Surgery and Surgery and Nutritional SupportNutritional Support

Chapter 22Chapter 22

Surgery and Nutritional SupportSurgery and Nutritional Support Malnutrition continues to occur among Malnutrition continues to occur among

hospitalized patients, many of whom are hospitalized patients, many of whom are surgical patientssurgical patients

The surgical process brings added The surgical process brings added nutritional demands and risks for clinical nutritional demands and risks for clinical problemsproblems

Careful attention to preoperative and Careful attention to preoperative and postoperative nutritional support can postoperative nutritional support can reduce complications and provide reduce complications and provide essential resource for healing and healthessential resource for healing and health

Surgery and Nutritional SupportSurgery and Nutritional Support

Key ConceptsKey Concepts– Surgical treatment requires added nutritional Surgical treatment requires added nutritional

support to tissue healing and rapid recoverysupport to tissue healing and rapid recovery– The special nutritional problems of GI surgery The special nutritional problems of GI surgery

require diet modifications because of the require diet modifications because of the surgery’s effect on normal food passagesurgery’s effect on normal food passage

– To ensure optimal nutrition for surgery To ensure optimal nutrition for surgery patients, diet management may involve patients, diet management may involve enteral and/or parenteral nutrition supportenteral and/or parenteral nutrition support

Nutritional Needs of General Nutritional Needs of General Surgery PatientsSurgery Patients

Nutritional deficiencies can easily Nutritional deficiencies can easily develop develop malnutrition and clinical malnutrition and clinical complicationscomplications

Pay careful attention to:Pay careful attention to:– Nutritional status pre-surgeryNutritional status pre-surgery– Individual nutritional needs post-surgery Individual nutritional needs post-surgery

for wound healing and rapid recoveryfor wound healing and rapid recovery

Poor Nutritional StatusPoor Nutritional Status

Defining factors:Defining factors:– Impaired wound healing, immune systemImpaired wound healing, immune system– Increased risk of postoperative infectionIncreased risk of postoperative infection– Reduced quality of lifeReduced quality of life– Impaired immune systemImpaired immune system– Impaired function of gastrointestinal tract, Impaired function of gastrointestinal tract,

cardiovascular system, respiratory systemcardiovascular system, respiratory system– Increased hospital stay, cost, mortality rateIncreased hospital stay, cost, mortality rate

Preoperative Nutritional Care: Preoperative Nutritional Care: Nutrient ReservesNutrient Reserves

Nutrient reserves can be built up prior to Nutrient reserves can be built up prior to elective elective surgery to fortify a patientsurgery to fortify a patient

ProteinProtein deficiencies among surgical deficiencies among surgical patients are commonpatients are common

Fortify with adequate body protein in Fortify with adequate body protein in tissues and plasma to counteract blood tissues and plasma to counteract blood losses during surgery and prevent tissue losses during surgery and prevent tissue breakdown in the immediate postop periodbreakdown in the immediate postop period

Preoperative Nutritional Care: Nutrient Preoperative Nutritional Care: Nutrient ReservesReserves

Energy: Sufficient kilocalories are required to spare protein for tissue-building– Extra carbohydrates

maintain glycogen stores

Vitamin/mineral deficiencies should be corrected

Water balance sufficient to prevent dehydration

Immediate Preoperative Immediate Preoperative PeriodPeriod

Patients are typically directed not to Patients are typically directed not to take anything orally for at least eight take anything orally for at least eight hours prior to surgery.hours prior to surgery.

Prior to gastrointestinal surgery, a Prior to gastrointestinal surgery, a “nonresidue” diet may be prescribed.“nonresidue” diet may be prescribed.– P. 435 Table 22-1P. 435 Table 22-1

Nonresidue elemental formulas Nonresidue elemental formulas provide complete diet in liquid form.provide complete diet in liquid form.

Nonresidue DietNonresidue Diet

Diet includes only those foods that Diet includes only those foods that are free of fiber, seeds, and skins.are free of fiber, seeds, and skins.

