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Surgery LO's > Perioperative Nutrition > Flashcards

Perioperative Nutrition Flashcards

1
Q

Why is nutrition important in surgery?

A

Malnourished patients make poor surgical candidates

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2
Q

Why do malnourished patients make poor surgical candidates?

A

Because surgery causes physiological stress with resultant hyper-metabolic state and catabolic response, which is not favoured in the malnourished patient

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3
Q

Why will a proportion of surgical patients have a degree of malnutrition?

A

Because their underlying disease process reduces their nutritional reserves in the post-operative period

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4
Q

What is the problem with malnourished patients post-operatively?

A

They are at increased risk of post-operative complications such as reduced wound healing, infection, and skin breakdown

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5
Q

What should be done regarding nutrition in surgery?

A

Any patient undergoing elective or semi-elective surgery should be assessed for evidence of malnutrition, and where possible this should be corrected, or nutrition supported both pre and post operatively

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6
Q

What should happen to all patients admitted to hospital, regarding nutrition?

A

They should be screened for malnutrition, and have their nutritional state assessed

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7
Q

How can screening for malnutrition be achieved?

A

Using the Malnutrition Universal Screening Tool (MUST)

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8
Q

When might MUST score calculation be unnecessary?

A

In disease-related cachexia

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9
Q

Why might MUST score be unnecessary in disease-related cachexia?

A

It is usually obvious with bedside observation

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10
Q

What features of disease-related cachexia may be obvious on bedside examination?

A
  • Muscle wasting
  • Loose skin
  • Patient’s usual clothes no longer fitting
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11
Q

What may following screening for malnutrition?

A

Nutritional assessment

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12
Q

What does a nutritional assessment require?

A

Expert input from a Registered Dietitian

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13
Q

What tools are used to assess nutritional state?

A
  • Weight
  • BMI
  • Grip strength
  • Triceps Skin Fold thickness
  • Mid Arm circumference
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14
Q

How is BMI calculated?

A

Weight (kg) / (height (m)2)

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15
Q

What is the normal range for BMI?

A

18.5-24.9 kg/m2

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16
Q

What features may be found on examination that suggest disease related cachexia?

A
  • Apthous ulcers
  • Angular chelitis
  • Pressure sores
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17
Q

What might be appropriate if malnutrition is identified?

A

Nutritional support

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18
Q

Why is nutritional support important in malnourished surgical patients?

A

It improves surgical outcomes

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19
Q

What decisions need to be made on a case-by-case basis regarding nutritional support?

A
  • When and how to deliver nutritional support
  • The timing of subsequent surgery
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20
Q

Who is involved in the development of an appropriate schedule for nutritional support?

A

It should be done with the assistance and under the direction of a registered dietician

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21
Q

What does the type of nutritional support that can be offered depend on?

A

Largely on the pathology present

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22
Q

As a general principle, what is the best way to administered nutrional support?

A

Best to give enteral nutrition via the oral route wherever possible (this applies to pre- and post-operative nutrition

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23
Q

Why might enteral nutrition via the oral route not be an option?

A

For many patients, it may not be possible to administered sufficient calories via this route

24
Q

What should be given if a patient is unable to eat sufficient calories?

A

Oral nutritional supplements

25
Q

What should be done if the oesophagus is blocked/dysfunctional?

A

Gastrostomy feeding (PEG/RIG)

26
Q

What should be done if the stomach is inaccessible, or there is outflow obstruction?

A

Jejunal feeding (jejunostomy)

27
Q

What should be done if the jejenum is inaccessible, or there is intestinal failure?

A

Parenteral nutrition

28
Q

Is malnutrition an indication for delaying surgery?

A

No

29
Q

What do patients with intestinal failure need?

A

Often (but not always) parenteral nutrition

30
Q

What does the acronym SNAP stand for when considering nutrition in intestinal failure?

A
  • Sepsis
  • Nutrition
  • Anatomy
  • Procedure
31
Q

What does sepsis in the SNAP acronym for intestinal failure nutrition refer to?

