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If you need anything. Hi, everyone. Sorry, I'm a couple of minutes late. I had some slight microphone issues, but we are good to go now. So again, thank you for joining us for another in our Fy Survival Guide series. And this session is going to be focused on postoperative care, but specifically about nutrition. Um Something that I think isn't often taught specifically to us. And when we're on the wards as an F one, quite often we can be asked about, you know, are we able to feed this person? Do they need any supplements, that sort of thing? And to be perfectly honest, when I was there for one, I thought I do not know. I have no idea what the options are here. So we're going to give you a bit of insight into what sort of things are out there and what sort of people might need support with their nutrition. So we're going to look specifically with a surgical um slant on it. Um looking at pre and POSTOP nutrition. So, firstly a little bit about me. Um so hopefully met the most of you on Tuesday. Um but mine's Claire, I'm an undergraduate clinical teaching fellow in Cumbria. Um and I'm one of the leads for this fy survival guide series um background. I studied at Newcastle University. I graduate in 2020 mid COVID. And so we were that group that started interim foundation early. Um I then complete my foundation program in Cumbria, which is home for me and they can't get rid of me and I've stayed on as a clinical teaching fellow and it's my second year there. Er move forward, hopefully, fingers crossed. Um I will start core surgical training next August. Um But that's enough about me. We'll get on to this evening's session. So key learning objectives for this evening. So I've taken these learning objectives from the Royal College of Surgeons of England undergraduate curriculum. So they devised this in 2015 to try and identify um some key learning outcomes for undergraduate specifically with regards to surgery um as depending on what university you go to, you get varying exposure to surgical specialties. So we're going to look specifically at the nutrition outcomes and identifying patients that are in need of nutritional optimization and how we identify those patients, the physiological effects of malnutrition and then identifying some forms of nutritional support. And um specifically, we're going to talk a little bit about TPN because this is a scary form of nutrition that we don't know enough about. Um or particularly f one I did not know enough about. Um So we'll hopefully try and clarify some questions about that for you. So first of all, we've got a mental meter here. So if you could all join in on me meter and scan this QR code, um What um I was hoping you could you could answer for me is specifically in a social environment. Why is it so important to identify patients in need of nutritional optimization? So if you can't get onto men meter, then please um put in the chart, I can see the chart so I can I can follow both the chat and the men meter. Give you a minute or so to do that. And if there's any problems with it, please put in the chat and I can try and fix any. Hey Clare, not sure if it's just me, but um I can't seem to hear you maybe try turning off your microphone and then turning it on again. No, still not working. You could try refreshing your page altogether and that should do the trick. Apologies to everyone for the technical difficulties. We will be right back with you in a sec. Can anyone hear? Yes, that's why here the back or the back. Yeah. Yes, that worked for me. OK, sorry about that iron, more technical issues. Um So meter. So why is it important in surgical patients um to optimize nutrition. So we got some great answers about um wound healing, POSTOP recovery, um recovery time, um reduced risk of pressure ulcers and um malnutrition. So excellent, all important things in um with specific regards to surgery. So these are some of the reasons I came up with why at some point. So our patients are at risk of deteriorating in their nutritional state if they were, you know, already at a point of malnourishment before. So that's because we sometimes keep our patients no by mouth and some of the conditions that they come in with mean that they are nauseous, they're vomiting, so they're not having as much intake. Um And a lot of them are gonna have a surgical procedure or have had a surgical procedure. So the body increased demands. Um As you all said, for wound healing, um for um it's important in mounting an immune response, it's going to impact on their activity levels and therefore their recovery and actually, malnutrition has been proven as an independent risk factor for morbidity and mortality. So that's why it's so important that we identify these patients. So, back to the mental meter. So what sort of surgical conditions might put people more at risk of um needing nutritional support or at risk of becoming malnourished? I'll give you all a minute to complete that again. Let me know if the meter is not working. So I'll give you another 10 seconds or so, just conscious of time since we had a little delay there, any thoughts again, use the track. If the meter is not not working. So, yeah, surgical, so, things I've got coming through