cleveland clinic surgical case study #1 nutrition webinar

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Cleveland Clinic Surgical Nutrition WebinarFriday, 10/30/2015

Vincent Vanek, MD, FACS, FASPENAssociate Director, Surgical Education

St. Elizabeth Youngstown HospitalProfessor Surgery, Northeast Ohio Medical University

Rootstown, OH

Case Study #136 year old female who had Roux-en-Y Gastric bypass in 1999. Weight decreased from 315 lbs to 135 lbs (100% EBWL) with BMI 21. In 12/2014 began having unintentional weight loss and in 1/2015 admitted with acute respiratory failure due to DVT/PE requiring intubation and mechanical ventilator support. Developed decubitus ulcer and was in LTAC for 3 months then discharged home on oral diet alone. She had nausea, vomiting, and continued to lose weight over the next 3 months and was referred for nutrition support. Patient seen in 7/2015. She is 5’7” tall and weighed 111 lbs (24 lbs below IBW) with BMI 17. What nutrition support would your recommend for this patient?

Case Study #1 (continued)Patient admitted to the hospital, PICC inserted, and PN started.• Day#1 – 90 gm pro (1.5 gm/K/d), 795 NPC (13 kcal/K/d)

Phos-1.9 mg/dl, K-3.7 mmol/L, Mag-2.2 mg/dl (15 mmol Phos PN)• Day#2 – 90 gm pro (1.5 gm/K/d), 1216 NPC (20 kcal/K/d)

Phos-1.9, K-5.2, Mag-2.3 (45 mmol Phos PN/bolus)• Day#3 – 90 gm pro (1.5 gm/K/d), 1548 NPC (25 kcal/K/d)

Phos-1.7, K-3.9, Mag-2.2 (45 mmol Phos PN/bolus)• Day#4 – 90 gm pro (1.5 gm/K/d), 1548 NPC (25 kcal/K/d)

Phos-1.6, K-4.8, Mag-2.9 (81 mmol Phos PN/bolus/infusion)• Day#5 – 90 gm pro (1.5 gm/K/d), 1548 NPC (25 kcal/K/d)

Phos-2.7, K-4.6, Mag-ND (66 mmol Phos PN/infusion)• Day#6 – 90 gm pro (1.5 gm/K/d), 1548 NPC (25 kcal/K/d)

Phos-6.3, K-ND, Mag-ND (40 mmol Phos PN/infusion stopped)• Day#7 – 90 gm pro (1.5 gm/K/d), 1548 NPC (25 kcal/K/d)

Phos-2.6, K-4.7, Mag-2.5 (30 mmol Phos PN)

Patients at Risk for RFS• Anorexia nervosa• Chronic malnutrition and underfeeding• Chronic alcoholism with severe weight loss• Morbid obesity with massive weight loss• Patient unfed for 7-10 days with evidence of stress

and depletion• Prolonged fasting• Prolonged intravenous hydration without nutrients

Risk Factors for RFS• Any one of the following:

ü BMI < 16ü Wt loss > 15% body wt. last 3-6 mosü Little or no nutrition > 10 daysü Low serum phos, potassium, or magnesium prior to

feeding• Any two of the following:

ü BMI < 18.5ü Wt loss > 10% last 3-6 mosü Little or no nutrition > 5 daysü History of alcohol or drug abuse

Rio et al. BMJ Open, 2013, pg 1-9

Criteria for Diagnosis of RFS

• Phosphorous < 0.99 mg/dl(normal 2.5-4.5)

• Potassium < 2.5 meq/L (normal 3.5-5.0)

• Magnesium < 1.22 mg/dl (normal 1.6-2.6)

Rio et al. BMJ Open, 2013, pg 1-9 and Eichelberger. Nutrition. 2014;30:1372-1378

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Prevention and Treatment of RFSGeneral Recommendations

• Be aware of RFS and that it can occur with any route of refeeding• Recognize “at risk” patients• Check for and correct electrolyte abnormalities (especially phos, K, &

