Nutritional Support in a General Urological Service

0022-534 7/84/1312-0302$02.00/0

THE

Vol. 131, February Printed in U.S.A.

JOURNAL OF UROLOGY

Copyright © 1984 by The Williams & Wilkins Co.

NUTRITIONAL SUPPORT IN A GENERAL UROLOGICAL SERVICE G. J. WISE, E. ALTMAN, A. WEISS, R. G. CARR, E. RAJARATNAM, K. LINDSAY

AND

B. HERZ

From the Division of Urowgy, Department of Surgery and the Nutritional Support Service of The Maimonides Medical Center and Coney Island Hospital, Brooklyn, New York

ABSTRACT

A nutritional support team was used in the assessment and management of patients on a general urological service. Indications for nutritional evaluation included history of weight loss, anorexia, significant infection, chronic neoplastic disease, trauma or major surgery. The fat and protein status of the patient was assessed by anthropomorphic and laboratory determinations. The patient then was categorized as having mild, moderate or severe degrees of nutritional depletion. Deficiencies in vitamins, trace elements or essential fatty acids were not noted. Caloric and protein needs were calculated by multiplication of the basal energy expenditure by a metabolic activity factor, which was derived from the degree of illness or stress. Nutritional support was provided by enteral feedings via oral, nasogastric or jejunal feeding tubes and/or intravenous hyperalimentation via peripheral or central venous nutrient lines. During a 6-month interval nutritional consultation was requested for 50 patients, who represented 7 per cent of the urological admissions. Nutritional support was provided for patients who had obstructive uropathy with or without neoplasms, radiation cystitis, sepsis, urinary fistulas, mental depression, end stage renal disease or neurological dysfunction. In patients in whom urological treatment controlled the disease nutritional support maintained the weight, and stabilized serum albumin and lymphocyte counts. We concluded that a nutritional support program has a significant and, often, unappreciated role in the management of urological patients. Nutritional support is a method by which basic and supplemental nutritional requirements are given to patients who cannot fulfill their essential needs by normal dietary intake or when a normal diet is not absorbed, digested or metabolized adequately. The hospitalized patient may not have an adequate diet for a variety of reasons, including mental depression, anorexia, underlying disease and unappealing hospital food. Nutritional support can be provided by the enteral route (oral, nasogastric tube, gastrostomy or jejunal feeding tube) or the parenteral route (peripheral or central infusion line). We have used a nutritional support team in the assessment and management of patients on a urological service. METHODS

A consultation by the nutritional support team was requested when the dietary intake did not appear to satisfy metabolic needs. History of weight loss, poor appetite or improper eating habits indicated the need for consultation before a urological procedure. During hospitalization nutritional assessment was made if the patient could not return to an adequate diet within 4 to 5 days after a urological procedure. After clinical evaluation of the patient by the urologist in conjunction with the nutritional support team to determine the basic nutritional needs, the patient was followed daily by the appropriate team member. The dietician determined the enteral feeding formulas, the pharmacist prescribed the daily intravenous requirements and mixtures in conjunction with the urologist, and the nurse clinician assessed the care, function, patency and sterility of the intravenous infusion lines. Assessment of nutritional needs. The standard anthropomorphic measurements, triceps skin fold, brachial mid arm circumference and mid arm muscle circumference provided an estimation of the fat reserve and somatic protein status of the Accepted for publication August 12, 1983. Read at annual meeting of American Urological Association, Las Vegas, Nevada, April 17-21, 1983.

