Surgical Nutrition

Given at the 2014 AAPA national CME conference

1. Surgical Nutrition Kristopher R. Maday, MS, PA-C, CNSC University of Alabama at Birmingham Physician Assistant Program Department of Nutritional Sciences Is It Still NPO Until Bowel Function Resumes?

2. 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

3. 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

4. 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. .

5. 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.

6. Pre-Operative Risk Reduction Nutritional assessment Concept of “prehabilitation” Pre-operative fasting

7. Nutritional Assessment Nutritional Risk Screening (NRS) 2002 Pre-operative serum albumin < 3.0 mg/ dL Impaired Nutritional Status Severity of Disease Absent Normal Nutritional Status Absent Normal Nutritional Requirements Mild 1 Weight loss > 5% in 3 months 50-75% of usual food intake over last week Mild 1 Hip fracture Cirrhosis, DM, Benign Cx Hemodialysis, COPD Mod 2 Weight loss > 5% in 2 months BMI 18.5-20.5 with impaired general condition 25-50% of usual food intake over last week Mod 2 Major abdominal surgery Stroke, PNA, Malignancy Severe 3 Weight loss of > 5% in 1 month Weight loss > 15% in 3 months BMI < 18.5 with impaired general condition 0-25% of usual food intake over last week Severe 3 Head injury Bone 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. .

8. Prehabilitation 12x increase rate of surgical complications in obese patients Increase rate of post-operative complications with hemoglobin A 1 c > 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. .

9. 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 .

10. Post-Operative Ileus http://melokinex.com/POI.html Hormones and Neuropeptides (CCK, CGRP, VIP, IL-1, TNF- ɑ) Surgical Manipulation Anesthesthesia Endogenous opiate r elease 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

11. Post-Operative Ileus Location Symptoms Signs Management Time to Resolution Stomach Nausea +++ Vomiting +++ Abdominal Pain + Distention + Succussion Splash NG Tube Metoclopramide Erythromycin 12-24hr Small Bowel Nausea ++ Vomiting ++ Abdominal Pain + Distention ++ NG Tube Alvimopan ( Entereg ) 6-12hr Colon Nausea + Vomiting + Abdominal Pain ++ Distention +++ Neostigmine Decompress 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

12. 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

13. 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

14. Banerjee B. Nutritional Management of Digestive Disorders.. 2011. Vassilyadi F, et al. Nutr Clin Pract .. 2013;28:209-217.

15. Enteral Nutritional Support Started 24-48 hour after surgery Access

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

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

18. Enteral Nutritional Support Lewis SJ, et al. BMJ . 2001;323:1-5.

19. Enteral Nutritional Support Complications Abdominal distention Aspiration Diarrhea Iatrogenic injury http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Dec3%284%29/Pages/23.aspx

20. Total Parenteral Nutrition Admixture of amino acids, dextrose, lipids, vitamins, minerals, and electrolytes Indications Non-functional GI tract Failure of PO/enteral route

21. Total Parenteral Nutrition Access Central Line Tunneled/Cuffed Catheter PICC Line Ports Peripheral IV

22. 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.

23. Heyland DK, et al. JPEN . 2003;27:355-373

24. Monitoring Nutritional Support More ≠ Better Accurate calori c intake Promote nitrogen retention Laboratory studies Acute Phase Reactants ≠ Helpful NICE Guidelines. Nutritional Support in Adults. 2006

25. 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

26. 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

27. 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

28. 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.

29. Kristopher R. Maday, MS, PA-C, CNSC Email : [email protected] Twitter: @PA_Maday Thank You For Your Time