Impact of nutrition care in surgery

Impact of nutrition care in surgery

Surgical Nutrition Training ModuleLevel 1

Philippine Society of General SurgeonsCommittee on Surgical Training

Objectives

• To discuss the impact of surgery on body composition, endocrine, and metabolic status

• To discuss the use of nutrition in modifying the impact of surgery on the patient

Surgery affects body composition and function (response to injury)

SURGERY

INFLAMMATION•Metabolic response•Endocrine response

POST-SURGERY STATUS•Resolution of inflammation•Wound healing•Recovery

COMPLICATIONS•Malnutrition•Inadequate intake•Current body composition•Pre-op preparation (NPO, antibiotic, fluid balance)•Post-op management

Nutrition management

COMPOSITION1.Carbohydrates2.Lipids

LCT (structural) MCT (energy) Fish Oils (immuno-

modulation)3.Protein

BCAA Glutamine

4.Vitamins/Trace elements5.Antioxidants

1. Sustains cellular metabolism and functions (MACRO & MICRONUTRIENTS)

2. Sustains mucosal cell quality and function (=GLUTAMINE)

3. Mucosal immunity sustained (GLUTAMINE & FISH OILS)

4. Reverses CARS (FISH OILS, GLUTAMINE, ANTIOXIDANTS)

• Requires protocols for access, feeding patterns, delivery• Needs calorie and protein counting practice• Strict fluid balance• MAY BE ENTERAL AND /OR PARENTERAL NUTRITION

Surgery causes immunosuppression

Nutrition management

Eicosanoids

Fish Oils: impact on liver function

Gura K et al. Safety and Efficacy of a Fish-Oil-Based Fat Emulsion in the Treatment of Parenteral Nutrition -Associated Liver Disease. Pediatrics 2008; 121: e678-68.

Severely malnourished patiets

• Nutritional build-up is required– Current ESPEN and ASPEN guidelines– Feeding pathways

malnutritionScheduled• esophageal resection• gastrectomy• pancreaticoduodenectomy

Enteral nutrition for 10-14 days

oral immunonutrition for 6-7 days

Early oral feeding within 7 days

yes no

within 4 days

yes

“Fast Track”

no

Parenteral hypocaloric

Adequate calorie intake within 14 days

Enteral access (NCJ)

yes no

enteral nutrition immunonutrition for 6-7 days

Oral intake of energy requirements

yes no

combined enteral / parenteral

no slight, moderate severe

SURGERY

PRE-OPERATIVE PHASE

POST-OP

EARLY DAY 1 - 14

LATE DAY 14

Oral intake of energy requirements

yesnosupplemental enteral diet

Feeding algorithmCan the GIT be used?

Yes No

Parenteral nutritionOral

< 75% intake

Tube feed

Short term Long term

Peripheral PN Central PN

More than 3-4 weeks

No Yes

NGT

Nasoduodenal or nasojejunal

Gastrostomy

Jejunostomy

“inadequate intake”

“Inability to use the GIT”

A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and

enteral nutrition in adult and pediatric patients, III: nutritional assessment –

adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA.

Outcome of surgical patients

Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients

nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, 2008.

Nutrition team and intake

Llido et al. Nutrition team supervision improves intake of critical care patients in a private tertiary care hospital in the Philippines: report from

years 2000 to 2011 (for submission)

Surgery induces insulin resistanceInsulin signaling blocked

↓ GLUT4 activity↑ blood glucose

Witasp A et al. Expression of inflammatory and insulin signaling genes in adipose tissue in response to elective surgery. J Clin Endocrinol Metab 2010; 95(7): 3460–9.