patient. 1 Laboratory determinants, such as serum albumin, transferrin and total lymphocyte count, provided an estimation of the visceral protein status. Initially, the nutritional support team used standard skin antigen reactivity to evaluate immunoreactivity. However, we and others 2 have found these tests to be unreliable parameters of subtle changes in the nutritional status. Twenty-four hour urine specimens were obtained for urinary nitrogen and creatinine. Urine nitrogen excretion> 11 gm. suggested increased metabolic activity. 3 Measurement of 24-hour creatinine excretion divided by the value of a normal adult of the same height provided the creatinine/height index, which is another estimation of skeletal mass. 4 Creatinine/ height excretion values of 60 to 80 per cent represented mild, 40 to 50 per cent moderate and <40 per cent severe muscle depletion. Urea.and nitrogen creatinine excretion studies were not used in patients with impaired renal function. The basic metabolic caloric needs of the patient were determined by the Harris-Benedict equation: basal energy expenditure= 66 + (13.7 X kg. weight)+ (5 X cm. height) - (6.8 X age) for men and 655 + (9.6 x kg. weight) + (1.7 X cm. height) (4.7 x age) for women. Multiplication of the basal energy expenditure by the metabolic factor provided the necessary caloric requirements for each patient." A rule-of-thumb method using 35 to 45 kcal./kg. provided an index for the necessary nonprotein caloric requirements for the patient. 1 Protein needs were estimated to be 1.5 to 2 gm./kg. daily for patients who underwent major surgery, such as cystectomy, while those with renal disease required modification of protein intake. For example, if a 70 kg. patient recovering from a urological procedure, such as radical nephrectomy, had a basal energy expenditure of 1,400 calories a metabolic factor of 2 was used and, therefore, the patient required 2,800 nonprotein kcal. daily. With the ruleof-thumb method a 70 kg. man required 40 kcal./kg. daily, which also yielded 2,800 calories daily as the necessary nonprotein requirement. Protein requirement~ were estimated as 1.5 gm./kg. body weight or 105 gm. protein daily. Nutritional support. Enteral: There are a variety of commer302

303

NUTRfTIOl\f,_t\.L SUPPORT II\J GENERAL "UROLOGICAL SERVICE

cially available that nutritional enteral replacements or supplementationo These vary in taste, nitrogen content (3 to 12 gm)L) and osmolarity 250 to 900 mOsmo)o The vitamin, electrolyte and trace element contents vary in different formulas but most fulfill the minimum daily allowanceo 6 Enteral feeding products provide a minimum of 1 kcaL/mL Special preparations are available for patients with renal disease, whose protein content is reduced or consists of essential amino acidso In patients with liver disease the protein content is modified to consist of branched amino acids and less aromatic amineso 5 Enteral formulas can be made in the hospital or purchased from commercial sourceso Many formulas are derived from a milk base that provides the essential nutritional requirementso Since 15 per cent of white adults may have a primary lactose intolerance these patients require a lactose-free enteral preparation that uses sucrose or corn syrup as the primary carbohydrate source and soybean as the protein sourceo 5 In patients with bowel disease, such as ileitis or malabsorption syndrome, a low residue, elemental or chemically defined diet is indicatedo These elemental or chemically defined diets are higher in cost since they use oligosaccharides, protein hydrolysates, polypeptides and/or essential amino acidso Most low residue, chemically defined diets provide 1 kcaL/mL but vary in fat, carbohydrate or protein content. In patients who cannot tolerate enteral feedings by mouth because of anorexia, poor conscious state or upper gastrointestinal disease a nasogastric tube provides another modality with which to give nutritional supporL 7 The availability of small nasogastric tubes (8 to has decreased the problems associated with larger tubes, such as esophageal reflux, esophagitis and aspirationo However, enteral formulas should be of a viscosity that can be administered through the small bore nasogastric tubeso In addition, a perfusion pump is necessary to ensure accurate delivery, which can range from 50 to > 100 mL per hour dailyo Small nasogastric feeding tubes do have inherent problems, including the potential for regurgitation or diarrhea secondary to rapid fluid or osmolar overload, which can be corrected by a slower infusion rate or a change in formula. Jejunal: The jejuna! feeding tube has gained wide use in the management of surgical patients with a variety of gastrointestinal procedures, such as biliary, pancreatic or bowel surge1y 8 We have found that the jejuna! tube is useful in patients undergoing urological procedures, such as correction of vesicocolic fistulas, ilea! diversion and radical nephrectomyo In these patients the jejuna! feeding tube is inserted and placed during the procedureo Postoperatively, contrast medium is placed through the tube and an x-ray is obtained to ascertain the accurate position of the tubeo The solution (initially dextrose and saline) is administered at a rate of 25 mL per houro If tolerated the solution is changed to a half strength defined formula, which subsequently is increased during 2 days to a full strength chemically defined formula administered at 100 mL per hour (providing 2,400 calories daily)o We have used a jejuna! feeding tube without complications in 7 patients for an average of 6 days until they could tolerate oral feedingso In 1 patient the jejuna! tube inadvertently was displaced early in the postoperative course, which necessitated parenteral nutritional supporto The jejuna! feeding tube has advantages over a feeding gastrostomy, since gastric dilatation may occur postoperativelyo There is less chance of regurgitation through the jejunal tubeo Based on the 3 cases reported in this series and 4 additional cases, we believe that the jejunal feeding tube has a role in the nutritional maintenance of patients undergoing transperitoneal urological procedures. Although the cost of lactose-free, elemental or chemically defined diets is more than the blenderized or other enteral formulas they are less expensive than intravenous feedings and do not require the nursing care of insulin coverage as may be the case with intravenous feeding (table 1). Whenever possible,

