Beruflich Dokumente
Kultur Dokumente
Surgical Conditions
Hormonal and
Inflammatory
Response
Initially, insulin levels are low and then they gradually rise, although insulin resistance is
present. The elaboration of the counter regulatory hormones cortisol, glucagon and
cathecolamines is increased, and these factors play a central role in the response.
Inflammatory factors (such as cytokines, leukotrienes, etc.) contribute to the catabolic
response, either directly or indirectly ( stimulating elaboration of catabolic hormones,
causing anorexia through central nervous system mechanism and increasing body
temperature ).
Translocation of the Amino Acids
The metabolic response to surgery is characterized by the breakdown of skeletal
muscle protein and the translocation of the amino acids ( mainly alanine and
glutamine ), to visceral organs and the wound. At these sites, the amino acids serve
to enhance host defenses and support vital organ function and wound repair.
Pre-operative Diet
The pre-operative diet aims to improve the nutritional status of the patient, to
prepare him for nutrient losses during surgery (e.g. protein, water, electrolytes,
protein), to help hasten post-operative recovery, to build up glycogen reserves, and
to strengthen bodily resistance to infections. Weight changes should be affected
during the pre-operative stage. Patients whose weights are nearly within desirable
levels are exposed to less surgical risks than obese or underweight patients. Diabetics
should be especially attended to. Nutritional anemia and other deficiencies should be
corrected prior to surgery.
For emergency cases, parenteral feeding is the fast method of nourishing the patient before
surgery. parenteral means other than the oral route; i.e., subcutaneous, intramuscular or
intravenous ( I.V ) feeding.
Diet immediately before surgery
Light evening meals is prescribed the day before the surgery. This is gradually restricted to
clear liquids and then all foods are withheld for at least 8 hours to empty the stomach. Some
clinicians prescribe a non-residue is clear liquid diet for several days especially when the
surgical site involves the gastrointestinal tract. This eliminates the possibility of inhaling the
vomitus during the anesthesia and reduces the feces in the colon.
In emergency cases, gastric lavage ( gastric suction) is administered to remove
gastrointestinal contents. For gastrointestinal operations, a non-residue diet is given for
several days. Clinically defined or elemental formulas can provide a complete diet in liquid
form.
Post-Operative Diet
A. Pre-Operative Diets
B. Post-Operative Diets
( Same as in A )
(same as in A) plus
Prevents dehydration and shock
during immediate postoperative
stage
Replaces losses during
surgery(e.g. from blood,
drainage, sweat, vomiting , renal
losses)
Promotes wound healing
( Same as in A)
( Same as in A)
Food
Exchange
Milk
Vegetable
sA
Vegetable
sB
Fruit
Rice
Meat
Fat
Sugar
Snacks
3
As desired
2
6
10
7 (5 LF, 2
MF)
10
6
As
needed
Total
36
6
60
230
30
70
432
24
2
20
56
1+
103
30
17
50
1+
98
Energy
(kcal)
510
32
240
1000
337
450
120
293
3022
Meal pattern
Breakfast:
Fruit
Cereal
Protein dish
Bread
Butter
Beverage(milk)
Sugar 1 tbsp.
Morning snack:
Protein source
Bread-butter
Fruit juice
Lunch:
Soup
Main dish w/ vegetables and
cooking fat
Salad
Rice
Dessert(fruit)
Afternoon snack:
Milk source
Rice exchange
Supper:
Soup
Main dish w/ vegetables &
cooking fat
Rice
Dessert(milk containing)
Bedtime snack:
Milk beverage w/ sugar
Rice exchange
Protein source
No. of exchange
Sample menus
2
1
1
1
2
1
3
1
2
2
2(meat)
3(fat)
3
2
1
2
Milk
2
3
3
1-3
2
1
Almondigas soup
Beef asado with carrots one
half c
Rice
Custard
Milo with milk
Crackers
Cheese
Intravenous Solution
Name and Type
A. Dextrose 5%
10%
20%
30%
B. Dextrose 5% in Lactated
Ringers solution
D. multi-Ion MB in D5 water
E. Multisol-R/Multisol-R in D5
water
F. Multisol M in D5 water
G. Multisol MK in D5 water
H. Onkovertin 70 in Dextrose
5%
2000 kcal
98g
65g
255g
1.8g
1.8g
24 mg
Potassium
Sodium
Vitamin A
Thiamin
Niacin
Niacin
Ascorbic acid
4.2g
1.1g
5228 IU
1.5mg
3.0mg
3.0mg
203mg
Viscosity refers to be resistance of a fluid to flow. Formulas containing larger molecules, such as whole
protein compared to amino acids, and formulas that have a higher caloric content per unit volume tent to
be more viscous. The viscosity of the formula and the caliber of the tube must be compatible. More viscous
formulas require a larger tube which is also generally less comfortable for patients. in tube feeding; both
the quantity and type of ingredients must be considered in relation to patients specific needs.
