Pre-operative CHO loading an integral component of peri- operative care - Only the Beginning-

Pre-operative CHO Pre-operative CHO loading an integral loading an integral component of peri-component of peri-

operative careoperative care- Only the Beginning-- Only the Beginning-

Response to Surgery and Response to Surgery and FastingFasting

SurgerySurgery FastingFasting Endocrine responseEndocrine response

GlucagonGlucagon

InsulinInsulin Metabolic responseMetabolic response

Glycogen breakdownGlycogen breakdown

Protein breakdownProtein breakdown

LipolysisLipolysis Insulin resistanceInsulin resistance

Fasting further increases metabolic response to surgery

Insulin resistance is a useful metabolic marker

IL1bTNFaIL6

Immune cells activated

Cytokines produced

Muscle mobilised LBM

Appetite Reduced

Effects of Cytokines on Nutritional Status

Altered fuel mix

Gluconeogenisis

lipolysis

Fat mobilised

WEIGHT LOSS

SURGERYSURGERY

Traditional Traditional

FastingPatient involvement – passive

Traditional Post-opTraditional Post-op Opiate analgesia patient unable to sit up and Opiate analgesia patient unable to sit up and

take fluids for several hours (no fluid pre-take fluids for several hours (no fluid pre-op).op).Also contribute to ileus, N&V.Also contribute to ileus, N&V.

NBM ?3-5/7 NBM ?3-5/7 Further starvationFurther starvationImmobilisationImmobilisation

Patient expectations – Patient expectations – passive in their passive in their carecare

expect to be hospitalised 10/7expect to be hospitalised 10/7lengthy recoverylengthy recovery

Where Are We Where Are We NowNow

Multimodel Strategies to Multimodel Strategies to Improve Surgical OutcomeImprove Surgical Outcome

Dela

yed

Accele

rate

d

• Anxiety/Fear

• Organ dysfunction

• Hypothermia

• Nausea, vomiting, ileus, semi- starvation

• Hypoxemia

• Sleep disturbance

• Drains, NG tubes,catheters

• Patient info• Optimise nutrition

• Modify alcohol/smoking

• Neuraxial blockade

• Laprascopic surgery

• Normothermia

• Nausea and ileus prevention

• Early enteral feeding

• Undisturbed sleep

•Opiate sparing analgesia

Adapted Kehlet, 2000

Patterns of RecoveryPatterns of Recovery

Enhanced Recovery

Traditional Care

Rate

of

Retu

rn o

f F

un

ctio

n

Days Weeks

Adapted Luff,2003

Where are we now –Where are we now –

CHO loading has CHO loading has influenced traditional influenced traditional peri-operative care in peri-operative care in colorectal surgery colorectal surgery

- Fast track peri-operative - Fast track peri-operative care.care.

Fearon et al, 2005 Clin Nut24: 466-467

Insulin Resistance Insulin Resistance Following Elective Following Elective

SurgerySurgery Enhanced by fastingEnhanced by fasting

Symptoms similar to type 2 diabetesSymptoms similar to type 2 diabetes

Reduced by regional anaesthetic and Reduced by regional anaesthetic and minimally invasive techniquesminimally invasive techniques

Related to magnitude of surgery Related to magnitude of surgery

Can remain for about 3 weeksCan remain for about 3 weeks

Associated with length of stayAssociated with length of stay

Insulin Resistance and Insulin Resistance and Length of StayLength of Stay

Thorell et al, Curr Opin Clin Nutr Metab Care 1999

Log length of stay (Days)

Pos

t-op

Ins

ulin

sen

sitiv

ity

(

% p

re-o

p)

1.41.21.00.80.60.40.2 0.0-0.20

20

40

60

80

100

R=0.53p<0.0001n=60

Preop CHO loading-Clinical Preop CHO loading-Clinical ResearchResearch

A pre-operative fast is not ideal to prepare a A pre-operative fast is not ideal to prepare a patient for surgical stress since:patient for surgical stress since: it is uncomfortableit is uncomfortable It contributes to an additional catabolic stress It contributes to an additional catabolic stress

and worsens recoveryand worsens recovery Hypothesis: Hypothesis:

The negative effects of pre-operative fasting can The negative effects of pre-operative fasting can be reduced by pre-operative carbohydrate loadingbe reduced by pre-operative carbohydrate loading Improve post-operative insulin sensitivityImprove post-operative insulin sensitivity Reduce post-operative insulin resistanceReduce post-operative insulin resistance Improve patient well being Improve patient well being Improve recovery and reduce length of stayImprove recovery and reduce length of stay

It has been demonstrated that CHO It has been demonstrated that CHO fluids provided 2-3 hours before fluids provided 2-3 hours before induction of anaesthesia induction of anaesthesia

- attenuate early - attenuate early postoperative postoperative metabolic metabolic stress.stress.

- improve insulin resistance.- improve insulin resistance.

- reduce recovery time.- reduce recovery time.

Preoperative oral Preoperative oral carbohydrate carbohydrate

administrationadministration

Fast Track vs Fast Track vs Traditional Traditional

Length of Hospital Stay in Length of Hospital Stay in Colorectal SurgeryColorectal Surgery

01

23

45

678

910

Days Stay

TraditionalEnhanced

Len

gth

of

Sta

y

n=48

n=33

**** p>0.01

Fearon and Luff, 2003

Fast Track vs Fast Track vs TraditionalTraditional

n=451 (Traditional n=333 (4 countries), Fast Track n=118 (Denmark))

Retrospective case note review.

Patients underwent laparotomy for colorectal resection.

No difference in morbidity or 30 day mortality between centres.

The median length of stay was 2days in Fast Track and 7-9 days in Traditional (p<0.05).

