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home - Nutrition - Clinical Conditions and Nutrition - ITU and surgery Written by Dr Sebastian Zeki
Knowledge
Assessment
Methods GMP
Knows the role of nutrition as therapy for active IBD SCE 1
Knows the role of dietary alteration in treatment of symptoms of IBD
e.g. low residue diet for stricturing disease
SCE, CbD 1
Knows the mechanism of nutritional deficiency in IBD, the importance
of gut preservation, and the role of nutritional support in IBD
SCE, CbD 1
Understands the circumstances when nutritional support should be
provided by enteral or parenteral routes, and to know the various
methods of delivery
SCE, CbD 1
Understands the possible methods of maximising bowel preservation
including appropriate medical therapy, endoscopic therapy and bowel
preserving surgery
SCE, CbD 1,3
Skills
Uses enteral feed as therapy for active disease in appropriate
patients, and to alter diets as appropriate to improve symptoms
SCE, mini-CEX, CbD 1
Can use enteral and parenteral nutrition appropriately to support
patients with active IBD and to prevent substantial malnutrition
mini-CEX, CbD 1
Can perform colonoscopic balloon dilatation to prevent the
requirement for resection, and to understand when to refer for
enteroscopic dilatation or for a surgical opinion
DOPS, CbD 1
Behaviours
Explains to patients and relatives the importance of nutrition as
treatment and support
mini-CEX, PS 1,3,4
Can work with the MDT to ensure all treatment decisions maximise
bowel length
CbD 1,3
Liaises with dieticians and other healthcare professionals to ensure
that all patients have appropriate nutritional support
Also...

Knowledge


Appreciates that preserving bowel length is important
Knows how to use immunomodulating or biological drugs to treat IBD
so as to maintain a maximum bowel length and avoid resections that
may result in a short bowel

Knows endoscopic and surgical techniques that avoid bowel being
resected (e g balloon dilatation and sphincteroplasty)

Knows the dietary therapies available to reduce disease and
symptoms (e g for intermittent obstruction l giving a liquid or low fibre
diet)

Skills
Appreciates that preserving bowel length is important
Can use immunomodulating or biological drugs to treat IBD so as to
maintain a maximum bowel length and avoid resections that may
result in a short bowel

Behaviours
Can empathise with and appreciate the needs of patients with IBD
Works within the multidisciplinary NST and also with the IBD nurses
and surgeons

Discuss any issue relating the disease honestly with the patient
carers friends and family

Also
Knowledge


Knows the causes of small bowel infarction
Knows the difference between arterial and venous gut infarction
Understands the problems and timing of anastomosing the small
bowel onto the colon

Knows the different methods of imaging the vascular supply to the gut
(e g CT angiography digital subtraction angiography angiograms
etc)

Skills
Is able to investigate the causes of a small bowel arterial or venous
infarction

Can identify other co-existing vascular problems
Can choose the appropriate route for nutritional support (EN or PN)
Be able to feed into defunctioned gut (fistuloclysis) when appropriate
Behaviours
Works within the multidisciplinary NST and with the vascular
surgeons and Haematologists
Appreciates there may be other co-morbidities that limit treatment
Can discuss disease-related issues honestly with the patient carers
friends and family

Also...

Knowledge


Knws the principles of normal post operative care including early fluid
management (avoiding excessive saline) and having a knowledge of
when to start nutritional support

Appreciates the reasons why surgical wounds and anastomoses can
break down

Knows the stages of development of an enterocutaneous fistula and
thus the appropriate fluid/nutritional management at each stage

Understands how complex abdominal wounds are dressed (e g
wound manager bags)

Understands what is meant by a frozen abdomen and sclerosing
peritonitis

Knows why intestinal obstruction occurs and the ways in which it can
be managed

Knows why abdominal surgery is best avoided 0- 00 days after the
last abdominal operation

Knows the principles of enhanced recovery after surgery (ERAS)
(including reducing insulin resistance and saline excess)

Skills
Can institute an appropriate investigation plan for occult sepsis
Can assess whether an enterocutaneous fistula is likely to close
spontaneously

Is able to prescribe appropriate pain relief (often with the pain team)
Can assess fluid losses and thus give appropriate fluid replacement
Appreciates the principle of later restorative surgery
Is able to arrange the appropriate tests for mapping the remaining gut
(both that is in and out of circuit)

Gives appropriate psychological care with the psychological medicine
team

Helps a patient to be physically and emotionally well so they are able
to tolerate more surgery if necessary or be able to cope at home

Can feed into defunctioned gut (fistuloclysis) when appropriate
Behaviours
Understands role of tissue viability nurses and can integrate care with
them

Explains to patients their anatomy the principles of intended
treatment and any procedures

Also...

ITU and surgery

Complications Of Malnutrition In Surgical Patients:-Increased susceptibility to infection (due to immune dysfunction).-Poor wound healing.-Increased frequency of decubitus ulcers.-Overgrowth of bacteria in the GI tract.-Abnormal nutrient losses through the stool. Oral feeding- Use gut early post-op usually can have oral intake after a few days. Parenteral feeding- This gives a higher sepsis rate with no better mortality unless severely malnour-ished when TPN gives a post op complication reduction. Nutritional support in critically ill surgical patientsDuring illness: Catabolism>anabolism so in -ve N-balance: fat as the major fuel source and protein wastingDuring recovery: Anabolism>catabolism.Therefore need to maintain postive N balance. iv vs enteral feed: No mortality diffe-ence Less infections enterally.Simultaneous admin gives same outcome as single route. Immunonutrition: Arginine — Arginine-enriched enteral nutrition gives no effect on infectious/ mortality rate.Glutamine — iv rather than oral glutamine may provide a benefit.Omega-3 fatty acids —Unknown if these are beneficial. -History etc-Low serum albumin (< 2.2 g/dL) predicts poor outcome-Serum transferrin has an intermediate half-life of eight to nine days, reflecting protein status over the past two to four weeks in context of normal serum iron.May be some benefit in delaying surgery until fed if very malnourished -Patients with preoperative hypoalbuminaemia are more likely to have postoperative organ dysfunc-tion, GI bleeding, nosocomial infections, increased ITU stay/ ventilation length and hospital death.-Low body mass index (BMI <20 kg/m2) was asso-ciated with lower morbidity and mortality. In surgical cases, it can give some reduction in infectious complications and length of hospital stay but no mortality benefit. Nutritional Assessment in Surgical Patients Outcome with Nutritional Intervention Written by Dr Sebastian Zeki

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