Nutrient contribution. Caloric density considers the energy value of the food in relation to volume.
Most tubfeeding yield 1 kcal/ml, but 1.5 and 2.0 kcal/ml formulas are available. These are useful for
patients with high caloric needs and limited appetites or volume tolerance. The more calorically dense
formulas also have high osmolarity and high RSL. Precautions must be taken to prevent dehydration and
the patient must be monitored carefully.
Carbohydrates may come from many sources including, fruits, cereals, vegetables, corn syrup, glucose,
sucrose, lactose, oligosaccharides and dextrins. Cornstarch , maltodextrins and oligosaccharides
saccharides have been used to provide carbohydrate while minimizing formulas osmolality and sweetness.
For patients who develop lactose intolerance, lactose free formulas are used.
Dietary fiber is present is formulas containing fruits, vegetables and cereals. Dietary fiber can be
increased by adding banana flakes, applesauce, pureed fruits or tender leafy vegetables and are beneficial
for patients with diarrhea and constipation.
Protein may be supplied in formulas as whole protein, hydrolyzed protein, or as free amino acids. A
formulas low in protein is administered to individuals with renal or hepatic impairment. A high protein
formula may be indicated for individuals who are manourished, for septic or pre and post-surgical cases or
for those who have experienced trauma. Individuals receiving high-protein formulas, particularly those who
are unconscious, who cannot communicate thirst, should be monitored for adequate water intake and fluid
and electrolyte balance.
Fat adds calories to formulas. It is generally provided in the form of vegetables oils, which contain glycerol
and long chain fatty acids and are called long chain triglycerides(LCT). If fat malabsorption is present, a
formula low in fat, or one that contains medium chain triglycerides (MCT) in place of long chain fatty acids
is indicated. LCT does not add to formula osmolality. Formulas containing MCT must contain some LCT to
provide the required essential fatty acids.
Vitamins, Minerals and Trace Elements: these nutrients are generally provided in commercial formulas
in amounts to meet recommended dietary allowances. Certain individuals with malabsorption or for those
under stress may be getting inadequate amounts of these nutrients and should be monitored and
Bolus feeding refers to rapid installation of feeding into the GI tract by syringe or funnel. The majority
of patients seldom tolerated this method. Patients on enteral feeding may experience complication as a
result of the formula, its administration or handling. Table 12.6 gives a list of potential complication and
suggestion for resolving these complications.
Table 12.6. Enteral Feeding Complications and Suggestion for Solution
Complication
Diarrhea
Aspiration
Clogged Tubes
Constipation
Abdominal
Distention
Nausea/Vomiting
Contamination of
Formula
Parenteral Feeding
Pre-surgical and post-surgical feedings are given in a variety of ways that
should be specific to each individual depending on the factors like the patients
nutritional status, ability to swallow, level of digestion and absorption, presence of
nausea, vomiting, anorexia and location of surgery, etc.
The oral route is always preferred, but if the patients cannot tolerate normal
eating, parenteral feeding is the alternative solutions. Parenteral feeding is a means
of providing the nutrients by routes other than the mouth and digestive tract, such
as subcutaneous, intramuscular or intravenous feeding.
Parenteral feeding can used in addition to enteral feedings or used alone. If
parenteral feeding is the main source if nutrition, other nutrients have to be given
via the small veins, usually in the arm ( peripheral, parenteral nutrition of PPN), or
centrally into the superior or inferior vena cava or the jugular vein. (centralparenteral nutrition or CPN) is also called total parenteral nutrition (TPN) or
intravenous hyperalimentation (IVH). The decision to use PPN or CPN is based on
the number of calories needed and the osmolality of the solution. TPN solutions are
Diet Therapy for Specific Surgical Conditions
best prepared by the experts such as a pharmacist pr in industrial laboratories. A
physician trained in this area prescribe and guides the use of TPN.
The main objective of dietary modification on specific surgical conditions ( such as
tonsillectomy, colostomy, rectal surgery, gastric resection, etc. ) is to rest the organ
involved and avoid irritation at the site of the resection. It also promotes rapid wound
healing and replaces nutrient losses.