Prohibited foods include fruits, Prohibited foods include fruits, vegetables, cheese, milk, potatoes, vegetables, cheese, milk, potatoes, unrefined rice, fats, and pepper.unrefined rice, fats, and pepper.

Vitamin/mineral supplements are Vitamin/mineral supplements are required for prolonged nonresidue required for prolonged nonresidue diet.diet.

Post Operative Nutritional CarePost Operative Nutritional Care Nutrient Needs for Nutrient Needs for

HealingHealing Postoperative Postoperative

nutrient losses are nutrient losses are great, but food intake great, but food intake is diminished.is diminished.

ProteinProtein: losses occur : losses occur during surgery from during surgery from tissue breakdown and tissue breakdown and blood loss.blood loss.– Catabolism usually Catabolism usually

occurs after surgery occurs after surgery (tissue breakdown and (tissue breakdown and loss exceed tissue loss exceed tissue buildup).buildup).

Need for Increased ProteinNeed for Increased Protein

Building tissue for Building tissue for wound healingwound healing

Controlling shockControlling shock Controlling edemaControlling edema Healing boneHealing bone Resisting infectionResisting infection Transporting lipidsTransporting lipids

Problems Resulting From Protein Problems Resulting From Protein DeficiencyDeficiency

Poor healing of wounds and fractures Poor healing of wounds and fractures Rupture of suture lines (dehiscence)Rupture of suture lines (dehiscence) Depressed heart and lung functionDepressed heart and lung function Anemia, liver damageAnemia, liver damage Failure of GI stomas to functionFailure of GI stomas to function Reduced resistance to infectionReduced resistance to infection Extensive weight lossExtensive weight loss Increased mortality riskIncreased mortality risk

Wound DehiscenceWound Dehiscence

Other Postoperative Concerns and Other Postoperative Concerns and CareCare

WaterWater: Ensure sufficient fluids to : Ensure sufficient fluids to prevent dehydrationprevent dehydration– Loss of water can occur from vomiting, Loss of water can occur from vomiting,

hemorrhage, fever, infection, or diuresishemorrhage, fever, infection, or diuresis Energy: Energy: Provide sufficient nonprotein Provide sufficient nonprotein

kcalories for energy in order to spare kcalories for energy in order to spare protein for tissue building- mainly protein for tissue building- mainly CHOsCHOs

Other Postoperative Other Postoperative Concerns and CareConcerns and Care

Vitamins: Vitamins: Ensure adequate vitamins Ensure adequate vitamins – esp. Vit. C in the postop period; Vit. – esp. Vit. C in the postop period; Vit. B’s become important as energy and B’s become important as energy and protein intake are increasedprotein intake are increased

Minerals: Minerals: Ensure adequate Ensure adequate potassium, phosphorus, iron, zincpotassium, phosphorus, iron, zinc

Avoid electrolyte imbalancesAvoid electrolyte imbalances

Special ConsiderationSpecial Consideration

Post op Bariatric Post op Bariatric surgery:surgery:

Typically have Typically have deficiencies in deficiencies in macro- and macro- and micronutrients for micronutrients for an extended an extended period of timeperiod of time

Vitamin and mineral Vitamin and mineral supplementation supplementation post oppost op

Initial Intravenous Fluid and Initial Intravenous Fluid and ElectrolytesElectrolytes

Oral feeding is encouraged as soon Oral feeding is encouraged as soon as possible after surgery.as possible after surgery.

Routine postoperative intravenous Routine postoperative intravenous fluids supply hydration and fluids supply hydration and electrolytes, not kcalories and electrolytes, not kcalories and nutrients.nutrients.