are inflammatory bowel disease patients. Um, a few, a few people have thought that excellent. Um, so no, by mouth patients, anyone's had G I surgery. Um, and particularly Ile. Absolutely. So these are all states or conditions in which we, we as a surgical team or the condition itself, um, puts people at risk of becoming malnourished. So, some of the things I came up with uh um particularly burns patients, this put people at high risk, um those that have sepsis or in a, in a general surgical perspective, that's usually um intra-abdominal sepsis. Um people with fistulas. So quite commonly fistulas and immunosuppression, I think like um patients as people rightly identified inflammatory bowel disease malignancy, we got high cata states, um patients that have had resections, so have reduced absorption or those that have stoma and particularly ileostomies or high output ileostomies, put people at, at specific risk. So all of these increase a patient's nutritional requirements from either increased metabolic demands, reduced absorption or excessive catabolism. And in surgery, these are all so so important to be aware of. I've included this slide just to sort of identify, particularly with regards to those patients that we just talked about that have reduced absorption or had resections, what sort of things are absorbed at what point in the bowel. And this can be really important at thinking about replacements for those sorts of patients. So, I'll give you a second to look at that. Um I'm not going to talk you the whole way through it, but for example, people with Crohn's disease, um most common site of inflammation is the terminal ileum. So you might be thinking about things like B 12 replacement or, you know, um lipid absorption depending on um your patient. So how do we identify those in need of nutritional optimization? So I'm gonna put that to you. Um So I'm gonna start my pull. And so which of these has not been used as a form of assessing nutritional status. So we've got BMI, we've got Grip strength, we've got serum albumin, we've got triceps, f, skin fold thickness, um and serum transferrin. Everyone start your voting. So which this has not been used. So I'll give you another 10 seconds and then when I submit my answer, um that will finish the point. So what did we go off for? 0 50 50 between Grip Strength and serum transfer? 14% is a BMI and 14% said, 0 13% said, I don't know. So unfortunately, it was a little bit of a trick question because all of these things, apart from the, I don't know, have been used as a form of assessing nutritional status. So, sort of that question. Um And we'll talk a little bit more about some of these um in a moment. So firstly, let's think about a must score. Hopefully, you've all heard from. Um and this is um a universal assessment tool for malnutrition and all patients that are admitted to hospital will be given a must score and how we work out a must score. It's got a number of different stages to it. So firstly, it includes BMI. So that's one of our methods that we had in the pool, which includes a height and a weight. If you're unable to get a height and a weight, there are other ways that we can more sort of inaccurately. But, but in, in some way, assess um for height and weight. So for example, to assess someone's height, you can see on the right here, um you can measure their ulnar length and then you correlate this to a table is provided within the mu tool. Um And that correlates to height, appreciate not as accurate as in the ideal situation. If we could just measure someone's height. And similarly, with weight, what we use is the um upper arm circumference. So mid upper arm, so you measure from the elbow down to up to the acromial, pick the midpoint, get the patient to straighten their arm and measure the midpoint. And that can give us a, a correlation to weight. And again, that tables provided on the um screening tool. So that's the first section, we work out the BMI, we then note if they've got a, had any unplanned weight loss over the past 3 to 6 months and we work out as a percentage, wherever percentage that is gives us a, a score again. And third, we assess for any um acute disease effect. So that's if um the patient is acutely unwell at the moment and also if that is gonna cause mean that they're unlikely to have any oral intake for the next five days. And those three things give us a score which we combine. And from that scar, there are some management guidelines, there are universal guidelines with the Muss tool, but trusts will have specific guidelines as well. But just to give you a bit of an idea about what that looks like. So if you score zero, you're low risk routine screening. So if you're in hospital, this still needs to be monitored in case that changes. It's a very dynamic thing. If you're medium risk, you need to, if you're in in hospital, the staff um will complete a food diary, monitor your oral intake. If that's adequate, you go back to regular screening. If that's inadequate, then they will refer on to dietitians because that's cause for concern. And if you're already at the point that do this must score deemed high risk, so you score two or more in any of those three parameters, then you refer onto the dietitian team straight