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Nutritional Management of the Surgical Patient Dropping pearls of wisdom J T able of Contents Malnutrition……………..……………………………………… 3 Dietetic referrals………………………………..6 Low fibre diet………………………………………………………45 Albumin…………………………………………… 8 Pancreatitis………………………………………………………….48 Post OP nutrition………………………………………….….12 severe acute pancreatitis………………………….52 Early enteral feeding……………………………14 PERT…………………………………………………………..54 Oral nutritional supplements………………..16 T3cDM………………………………………………………..56 Routes of nutritional intervention…………19 Gallbladder disease and low fat diet…………………...…58 Colorectal surgery………………………………………………23 Outpatient dietetic services…………………………………..62 High output stoma management…………28 Paralytic ileus…………………………………………………….32 PN referrals……………………………………….36 Bowel obstruction…………………………………………….38 Build up diet ………………………………………….42malnutrition /ˌmalnjʊˈtrɪʃn/ noun A state resulting from a lack of intake or uptake of nutrition that leads to altered body composition and body cell mass leading to a diminished physical and mental function and impaired clinical outcome from disease', which can result from starvation, disease, or advanced ageing, alone or in combination.50% of all hospitalised patients (70% of cancer Malnutrition patients) Consequences: higher complications, infections, mortality, prolonged ventilator dependence, and ICU stay, peri-operative risks and delays post- operative recovery. Post-operative stress response: increased circulation of catabolic hormones -> protein catabolism of glycogen, skeletal muscle, and adipose tissue -> significant muscle wasting. Malnutrition Universal Screening Tool (MUST): BMI, involuntary weight loss history and current dietary intake linked to the presence of acute disease. MUST 2 Low Albumin High Tube feed output assessment stoma POOR Low fat Gastric outflow APPETITE diet for Bowel obstruction obstruction gallstones POST SEVERE ACUTE Refeeding Ileostomy PANCREATITIS syndrome PERT education dietary risk advice Is albumin a marker of nutritional status? NO due to: Long half life of 20 days Negative correlation with CRPCRP ALBUMIN Post OP Current guidelines recommend initiating oral intake on the first post-operative day in most cases. Nutrition Fewer complications + positive impacts on outcomes: return of bowel function, anastomotic leak, hospital length of stay (LOS), mortality No evidence to suggest that EN should be delayed in the absence of bowel sounds. Key benefits of early EN: - maintaining structural/functional gut integrity and reduce intestinal permeability. - attenuate the inflammatory response and favourably modulate the immune system. - regulate the metabolic response, reducing insulin resistance Post OP Nutrition Contraindications of early EN: intestinal obstruction or ileus, high-output fistula, intestinal ischaemia, severe shock, and severe intestinal haemorrhage. Enteral feeding intolerance: evidenced by persistent vomiting or high GRVs, prokinetics started Post-pyloric feeding should be considered when prokinetic agents have failed. In case of severe abdominal PN considered anastomotic leak, EN should be ceased andDO NOT DELAY FEEDING • DON’T wait for bowel sounds. • delay nutrition.iet post op or • Feed early for best outcomes! • trophic feedtrophy, consider Oral Nutritional Supplements Oral Nutritional Supplements Oral Nutritional Supplements Oral Nutritional Supplements Oral Nutritional SupplementsColorectal surgery Colorectal surgery Most patients can be recommenced on an oral diet from the day of surgery. Clear fluids, free fluids and a soft-low residue diet. Low fibre diet: Colostomy or Ileostomy formation: 4 - 6 weeks unless No stoma formation: 1 - 2 weeks.High Output StomaHigh Output Stoma >1200mls output in 24 hours for 2 consecutive days Rule out the following: • Infective diarrhoea (e.g. C-Diff, norovirus) • Laxatives / prokinetics • Oral magnesium supplementation • Rapid withdrawal of medications e.g. steroids, codeine • Sepsis • Sub-acute bowel obstruction • Bacterial overgrowth e.g. SIBO • Disease e.g. Crohn's Disease, cancer recurrence Stage 1 • Conti • Replace electrolytes as indicated • Start Low Fibre diet and increase dietary salt. • Conti • 4mg starting dose of Loperamide QDS (administered 30-60 minutes before electr meals and at bedtime) • Incre • Prescribe PPI e.g. omeprazole 20mg BD • Cons • Restrict oral hypotonic fluids to <1L/ 24hrs and prescribe 1L St Marks or IV saline Stage 2 • Continue Low Fibre diet and increased dietary salt. • Continue to restrict oral hypotonic fluids to <1L and 1L St Mark’s electrolyte solution per day or IV saline. efore • Increase Loperamide to 8mg QDS • Consider increasing dose of PPI (e.g. Omeprazole 40mg BD). or IV Stage 3 • Refer to Nutrition Team • Continue Loperamide 8mg QDS ark’s • Continue low fibre and increase dietary salt. • Codeine Phosphate starting dose of 30mg BD titrating up to 60mg QDS • Further restrict oral hypotonic fluids to <500mls/24hrs ).Paralytic ileus Paralytic ileus • The transient