Methods of FeedingMethods of Feeding

Oral Feeding Allows more needed nutrients to be added Stimulates normal action of the

gastrointestinal tract Can usually resume once regular bowel

sounds and passing of gas return Progresses from clear to full liquids, then

to a soft or regular diet Individual tolerance and needs are always

the guide

Methods of FeedingMethods of Feeding

Enteral: when regular oral feedings Enteral: when regular oral feedings are not tolerated, nutrient formulas are not tolerated, nutrient formulas may be fed by tubemay be fed by tube– Preferred if the GI tract can be usedPreferred if the GI tract can be used

Parenteral: nourishment Parenteral: nourishment administered directly into the blood administered directly into the blood circulation through small peripheral circulation through small peripheral veins or large central veinveins or large central vein

Tube FeedingTube Feeding Used when oral Used when oral

feeding cannot be feeding cannot be tolerated d/t:tolerated d/t:– Coma stateComa state– Severely debilitatedSeverely debilitated– Radical Radical

heal/neck/face heal/neck/face surgerysurgery

Nasogastric (NG) Nasogastric (NG) tube is most tube is most common routecommon route– Inserted through the Inserted through the

nose nose stomach stomach

Tube FeedingTube Feeding Nasoduodenal (ND) Nasoduodenal (ND)

or nasojejunal tube or nasojejunal tube more appropriate more appropriate for patients at risk for patients at risk for aspiration, for aspiration, reflux, or reflux, or continuous vomitingcontinuous vomiting– Tube passed Tube passed

through stomach through stomach into the into the appropriate appropriate section of the section of the small intestinesmall intestine

Alternate Routes for Enteral Tube Alternate Routes for Enteral Tube FeedingFeeding

Esophagostomy Esophagostomy – a – a cervical cervical esophagostomy is esophagostomy is placed at the level of placed at the level of the cervical spine to the cervical spine to the side of the neckthe side of the neck– This placement This placement

removes the removes the discomfort of the discomfort of the nasal route and nasal route and enables the entry enables the entry point to be easily point to be easily concealed under concealed under clothingclothing

Alternate routes: enteral tube Alternate routes: enteral tube feedingfeeding

Percutaneous Percutaneous endoscopic endoscopic gastrostomy (PEG)gastrostomy (PEG) – gastrostomy tube – gastrostomy tube surgically placed surgically placed through the through the abdominal wall into abdominal wall into the stomachthe stomach

Alternate routes: enteral tube Alternate routes: enteral tube feedingfeeding

Percutaneous Percutaneous endoscopic endoscopic jejunostomy (PEJ)jejunostomy (PEJ)– Surgical Surgical

placement of placement of jejunostomy tube jejunostomy tube through the through the stomach wall, stomach wall, passed through passed through the duodenum the duodenum jejunumjejunum

Tube-Feeding FormulaTube-Feeding Formula

Generally prescribed by the physician and Generally prescribed by the physician and clinical dieticianclinical dietician

Important to regulate amount and rate of Important to regulate amount and rate of administration. Start slow - due to:administration. Start slow - due to:– Concentrated nutrientsConcentrated nutrients– Smaller capacity if not fed for several Smaller capacity if not fed for several

daysdays Diarrhea is most common complicationDiarrhea is most common complication Wide variety of commercial formulas Wide variety of commercial formulas

available available

Parenteral Feeding RoutesParenteral Feeding Routes

Peripheral parenteral nutrition (PPN): uses Peripheral parenteral nutrition (PPN): uses less concentrated solutions through small less concentrated solutions through small peripheral veins when feeding is necessary peripheral veins when feeding is necessary for a brief period (10 days)for a brief period (10 days)

Total parenteral nutrition (TPN): used Total parenteral nutrition (TPN): used when energy and nutrient requirement is when energy and nutrient requirement is large or to supply full nutritional support large or to supply full nutritional support for long periods of time through large for long periods of time through large central veincentral vein

Peripheral Parenteral Peripheral Parenteral NutritionNutrition

Catheter Placement for TPNCatheter Placement for TPN

Central Venous CatheterCentral Venous Catheter

Mouth, Throat, and Neck SurgeryMouth, Throat, and Neck Surgery

This surgery requires modification in the This surgery requires modification in the mode of eating.mode of eating.