away. So they can have some form of intervention and you monitor these patients very closely to ensure that's not worsening throughout their admission. So that's one tool you'll see that really commonly of all the tools that people can use to assess nutritional status that that is the most common. So let's think about some of the other ones that we mentioned there. So, um, triceps, fold, skin thickness and it looks very bizarre as you can see on that picture. But it can be used in assessing patients who are unable to, for example, be hoisted out of bed and don't have the sitting balance to sit on the scales for those patients that are bed bound for, you know, a number of reasons they can't be weighed. This is quite a crude measurement of their nutritional status. And what you do is use caliper um and essentially pinch the skin fold at the back of the arm there around the tricep and measure it to the nearest millimeter. As you can probably imagine this has quite large variations in user and even within the same user, you can get multiple different measurements. So it's not the most accurate. It also assumes that um your subcutaneous fat reflects your total body fat, which is not always the case in some patients. Um this differs between males and females. Um different body compositions will have different visceral levels of fat as opposed to subcutaneous levels of fat. But what it is useful in is identifying severely malnourished and also for monitoring. So if you're doing serial measurements, the one off may not be totally useful. Um but if you're doing serial measurements, it can give you an indication of those patients that nutritional status is deteriorating serum albumin. Another another um method that we mentioned. So serum albumin is used as an indicator of protein reserves and therefore nutritional status. However, it's not particularly accurate in the acute setting. So it has a half life of around 20 days, which means that its response to supplementation is not going to be particularly measurable. About 5% of your total body albumin is produced each day and only 50% of that. So 2.5% is intravascular and therefore measured on your blood test. So only a tiny percentage of proportion of keto albumin will be measurable within the the intravascular um blood test. So it's not particularly helpful in assessing response to supplements response to treatment or in that acute phase. It's also affected by a number of other conditions. So it's what we call a negative acute phase protein. So in um acute conditions like infections, burn burns, trauma, it actually reduces and therefore gives us an unreliable measurement in the acute setting. But in the chronic setting, it can, in some cases be useful um typically used alongside something like the mu screening tool. So there's some of the ways that we can assess nutritional status. I'm not going to go through them all because we've been here all night. But there's some of the things that might, you might see used on the ward and mostly in combination. So possibly altogether and possibly one or the other. So in summary, um identifying those in need of nutritional support or at risk of nutritional support is really, really important, but it can be quite difficult and specific to surgery. Those who we need to consider for nutritional support are those that aren't able to have their full, fulfill their daily intake requirements. So that aren't eating for numerous reasons, those that have malnutrition states or those that have excessive cata states or postoperative or septic patients. And that's, that's a bit of a, an overview of identifying those at risk. So what happens? Why, why are we so bothered about it? Why is it a bad thing that we want to identify? So what are the physiological effects? So, protein calorie malnutrition is where the body shifts from a nice happy fed state where it's fulfilling its um intake requirements to essentially a starved state where the protein and energy intake is not meeting the body's daily requirements. And the body does a really good job at adapting to this. So by using up protein stores, which is why we think traditionally albumin might have been used as a good marker of malnutrition. So it uses up protein reserves, it reduces muscle mass. So particularly skeletal muscle, those that are less, you know, immediately important. So, peripheries and it protects the central muscles in the initial phase. It does however, also reduce your cardiac muscle mass and your respiratory muscle mass, which can lead to a number of complications. It compensates quite well until a point where a continued starve, it means that it can no longer adapt, it can no longer manage the lack of intake that it's receiving and not receiving. And some of the problems that are associated with that are reduced immune function, impaired albumin production, impaired wound healing, um as mentioned. So, respiratory and cardiac muscle mass loss, therefore, respiratory complications and also intraabdominal complications, but also nutrient deficiencies. And as you can see, some of these wound healing, immune function is so important in our surgical patients in their um recovery um and in managing their conditions. So we want to avoid that wherever possible. So what