Introduction
Postoperative osteotomy and fracture patients are often neglected from a nutritional point of view, despite obvious eating and drinking difficulties, pain and orofacial swelling. Malnutrition is a well-recognised problem in hospitals, with 40%-50% of all patients found to be malnourished on admission and 70%-80% on discharge. Although the former statistic is unlikely to apply to orthognathic patients the latter is often the case.
This patient group are by the nature of their surgery at risk of malnutrition owing to raised nutritional requirements and impaired nutritional intake. Consequences of malnutrition for the postoperative patient include decreased wound healing, decreased immune function and increased infection risk which can lead to unnecessary morbidity. Establishing and maintaining adequate intake should be seen as a priority. Patients with inadequate oral intake post-surgery or those requiring modified texture diets on discharge from hospital, should be referred to a dietician for individualised nutritional assessment and advice. Energy and protein requirements vary according to a patient's age and gender, and individualised nutritional assessment ensures optimum daily requirements are highlighted and achieved.
Optimum Daily Requirements
· Men and women average 2000-3000 kcal.
· 0.8 g protein/kg; 65-1000 g protein.
· 2-3 litres fluid.
Immediate Postoperative Feeding
1. 0-24 Hours Post-Operation: Intravenous Fluids
Having replaced blood loss to within 500 ml, compound sodium lactate (Hartmann's) solution is given to balance vomited fluid, gastric aspirate, urinary output and metabolic needs. The volume will be 2 to 3 litres depending on the patient's weight and the ambient temperature. The patient should also be encouraged to drink a little.
2. After 24 Hours
If the patient is well, and the surgical procedure allows, trials of oral fluid should be commenced using a feeding cup, straw or a large bore syringe and quill. Most orthognathic cases can cope, but if oral intake is proving difficult, enteral feeding should be commenced using a fine bore nasogastric feeding tube. This should be carried out under dietetic supervision to ensure the appropriate calorie and protein content, and minimise the side effects sometimes experienced with enteral feeding such as nausea, vomiting and diarrhoea. Supplemental intravenous fluids are often needed until the patient's normal oral feeding rate is achieved and to prevent dehydration and electrolyte disturbances.
3. After 48 Hours
Patients who have commenced nasogastric feeding should continue to receive this until the optimum oral intake has been established. Patients who have tolerated oral fluids from the start can progress to a full diet, but with a liquidised texture.
In many cases of bimaxillary surgery involving the lower labial sulcus with impaired mental sensation, adequate oral feeding may not be possible for up to 7 days and need special attention.
A Range of Commonly Used Supplements
· Ensure Plus/Fortisip/Fresubin Energy.
· Enlive Plus/Fortijuce/Provide Xtra.
· Fortifresh/Ensure Plus Yoghurt Style.
· Scandishake/Calshake.
· Calogen.
· Maxijul.
· Protifar.
These are in a variety of flavours for inpatient care, and can be obtained with or without a prescription on discharge.
On Discharge
The patient should have a comprehensive assessment and education regarding food preparation, food fortification and the use of dietary supplements. Patients must be routinely weighed when attending their outpatient review, and any weight loss addressed. In particular, children and adolescent patients need to be stringently monitored to minimise disruption to growth, along with patients with diabetes and food allergies.
Achieving nutritional requirements is difficult whilst following a liquidised diet. Liquids are more filling than solid foods, decreasing the patient's appetite. In addition, where non-nourishing fluids are used, liquidising can have a nutrient dilution effect causing inadequate calorie, protein and micronutrient intake. Choosing high-energy foods and fluids, encouraging small frequent meals and snacks and using food fortification techniques can help to counteract this.
General Guidelines for Patients
· Aim to include as much variety in the diet as possible, no single food will provide all the nutrients needed.
· Liquids are more filling than solids, so more will be needed to prevent weight loss. Small frequent meals including nourishing fluids will need to be taken.
· Aim for weight maintenance.
· Liquidised foods must be thin and smooth enough to pass through a straw or quill.
· Foods are often more palatable if liquidised separately to preserve individuals flavours and colours.
· Milk is a useful source of protein and calories, and can be fortified further by adding dried milk powder; 3-4 tablespoons of any dried milk powder to 1 pint of full cream milk. When whisked well this can be used as ordinary milk — for drinks, to make milk puddings, sauces etc.
· Vitamin C is an important nutrient for wound healing; a glass of pure orange juice or blackcurrant drink should be taken daily.
· Essential utensils are a liquidiser (blender) or food processor, a sieve, a beaker with feeding spout and straws. This should be discussed preoperatively and on the patient's information sheet.
Sample Meal Plan for Patients
Breakfast
· Fruit juice.
· Ready Brek/Porridge/Weetabix made with fortified milk, cream and sugar.
· Fortified milky drink/milky tea or coffee with sugar if desired.
Mid Morning
· Milky or nourishing drink.
· Mousse or smooth yoghurt.
Lunch
· Soup with cream/milk powder.
· Liquidised meat/chicken/fish/beans and pulses.
· Mashed potato with fortified milk/butter/cream/cheese.
· Pureed vegetables with butter and cheese.
· Milky pudding/smooth yoghurt.
Mid Afternoon
· Milk pudding with pureed fruit.
· Nourishing drink.
Evening Meal
· As per lunch.
Bedtime
· Hot milky drink — Horlicks, hot chocolate, ovaltine.
This diet also requires a dedicated oral hygiene regime with a child's soft tooth brush and a chlorhexidine mouth wash after meals to control plaque.
Information on feeding supplements can be found in the British National Formulary published twice yearly by the British Medical Association and the Royal Pharmaceutical Society of Great Britain.