TABLE

L Coniparatiue costs of various nutritional forniulas Composition (gmJL)

Formula (mOsmo)

Carbohydrates

KcaL/mL Protein

Fat

Cost (1,000 kcaL)

Enteral Lactose free: Ensure (450) Ensure Plus (600) lsocal HCN (600) Osmolite (300) Elemental chemically defined: Vivonex (550) Vivonex High Nitrogen (840) Vital (460) Central venous nutrition (1,800) Peripheral venous nuo trition (800-900)

197 197

37 55

37 53

1 L5

L33 LOS

225

34

44

2

L47

145

37

39

231 210

22 44

1 1

185

1

250

42 Intravenous 41

100

41

2008

1 1

5016 9074 5027

6

0087

35A6

33

0059

48069

enteral hyperalimentation by oral, nasogastric or jejuna! feeding is preferred to intravenous parenteral nutritional support. 9 Patients on enteral feedings require less exogenous insulin and do not suffer excess carbon dioxide production, which is associated often with intravenous feedingso In addition, the functional integrity of the intestinal mucosa is maintained. 8 In patients with a defunctionalized bowel or who cannot tolerate nutrition mouth, or through nasogastric or jejunal feeding tubes the intravenous or parenteral route is preferredo Intravenous: Dudrick and associates reported that intravenous mixtures of glucose, fibrin hydrolysates, electrolytes, vitamins and trace elements provide adequate metabolic support for debilitated patients, which demonstrated clearly the role of intravenous feeding in the management of the critically ill patiento 10 The use of subclavian catheters has permitted high volume, high osmolar (1,800 mOsmo) loads to be infused directly into the venous systemo However, use of subclavian catheters has the potential complications of sepsis, hemothorax, pneumothorax and venous thrombosiso 3 The peripheral venous nutrient lines provide another access for intravenous nutritionai supporto Although phlebitis may occur the potential complication rate for peripheral lines is far less than for central venous lineso Moreover, the peripheral line is limited by the osmolar load (800 to 900 mOsmo) in contrast to the central venous line (1,800 mOsmJ and, thus, the amount of carbohydrates that can be administered is limitedo In addition, long-term use of the peripheral venous lines is 1111µv'""1,u1e, since they must be changed every 2 to 3 days, while central venous lines can remain in situ for many weeks with proper careo The availability and simultaneous administration of intravenous fat emulsions with peripheral venous solutions provide a diluent for the hypertonic solution and additional calorieso In ~,,,,,r,,rm the fat emulsions are necessary to provide essential fatty acidso 11 Intravenous nutritional feedings have been used widely in the management of patients with serious abdominal problems, such as pancreatitis, bowel fistulas and inflammatory bowel disease, and in those requiring intensive surgery for malignant disease, chemotherapy and even some forms of radiotherapyo Intravenous nutritional support with crystalline amino acids has been effective in the sparing of visceral proteins in patients requiring cystectomy and urinary diversion for invasive bladder carcinomao12· 13 Our nutritional support team has used a high caloric formula (glucose) plus fat emulsions and amino acid mixtures in the management of urological patients requiring intravenous feedingso The adult central venous nutritional lines used an equal mixture of 500 mL 8.5 per cent amino acids and 50 per cent dextrose per L, yielding 40 and 250 gm)l. of protein and glucose, respectivelyo