we're gonna do about it, what nutritional support is out there to help these patients? So, back to Minter. So what nutritional forms or nutritional supplements? Are you aware of? What have you heard of in the past or you maybe seen used? So I'll give you a minute or two to respond to that again. Do let me know if it's not working or post in the chat if you have any, any other responses. I'm watching my, my other screen for your responses. You you know, oh there we go. Oops uh mg or peg um NG. Again, we've got some specific names. So ensure faucet scan ship. Yeah. So excellent. All different forms of nutritional support. Perfect. So these are some of the the nutritional support options. So a lot of people there mentioned some different oral supplementations, a ensure. Um what else have we got on there? Um Stand Shak I've not heard of that one but it sounds as though it's uh a a bit similar to 46. Um we had some people mention um energy feeding and mm I haven't got any mentions of NG, but that is another option. We've got gastrostomy feeding, Vanoy feeding or PM parenteral nutrition. And we're gonna look at each of these and in what situation specific surgery you might want to use these in. So, firstly, oral supplementation. So this is something we use typically alongside diet and it can be high calorie, high protein um, supplementation to meet the patient's needs. Before starting any of these supplements, we should always ask a dietician what they would recommend. Each person is going to need something different. And all of these drinks, juices, soups have slightly different makeups. So if someone needs, um, you know, fluid restricted, they have quite um condensed ones. If someone needs a high protein specimen, they can use um, high protein drinks. If it's purely calorie, then we'll try and get anything into them. We can, um, but they're all slightly different. So it's always best to ask a dietician their advice before starting any of these because these are all prescribed, um, drinks, um, supplements. So before you put your name to it, you want to know exactly that, that is the right, the right supplement for that person. Um, enhanced recovery after surgery. I'm not sure if anyone has heard of this before, but this is something where oral supplementation is really important. So, enhanced recovery after surgery, if we, if we relate this specifically to general surgery, it's often used in colorectal following receptions for malignancy. It is a combination of preoperative perative and post operative actions that help a patient return to their preoperative state, functional state as soon as possible. It helps their recovery. It helps reduce complications and ultimately, it helps to try and reduce length of hospital stay and therefore, costs is a lot of different things that encompass enhanced recovery and one thing on its own probably will not make that big difference. But putting them all together has been proven to have a big effect on people's recovery. So for example, preoperative things and specific to nutrition and we try and carb load patients. So they have carbohydrate rich drinks and presurgery to try and reduce that early cata state that is associated with having a surgical procedure. Perioperative things include um good analgesia in theater, um using laparoscopic surgery rather than open surgery, colorectal handling the bowel as little as possible to help prevent ie ss and postoperative. Again, things specific to nutrition. Um we use things like an oral supplementation. We try and get them back to their normal diet as soon as possible. Um And if patients aren't achieving that, which commonly they're not because they're not feeling up to eating a full meal, POSTOP, you know, day one POSTOP, they don't really fancy the usual diet. We can supplement that with sort of high protein drinks to try and meet that requirement. Well, a number of other postoperative aspects like early mobilization, um you know, turning the person when they come back from theater, getting them as active as possible, getting the pain under control, but also trying to avoid using opioids again to try and help with that. Eye Los. Uh I've got a question here. So how do you car blood a patient if they have to be nil by mouth for surgery? So we try to keep a patient. So no food by mouth from the night midnight and they can have drinks up to two hours before. Um But ideally sort of, you know, between six and two hours before we can give them fluids. Um Again, we're trying to reduce the length of time that shouldn't, yeah, the intake prior to and reduce the early state that surgery causes. It's very, it's not quite as it used to. I think it used to be much more recommended that patients were nail by mouth for much longer. But now we try and make that as little as possible that's going to be safe for the aspiration risk. So that's a little bit about enhanced recovery. You'll hear quite a lot about enhanced recovery, particularly when you get on to surgical wards. And it's commonly used for patients that are sort of elective patients. So as I say, those cancer operations, because you can't prep an emer emergency surgical patient with the pre op phase. But again, a lot of nutritional input there to try and prevent IES and further