Readmission rate was 22% in Fast Track cf 2-16% Traditional (p<0.05).

Nygren et al, 2005 Clin Nutr. 24: 455-61

Early Oral Nutrition After Early Oral Nutrition After Elective Colorectal SurgeryElective Colorectal Surgery

Influence of balanced analgesia and Influence of balanced analgesia and enforced mobilisation.enforced mobilisation.

- Mobility significantly improved - Mobility significantly improved (5.5 (5.5 hrs/day vs 1.7 hrs/day).hrs/day vs 1.7 hrs/day).

- Nutritional intake greater.- Nutritional intake greater.

- No significant loss of body - No significant loss of body compositioncomposition

Henriksen et al, 2002 Nutrition18: 263-267

What role the What role the Dietitian ?Dietitian ?

Pre Surgery Pre Surgery DischargeDischarge

Weight

BMI

Anthropometry (TSF/AMC)

800mls placebo/CHOD

2-3hours pre-surgery

400mls placebo/CHOD

Weight

BMI

Anthropometry(TSF/AMC)

LOS

New Approach to Pre-op New Approach to Pre-op Management (n=65)Management (n=65)

Preoperative vs Preoperative vs Discharge BMIDischarge BMI

19

20

21

22

23

24

25

26

Pre-op Discharge

BM

I (k

g/m

)

Placebo

CHOD

2

Anthropometry changesAnthropometry changes

-1.6

-1.4

-1.2

-1

-0.8

-0.6

-0.4

-0.2

0

un

it c

han

ge

Placebo

CHOD*

*p<0.05

AMC TSF

Preoperative oral Preoperative oral carbohydrate carbohydrate

administration administration

The provision of utilisable energy can The provision of utilisable energy can minimise the loss of lean body mass.minimise the loss of lean body mass.

What remains to be elucidated is What remains to be elucidated is whether:whether:

This attenuation of lean body mass This attenuation of lean body mass can improve sustainable can improve sustainable improvement of functionimprovement of function

Dietitians taking this Dietitians taking this Forward ?Forward ?

Henriksen Henriksen et al et al (2002) provided 200ml (2002) provided 200ml ONS to intervention group 1day pre-op ONS to intervention group 1day pre-op and 7 days post-op. Assumption made and 7 days post-op. Assumption made that patients compliant.that patients compliant.

Alluded to other factors that may have Alluded to other factors that may have improved intakeimproved intake

- patient involvement- patient involvement

- early mobilisation- early mobilisation

Nutrition as Component Nutrition as Component ERER

As with pharmacological As with pharmacological interventions this nutritional interventions this nutritional approach relies strongly on patient approach relies strongly on patient compliance however the compliance however the commitment from patients to adhere commitment from patients to adhere to prescribed nutritional regimens is to prescribed nutritional regimens is poor (Bruce poor (Bruce et al, et al, 2003; Akner and 2003; Akner and Cederholm, 2001; Lawson Cederholm, 2001; Lawson et al, et al, 2000)2000). .

Appropriately Involve Appropriately Involve PatientPatient

Where do we Start ?Where do we Start ? Patient’s perception of dietetic Patient’s perception of dietetic

consultation.consultation. How does the patient value nutrition as a How does the patient value nutrition as a

component of their nutritional care?component of their nutritional care? Determine the patient’s knowledge and Determine the patient’s knowledge and

understanding of key nutritional understanding of key nutritional concepts.concepts.

Explicitly identify what contribution the Explicitly identify what contribution the patient can make to their nutritional care. patient can make to their nutritional care.

Patient Perception of Dietetic Patient Perception of Dietetic ConsultationConsultation

Rate nutrition as factor in recovery Rate nutrition as factor in recovery (VAS) and justify.(VAS) and justify.

What advice given and asked in their What advice given and asked in their view advice acceptableview advice acceptable

Did patient feel able to contribute to Did patient feel able to contribute to dietary targets set ? How could dietary targets set ? How could patient involvement be improved?patient involvement be improved?

Out-patient review mode and media Out-patient review mode and media of consultation.of consultation.

Do Patients Understand Key Do Patients Understand Key Nutritional Concepts?Nutritional Concepts?

Health literacy importance element Health literacy importance element in achieving compliance.in achieving compliance.

Use body map as tool to allow Use body map as tool to allow patient to patient’s understanding of patient to patient’s understanding of the relationship between the relationship between pathophysiology/recovery.pathophysiology/recovery.

Non- threatening multiple choice Non- threatening multiple choice questions and ask for justification questions and ask for justification for their selection.for their selection.

Where are we GoingWhere are we Going Examine the use of multimodal Examine the use of multimodal

accelerated recovery programme in accelerated recovery programme in elderly elderly #NOF patients.#NOF patients.

- pre-op carbohydrate loading.- pre-op carbohydrate loading.- anaesthesia and pain control.- anaesthesia and pain control.- training programme.- training programme.- nutrition.- nutrition.- active patient involvement.- active patient involvement.- monitor in the rehabilitation phase - monitor in the rehabilitation phase

of care.of care.

TeamTeam

DietitiansDietitians- Emma Kehoe, Project Lead.- Emma Kehoe, Project Lead.- Jackie Bird, Patient Involvement.- Jackie Bird, Patient Involvement.

Clinicians – Dr Alan Davidson, Dr Eric Clinicians – Dr Alan Davidson, Dr Eric GardinerGardiner

Physiologist – Dr Isobel Davidson.Physiologist – Dr Isobel Davidson.Physiotherapist – Dr Sarah Mitchell.Physiotherapist – Dr Sarah Mitchell.OT – Claire Ritchie.OT – Claire Ritchie.Cosultant – Christine Russell Cosultant – Christine Russell