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WISE AND ASSOCIATES

The resultant intravenous mixture contains 850 nonprotein kcal.fl. Electrolytes, vitamins and trace elements are added every 1 or 2 days. The peripheral venous nutritional line formula consists of 500 ml. 20 per cent dextrose and 500 ml. 8.5 per cent amino acids, and has 340 nonprotein kcal.fl. and 40 gm.fl. protein. The simultaneous administration of fat emulsions with the dextrose mixture allows the solution to be uniformly well tolerated. Electrolytes, vitamins and trace elements are added on a daily basis, as necessary. Patients on intravenous nutritional support may require insulin coverage to maintain homeostasis of blood sugar. Modified protein solutions of 5.4 per cent amino acid in patients with renal disease yield 1,190 kcal. glucose and 12. 7 gm. protein per 750 ml. Special formulas also are used in patients with liver disease. RESULTS

During the first 6 months of 1982 nutritional assessment was requested for 50 of approximately 700 hospitalized patients under urological care (7 per cent). Of the 50 patients requiring nutritional support 8 had undergone cystectomy and/or urinary diversion for management of carcinoma of the bladder and 42 represented a diverse group that included genitourinary malignancies, urosepsis and obstructive uropathy (table 2). Modalities for providing initial nutritional support included enteral feedings in 16 patients, nasogastric tubes in 12, jejunal feeding in 3, peripheral venous nutrition in 13 and central venous nutrition in 6. No untoward effect, such as sepsis or hyperosmolar state, was noted in patients receiving central venous nutrition. In patients receiving peripheral venous nutrition minor localized phlebitis was noted if the line was not changed by day 5 of infusions. Most patients required a minimum of 7 days of intravenous feedings and then were switched to enteral feeding formulas. Nutritional support was given to patients with malignant disease in whom therapeutic modalities of radiation, chemotherapy, hormonal therapy or surgery had not been exhausted fully. CASE REPORTS

Case 1. A 68-year-old man required an ileal conduit for management of severe radiation cystitis. Postoperatively, the patient received 10 per cent dextrose in water and did not have an adequate oral dietary intake. Ureteroileal anastomic leakage persisted, and the lymphocyte count and albumin decreased to below normal. Nutritional consultation advised the use of a peripheral venous nutritional line followed by enteral support. TABLE 2.

Diagnostic categories of 50 urologic patients requiring nutritional support No. Pts.

Neoplastic disease: Renal cell Ca Invasive bladder Ca: Cystectomy and urinary diversion Urinary diversion alone Metastatic disease Prostate Ca stages Dl and D2 Testicular Ca and retroperitoneal lymph node metastasis Lymphosarcoma Associated gastrointestinal disease: Enterovesical fistulas Obstructive uropathy and concomitant gastrointestinal neoplasm Serious urinary tract infection Obstructive uropathy: Benign prostatic hypertrophy* U reteral stone Ureteral stricture Neurological disease End stage renal disease * One patient had trauma.

2 6 2 2 5 1 1 6 6 10 2 1 1 2 3

The serum albumin and lymphocyte count improved, and the ureteroileal leakage resolved. Case 2. A 69-year-old man with a history of a 12-pound weight loss was hospitalized with a large left renal mass, which proved to be renal cell carcinoma. During transperitoneal nephrectomy a jejunal feeding tube was inserted and nutritional support was provided postoperatively. The serum albumin, lymphocyte count and weight remained stable, and the patient was discharged from the hospital 8 days after radical nephrectomy. DISCUSSION