complications. So uh feeding, this is another another option that is out there. So this is something that is usually a short term solution. So by short term, we mean less than 30 days requirement. Who gets it? When do they get it? How do they get it? So NG feeding is for those with a normally functioning G I tract. So we're not thinking about those malabsorptive states that we'll talk about in a little while and we talked about those that have a normal G I tract. A normally functioning G I tract. But for some reason cannot take oral, oral supplements or oral, you know, normal food intake. So these sort of things are neurological disorders. So post stroke patients in the early phase, um more surgically or it, we've got things like head and neck malignancy, um esophageal gastric disease. So if they've got again, a malignancy, a stricture something that food cannot physically pass by. Um but the rest of their G I tract is functioning normally, we can supplement that with NG I NGA feeding. Um for those that have inadequate oral intake or for ng those that have reduced gastric emptying. So for gastroparesis or some, some similar condition that is gonna reduce that gastric emptying. And how do we do it? How do we, how do we start these patients on N feeding? So N tube we can put in at the bedside depending on what trust you work in is whether you can do this as an F one. I know the trust I work in, they're very strict on who can do this and you have to do special e-learning to be able to put in an energy. Um And an N chair tube um is usually done during endoscopy or during a surgical procedure. An NJ, it, it's often used to allow the stomach or the duodenum to rest. So for example, if you say a patient that had a perforated duodenal ulcer, um they've had that repaired, but you don't start feeding them straight away because the risk of that repair opening, um you might put an NJ in to bypass that for uh you know, a few days allow that to heal and then resume feeding. So it's a short term solution. But what are some of the complications with this? So common complications with this form of feeding are displacement or incorrect placement. So they can be pulled. They can be, if you've got a delirious person, they've got something uncomfortable hanging out their nose um that's, you know, they can feel it at the back of their throat, it's uncomfortable. Um, it might be pulled, it might be, you know, unintentional or it could be put in, in the wrong place to start with. Um, so these have s have to be checked, meticulously and again, work, depend on what trust you work in. Depends whether you can sign the form to say they are ok to be fed via this NG. So make sure whatever you trust you're in, you know their policy. So my trust to sign off an NG placement on a chest x-ray, you have to be reg level or above and you have to have done the ele I cannot do it. But you know the trust that that's not the case and the things you look for in a chest x-ray uh that you can see the NG in the midline of the chest where it biceps, the carina and you can see the tip visible below the left hemidiaphragm. And that is approximately si uh 10 centimeters below the gastroesophageal junction. When you, you, it initially, you also aspirate it and test the P to make sure it's acidic. You don't always get an aspirant back and you can reposition the patient to try your best to get an aspirant. But ultimately, you're gonna want a chest x-ray. If you can't aspirate the, the tube tubes can also get blocked. Um So we can give more things via an n medications as well. And quite often they have to be converted to liquid form or they have to be, um, sort of altered in dissolved or, or similar and that can cause a blockage in the tube. Other complications are feed and drug interactions. So for patients that are on long feeding regimes where they might have be fed for, you know, 12, um this can affect them medication timing because certain medications such as um Floxacin or Phin or Warfarin um can interact with the feed and affect the absorption of either the drug or the feed. Um So always involve the pharmacist when you're converting someone's meds to ng appropriate because they will, they will work out what needs to be given when in relation to the feed. That's what the doctor of N or N feeling any quick questions about that form. Ok, I'll move on then. So gastrostomy or Jejunostomy. Um A few people have heard of this on the men meter. So this is a more long term solution. So on those patients that are going to require feeding or supplementation for more than 30 days is where we would consider a longer term solution like gastrostomy or Trost. Hopefully, this picture illustrates it quite well for anyone who's not familiar with these forms of feeding. It is essentially a tube that goes through the skin, through the subcutaneous fat all the way down into the stomach or the jug. This one's obviously depicting the stomach inside the stomach. What they have is a little balloon or almost like nut and bolt type um system that holds the tube in place internally. And you feed either in bolus feeding like bolus feeding or long term maintenance feeding. So usually overnight, like with feeding. So gets them when, when do they get them and how do they get