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Flashcards in Surgery Nutrition Deck (20)
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1
Q

What are nutritional challenges in surgery?

A
  • chronically ill
  • diabetes
  • advanced lung disease
  • perioperative
  • advanced age
2
Q

How is nutritional status assessed b/f surgery?

A
  • hx
  • physical
  • labs to assess protein status
3
Q

What are the fundamental goals of nutritional support?

A
  • meet energy requirements for metabolic processes: basic metabolic rate
  • tissue repair
4
Q

Amt of energy needed during diff circumstances?

A
  • during physical activity: 10-50% above basal metabolism
  • hosp pt: 10-20% above
  • trauma: 10-30% above
  • sepsis: 50-80% above
  • burns: 100-200% above
  • stress of surgery creates hypermetabolic (catabolic state)
5
Q

Malnutrition consequences?

A
  • increased susceptibility to infection
  • poor wound healing
  • increased frequency of decubitus ulcers
  • overgrowth of bacteria in GI tract
6
Q

Nutritional assessment components?

A
- Hx:
chronic medial illnesses
recent hosp.
past surgeries
meds
- Social hx:
socioeconomic status 
use of alcohol, tobacco, other drugs 
- diet hx:
supplements
square meals 
- ROS:
wt loss or gain
GI sx: N/V, diarrhea, constipation 
- Physical exam:
ht and wt: BMI
HEENT: temporal wasting, pallor, xerostosis, bleeding gums, dentition, angular cheilosis, dentition 
neck: thyromegaly
extremities: edema, muscle wasting
neuro: peripheral neuropathy
skin: ecchymosis, petechiae, pressure ulcers, pallor (wound healing/signs of wound infection)
CV: evidence of heart failure
7
Q

Lab eval b/f surgery if concerned about nutritional status?

A

protein status assessment:

  • serum albumin (most frequently used) - less than 2.2g/dL predictor of poor outcome
  • serum transferrin (over past 2-4 wks) - also reflects iron status, low indicator of protein status if normal serum iron
  • serum prealbumin (transthyretin)
  • others: CBC, CMP, vitamin levels as indicated (B12)
8
Q

What pts need preop nutrition?

A
  • generally healthy, well nourished pts who are going in for scheduled surgeries don’t need any preop nutrition
  • those w/ preexisting conditions such as cancer, particularly GI tract cancer may need preop enteral nutrition IF they are significantly malnourished
  • if a pre-op pt is mildly malnourished he/she may need early nutritional support:
    if not on bowel rest and can take PO diet: make sure high protein, high calorie
    if on bowel rest b/c of bowel surgery/unable to eat for so many days then parenteral support is indicated - earlier if significantly malnourished
9
Q

Postop nutrition for pt?

A
  • if able to use gut by day 2-3 again high protein, high calorie diet orally if malnourished
  • if unable to use gut b/c of bowel surgery need parenteral nutrition early if still not going to be eating for prolonged period
10
Q

Why may a pt not be eating postop?

A
  • still nauseated from the anesthetic and/or pain meds
  • ileus
  • start of an infection
  • depression
  • anorexic b/c of cancer
  • Nutrition consult
11
Q

if a pt has severe malnutrition should the surgery go on?

A
  • it depends on the situation, may benefit to have surgery delayed to get either enteral or parenteral nutrition depending on situation
12
Q

Mortality rate and low albumin correlation?

A
  • study done of 2006 hosp veterans found a linear correlation b/t plasma albumin concentration and short term mortality
  • 30 day mortality rate of 62% was seen among pts whose plasma albumin fell below 2.0 g/dL
  • at BMI below 15th percentile on admission was assoc w/ 23% increase in 6 month mortality
13
Q

When is enteral feeding CI?

A
- when the gut isn't working:
obstruction
ileus
GI ischemia
bilious or persistent vomiting 
- need to intervene via parenteral (IV)
14
Q

What is enteral intervention? Diff types?

A

nutrition via intestinal route orally or via feeding tube

  • calories, protein, lytes, vitamins, minerals and fluids either orall or via a feeding tube
  • wide variety of supplements
  • NG tubes - MC, high feeding rates, simple to insert, short term usually
  • NJ tubes - short term, reduce GERD, impaired stomach motility, increased risk of aspiration: frequent in post op, more difficult than NG
  • PEG tubes (percutaneous endoscopic gastrostomy): extended period of time, indications: parkinsons, esophageal cancer, inserted through stomach wall endoscopically or surgically
  • percutaneous jejunostomy tubes: early postop feedings, useful in pts at risk for reflux, difficult and more complications
15
Q

Benefits of enteral feedings compared to parenteral?

A
  • lead to more rapid advancement of PO feedings
  • fewer infections
  • lower costs
  • shorter hosp stays
  • more physiologic way to provide nutrition
16
Q

When should enteral nutrition be used? How does it work?

A
  • used when only short term (less than 30 days) needed
  • NG or nasoenteric tubes preferred over gastrostomy or jejunostomy tubes
  • tubes placed in 3rd portion of the duodenum (past ligament of Treitz) are assoc w/ less risk of aspiration
  • intermittent (bolus) gravity feeding is usually done, but continual infusions can be done for jejunal feedings or to reduce GER
17
Q

Complications of tube feeding?

A
  • aspiration: prevent this by giving smaller volumes, keep pt upright
  • diarrhea: mult causes - meds (formula composition), infusion rate, physiological disturbances
  • metabolic disturbances: careful attention to fluid and lyte management
18
Q

Risks of specific eneteral feedings?

A
- NG tube: 
short term use
aspiration risk
- nasoduodenal/nasojejunal:
short term use
less aspiration risk (reduced by 25% c/w NG)
- percutaneous endoscopic gastrostomy (PEG): need endoscopy, last 12-24 months,  aspiration risk 
- surgical feding tubes:
feeding jejunostomy
19
Q

What is dumping syndrome? Sx? Response?

A
  • can follow the rapid infusion of feeds via jejunal tubes or rapid gastric bolus feeds
  • Sx: faintness, palpitations, diaphoresis, pallor, tachycardia and hypoglycemia
  • response: slow rate of feeding or change formula to one w/ more complex carbs
20
Q

When is parenteral nutrition indicated? What are these solns usually?

A
  • necessary when oral route can’t be used
  • genearlly hypertonic solns:
    infused into a large central vein to reduce the risk of intimal damage from the catheter and infusate
  • catheter tip has to be in a blood vessel w/ high blood flow
  • central locations are SVC, RA, IVC; not the internal jugular or subclavian or axillary veins