[IRS1=insulin receptor substrate1; SOCS3, suppressor of cytokine signaling 3]

Fasting (within 2-3 days acceptable)

Awad S et al. The effects of fasting and refeeding with a ‘metabolic preconditioning’ drink on substrate reserves and mononuclear cell

mitochondrial function. Clin Nutr 2010; 29: 538–44

Cancer Cachexia

New paradigm in nutrition oncology

High dose nutritionStandard contentHigh dose nutritionStandard content

Cancer patientWeight lossCancer patientWeight loss

Hardly any weight change

Hardly any weight change

BEFORE

High dose nutritionStandard contentHigh dose nutritionStandard content

Cancer patientWeight lossCancer patientWeight loss

Weight changeLife span

Better function

Weight changeLife span

Better function

New drugsSurgeryEN/PNPharmaconutritionAggressive mgtSupportive/functionExercise

New drugsSurgeryEN/PNPharmaconutritionAggressive mgtSupportive/functionExercise

TODAY

Fish oils and cancer

Antioxidants

Nathens AB, Neff MJ, Jurkovich GJ, Klotz P, Farver K, Ruzinski JT, Radella F, Garcia I, Maier RV. Randomized, prospective trial of antioxidant supplementation in critically ill surgical

patients. Ann Surg. 2002; 236(6): 814-22.

Nathens AB, Neff MJ, Jurkovich GJ, Klotz P, Farver K, Ruzinski JT, Radella F, Garcia I, Maier RV. Randomized, prospective trial of antioxidant supplementation in critically ill surgical

patients. Ann Surg. 2002; 236(6): 814-22.

1. α-tocopherol 1,000 IU (20 mL) q 8h per naso- or orogastric tube

2. ascorbic acid 1,000 mg given IV in 100 mL D5W q 8h for the shorter of the duration of admission to the ICU or 28 days.

Management:

• Goal: adequate intake– Protein, carbohydrates, fat– Vitamins and trace elements– Fish oils (EPA/DHA)– Glutamine– Antioxidants (vitamin C, Vitamin E, zinc, copper,

selenium)• Strict fluid management

– Saline and balanced salt solutions• Early enteral feeding

Nutrition and fluid management go together

INJURY = SURGERY

↑albumin escape from intravascular

space

Inflammatory mediators ↑vasodilation effect of anesthetic agents

↑K+ release from cells

↓K+ and ↑ Naintracellular

Sick cell syndromeof critical illness

↑hypotonic fluid infusion

90% cause of hyponatremia in

surgery

Fluid Retention + Electrolyte Imbalance

Lobo D, Macafee DL, Allison S. How perioperative fluid balance influences postoperative outcomes. Best Pract Res Clin Anaesthesiology 2006; 20(3): 439–55.

Problems with saline

Appropriate fluid management

Ileus and dehiscenceSalt and water overload

↑intra-abdominal pressure

↓mesentery blood flow

Intestinal edema

↓tissue OH-proline

STAT3 activation↓myosin phosphorylation

ILEUS

Impaired wound healing

DEHISCENCE

Intramucosal acidosis

↓muscle contractility

Chowdhury and Lobo. Curr Opinion Clin Nutr Metab 2011

Effect of positive fluid balance

Brandstrup B et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-

blinded multicenter trial. Annals of Surgery 2003; 238: 641–648.

SURGICAL CRITICAL CARE

Inflammation phases of injury

Moore FA. Presidential address: imagination trumps knowledge. Am J Surg 2010: 200: 671-7.

24 hours

↑inflammation→organ dysfunction

↑immunosuppression→infection→organ dysfunction

Inflammation and organ failure in the ICU

SIRSTNF, IL-1, IL-6, IL-12, IFN, IL-3

IL-10, IL-4, IL-1ra, Monocyte HLA-DR

suppression

CARS

days

Insult(trauma, sepsis)

Infla

mm

ator

y ba

lanc

e

ANTI

PRO

Tissue inflammation, Early organ failure and death

weeks

Immunosuppression

2nd Infections Delayed MOF and death

Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle

Nutrition Workshop Series

Pharmaconutrition

Early feeding

1. EPA/DHA (fish oils)

2. Glutamine3. Antioxidants4. Arginine5. Vitamins6. Trace

elements

CONCLUSION

Nutrition care in surgery

• improves outcomes in surgery by addressing pathophysiologic changes induced by injury on the cellular and organ-system levels.

• This is achieved through:– Appropriate fluid management– Early enteral nutrition– Adequate nutrient intake– Pharmaconutrients