them? So as I said, these are um these are for longer term um disorders. So for example, medical patients and those post and their swallow has not improved. They're very common candidates for these sorts of procedures, those with esophageal pathology. So again, malignancy structures and that sort of thing, head and neck, malignancy, brain injury, um a specific to jejunostomy. Um we've got patients that have gastroparesis or reduced gastric emptying. Um and how are they put in? So this is either done during endoscopy. So if um particularly if the patient is already having an endoscopy for diagnosis, et cetera, it can be done at the same time. It can also be put under radiological guidance or during a surgery itself and some of the complications that come with these. So again, you can get displacement. And one of the really important things with these tubes is if they fall out, you need to put something in that tract to avoid the tract, closing tracts can close in up to, you know, minimum of about four hours. So as soon as you notice that that tube has come out because often patients won't, particularly if they're very elderly and they have some sort of neurological issue. That means they're not able to communicate particularly well. They may not notice that this has come out. So if you notice this, you need to put something in the lumen of that tract to keep it open. I've seen um when this happened when I was on medical ward F one um that um a catheter. So a normal urinary sterile catheter was put through the, the lumen as soon as it was noticed, just to try and maintain the patency of that tube could also cause local leakage. So if there's any um area where it's not, you know, it's, it's loosened off. Um Obviously, this is gonna be a very acidic um environment. So if that's causing a leak around onto the skin, that's gonna be very irritant to the skin, you can also get infection or abscesses. Um You got what we call a buried bumper, which is that that mechanism inside. It's that balloon um system inside that holds it in place can erode through the mucosal wall of the stomach to a point where it can only partially or sometimes not at all be seen um on endoscopy and it, you can also get damage to the tube, which is gonna cause feeding problems. So that's some of the complications associated with those forms of feeding. And finally, we'll talk a little bit about TPN. Um So this is um why I say is the the most scary form of feeding probably because I, I feel least comfortable about it and about the makeup of it. Um Is it something you don't who was given I caliber vessel or a medium or cannula? Because it's very ir and can cause thrombophlebitis, it can be used alongside or as an alternative to oral nutrition. And if this is something that you think a patient may need, it's really important to think about early because you need to allow time to organize, getting a line put in, I know in the trust I work in that can take a week to get a slot to get a line. So it's something we need to think about early. Um I've just included this um small section on intestinal failure. This is um a description that I think is really useful when thinking about TPN. So type one intestinal failure refers, it all refers to the time scale and the changes that occur. So type one is an acute short term and usually self limiting condition. Um for example, a postop ileus where someone cannot have, they don't have a normally functioning G I tract because it's not working. You've got an ile S, it's, you know, paralytic ileus and they might need some support. So they might need T PM for, you know, a few days until the I resolves. Type two sort of prolonged acute condition. So patients, for example, that have been to theater, have very complex operations or being particularly unwell and they require TPN usually sort of ICU level for period of weeks, months um until they're at a point where they can um start having oral feeding again or type three, which is a chronic condition. So those patients that are quite stable, you know, this is something where they can manage at home and it's going to be, you know, months, years or irreversible even. So those have had multiple receptions, um those that have, you know, poorly controlled inflammatory conditions, that sort of thing and what complications come with TP A. So I think this is why it's quite scary because there's a lot more than the other, the other forms of feeding that we looked at and you can have complications related to the insertion. Um So the the line insertion, bleeding, misplacement, pneumothorax, um infection from the insertion itself which can compromise the whole use of the line. So, lines that get infected are extremely difficult to treat with antibiotics and quite often need to be removed, the patient given time to respond to antibiotics and then a new one put in, not a new one, put in stress wear. So it can be, you know, infection in any indwelling line is a big concern and a big worry. Um you can get line related complications. So thrombophlebitis, which we briefly talked about the line can brick, the line can become occluded and they're a little bit similar to your NG and G gastrostomy sort of complications, but then complications with PN itself. So it's a very hyperosmolar