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Good afternoon, everyone. Um, this is ST in our teaching um, series. Uh, today we have one of our brilliant dietician and nutritionist, uh ZB who will speak to us about nutritional management of the surgical patient. And for those who are online, we have food. So we wish you were here. But, uh, no, it's, uh, it's ok. So, uh, we thank for her time and for arranging everyone, everything and everyone from being here, they will be recorded. So guys, if you're missing, uh, it, we can, you will find it recorded on me and let's get started. All right, we did the night. So it, hello everyone. My name is Zip. I'm the surgical dietician. Yep. Ok. Today I'll be talking to you about the nutritional management of the surgical patient. So we're going to cover quite a bit. Um, I'll start off with malnutrition, uh, talk about our referrals album, um, POSTOP nutrition, early enteral feeding. And then we'll talk about some of the old supplements, um, routes of nutritional intervention, colorectal surgery, paralytic ili bowel obstruction, low fiber diet, pancreatitis, gallbladder disease. Oh, and, um, a little bit about our, our outpatient services. What is malnutrition. So um the European Society of Clinical Nutrition and Metabolism SN defines malnutrition as a stage resulting from a lack of intake or uptake of nutrition that leads to altered body composition and body cell mass. Um leading to a diminished physical and mental function and impair clinical outcome from disease which can result from starvation disease or advanced aging alone or in combination. Good. Yeah. Um it is prevalent in preoperative patients, especially in patients with underlying malignant disease. Um studies show that 50% of all hospitalized patients um present with MMM show on admission and um it's even higher in those with malignancy cancer patients. Um So, the consequences of um malnutrition include higher complications, infections, mortality, prolonged ventilator dependence and um ICU stay perioperative risks and delays, postoperative recovery. Um There's also major surgery, um elicits a series of reactions which is uh referred to as the stress response. Um is characterized by hypermetabolism, hyperglycemia, catabolism, increased lipolysis and sodium and water retention. Um So what happens is uh there's an increased circulation of catabolic hormones like cytokine and um postoperatively. And then this induces protein metabolism of glycogen, skeletal muscle and adipose tissue. Um and then this leads to significant muscle wasting uh where the turno turnover of um pro protein is increased, breakdown, accelerates and I synthesis. So, it's really important um for us to um screen patients early um assess their nutritional status um and minimize uh minimize any perioperative risk and support enhanced postoperative recovery in the UK. We use a Malnutrition universal screening tool, uh which involves the, um it is, it, it involves the current changes in tissue mass. So body mass index, involuntary weight loss, uh dietary intake related to presence of acute disease. And then those identified on um at risk of uh nutritional risk should be referred to the dietician. So I get quite a few referrals. Um, these are some of them. Uh So you've got the low albumin referral, high output stoma. Most of two. we see a lot of tube feeds, er poor appetite, gastric outflow obstruction, uh post iost advice, uh pancreatic enzyme replacement therapy, bowel obstructions, refeeding syndrome risk, uh severe acute pancreatitis, low fat diet, Freston. Um And yeah, I just, I just wanted to kind of um see what do you think? Which of these referrals do you think would be a reject from me? Any guesses for um poor appetite? Lovely. Yes. So lower albumin is albumin a marker of nutritional status, not in the infected period. No. Yes. So albumin is a, a visceral protein produced by the liver like all visceral proteins. Um and it's deemed a negative acute phase of reactant and during times of acute inflammation, plasma concentrations of albumin is reduced while production of proteins like C RP increases. Um So this is uh a chart of inflammation um with patient with inflammation. So as the C RP increases, albumin reduces uh the liver Reprioritize the protein production of um and albumin is downregulated. Um Also album has a long half life. It's so, so it's not a marker of acute changes in the nutritional state. Um and also decreases with renal losses and gi losses, gi tract losses, right? Post nutrition. Oh, so current guidelines recommend initiating oral intake on the first post operative date. In most cases, uh long periods of fasting should be avoided and uh provision of early postoperative nutrition is associated with fewer complications and it has positive impacts on outcomes. Uh for example, return of bowel function, reducing somatic leak, uh hospital length of stay and mortality. It's also important to note, no evidence suggests that um enteral nutrition should be delayed in the absence of bowel sounds. Um So the key benefits of early enteral nutrition, maintaining structural fun, functional gut integrity and reducing intestinal permeability, um attenuating