The guidelines must be tailored to each patients needs such as surgery, food tolerances and
intolerances and nutritional problems and deficiencies:
1. Diet should be low in simple carbohydrate but should be high in complex carbohydrates, high
in protein and moderate in fat.
2. Liquids should be given 30-60minutes after each meal.
3. Small frequent feeding should be given , the number of which depends on the patients
tolerance to specific portions of food.
4. Small amount of milk of milk maybe tolerated than large amounts . If there is milk
intolerance ,lactose free products maybe used.
5. Foods should be eaten slowly and chewed well.
6. If there is steatorrhea, use of medium chain triglycerides and MCT oil may be indicated.
7. If dumping is a problem, it may help to lie down immediately after meals to retard transit
to the small bowel.
8. The dietary fiber pectin, found in fruits and vegetables, may be helpful in the treatment of
dumping syndrome. Pectin delays gastric emptying time reduces the glycemic response and
slows down carbohydrate absorption.
9. All food and drink should be moderate in temperature. Cold drinks tend to cause increased
gastric activity.
Dumping Syndrome
Individuals who have had gastrectomy may experience the dumping syndrome characterized
be nausea, weakness, syncope and diarrhea. This happens when the stomach contents are
emptied into the jejunum at an abnormally fast rate. The guidelines of the post-gastrectomy
diet for dumping syndrome ( especially in cases of total gastrectomy ) are follows:
10.Small frequent feeding 5-6 times per day
11.Restricted liquid or a dry diet. Avoid fluid at least one hour before and after a meal.
12.Low fiber low residue diet ( avoid milk, raw fruits and vegetables high in fiber)
13.Low carbohydrates to prevent dumping of readily utilized carbohydrates in the jejunum. This
causes disruption in the water balance leading to the withdrawal of fluid from the blood to
the intestine.
Ostomies
An ostomy is the surgical procedure of creating an opening of the stomach
wall of the abdomen. It is a procedure that brings movement of the GI tract usually
intestinal to the skin surface. The main purpose is to evacuate stools or move the
bowels when the normal route via the colon, rectum and anus is not medically
allowed. Immediately after the surgery, IV feeding is given for 2 to 3 days until
bowel sounds return.
Start with clear liquid diet and progress gradually to one low in residue.
Then give a soft or low fiber diet as tolerated. Gradually introduce fiber as
tolerated. Avoid tough skin from fruits and vegetables and other foods that may
cause stoma obstruction. Take plenty of fluids ( at least 8 to 10 cups per day )
especially of the ostomy output is excessive. When steatorrhea occurs, restrict fat
and use MCT oil. A liberal supply of calories and protein ( at least 1.5 times the
recommended nutrient intakes) will speed up recovery and prevent weight loss.
In all cases, small frequent feedings are recommended. In ileostomy, MCT
diet (medium chain triglycerides) is prescribe and fat soluble vitamins ADEK are
supplemented. If there is increased fluid loss, both water intake and electrolytes
are replenished.
Rectal Surgery
This condition refers to any operation done the rectum, as in rectal cancer or
hemorrhoidectomy. A clear liquid diet is given within the first 24 hours after the
operation, followed by a non-residue diet. In hemorrhoidectomy, diet is progressed
from clear to full liquid omitting milk, then a low-residue diet until wound has
healed and the patient can tolerate the regular diet. The use of mineral oil for a
few days, helps, but should not be prolonged since mineral oils interfere with the
utilization of fat soluble vitamins and some minerals. Some physician prescribe a
Wound healing
Wound is a physical injury to the body tissues disrupting the normal
continuity of structure. Wound healing involves tissue synthesis and occurs in
two phases. Initial wound healing occurs readily during a period of negative
energy balance; subsequent healing occurs between the fifteenth day after
surgery or trauma.
Diet therapy. Increased protein of 1.2-2.0 g/kg body weight is required to
promote wound healing and preserve tissue integrity. Sufficient energy about 2535 kcal/kg body weight is considered necessary to meet metabolic needs and to
prevent protein from being utilized as fuel. Zinc, vitamin A and vitamin C are also
necessary for continued wound healing. Other nutrients required in wound
healing include arginine, magnesium, and selenium. In general, all nutrients
related to immune function are needed to hasten wound healing. The provision of
sufficient fluid is also necessary. Adjunctive enteral support may be necessary to
facilitate wound healing, particularly when oral intake is suboptimal.