solution. Um you can get different os osmolality solutions. Um but the more concentrated, the more risk you are of causing thrombophlebitis. Um you can get poor glycemic control um with it with patients that have PN. So PN generally has a much higher glucose content than the body is used to managing. Um and it can't quite cope with this. So for all patients, but particularly those that have, for example, diabetes, they're going to have terrible glycemic control while they're adjusting to this can get micronutrient deficiency. So for those patients, this is all they're getting all, you know, if, if it's not in that bag of nutrition, they're not getting it at all. So we need to identify what, what sort of things they are missing in their set. Um TPN, you can get cholestasis, you get pancreatic atrophy. And this is because patients aren't having anything orally, they're not producing the same amount of stimulants, for example, cause cytokinin, they're not producing it. And because that's producing duodenum as a response to the influx of food and gastric content, they don't have that. So it can result in sort of pancreatic atrophy and other conditions, it can also be quite high volume. And so when I worked on a renal ward and we had to have um patients that had very specific PN that was low volume to try and meet their fluid restrictions. So it's something that you need to be aware of with all these patients and the main complication talk in could be. So in uh has reduced intake, either malnourished at the start or reduced intake, resulting in malnourishment is at risk of re feeding syndrome and it's a potentially fatal condition. So what it is is a shift in electrolytes of fluids after prolonged reduced intake and it presents biochemically in that of reduced potassium, reduced magnesium, reduced phosphate, and often a high glucose um which can cause encephalopathy. It can cause cardiac arrhythmias. It can cause edema life-threatening conditions. So we need to monitor those that are at risk very closely. So we want to monitor their BMS four times a day, even if they're not diabetic, want to do daily blood to monitor if their electrolytes or if they're deranged to start with possibly even more than once daily, want to replace any electrolytes that were already deficient. And we want to keep a very close fluid balance for these patients. And who do we class as at risk? Then who are we going to include in this, you know, at risk of re feeding syndrome and monitor really closely. So those that have had little or no intake for five days, if any of you have been on surgical wards on placement or our current ones on surgical wards, you know, that people have little unknow intake of five days. It's really, really common. Um, people can be kept nil by mouth for 23 days waiting for an operation and, or be so unwell that they don't want to eat, they don't feel they can, they're vomiting. Um, their intake is very poor. It's actually much more common than you might think. So, those are at risk but those that we really worry about those that are high risk. So those that have had little or no intake for 10 days, those that have a BMI of less than 16, those that have more than 15% or more weight loss over 3 to 6 months. And those that have deranged electrolytes prior to feeding, which will not be uncommon in those that have little in oral intake. And those are a severe risk. Are those with a BMI under 14 or have little or no intake for 15 days, which is a significant amount of time. So what we're gonna do about it? So as I mentioned, we want really good monitoring of these patients to avoid re feeding syndrome other things. So we put almost, but we never start feeding out of hours almost in certain situations. It is vitally important that we do start feeding patients and all trusts will have a re feeding policy and they have an emergency feeding protocol which starts off very slow, so very low and slow to avoid re feeding syndrome when perhaps dietitian cover isn't available, um, when they may not be able to be monitored as closely because there's one f one covering six watts and they have policies to try and avoid these complications. But also what we can do is, um, supplement these patients with vitamins, those that are high, high risk or severe risk. We want to, you know, there, there's such significant risk that we want to avoid that completely and we can give them pari, you might have heard of this, um, commonly given to patients, um, with alcohol excess history to avoid encephalopathy. So that's IV and it's bright yellow, you can't miss it. Um, in tablet form, thiamine or vitamin B core strong are things that you might again also see in, um, patients with alcohol excess and it's all to do with avoiding those complications, particularly that encephalos side of things. So I'm going to do a little couple of pas to finish to see if, if we've taken anything in from this session. Um, so I've got a few little cases. So what I want to know is for each of these scenarios, which of these would be the most appropriate feeding method. So, we've got 56 year old patient. He got two days post, right? Hemi. And that has a primary osmosis and no stoma. They feel nauseated, the bowels haven't opened yet, POSTOP. Um, but