A

Any overwhelming infection present must be corrected, otherwise feeding will be largely useless

32
Q

What does nutrition in the SNAP acronym for intestinal failure nutrition refer to?

A

Once the infection is corrected, suitable nutritional support should be provided

33
Q

What does anatomy in the SNAP acronym for intestinal failure nutrition refer to?

A

You should define the anatomy of the GI tract so that surgery can be planned

34
Q

What does procedure in the SNAP acronym for intestinal failure nutrition refer to?

A

Definitive surgery should be performed once any infection is eradicated, the patient nourished, and the anatomy defined

35
Q

How is serum albumin involved in nutrition and surgery?

A

A low serum albumin is associated with poorer surgical outcomes, but it does not reflect nutritional state

36
Q

What can a low serum albumin reflect?

A
  • Chronic inflammation
  • Protein loosing enteropathy
  • Proteinuria
  • Hepatic dysfunction
37
Q

What are the tenets of Enhanced Recovery After Surgery (ERAS)?

A
  • Reduction in NBM times
  • Pre-operative carbohydrate loading
  • Minimally invasive surgery
  • Minimising the use of drains and nasogastric tubes
  • Rapid reintroduction of feeding post-op
  • Early mobilisation
38
Q

How short can NBM be made?

A

Fluids can be taken up to 2 hours pre-surgery

39
Q

What does evidence suggest that early post-operative feeding causes?

A

A reduction in post-operative complications

40
Q

How long after an uncomplicated gastrointestinal surgery can patients safely tolerate an enteral diet without increasing the risk of post-operative complications?

A

24 hours

41
Q

Is an entero-cutaneous fistulae an absoloute indication for parenteral nutrition?

A

No, the proportion of ECF that will heal spontaneously with PN is relatively small

42
Q

What nutritional strategy should be employed in an entero-cutaeous fistulae?

A

Supporting nutrition prior to a likely surgical repair

43
Q

What is the modern nutrition management of an entero-cutaneous fistula dependant on?

A

The level of the fistula

44
Q

What nutritional support may be needed with a high entero-cutaneous fistula (jejunal)?

A

Enteral or parenteral nutrition

45
Q

What nutritional support can be employed with a low entero-cutaneous fistulae (ileum/colon)?

A

Low fibre diet

46
Q

What investigation is often critical in deciding how an entero-cutaneous fistula should be managed in terms of nutrition?

A

Imaging

47
Q

What is the nutritional support and treatment for a high output stoma dependant on?

A
  • Length of bowel to stoma
  • Presence of disease
  • Medical management
48
Q

If the distance from the DJ flexure to jejunostomy is 150-200cm, what are the probable nutritional requirements?

A

Enteral support

49
Q

If the distance from the DJ flexure to jejunostomy is 100-150cm, what are the probable nutritional requirements?

A

Enteral support, with or without IV fluids

50
Q

If the distance from the DJ flexure to jejunostomy is <100cm, what are the probable nutritional requirements?

A

Parenteral nutrition

51
Q

If the distance from the DJ flexure to colostomy is 100-150cm, what are the probable nutritional requirements?

A

Enteral support

52
Q

If the distance from the DJ flexure to colostomy is 50-100cm, what are the probable nutritional requirements?

A

Enteral support with or without IV fluids

53
Q

If the distance from the DJ flexure to colostomy is <50cm, what are the probable nutritional requirements?

A

Parenteral nutrition

54
Q

What can drive stoma output independent of the length of residual bowel?

A

The presence of persistent disease or systemic infection

55
Q

How can a reduction in stoma output be achieved once active disease or infection have been excluded?

A
  1. Reduction in hypotonic fluids to 500mls/day
  2. Reduction in gut motility with high dose loperamide and codeine phosphate
  3. Reduction in secretion with high dose PPIs (twice daily dose)
  4. Use of WHO solution to reduce sodium losses
  5. Low fibre diet to reduce intraluminal retention of water

Surgery LO's (10 decks)

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