the inflammatory response and favorably favorably modulate the immune system. It regulates the metabolic response, reducing insulin resistance. Um Also there is a higher risk of mortality when there's been an inadequate oral intake for more than 14 days of post surgery. Um and there's sub optimal fluid administration can also result in intestinal edema and reduced gut motility, contributing further to postoperative nausea and vomiting and postoperative vis er which we will cover later. Um So they can be contraindications of early enteral nutrition. Um This includes intestinal obstruction or eyes, high output fistula intestinal is ischemia, uh severe shock and severe intestinal hemorrhage. And um, in these instances, PN can be um, more appropriate. Um, if there is an intolerance to enter feeding, uh, pro kinetics should be started. Um, and intolerance will be evidenced by persistent vomiting or high gastric residual volumes. Um, it's important to note though that metoclopramide which is commonly used, um, is contraindicated in the initial 3 to 4 days post gi surgery. Uh, postpyloric feeding, uh, should be considered when prokinetic agents have failed in case of severe abdominal distention or anastomatic leak, enteral nutrition should be seized and PN should be considered. So the message is do not delay feeding. POSTOP. Don't wait for bowel sounds. Don't restrict diet POSTOP or delay nutrition, feed early for the best outcomes and gut rest equals atrophy. And you should consider trophic feeding which is, uh below the requirements. Uh, feeding below the requirements. Um We use a range of different ways to supplement nutrition. Uh These can be in the form of nutritional supplements as well as we tend to go food first. Um, diet optimization first. So these are some of the ones you might have seen and tried. Uh, I've got some to try here. Actually, II think haven't heard about 4040. One of my personal favorites, um, is the mocha flavor and then we've got Scan shake which make we make from fresh milk. I've made some there flavor 40 juice. We've got So we got, yeah, nut cream. This is more like a pudding. Um, we also have savory soups, um, which are similar to a composition of 40. So we've got quite a range. Would anyone like to try any at all? I think we should try the things we give you? Yeah. Ok. Oh, so we also have other routes of, um, nutritional therapy. So we have the enteral nutrition routes uh via oral or given by a feeding tube. Um, the tube will either be nasal, um terminating at the stomach. NG duodenum, ND Jejunum, NJ. It's the difference and then you will have longer, longer term feeding tube. Um, gastrostomy, it's an artificial external opening. Um It's either endoscopically inserted or radiologically inserted and then you will have a surgically inserted Ginos stomy. Um And then there's the parenteral nutrition route, feeding intravenously, bypassing the usual process of digestion, uh either through the central vein or the peripheral veins. So that's the difference between TPN NGN J peg Grigg, et cetera, colorectal surgery. Ok. Maybe I don't mind. Time. Was that she? Not loud? Yeah, this is ok. We have choc chocolate fatty kicks. So I think it will straighten us. Ok. That's fine. Um, so most patients can be recommended on a normal diet from the day of surgery. Uh, you tend to go through clear fluids, free fluids and soft, low residue diet. But um, it changes with institution and surgeon. Uh low fiber diet is recommended for 4 to 6 weeks. Yeah. Sure. Low residue and low fiber, low residue is a more dated term. It's outdated. We tend to go with fiber residue essentially means that it leaves a tiger in the gut. Um Whereas it's a bit ambiguous that time, so we tend to just say fiber so high output stoma um defined as more than 1.2 L output in the last 24 hours for two consecutive days. Um It can be quite common with uh patients who has less than 200 centimeters of residual small bowel with young age and high POSTOP white cell count are all associated um with the occurrence of high output. Um It also happens because uh codons main um role is to absorb water and electrolytes and it from ileostomy output can be high initially. Um So we should first rule out the following uh infective diarrhea, laxatives of prokinetic oral magnesium supplementation drives out for um Yes. So and uh rapid withdrawal of medications, sepsis, subacute bowel obstruction, uh short bowel, um small intestinal bowel, uh bacterial overgrowth disease, exacerbation of like Crohn's disease, cancer recurrence, et cetera. So, with the management, uh you can all find these guidelines, by the way on the um internet, on the High Apple guidelines with all the rationale as well. So stage one should be commenced uh replacing electrolytes as indicated, starting low fiber diet and increasing dietary salt. Um We would also like you to uh refer to dieticians. Er, so we can give that advice, 4 mg starting dose of loperamide four times a day. Um and it's also important with timings as well of meals, 30 to 60 minutes before meals and at bedtime, um prescribing PPI S omeprazole, 20 mg twice a day, uh restricting oral hypertonic fluids to less than 1 L per 24 hours and prescribing