Patients cannot chew or swallow normally.Patients cannot chew or swallow normally. Oral liquid feedings ensure adequate Oral liquid feedings ensure adequate

nutrition.nutrition. When able to advance: mechanical soft When able to advance: mechanical soft

diets diets Tube feedings are required for radical Tube feedings are required for radical

neck or facial surgery or comatose stateneck or facial surgery or comatose state

Stomach SurgeryStomach Surgery

Because the stomach is the first Because the stomach is the first major food reservoir in the GI tract, major food reservoir in the GI tract, stomach surgery poses special stomach surgery poses special problems in maintaining adequate problems in maintaining adequate nutrition.nutrition.

Problems may develop immediately Problems may develop immediately after surgery or after regular diet after surgery or after regular diet resumes.resumes.

GastrectomyGastrectomy

Immediate Postoperative Immediate Postoperative PeriodPeriod Serious nutritional deficits may occur Serious nutritional deficits may occur

immediately after surgery –esp. total immediately after surgery –esp. total gastrectomygastrectomy– Increased gastric fullness and distention Increased gastric fullness and distention

may result if gastric resection involved a may result if gastric resection involved a vagotomy (cutting of the vagus nerve vagotomy (cutting of the vagus nerve which supplies major stimulus for gastric which supplies major stimulus for gastric secretions) secretions) atonicity & poor emptying atonicity & poor emptying of the stomach. Food fermentation of the stomach. Food fermentation flatus (gas), diarrheaflatus (gas), diarrhea

Weight loss is common.Weight loss is common. Patient may be fed via jejunostomy.Patient may be fed via jejunostomy. Frequent small, simple oral feedings are Frequent small, simple oral feedings are

resumed according to patient’s tolerance.resumed according to patient’s tolerance.

Dumping SyndromeDumping Syndrome Frequent complication of extensive gastric Frequent complication of extensive gastric

resection in which readily soluble resection in which readily soluble carbohydrates rapidly “dump” into small carbohydrates rapidly “dump” into small intestineintestine

When the patient begins to feel better and When the patient begins to feel better and eats a regular diet in greater volume and eats a regular diet in greater volume and variety, discomfort may occur 30-60 minutes variety, discomfort may occur 30-60 minutes after mealsafter meals

Symptoms include:Symptoms include:– Cramping, full feelingCramping, full feeling– Rapid pulseRapid pulse– Wave of weakness, cold sweating, dizzinessWave of weakness, cold sweating, dizziness– Nausea, vomiting, diarrheaNausea, vomiting, diarrhea

Results in patient eating less foodResults in patient eating less food

Dumping SyndromeDumping Syndrome

When the stomach has been removed, When the stomach has been removed, food passes directly from the food passes directly from the esophagus into the small intestineesophagus into the small intestine

This rapidly entering food mass is a This rapidly entering food mass is a concentrated solution (higher concentrated solution (higher osmolality) in relation to the osmolality) in relation to the surrounding circulation of bloodsurrounding circulation of blood– To achieve osmotic balance, water is To achieve osmotic balance, water is

drawn from the blood into the intestine drawn from the blood into the intestine rapidly shrinks the vascular fluid volume rapidly shrinks the vascular fluid volume BP dropBP drop

Dumping SyndromeDumping Syndrome

Also, the initial concentrated solution that Also, the initial concentrated solution that has been rapidly digested and absorbed has been rapidly digested and absorbed rapid rise in blood glucose level rapid rise in blood glucose level stimulates overproduction of insulin stimulates overproduction of insulin eventual drop of blood glucose to below eventual drop of blood glucose to below normal levels with sx. of hypoglycemianormal levels with sx. of hypoglycemia

Dramatic relief from these sx. and Dramatic relief from these sx. and stabilization of weight follows careful stabilization of weight follows careful control of dietcontrol of diet

Diet for Postoperative Gastric Diet for Postoperative Gastric Dumping SyndromeDumping Syndrome

Five or six small meals dailyFive or six small meals daily Relatively high fat content, low simple Relatively high fat content, low simple

carbohydrate content, low-roughage carbohydrate content, low-roughage foods, high protein contentfoods, high protein content