they're still passing wind So what feeding option might you suggest for this patient? So I'll give you all about 20 seconds to answer that. Ok. All right. So I think once I submit my option, um, it will close. So have a look what, what everyone's thought to. So the majority have gone for oral nutritional supplementation. Um, so that, that is what I would go with. So I think points that I've tried to make here are the patient feels nauseated. So their intake is probably going to be less than we'd hope. And the thing in particular about the enhanced recovery pathway, um we'd want to give them some good antiemetics. Um But we'd probably just want to supplement their diet. They're passing wind. So I'm not too concerned at this point about an IES. Um If this was day six and they're open in the bowels, that might be a different story. We were day two, the passing wind, not too concerned about an IES, but the feeling nauseated. So probably not getting that full oral intake. Um So oral nutritional supplementation would be what I would suggest in this situation. Excellent, well done. So next case is we've got an 84 year old post laparotomy for a perforated anterior duodenal ulcer that cause intraabdominal sepsis. What form of feeding may you use in this person? And there's not, there's always one correct answer. Um People will argue different things. Um So give it a go. What do you think so. I'll submit my answer in 10 seconds and then it will close. So the majority have gone for NJ Feeded and quite a few have gone for TPN. Um Would anyone like to explain why in the chart, why they would go for TPN? Or alternatively, why the micro? So if anyone would like to, to answer why, why they feel that TPN is most appropriate, please do um better recovery in what way do we have a, would they have a better recovery? I'll let you type that while I argue my point. So I would say this patient would be for NJ feeding. So key points here had a duodenal problem. So we're gonna give it a rest. We don't want to be feeding. Um that duodenum, there's a risk of it perforating again. Um But also this is likely to be quite a shortlived scenario. So they're likely to improve after, you know, a few days a week. Um I'm expecting they're going to return to the normal intake. So I think TPN might be slightly unnecessary. Um And I would go for NG in terms of better recovery. I mean, I, I sort of guessing what you mean by that in that you aren't ensuring that the nutritional requirements are met. Um But you can still do that with NG feeding. Um In an ideal world, we will, everyone will have optimal oral nutritional intake and we won't need to supplement them. So anything that's as close to that as possible. She's got no patient's got a normal functioning G I tract posts that duodenal ulcer. So let's try and use it where we can. And finally, um last one is what would be most appropriate. So we've got 47 year old who's got past medical history of Crohn's disease has had multiple resections following obstructions, fistulation disease, both small and large bowel. Um, not ideal as we try to avoid surgical intervention in um Crohn's patients. But when needs must, this patients obviously had had need for multiple operations. What might you suggest for this person? Just in the interest of time? I will submit my answer. So most people have gone for TPN here. Yeah. So TPN is the answer I would go for here. And the key point here is that they've had multiple resections. So they've probably got what we call shot gut syndrome, which means that the absorption of any G I feeding is going to be poor. Um to explain why you thought maybe she had lost me. But yeah, absorption is they've had multiple receptions and we want to try and probably avoid that G I tract because they're not going to get optimal nutrition from that. And this is that person with that type three failure where irreversibly they have had their absorption affected. Is it well done everyone? So just to summarize, we have these are the outcomes we hopefully have covered identifying patients that need nutritional optimization. What are the physiological effects of that and what support is available and specifically TPN? So, thank you all for attending. Um Here is a QR code for the um feedback. Once you complete feedback, um you'll get a certificate sent to you via medal little plug for next week. Um So next week is all radiology week. This is going to be a really good week. So we've got two speakers coming on Tuesday and we've got a consultant, radiologist and a radiology, um, SC two to cover in CT specifically with regards to general surgery, um, bit about other forms of radiological investigation, but that, that's gonna be a really good session, slightly longer session till half past eight just to give them both time to cover everything they'd like to. Um, and then on Thursday, we've got our orthopedic session which should be focusing more on x-ray interpretations, fractures, um, all your orthopedic um, problems. So it's going to be a really good week and we're halfway through the series now. So thank you all for coming. Um, and please please keep attending if you've got any questions, feel free to put them in the chat. Um, we'll stay on for a couple of minutes just to answer any of those.