either Saint Mark's or IV Saline. So, um I was actually gonna make up some Saint Mark's for you guys to try as well, but there's a national shortage of sodium bicarbonate. Um So I couldn't make up any. Um It's very salty. Uh but we would um kind of make it more palatable by adding that flavorings squash can be added, for example. Um It's uh S Marks is actually like a iso osmolar solution. Uh which essentially means it has the same sodium glucose and potassium um in the same concentration as extracellular fluid. Uh So it won't cause fluid shifts in the gi tract. Um And also one thing to note about, about loperamide. We should avoid liquid loperamide as it's high and sorbital and will exacerbate high outcome. It's a stage two following this management. If the output is still high, we'll continue the low fiber diet. Um increasing dietary salts um continue to restrict the fluids to 1 L and replace the um deficit with S Marks or IV Saline. Increase loperamide to 8 mg. Q DS. And then uh we would also consider increasing the PPI as well to 40 mg feeding. And then if it's still high, you would need to refer to the nutrition team, um add them on 475 and um continue the loperamide dose. Um And then we would uh consider in uh starting a dose of codeine phosphate, 30 mg twice a day titr up to 60 mg if required. Um and then uh further restrict the hypertonic fluids to less than 500 mils per 24 hours. That's how you make it say solutions. Uh we will order the glucose and so you and um just make it up on the award. Huh? Um Yeah. So paralytic ileus, what is it? It is a the transiency of bowel um motility following surgical intervention. Um, a lack of postal within the digestive tract results in a build up of fluids and gas within the intestine resulting in functional obstruction. Um And um the criteria for diagnosis is absence of mechanical obstruction, nausea, vomiting, intolerance to oral intake, obstipation, um, abdominal distension and pain. Um, some degree of gut paralysis is expected following surgical intervention. However, this usually lasts around um only for 24 hours in the small bowel and 48 to 72 hours in the codon. Uh prolonged postoperative v occurs in around the 16% of patients following surgery to the codon management is usually by to keep patients near by mouth and replace IV fluids. Um So it's symptom control. Um It is quite important to maintain the hydration status and prevent electrolytes imbalance. Um So it's really important to measure the fluid input versus output. Um If the patient is without nutrition for 5 to 7 days or deemed unlikely to have nutrition for 5 to 7 days, then PN um should be considered. Ok. So PN referrals, they need to be made by a consultant or registrar. Um They need to be made by 10 a.m. You need to have central access CBC or PICC line and also have full user. These uh ready including bone profile and um magnesium corrections are required. You should also be cautious with IV fluids and double dextrose has 200 calories um per liter, I believe. And also PN should be discussed with the patient prior to the referral. Oh, bowel obstruction. So, symptom control is usually the priority in bowel obstruction. Um NG is using for drainage um considered to alleviate the vomiting. PN is not indicated if the bowel obstruction is intermittent or incomplete gut function is maintained. Um We tend to follow a um clear, clear fluids, free fluids and then soft diet and increase the consistency of foods if symptoms improve or return to clear fluids if they remain. If the patient remains symptomatic. Um Long term long low fiber diet is recommended for patients who have stricturing uh from adhesions or malignancy. Um without the management, it's just that the order um starting them after, you know, let's say we do an operation. Um we remove part of the bowel or we just elevate the adhesion, it cut the adhesion. Um-hum. Uh Do we start with clear free fluids and soft diet? Yes. And then we would just increase the consistency. We will um keep reviewing. If they're, if they're not symptomatic, then we'll go up to the next stage. So this is, this is what it tends to look like in hospital. Uh so clear fluids can be anything from clear fruit juice. Also, Fty Juice is a clear fluid uh soups, er consumer soups, coconut water Lucozade. And then you've got the free fluids which um gives us more flexibility with our supplements. Um Milky coffees, soups, thin custards, jelly, ice creams and then the soft diet. Um what it looks like in hospital, it tends to be like soggy cereal. It doesn't sound great. But um and then you've got ready brick eggs, cottage shepherd's pie, poached fish, things that can be mashable with a fork. Really? Um Back to your question, why do we keep going on about low fiber? So low fiber diet then tends to reduce of the stools and um reduces the risk of fecal loading, constipation and recurrence of symptoms of abdominal bloating pain in early satiety. So, fiber tends to be quite hard for the bowels to digest. Um and it cause it uh the stools and it also kind of um, keeps the bowels moving. So what about just giving a leaflet? I've been on this before. Um It has risks. So if you, it's quite a restricted diet to be