Mag) prior to starting nutrition support• Carefully restore circulatory volume and monitor BP, HR, and I/O

closely• “Start low, advance slow” Calories while providing adequate protein

(1.2-1.5 g/day)• Routinely administer vitamin supplements• Carefully monitor phos, K, Mag, and blood glucose especially over the

first week of nutrition support • Aggressively treat any fluid, electrolyte, or other micronutrient

deficiencies that occur

Solomon et al. JPEN. 1990;14:90-97Stanga et al. European J Clinical Nutrition. 2008;62:687-94

Case Study #276 year old male with locally advanced squamous cell carcinoma oropharynx referred for PEG tube placement prior to chemo and radiation therapy. Patient was 5’8½” tall and weighed 196 lbs (BMI 29). In March 2013, PEG was inserted without difficulty. Patient subsequently underwent chemo and radiation therapy and developed severe dysphagia so he could not eat. He was given enteral nutrition support via the PEG tube. He had a complete response to his cancer therapy and was disease free but continued to have severe dysphagia. He continued on tube feedings and PEG was changed several times with external removal and replacement. He returned in May 2015 because of leakage around the PEG tube and severe weight loss (49 lbs wt loss last 2 yrs). He had recently been seen by an ENT oncologist at OSU and work up found no evidence of recurrent cancer and no sign of stricture.

Case Study #2 (continued)

Above picture provided by Dr. Mark H. DeLegge but looks similar to what this patient’s PEG looked like.


EGD showed no esophageal strictures and no gastric outlet obstruction. There was ulceration of the gastric mucosa around the gastrostomy tube site. What do you do now?


• Tube/Site Infectionü Change the tubeü Topical and/or systemic antibacterial and/or

antifungal agents


• Tube/Site Infection• External Bumper too tight causing skin

necrosis

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Gauderer-Ponsky “pull”

technique (12F-28F)

Vanek VW. Ins and outs of enteral access: part 2—long

term access—esophagostomy and gastrostomy. Nutr Clin

Pract. 2003;18(1):50-74.

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• Tube/Site Infection• External Bumper too tight causing skin

necrosis• Too much lateral pulling on the gastrostomy

tube putting tension on the sides of the gastrostomy site


Gastrostomy tube leakage continued to worsen. Patient stopped using his tube feedings because of the leakage. He returned to the clinic 2 months later and had lost another 3 lbs (down to 121 lbs, BMI 18). The gastrostomy site had now enlarged to point that you could actually see the balloon of the G tube through the skin inside of the stomach. What do you do now?

Case Study #365 year old male with large sigmoid adenocarcinoma colon is being scheduled for a laparoscopic colon resection. He is 6’2” tall and his usual body weight is 220 lbs. He denied any nausea or vomiting but has had a decreased appetite and has lost 5 lbs (2% weight loss) over the last 3 months. What is his nutrition status and what, if anything should be done regarding his nutrition status prior to surgery?

JPEN. 2012;36(3):275-83

Etiology Based Malnutrition Definition

Wh ite JV,etal . JP EN.2 0 1 2 ;36 (3 ):2 75 -8 3

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Characteristics for the identification and documentation of adult malnutrition

(require 2 of the 6 below for diagnosis malnutrition)Malnutrition in the Context of Acute

Illness or InjuryMalnutrition in the Context of

Chronic Illness

Malnutrition in the Context of Social or

Environmental Circumstances

Clinical characteristics

Non-severe (moderate)