No milk, sugar, alcohol, or sweet No milk, sugar, alcohol, or sweet sodas; no very hot or very cold foodssodas; no very hot or very cold foods

Fluids avoided one hour before and Fluids avoided one hour before and after meals; minimal fluids during after meals; minimal fluids during mealsmeals

Gallbladder SurgeryGallbladder Surgery

For pts. with cholecystitis or cholelithiasisFor pts. with cholecystitis or cholelithiasis Tx.: Cholecystectomy - the removal of the Tx.: Cholecystectomy - the removal of the

gallbladder.gallbladder. Surgery is minimally invasive - laproscopicSurgery is minimally invasive - laproscopic Some moderation in dietary fat is usually Some moderation in dietary fat is usually

indicated after surgery.indicated after surgery. Depending on individual tolerance and Depending on individual tolerance and

response, a relatively low-fat diet may be response, a relatively low-fat diet may be needed over a period of time.needed over a period of time.

Gallbladder with StonesGallbladder with Stones

Intestinal SurgeryIntestinal Surgery

Intestinal resections are required in Intestinal resections are required in cases involving tumors, lesions, or cases involving tumors, lesions, or obstructions.obstructions.

In complicated cases when most of the In complicated cases when most of the small intestine is removed, TPN is used small intestine is removed, TPN is used with small allowance of oral feeding.with small allowance of oral feeding.

Stoma may be created for elimination Stoma may be created for elimination of fecal waste (ileostomy, colostomy).of fecal waste (ileostomy, colostomy).– See p. 449See p. 449

ColostomyColostomy

Rectal SurgeryRectal Surgery

Clear fluid or nonresidue diet may be Clear fluid or nonresidue diet may be indicated after surgery to reduce indicated after surgery to reduce painful elimination and allow healing.painful elimination and allow healing.

Return to a regular diet is usually Return to a regular diet is usually rapid.rapid.

Nutritional Needs for Burn PatientsNutritional Needs for Burn Patients

Tremendous nutritional challengeTremendous nutritional challenge Plan of care influenced by:Plan of care influenced by:

– AgeAge– Health conditionHealth condition– Burn severityBurn severity

Plan constantly adjustedPlan constantly adjusted The depth of the burn affects tx. and The depth of the burn affects tx. and

healing processhealing process Critical attention paid to amino acid needs Critical attention paid to amino acid needs

for tissue rebuilding; fluid and electrolyte for tissue rebuilding; fluid and electrolyte balance, and energy (kcal) support.balance, and energy (kcal) support.

Nutritional Needs for Burn PatientsNutritional Needs for Burn Patients

3 periods of care during the 3 periods of care during the immediate shock, recovery, and immediate shock, recovery, and secondary feeding periodssecondary feeding periods– Stage 1/ Part I Immediate shock periodStage 1/ Part I Immediate shock period– Stage 1/part II Recovery PeriodStage 1/part II Recovery Period– Stage 2/ Part I Secondary Feeding PeriodStage 2/ Part I Secondary Feeding Period– Stage 2 / Part II Nutrition TherapyStage 2 / Part II Nutrition Therapy– Stage 2/ Part III Dietary managementStage 2/ Part III Dietary management– Stage 3/Follow-up ReconstructionStage 3/Follow-up Reconstruction

Nutritional Care for Burns: Stage 1, Nutritional Care for Burns: Stage 1, Part 1 – Immediate Shock PeriodPart 1 – Immediate Shock Period

Massive flooding edema at the burn site Massive flooding edema at the burn site occurs from the first hours through the occurs from the first hours through the second day after a burnsecond day after a burn

Large losses of water, electrolytes, and Large losses of water, electrolytes, and protein due to destruction of protective protein due to destruction of protective skinskin

Blood volume drops, blood pressure drops, Blood volume drops, blood pressure drops, urine output decreasesurine output decreases

Nutritional Care for Burns: Stage 1, Nutritional Care for Burns: Stage 1, Part 1 – Immediate Shock PeriodPart 1 – Immediate Shock Period