on um low fiber. Um so, or, or it might not be adequate where the patients um under restricted. Um So I tend to follow up my low fiber patients and um I would advise them whether to introduce or restrict even further. Um So foods high in fiber include whole meal grains, nuts and seeds, legumes, chickpeas, lentils, skin spits and seeds or fruits and vegetables. There's a lot of typos there. I don't know. Um So let's play a game high and low. Oh, what's going on? Oh, ok. Can anyone tell me if this is high fiber or low fiber if you eat the whole thing? High. Yes. Um The fiber content of the beans and then the skin of the potatoes as well. High or low fiber. Yes. Yes. Yeah. Lentil, lentil is what I touch. That is high or low. Yes. You guys are good high or low. Spaghetti, bolognese. No. Well, if you eat the leaves, is it whole? Yes, because of the whole meal spaghetti. Otherwise it's relatively low in terms of the sauce high or low. It's like it um like preserved. Yeah. Yes, it's low. We tend to say you can have fruit um especially tinned fruits and you know, prepared in a certain way. That's low. In fiber pancreatitis. So, guidelines um of acute pancreatitis. Um Number one, ensure the patients, people with acute pancreatitis are not made near by mouth or don't have any food withhold unless there's a clear reason for this or if they have like vomiting. Um, you should offer enteral nutrition to anyone with severe or moderately severe acute pancreatitis. Um, start within 72 hours of presentation and aim to meet their nutritional requirements as soon as possible. Um Anyone with severe or moderately severe acute pancreatitis should be offered. PN um only if nutri enteral nutrition has failed or is contraindicated. Uh people with chronic pancreatitis are very high risk of malabsorption, malnutrition and deterioration in their quality of life. Um Also a assessment by dietician should be considered for anyone diagnosed with chronic pancreatitis. So I tend to see a lot of severe acute pancreatitis. Um Early nutritional intervention is essential in this um group of patients. Um The early nut uh intervention with enteral nutrition is associated with reduced morbidity and mortality or wine. Ok. Yeah. Um The decision for the route of feeding, it should be a clinical one. with patients who cannot tolerate NG feeding and showing signs of developing gastric outflow obstruction or have significant inflammation in the head of the pancreas and therefore likely to develop. Um extrinsic duodenal compression are recommended um to insert an NJ for feeding. Um The earlier in the disease, the process of NJ tubes are inserted the less difficult the procedure is later on when the um collections grow. Um Also, um we tend to use a predigestive feed, a peptide based feeds. Um, it's quite difficult to determine if a patient is um tolerating the feed, especially with severe acute pancreatitis. There's a lot of other factors that can be kind of contributing to intolerance of the feed. So, antibiotics, opiates, edema of and um on the bowel function, uh influence of um peripheral edema, ascites on the body weight and the effect of prolonged catabolic state. Um use of paralytics, sedation or muscle functions tests. So, um with experience, it's safer to use peptide based uh feed first line. And uh once an oral diet is resumed, there's very limited data to suggest how this should be carried out. So, most of us, er, believe that low fat foods should be tried first, but evidence is only available for the introduction of soft foods. So, low fat diet is not indicated. So, pancreatic exocrine insufficiency and pancreatic enzyme therapy. So, it's quite common, especially with acute pancreatitis. Prevalence is around 60 to 80% of patients with severe acute pancreatitis, 13 to 39% in those with mild disease. Um because it's such a um complex in determining presence of pancreatic enzyme insufficiency and it has very detrimental effects. Um if untreated, all patients with severe acute pancreatitis should be started with pancreatic enzyme replacement. Um as soon as they begin feeding, uh this should be continued until they're fully recovered. Um So doses are escalated until symptoms are under control. So we can increase this to the doses as much as we need. Um It should be swallowed with a cold drink um stored below 25 degrees and capsules distributed throughout the meals. Um The branding is Creon Pancre or Nutrizym starting those. Uh what we recommend is free with meals to with snacks. And then um so what, what does the Creon have? It has lipase protease amylase to fat protein and starch. Um So patients with symptoms of babs sop um where the diagnosis is unclear, fecal elastase should be performed. Um Anything below 500 is um shows pancreatic enzyme um insufficiency. Yeah, the nature in um hot temperatures. Yeah, it's also important to kind of store it in um colder cool places as well. Um And just a quick note on type three C diabetes. Uh 40% of patients um acute pancreatitis develop type three C diabetes. Um It should uh careful blood glucose monitoring is essential during the acute management and poor glycemic control um is seen in patients with erratic oral intake, nearby mouth