Update    Useful Links     MCQs     CTSS     Protocols     Arabic عربي 

 __________________________________________________________

NUTRITION POST-CARDIAC SURGERY

Enteral Feeding Guidelines for Cardiac Surgery intensive care unit

Enteral nutrition should be considered for all patients admitted to cardiac ICU within 24 hours of admission.  Contact dietitian to select feed type (guide attached).  Feeding should follow the below protocol unless otherwise advised.


Feed rate

Volume of aspirate after 4 hours

Volume to be replaced

Action to be taken

30ml/hr

<200ml

>200ml

 

 

Up to 120ml

120ml

 

 

Increase rate to 60ml/hr

Maintain rate of 30ml/hr

 

After 3 attempts commence IV metaclopramide, 5mg every 4hr

After 24hrs commence

IV glutamine at 4ml/hr

After 3 days, consider

endoscopic NJplacement

60 ml/hour

<200 ml

-

-

-

-

-

>200 ml 

Up to 120 ml

-

-

-

-

-

120 ml

If patient <60kg

maintain rate of 60ml/hr

until reviewed by

dietitian

If patient >60kg increase

to 80ml/hr

-

Reduce rate to 30ml/hr +/- metaclopramide

80 ml/hour

< 300 ml

-

> 300 ml

 

 

Up to 160 ml

-

160 ml

 

Maintain rate of 80ml/hr

until review by dietitian

-

Reduce rate to 60ml/hr

 +/- metaclopramide

Contact the dietitian as soon as feeding begins.

Additional Information

·        Ryles NG tubes should be replaced with a fine bore NG tube when the patient is fully established on feeding. Confirm position of fine bore NG and NJ tubes by pH and CXR at initial placement (level II and III) and note exteranl tube length. The position of the tube should be re-confirmed following a break in feeding or if the tube has been removed. All procedures should be documented.

·         Please discuss with dietitian before removing NG tubes to trial oral intake

·        Increase feed rate according to the protocol, unless otherwise advised or if the patient shows signs of intolerance such as : Nausea, vomiting, abdominal pain, distension, bloating, profuse diarrhoea

·        All patients should be fed over 24 hours (to aid tight glycaemic control, etc), unless the patient is receiving medication which may react with the feed (consult pharmacist), or the patient is also eating and drinking

·        It is not usually necessary to stop the feed for long periods prior to surgery, (except bowel surgery). Aspiration of the feeding tube before tracheostomy , trauma surgery, etc. – consult the intensivist on duty.

·        It is recommended that patients returning to oral intake following a prolonged period of NBM (tracheostomy, etc) should be referred to SALT (Speech and Language therapy)

·        Patients who are eating and drinking small amounts should be fed overnight from 8pm to 6am to supplement oral intake until adequate intake is established, and a food record chart maintained. Please consult the dietitian as soon as oral intake begins.

·        Giving sets should be labelled with the patient’s name and the date and time it was set up, and changed every 24 hours

·        Sterile water should be used for hydration (using a flexitainer for large volumes) and for drinking or flushing the feeding tubes (30ml every 6 hours, or every bottle change).

·        On discharge from cardiac ICU/HDU, ensure patient has a feeding regimen attached to their notes. 

 

Contra-indications:

·        Metabolic acidosis thought to be due to tissue hypoperfusion

·        GIT surgery with formation of an anastomosis or pancreatic disorders (unless discussed with consultant)

·        Documentation from the consultant responsible for the patient

·        The patient is able to take adequate food/fluid orally

·        Patients with an extremely poor prognosis – to be discussed with consultant

 

If the patient is not for enteral feeding and is unable to take food/fluid orally, consider:

·        Glutamine (dipeptiven) given IV, 100ml at 4ml/hr

Micro-nutrients

Pabrinex I and II should be given IV for up to 7 days in those who:

·        Consume >30 units of alcohol per week

·        Are severely malnourished and at risk of re-feeding syndrome (see attached sheet on re-feeding syndrome) 

Parenteral Nutrition

Parenteral Nutrition must be consultant authorised; and can be requested via referral to a member of the nutritional support team.  Consult a member of the nutritional support team before removing a tunnelled feeding line from a patient receiving parenteral nutrition.

------------------------------------

Gastric Protection

Omeprazole is prescribed with the premed for all cardiac patients. It is continued postoperatively until the patient is established on full enteral feed. However if the patient has been prescribed omeprazole preoperatively on a regular basis then the same should be continued.

Intravenous omeprazole is preferred to ranitidine if there is bleeding oesophagitis, when it is usually also necessary to remove the NG tube.  Also consider PEG feeding in this situation.

Gastrointestinal Failure

GI bleeding Mesenteric ischaemia  Pancreatitis  Cholecystitis  Perforated peptic ulcer  Paralytic ileus  Pseudo-obstruction

Small bowel obstruction  Diverticulitis  Hepatic failure  Hyperamylaseaemia