Nutritional management of long-stay, complex gastro-surgical patients by Emma Osland, AdvAPD.
Intestinal failure occurs when there is a reduction in gut function through physiological or anatomical changes which can result in inadequate nutritional, hydration and electrolyte absorption, requiring intravenous support to maintain health and function. It is complex and can be acquired (such as from trauma), congenital, systemic, benign or malignant causes (ESPEN, 2016). There are three functional sub-types of intestinal failure, with Type 1 often resolving with minimal management, Type 2 requiring specialist multidisciplinary care for the best outcomes, and Type 3 generally being more medically stable and able to be managed outside of a hospital setting.
Patients presenting with Type 2 intestinal failure are often very unwell, and it is critical that patient-centred care is provided, including psychological support. The management and subsequent treatment of intestinal failure can be divided into 3 key management phases. The first, or immediate, management phase involves intial treatment to resolve sepsis, optmise wound management, and ensure that there is adequate fluid and electrolyte stabilisation. The second, or early, management phase involves establishing nutritional support (often parenteral nutrition initially), reducing stomal/ fistula losses, providing psychosocial support, and focusing on mobilisation. The third phasefocuses on resolving the underlying condition (such as through surgery to reconnect bowel or excise fistulae) once the patient is more medically stabilised.
In relation to the nutritional assessment of Type 2 intestinal failure, Advanced Accredited Pracitising Dietitian Emma Osland explains the complexity in managing this patient group, with an underlying goal being to meet energy and protein requirements to prevent lean muscle mass loss, and ensure an optimal electrolyte, micronutrient and hydration status, while taking into account losses (such as from wounds, a stoma or fistulae). Through the use of a case study involving a patient with a mechanical obstruction in the distal small bowel that lead to the development of a high output fistula, Emma explains through the use of an acronym ‘SNAP’ the importance of ensuring sepsis is treated (noting that nutritional repletion cannot be managed without controlling the source of sepsis), that nutrition is optimised, that there is anatomocial clarification to understand what is going on and therefore the available nutritional and surgical management strategies, and finally coming up with a treatment plan.
Emma emphasises that as a general rule, if at least 100cm of the functional gut is in continuity, then oral or enteral nutrition can be initiated. However, for some patients, parentral nutriton may be warranted for several months. Further to this, Emma also highlights the specific nutritional management which can vary from patient to patient including modalities of distal feeding - the management of enteroclysis/ fistuloclysis, and a chyme reinfusion - as well as the nutritional considerations in PN monitoring.
Overall, Type 2 intestinal failure is the most likely reason that a dietitian will provide complex, long-term nutrional support is provided for an inpatient. This requires multidisciplinary support in providing patient-centred care and in ensuring that the underlying issue is resolved, while safely optimising the patient’s nutritional status.
- Intestinal failure occurs when there is a reduction in gut function through physiological or anatomical changes which can result in inadequate nutritional, hydration and electrolyte absorption, requiring intravenous support to maintain health and function. It is complex and can be acquired (such as from trauma), congenital, systemic, benign or malignant causes (ESPEN, 2016).
- It is important to consider that long PN has a different management focus to short-term PN. In monitoring parenteral nutrition in Type 2 intestinal failure patients, screening for micronutrients (especially of zinc and selenium) should be considered only once patients are medically stable, when inflammatory and acute phase drivers have been resolved (i.e. CRP levels are within normal range).
- Type 2 intestinal failure is complex and can involve complex fistulae, surgical wounds, and emergent/ salvage stomas, requiring multidisciplinary care and often a specialised care unit. The length of stay can be extensive, and it is critical to consider the provision of psychosocial supports to optimise patient well-being and recovery.
Emma Osland is an Advanced Accredited Practicing Dietitian currently based at the Royal Brisbane and Women’s Hospital. In her career to date, Emma has worked across a broad range of practice areas and is recognised for her expertise in nutrition support and surgical nutrition. Her particular clinical interests include micronutrients, parenteral nutrition, intestinal failure, and she loves seeing how nutrition can positively impact her patients’ quality of life.
To register for the presentation, case study and associated documents including the assessment quiz
Part 1 click here:- Overview and Clinical Management of managing Type 2 intestinal failure
Part 2 click here:- Case Study