times inflammation and infection can, can be quite difficult to manage. It's a quick note about gallbladder disease and low fat diet. Uh there's no published evidence um of the benefits of a low fat diet compared with a standard diet in gallbladder disease. Um This is because the gallbladder contracts um spontaneously and in, in response of mixed meals, protein or fat stimulation. So, um it doesn't just contract with fat. Um just a little bit about some of the services we have at Kingston for any um discharge planning uh colorectal cancer patients are usually under me. Um I would do my telephone clinics or I would see them in if they are for chemo in the chemo clinic. Um And then we have gastro dietetic um outpatients. If your patient has a stoma IBD IBS pancreatitis, we also have a home mental feeding um service. Uh We have general dietetic clinics for things like diverticulitis, weight management, low BMI um oncology clinic for all cancers, um who patients that are having their treatment here. Um And then we have the ICU rehab clinic with a dietician for anyone that stays longer than five days. Real footage of me right away. Not really. So let's play another game 22 and one line. Let's see how well you were listening. So, 50% of all hospitalized patients are malnourished. Albumin has a short half life, liquid loperamide should be avoided in high output stoma management which runs the lie. Do they offer liquid loperamide? Then what's the point if it causes diarrhea and it is an antidiarrheal? What is the actual point of just having it as a thing? I don't know. I don't know for it. You should look into that. Yeah, I guess it's something you can't tolerate, but then it just does, it cause diarrhea in all patients? Yeah. Oh, ok. Then it's probably a little cold. I'm gonna delve into that. And I'll let you know. Um, moss screening involves assessment for cachexia and sarcopenia, including obesity, sarcopenia. No evidence for recommendation of low fat diet in pancreatitis, predigestive peptide feed is used as the first line in um severe acute pancreatitis, which was the lie. No, that's true. True. True. No, my screening does not involve assessment of just like skip. Um Yeah. So moss screening only shows the BMI if there's been a weight loss and if there's been poor um intake with like a um if they're clinically unwell. So it doesn't account for things like muscle loss. That's where we would come in and do assessments like whip strength. Um And yeah, that's about it. And um so mid upper arm circumferences we do um quite a few for pulmonary assessments. Ok. Uh Which one's the lie low fiber diet is recommended following all colorectal surgeries. Saint Mark's is an iso osmolar solution. Codeine phosphate, uh 30 mg BD should be started in stage two of high output stone management. Is it stage three? Yeah. Do we agree? So, is it like at least 1 to 2 week if you have a and then if you do have a 6 to 8. So it is all of them? Yeah. So which one is alive? Yes. Yes. So codeine is on stage three, I already seen one patient with Yeah, we should really titrate the loperamide first and then use codeine. OK. Questions. I thought this was really cute. Nothing to do with a It's so cute. You about that like a rat? OK. Now before we have like uh both us from so questions guys, questions. Yeah, very good job. Um Quick question. If we have a patient, let's say with a glass score of two or three and uh for pancreatitis, sorry, it's a, a score that predicts severity. Um but there are not severe pancreatitis yet. Yes, when we admit him and we think this patient is higher risk of becoming severe. Um Should we like preemptively refer to that? Yes. Yeah. Um As the guidelines suggest. Yeah. Uh um if we anticipate like the collection growing or there's the collection has not formed yet or we, yeah, we need to get in there quick before it causes a full obstruction. Um Otherwise you will, the only other route is PN. So um we need a nasal, nasal gin tube insertion. Yeah. Any other questions? Oh, do we have a chat here? Yes. Where? Hm. That's five new messages. Hello, everyone at home. Oh, and then um some high, high. Oh, no, we didn't see. Yeah, some. Hello. Hello, Ellen. Where are you, Jada? We do have a chat. Ok. So put your questions in and if you have a question also think the HED cut out Charlotte. This is another red flag. Check the Ph OK, great presentation. Thank you for listening. Ellen. OK, guys. Um Once we remove some self incriminating statements that I made, I will, I'm joking. Yeah. Um I will um I will upload it to metal so I think you can watch it and uh if X is fine with it, uh we have uh we can upload the pedia as well if it's fine with you. Ok. Yeah. Sure. Yeah. Uh, metal is, uh, like a very popular, uh, like the Royal College has it. So it's like, it's like youtube for doctors. Yeah. Yeah, it's really good. Yeah. Yeah. Yeah. Well, um, so thank you everyone and thank you. Uh, if you have any questions, uh, you can drop them and I'm always here or. Yeah. Yeah, of course. Um, also we'll get at least, uh, complete your post event feedback. So you get your certificate of attendance and, uh, I will send you a certificate of teaching. Ok. Ok. Ok. All right.