The use of serum albumin and transferrin has been questioned as appropriate guidelines for nutritional depletion because of their long half-life (19 and 10 days, respectively) and other factors that can affect their value, such as gastrointestinal albumin loss and iron deficiency. 2 Thyroxin binding prealbumin and retinol binding protein (half-lives 2 days and 12 hours, respectively) are far more accurate laboratory guidelines to determine the subclinical forms of malnutrition. 2 From a practical standpoint serum albumin and transferrin levels were more readily available and, thus, were used in the clinical assessment of these patients. Skin antigen sensitivities have been found to be unreliable determinants of subclinical malnutrition and may manifest false negative reactions secondary to steroids, fever, sepsis, tumor or trauma. The nutritional support team used the total evaluation, recent history of weight loss (>7 per cent), poor eating habits, anthropomorphic measurements and laboratory data to provide a total view of nutritional needs. Most of our patients were elderly (>65 years old) and were known to have less muscle mass and to be less responsive to increases in dietary protein intake. 14 This factor suggests that elderly patients may have a greater tendency for protein deficiency and may explain partly the relatively rapid decrease in serum albumin within a few days of poor nutritional intake. Our clinical study indicated that a small but diverse group of urological patients (7 per cent) required some form of nutritional support. The availability of various nutritional modalities provides the urologist with various methods with which to treat the patient. The use of a nutritional support team has proved to be invaluable in the assessment and management of these patients. REFERENCES

1. Ruderman, R. L. and Pollard, A.: Basic principles of surgical nutrition. In: Nutrition in Clinical Surgery. Edited by M. Deitel. Baltimore: The Williams & Wilkins Co., chapt. 2, pp. 13-27, 1980. 2. Michel, L., Serrano, A. and Malt, R. A.: Nutritional support of hospitalized patients. New Engl. J. Med., 304: 1147, 1981. 3. Grant, J. P.: Handbook of Total Parenteral Nutrition. Philadelphia: W. B. Saunders Co., 1980. 4. Hensle, T. W.: Surgical nutrition: part I, general principles and alimentation. In: Weekly Urology Update Series. Princeton: Biomedia, Inc., vol. 1, lession 10, 1978. 5. Gordon, A. M., Jr.: Enteral nutritional support: guidelines for feeding product selection. Postgrad. Med., 72: 72, 1982. 6. Hamaoui, E., Ahart, H. E., Eisen, R. F., Hinsdale, J. G. and Pollock, T. W.: Nutritional requirements and considerations. Res. Staff Phys., 29: 40, 1983. 7. Griggs, B. A. and Hoppe, M. C.: Nasogastric tube feeding. Amer. J. Nursing, 79: 481, 1979. 8. Hoover, H. C., Jr., Ryan, J. A., Anderson, E. J. and Fischer, J. E.: Nutritional benefits of immediate postoperative jejuna! feeding of an elemental diet. Amer. J. Surg., 139: 153, 1980. 9. Heymsfield, S. B., Bethel, R. A., Ansley, J. D., Nixon, D. W. and Rudman, D.: Enteral hyperalimentation: an alternative to central venous hyperalimentation. Ann. Intern. Med., 90: 63, 1979. 10. Dudrick, S. J., Wilmore, D. W., Vars, H. M. and Rhoads, J.E.: Can intravenous feeding as the sole means of nutrition support growth in the child and restore weight loss in an adult? An

SDPPOR.T Ii\J GEJ\JERAL UROLOGICAL SERVICE affi:nnative anS\.iVer. Ann. 1£9~ 974, 1966. 11. Alexander, M. A.: Use of Nutrition in Clinical Edited by M. Deitel. The Williams & Wilkins chapt. 83-90, 1980. 12. Soiomon, Smith, M. F., Dowd, J. B., Bistrian, B. R. and Blackburn, G. L.: Optimal nutritional support in surgery for

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bladder cancer: preservation of visceral protein by ar.nino acid infusions. J. Urol., 119: 350, 1978. 13. Hensle, T. W.: Protein-sparing in cystectomy patients. J. UroL, 119: 1978. 14. Munro, H. · Nutritional requirements in the elderly. Hosp. Prac., 17: 143, 1982.