malnutrition

Severe malnutrition


malnutrition

Severe malnutrition


malnutrition

Severe malnutrition

Energy intake<75% of estimated

Energy requi rement for >7 day s

≤50% of estimatedEnergy requi rement

for ≥5 days

<75% of estimatedEnergy requi rement

for ≥1 month

<75% of estimatedEnergy

requi rement for ≥1 month

<75% of estimatedEnergy requi rement

for ≥3 months

≤50% of estimatedEnergy requi rement

for ≥1 month

Weight loss

% Time % Time % Time % Time % Time % Time

1-2 1 wk >2 1 wk 5 1 mo >5 1 mo 5 1 mo >5 1 mo

5 1 mo >5 1 mo 7.5 3 mo>7.5

3 mo 7.5 3 mo >7.5 3 mo

7.5 3 mos >7.5 3 mos10 6 mo >10 6 mo 10 6 mo >10 6 mo

20 1y >20 1y 20 1y >20 1y

Body fat Mild Moderate Mi ld Sev ere Mi ld Sev ere

Muscle mass Mild Moderate Mi ld Sev ere Mi ld Sev ere

Fluid accumulation Mild

Moderate to Sev ere

Mi ld Sev ere Mi ld Sev ere

Reduced gr ip strength N/A*

Meas urably reduc ed

N/AMeas urably

reduc edN/A

Meas urably reduc ed

Wh ite JV,etal . JP EN.2 0 1 2 ;36 (3 ):2 75 -8 3DOES NOT INCLUDE ANY SERUM PROTEIN MARKERS!!


• Nutrition assessment in the context of chronic inflammation (due to his cancer) reveals that the patient has been eating more than 75% of his estimated needs. He has a 2% weight loss over the last 3 months. He had no significant fat loss, muscle wasting, or fluid accumulation on examination and his grip strength was not measured. So what is his nutrition status?

• Patient does not meet the criteria for moderate or severe malnutrition but his nutrition is not normal so he is categorized as mildly malnourished.

• Is any preoperative nutrition therapy indicated?


• Would preoperative oral nutrition supplements (ONS) improve postoperative outcomes?

• If so, would immunonutrition (IN) ONS be better than standard ONS?

• What is IN ON?ü Arginineü Omega-3 fatty acidsü Dietary nucleotidesü Glutamineü Antioxidants (selenium, ascorbic acid, etc.)

• BUYER BEWARE!!! – not all IN ONS are the same

Meta-Analysis Comparing Periop IN EN vs. Standard EN or No EN

• Drover et al. JACS. 2011;212(3):385-99• 35 RCTs of elective surgery patients comparing

arginine supplemented EN vs. Standard or no EN given in perioperative period on surgical outcomes

• Surgeries included:ü GI/Pancreas Surgeryü Head and Neck Surgeryü Cardiac Surgeryü GYN Oncology Surgery

Drover et al. JACS. 2011;212(3):385-99 Drover et al. JACS. 2011;212(3):385-99

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Drover et al. JACS. 2011;212(3):385-99

Meta-Analysis Comparing Periop IN EN vs. Standard EN or No EN

• Hegazi et al. JACS. 2014;219(5):1078-87• 8 RCTs preop IN vs. Standard ONS• 9 RCTs preop IN ONS vs. No ONS• Surgeries included only GI, Pancreas, and Liver Surgery

Hegazi et al. JACS. 2014;219(5): 10 78 -8 7

Preop IN ONS vs. Standard ONS for Postop Infectious Complications

Preop IN ONS vs. Standard ONS for Postop LOSHegazi et al. JACS. 2014;219(5): 10 78 -8 7

Preop IN ONS vs. No ONS for Postop Infectious Complications

Preop IN ONS vs. Standard ONS for Postop LOS


• Recommend giving ONS 1 serving 3 times day for 5 days prior to surgery.

• IN ONS may be more effective than a Standard ONS

Question #1. All of the following are risk factors for refeeding syndrome except:a) No feeding for 3 daysb) BMI 17c) History of alcohol or drug abused) > 10% weight loss over 3-6 monthse) Anorexia nervosa with severe weight loss

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Question #2. Which of the following would decrease complications with PEG tubes?

a) Never change the PEG tubeb) Do not cinch down the external bump too tightlyc) Do not flush PEG tubesd) Do not secure the PEG tube externallye) Have Dr. Ponsky insert all PEG tubes

Question #3. Serum albumin is a significant metric for evaluating for malnutrition. a) Trueb) False

Question #4. All of the following are true regarding perioperative oral (ONS) or enteral (EN) nutrition supplements except:a) May decrease postop infectious complicationsb) May decrease postop length of stayc) Immunonutrition may be more effective than

standard oral/enteral supplementsd) ONS is not effective in improving surgical

outcomes if only give preope) Perioperative ONS/EN supplements does not

decrease postop mortality

cleveland clinic surgical case study #1 nutrition webinar

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