POST SURGERY NUTRITION SUPPORT

RATIONAL FOR NUTRITIONAL SUPPORT

Nutritional depletion has been demonstrated to be

a major determinant of the

development ofpost-operative complications.

Nutritional support leads to

improved nutritional status

and clinical outcome in

severely depleted patients.

Gastrointestinal surgery patients are at

risk of nutritional depletion from

inadequate nutritional intake, surgical stress & increased metabolic

rate.

Studies of postoperative

nutritional support have demonstrated reduced morbidity and reduced length

of hospital stay.

ALL THE NUTRITIONAL NEEDS COULD NOT BE MET BY NATURAL FOODS RIGHT AFTER SURGERY

▪ Calories: ▪ Increase to 30-40 kcals/kg▪ Patient on ventilator usually require less calories ~20-25 kcal/kg

▪ Protein:▪ Increase to 1-1.8 grams/kg

▪ Fluids: ▪ Individualized

POST-OPERATIVE NUTRITION REQUIREMENTS

METHODS OF NUTRITIONAL SUPPORT

▪ Use gastrointestinal tract if available

▪ Prolonged post-operative starvation is probably not required

▪ Early enteral nutrition reduced post-operative morbidity

An alternate means of providing nutrients to people who cannot eat any or enough food

HOW EARLY????▪ Enteral Nutrition usually can begin post operatively as

soon as the patient is haemodynamically stable.

Preferably it should start within 24 hours after surgery

and no later than 48 hours.

▪ As long as there is no significant abdominal distension,

or flatus enteral feeding is not contraindicated.

ENTERAL ACCESS DEVICES

ORAL NUTRITION SUPPLEMENT

▪ Patients who are malnourished either at the time of, or

shortly following, major abdominal or vascular surgery have

a more rapid recovery of nutritional status, physical function

and quality of life, if given nutritional advice and prescribed

routine oral supplements in the immediate postoperative

period and following two months.

(Postoperative management in adults, A practical guide to postoperative care for clinical staff. Scottish Intercollegiate Guidelines Net work. Aug 2014)

ADVANTAGES OF EARLY ENTERAL FEEDS IN POST OPERATIVE PATIENTS

▪ Enteral feeding reverses mucosal atrophy induced by starvation and it increases anastomotic collagen deposition and strength.

▪ Enteral feeding helps in wound healing.

▪ Early Enteral feeding reduces septic morbidity after abdominal trauma and pancreatitis.

▪ Early Enteral feeding helps to increase the strength of the tissues.

GASTROINTESTINAL DYSFUNCTION IN ICUIT OCCURS FREQUENTLY IN CRITICALLY ILL PATIENTS AND IS

ASSOCIATED WITH ADVERSE OUTCOMES

Difficulty for ICU patient to maintain adequate nutrition is that patients commonly have gastrointestinal dysfunction caused mainly by failing intestinal motility plus due to Fecal lost.

-The diarrhea frequently observed in ICU may be ascribed to several causes, including the use of drugs or laxatives.

-Absorption of both energy and all macronutrients is significantly less in patients if fecal output exceeds 350 g/day.

▪

SEMI-ELEMENTAL DIET▪ Although semi-elemental formulas cost more than polymeric formulas they are still widely used because

they are believed to be better absorbed, less allergenic, better tolerated.

▪ Semi elemental diet is designed for use in patients suffering from maldigestion and malabsorption.

▪ They contain dipeptides, tripeptides and some free amino acids as nitrogen source and variable doses of fat in the form of long chain triglycerides and MCTs, carbohydrates, minerals, vitamins and trace elements.

▪ Therefore, it is recommend that enteral support with a peptide-based diet is safe and extremely useful in the catabolic, critically ill patient or in patients with significant gastrointestinal malabsorption associated with a protein-losing enteropathy .

1. Brinson, R R; A reappraisal of the peptide-based enteral formulas: clinical applications. Nutr Clin-Pract. 1989 Dec; 4(6): 211-7

Semi elemental diet

• Critical illness or malnutrition affects the Gut nutrient intake and barrier function

• Gut permeability increases - higher risk of potential Bacterial translocation and Sepsis

Maintains Gut Integrity

SEMI-ELEMENTAL FORMULA ▪ Gastrointestinal (GI) intolerance symptoms are the limiting factor to enteral alimentation in the

immediate postoperative period.

▪ Study has been conducted to postulate semi elemental diet might be better absorbed and better tolerated so as to avoid the need for TPN, to the patients undergoing major abdominal surgery.

▪ Feeding begun 6 hr postoperatively at 25 ml/hr and increased by 25 ml/hr at 12-hr intervals up to the rate providing 1.5 times the calculated REE (via jejunostomy &TPN regimen).

▪ Although overall mean daily calorie and nitrogen intakes were lower for the enteral than for the TPN group, the enteral group was nevertheless in positive caloric and nitrogen balance, and maintained similar serum albumin, prealbumin, and plasma transferrin levels.

GI tolerance to enteral feeding was excellent during the first three postoperative days, allowing the progression of the feeding rate to 99% of goal.

Hamaoui E, Lefkowitz R;Enteral nutrition in the early postoperative period: a new semi-elemental formula versus total parenteral nutrition. JPEN J Parenter Enteral Nutr. 1990 Sep-Oct;14(5):501-7.

CONT….

▪ Average daily cost of supplies was more than double in TPN in comparison with EN (jejunostomy).

▪ Conclusion: enteral feeding using this formula is well tolerated and cost-effective in the immediate postoperative period.

Hamaoui E, Lefkowitz R;Enteral nutrition in the early postoperative period: a new semi-elemental formula versus total parenteral nutrition. JPEN J Parenter Enteral Nutr. 1990 Sep-Oct;14(5):501-7.

STUDY OF PEPTIDE DIET IN LIVER TRANSPLANT▪ Peptide-based enteral formula diet as started around 14 days after liver transplantation

- End-stage liver disease score in the experimental group was significantly lower than that in the control group

- Elevation of enzymes in the liver function tests such as alanine aminotransferase and total bilirubin, and C-reactive protein in the experimental group had significantly improved, and became almost normal values.

- These findings suggest that administration of whey-hydrolyzed peptide attenuates the post-transplant liver dysfunction and may avoid an unnecessary liver biopsy.

Arakawa Y, Shimada M, Effects of a whey peptide-based enteral formula diet on liver dysfunction following living donor liver transplantation. Surg Today. 2014 Jan;44(1):44-9.

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