Cell dehydration and cell potassium Cell dehydration and cell potassium loss occursloss occurs

Intense IV fluid replacement (e.g. LR) Intense IV fluid replacement (e.g. LR) followed by albumin solutions or followed by albumin solutions or plasma to restore blood volume and plasma to restore blood volume and help prevent shockhelp prevent shock

Protein and energy requirements are Protein and energy requirements are not met at this timenot met at this time

Nutritional Care for Burns: Stage 1, Nutritional Care for Burns: Stage 1, Part 2 – Recovery PeriodPart 2 – Recovery Period

48 to 72 hours after burns48 to 72 hours after burns Fluids and electrolytes are gradually Fluids and electrolytes are gradually

reabsorbedreabsorbed Balance is re-establishedBalance is re-established Diuresis occursDiuresis occurs Constant evaluation of intake and Constant evaluation of intake and

output must occuroutput must occur Enteral nutrition may be initiatedEnteral nutrition may be initiated

Nutritional Care for Burns: Stage 2, Nutritional Care for Burns: Stage 2, Part 1 – Secondary Feeding PeriodPart 1 – Secondary Feeding Period

End of first weekEnd of first week Bowel function Bowel function

returnsreturns Vigorous feeding Vigorous feeding

program beginsprogram begins Patient may be Patient may be

depressed and depressed and may have lack of may have lack of appetiteappetite

Nutritional Care for Burns: Stage 2, Part 1 – Nutritional Care for Burns: Stage 2, Part 1 – Secondary Feeding PeriodSecondary Feeding Period

3 major reasons exist for the 3 major reasons exist for the increased nutrient and energy increased nutrient and energy demands:demands:– Tissue destruction – large loses of Tissue destruction – large loses of

protein and electrolytes that need protein and electrolytes that need to be replacedto be replaced

– Tissue Catabolism – loss of lean Tissue Catabolism – loss of lean body mass and N+body mass and N+

– Increased metabolism Increased metabolism

Nutritional Care for Burns: Stage 2, Part 2 – Nutritional Care for Burns: Stage 2, Part 2 – Nutrition TherapyNutrition Therapy

High proteinHigh protein– Promotes healingPromotes healing– Promotes Promotes

immune functionimmune function High energyHigh energy

– Spares protein Spares protein for tissue healingfor tissue healing

– Supplies energy Supplies energy for increased for increased metabolic metabolic demandsdemands

Nutritional Care for Burns: Stage 2, Nutritional Care for Burns: Stage 2, Part 2 – Nutrition TherapyPart 2 – Nutrition Therapy

High vitamin and mineralsHigh vitamin and minerals– Vitamin C partners with amino Vitamin C partners with amino

acids for tissue rebuildingacids for tissue rebuilding– Vitamin A and zinc for optimal Vitamin A and zinc for optimal

immune functionimmune function– Thiamin, riboflavin, and niacin for Thiamin, riboflavin, and niacin for

increased energy and protein increased energy and protein metabolismmetabolism

– Serum Calcium-phosphorus ratios Serum Calcium-phosphorus ratios should be monitoredshould be monitored

Nutritional Care for Burns: Stage 2, Nutritional Care for Burns: Stage 2, Part 3 – Dietary ManagementPart 3 – Dietary Management

Enteral or parenteral feeding may be Enteral or parenteral feeding may be neededneeded

Oral feedings with added protein or Oral feedings with added protein or amino acids (commercial formulas)amino acids (commercial formulas)

Solid foods based on preferencesSolid foods based on preferences Oral intake may be inadequateOral intake may be inadequate

Nutritional Care for Burns: Nutritional Care for Burns: Stage 3 – Follow-up ReconstructionStage 3 – Follow-up Reconstruction

Continued Continued nutritional supportnutritional support

Maintain tissue Maintain tissue strength for strength for successful skin successful skin grafting or plastic grafting or plastic surgerysurgery

Encouragement Encouragement and support are and support are criticalcritical