Establish acute disease effect and score. Step 4 - Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition. and/or local policy to develop care planManagementTriceps fold thickness - Patients that cannot be weighed - Measured to the nearest millimeter - Subjective/large variations - Assume that subcutaneous fat reflects total body fat - Useful in identifying the severely malnourished - Serial measurements can help in monitoringSerum albumin - Indicator of protein reserves & nutritional status - N-t aHalf life 20 days - Slow response to supplementation - Affected by many other conditions - Negative acute-phase protein - Infection, burns, fluid overload, trauma, hepatic/renal disorders - Unreliable – especially in acute settingsIdentifying those in need/at risk - It’s important - but it can be difficult to identify - Who do we need to consider for nutritional support/supplementation: - Unable to fulfill daily intake requirements - Not eating for 5 days - Malnutrition states/disease - Crohn’s, fistula, high output stoma - Excessive catabolic states - Post-operative, sepsisPhysiological effects of protein-calorie malnutritionProtein-Calorie Malnutrition - What is it? - Where the body shifts from a fed to a starved state. - Protein and energy intake is not meeting the bodies daily requirementsProtein-Calorie Malnutrition - Reduced neutrophil and lymphocyte function - Impaired albumin production - Impaired wound healing & collagen deposition - Skeletal muscle weakness à respiratory + intra-abdominal complications - Micronutrient deficiencyIdentify different types of nutritional supportWhat forms of nutritional support are available? ▯ Code: 8221039 ▯ https://www.menti.com/alvuawm75kp6Supplementation/Feeding Options Oral supplementation Nasogastric/nasojejunal feeding NG/NJ Feeding gastrostomy/jejunostomy Parenteral nutritionOral Nutritional Supplementation • Used alongside diet • High calorie • High protein • ALWAYS ASK A DIETICIAN Examples • Milkshakes - Fortisip, Ensure • High protein - Fortisip Compact Protein, Jellies • Juice – Fortijuice • Soups • Puddings – semi-solidEnhanced Recovery After Surgery - Pre-, Peri- & Post-operative actions to help patients return to their pre-operative function ASAP. - Reduces complications - Reduces length of hospital stay - Pre-operative carbohydrate loading - Early re-introduction to full nutrition - +/- supplementation to achieve thisNG/NJ Feeding • Usually a short term solution • <30 days Who? When? How? • Those with a normally functioning GI tract • E.g. neurological disorders, head and neck malignancy, oesophago-gastric disease, inadequate oral intake, reduced gastric emptying • How – NG at bedside, NJ endoscopyNG/NJ Feeding Complications • Displacement / incorrect placement • Blockage • Drug / feed interaction Ensuring safe NG placement: - pH aspirate on insertion - CXR: Midline Bisects the carina Tip visible below the left hemi-diaphragm Tip approximately 10cm beyond GOJGastrostomy/Jejunostomy • Long term >30 days Who? When? How? • Longer term neurological disease, oesophageal pathology, head & neck malignancy, brain injury • Gastroparesis, reduced gastric emptying • Endoscopy, radiology, surgeryGastrostomy/Jejunostomy Complications • Displacement +/- tract closure • Local leakage à skin irritation • Abscess • Buried bumper (gastrostomy) • Damage to the tubeTotal Parenteral Nutrition (TPN) • IV nutrition • Central or peripheral (medium calibre vessel) • Alongside or alternative to oral nutrition • Need to think about early to allow time to get a line Intestinal failure has been classified according to time scale, metabolic changes and outcome (Shaffer, 2002). Type I - an acute, short-term and usually self-limiting condition eg post- operative ileus Type II - a prolonged acute condition, often in metabolically unstable patients, requiring PN over periods of weeks or months. Type III - a chronic condition, in metabolically stable patients, who require PN over months or years. It may be reversible or irreversibleComplications with TPN Insertion related: General: • Bleeding • Hyperosmolarity • Misplacement • Poor glycaemic control • Pneumothorax • Micronutrient deficiencies • Early infection • Cholestasis, liver Line related: dysfunction, pancreatic •Thrombophlebitis atrophy •Line fracture • Fluid overload •Line occlusionRefeeding syndrome • Potentially fatal condition • Electrolyte and fluids shifts after prolonged reduced intake • ↓K, ↓Mg, ↓PO4, Hyperglycaemia, Encephalopathy, Arrhythmias, Oedema • Monitoring those at risk: • QDS BM • Daily bloods – U&E, Mg, PO4 • Electrolyte replacement • Fluid balanceRefeeding syndrome • Who is at risk? • Little or no intake for 5 days • High risk: • Little or no intake for 10 days • BMI <16 • 15% weight loss in 3-6 months • Deranged electrolytes prior to feeding • Severe risk: • BMI <14 • Little or no intake for 15 daysRefeeding syndrome • What do we do? • Good monitoring to avoid • (Almost) never start feeding out of hours • Start slow • Vitamin supplementation to those at high/severe risk: • Pabrinex • Vitamin B Co StrongWhich would be the most appropriate feeding method?KEY LEARNING OBJECTIVES ▯ Identify patients in need of nutritional optimisation, especially pertaining to BMI, serum albumin, frailty or triceps skin fold thickness. ▯ List the physiological effects of protein–calorie malnutrition ▯ Identify the different types of nutritional support – oral, nasogastric, gastro/jejunostomy and parenteral. ▯ Describe what total parenteral nutrition (TPN) entails, its associated risks, and the additional and particular parameters of care for these patients. THANK YOU! ● QR code and survey link ● Stay tuned for… Radiology week! ● Intro to CT – Tuesday 26 ● Orthopaedics – Thursday 28th