cessation of bowel motility following a surgical intervention. • Lack of peristalsis within the digestive tract results in a build-up of fluid and gas within the intestine, resulting in a functional obstruction. • Diagnosis: absence of a mechanical obstruction, nausea, vomiting, intolerance to oral intake, obstipation, abdominal distension, and pain. • Management: NBM and IV fluids • PN considered: nil nutrition for 5-7 days or unlikelyPN referrals • To be made by a consultant or registrar. • Need to be made by 10:00am. • Central Access – CVC or PICC line required. • Full U&E’s including bone profile and Mg • Corrections if required. • Cautious IV fluids. (Dextrose 5% = 200kcal) • Discussed with the patient.Bowel obstruction • Symptom control NGT for drainage considered to alleviate vomiting. • PN not indicated if BO is intermittent or incomplete, gut function is maintained • Clear, free fluids, soft diet: increase the consistency of food if symptoms improve, or return to clear fluids remain symptomatic. • Obstruction from adhesions or malignancy is still present: low-fibre dietClear fluids Free fluids Soft diet Soggy cereal Black tea/ coffee Milk/Nespuick Squash Milky coffee Eggs Smooth clear fruit juice Yogurt drinks Cottage/ shepherds pie Oasis/ rubicon/vimto Soup Poached fish Coconut water Thin custard Pasta Consume soup Jelly Rice Lucozade Ice cream/ ice Jacket potato lollies Cake and custardWhy low fibre? • Reduce bulking of stools and risk of faecal loading, constipation, and recurrence of symptoms of abdominal bloating, pain, and early satiety. • What about just giving a leaflet? Risks: over or under restrictions-> Unbalanced and unvaried diet • Foods high in fibre: whole meal grains, lentils, skins pips and seeds of fruits and vegetablesHIGH LOWHIGHHIGHLOWHIGHLOWPANCREATITIS• 1.2.5 Ensure that people with acute pancreatitis are not made 'nil-by-mouth' and do not have food withheld unless there is a clear reason for this (for example, vomiting). • 1.2.6 Offer enteral nutrition to anyone with severe or moderately severe acute pancreatitis. Start within 72 hours of presentation and aim to meet their nutritional requirements as soon as possible. • 1.2.7 Offer anyone with severe or moderately severe acute pancreatitis parenteral nutrition only if enteral nutrition has failed or is contraindicated. • 1.3.3 Be aware that all people with chronic pancreatitis are at high risk of malabsorption, malnutrition and a deterioration in their quality of life. • 1.3.5 Consider assessment by a dietitian for anyone diagnosed with chronic pancreatitis. Severe Acute Pancreatitis • Early nutritional intervention: associated with reduced morbidity and mortality • NJT feeding: patients who cannot tolerate NG feeding, show signs of developing GOO, or have significant inflammation in the head of the pancreas, and therefore likely to develop extrinsic duodenal compression • Evidence only available for the introduction of soft foods PERT • Doses escalated until symptoms are under control. PERT should be swallowed with a cold drink, stored below 25 °C and capsules distributed throughout meals. • Nutrizym, Creon, Pancrex • Starting dose: 3 x 25,000IU with meals 2 x 2500IU with snacks Lipase – to digest fat Protease – to digest protein Amylase – to digest starch T3cDM T3cDM • 40% after an episode of AP. • Careful blood glucose monitoring is essential • Careful blood glucose monitoring is essential duduring acute managementnt • • Poor glycemic control: erratic oral intake, nil- byby-mouth times, inflammation, and infectionGallbladder disease and low-fat diet • There is no published evidence of the benefits of a low-fat diet compared with a standard diet in gallbladder disease. • The gallbladder contracts spontaneously and in response to an intake of mixed meals, protein or cephalic stimulation Outpatient dietetic services at Kingston Hospital Colorectal cancer outpatients Gastro dietetic outpatients (stoma, IBD, IBS, pancreatitis) Home enteral feeding General dietetic clinic(diverticulosis, weight management, low BMI) Oncology clinic (all cancers) ICU rehab clinic (stay longer than 5 days)Two truths One lie 50% of all hospitalised patients are malnourished Albumin has a short half life Liquid loperamide should be avoided in HOS managementTwo truths One lie MUST screening involves assessment for cachexia and sarcopenia including obesity No evidence for sarcopenia recommendation of low fat diet in pancreatitis Pre-digested peptide feed is used as first line in SAPTwo truths One lie Low fibre diet is recommended following all colorectal surgeries St Marks is an iso-osmolar solution Codeine Phosphate (30mg BD) should be started in stage 2 of HOS managementQUESTIONS?References Pu et al. Perioperative Medicine (2021) Early oral protein-containing diets following elective lower gastrointestinal tract surgery in adults: a meta-analysis of RCTs. Philips et al (2023) Nutritional management of the surgical patient Madden et al. (2017) Modified dietary fat intake for treatment of gallstone disease