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Malnutrition in Surgery
Symposium organized by the Committee on Critical Care
Philippine College of Surgeons
Objectives
• To discuss malnutrition
• To discuss the effect of malnutrition in surgery
• To discuss ways of correcting malnutrition in surgery to improve
outcome(s)
• To discuss why early enteral feeding is crucial to improved surgical
outcome(s)
What is malnutrition?
• Chronic infections e.g. TB
• Chronic poor intake
• Extreme poverty
• Diabetes
• Chronic systemic disease (e.g.
autoimmune disease)
• Cancer
•
•
•
•
Critical care
Trauma
Post-surgical complications
Infection, sepsis
Sarcopenic obesity
(=too much fat, loss of
protein)
Selective intake (=vitamin
and/or trace element
deficiency)
Why is there a need to address malnutrition in
surgery?
The modified SGA form of PhilSPEN
SGA
• A (normal)
• B (mild/mod malnutrition)
• C (severe malnutrition)
Nutrition Risk Score:
• 1-3: Low Risk
• 4-6: Moderate Risk
• 7-9 High Risk
Sensitivity: 94.7%
Specificity: 96.2%
Positive Predictive Value: 95.7%
Lacuesta-Corro L et al. The results of the validation process
of a Modified SGA (Subjective Global Assessment) Nutrition
Assessment and Risk Level Tool designed by the Clinical
Nutrition Service of St. Luke’s Medical Center, a tertiary care
hospital in the Philippines. (Article 12 | POJ_0002.html)
Issue February 2012 - December 2014: 1-7 (n=179)
Severe malnutrition and high risk status
Bernardino J. The prognostic capacity of the
Nutrition Risk Score and SGA grade of the
PhilSPEN modified SGA (Subjective Global
Assessment) on mortality outcomes – An Initial
Report. PhilSPEN Online J Enteral Parenter Nutr
(Article 29; Issue July 2016 - December 2016:
134-136. Available at:
http://www.dpsys120991.com/POJ_0023.html
Malnutrition and surgical outcomes
SGA
• A (normal)
• B (mild/mod malnutrition)
• C (severe malnutrition)
Nutrition Risk Score:
• 1-3: Low Risk
• 4-6: Moderate Risk
• 7-9 High Risk
Ocampo R B, Kadatuan Y, Torillo MR, Camarse CM.
Predicting post-operative complications based on
Surgical nutritional risk level using the SNRAF in
colon cancer Patients - a Chinese General Hospital
& Medical Center experience. Phil J Surg Specialties
2007. Available at:
http://www.dpsys120991.com/POJ_0012.html
Malnutrition and surgical outcomes
Surgical patients
• 9% of moderately malnourished
patients → major complications
• 42% of severely malnourished
patients → major complications
• Severely malnourished patients
are four times more likely to
suffer postoperative
complications than wellnourished patients
Detsky et al. JPEN 1987
Detsky et al. JAMA 1994
Malnutrition correction and outcome(s)
Del Rosario et al. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients
nutritionally assessed as high or low risk. PhilSPEN Online J Parenter Enteral Nutrition; (Article 9 | POJ_0006.html)
Issue January 2010 - January 2012: 67-74. Available at: http://www.dpsys120991.com/POJ_0006.html
Basis for addressing malnutrition in surgery
Total cells in the body
Body Compartment
Total cells in the
body
Number/Percent of
cells in the body
Glucose Transporter
IV (GLUT4)
37 trillion *
Skeletal muscle cells
Cardiac muscle cells
14.8 trillion (40%)
Present/active in 40% of cells
in the body
Fat cells
7.4 trillion (20%)
Present/active in 20% of cells
in the body
* Bianconi E et al. An estimation of the number of cells in the human body. Ann Hum Biol. 2013 Nov-Dec; 40(6): 463-71
Body compartments: nutrition standpoint
Technically body
composition can be
simplified to consist of:
• Protein (15% of weight)
• Fat (25% of weight)
• Water (60% of weight)
Lean body mass components
Wound Healing
Wound Healing
Malnutrition
• Poor protein reserves
• Less energy supply
• Fat > higher inflammatory state
Resolution
• Neutrophils
• Macrophages >
active resolution
• Collagen
• Basement membrane
• Angiogenesis
Poor intake
• Poor nutrient supply
• Poor quality of wound healing
• Other complications like
dehiscence, ulcers, fistulas
RESOLUTION
PROCESS
• Success > good wound healing
• Failure > poor healing / sepsis
Resolution is an active process
• The pro-inflammatory mechanisms probably are counterbalanced by
endogenous anti-inflammatory signals that serve to temper the severity
and limit the duration of the early phases, which leads to their resolution,
an active rather than a passive process.
• The resolution of the inflammatory response is mainly mediated by
families of local-activity mediators that are biosynthesized from essential
fatty acids eicosapentaenoic acid and docosahexaenoic acid.
• These resolution mediators were termed resolvins and protectins.
• Inflammation resolution is also mediated by lipoxins, trihydroxystearincontaining eicosanoids that are generated within the vascular lumen
through platelet-leukocyte interactions.
https://www.ucm.es/data/cont/docs/420-2014-02-07-WOUND-HEALING-3Nov-2013.pdf
What happens when malnutrition is not
addressed?
Calorie and protein reserves
Nutrient
Reserve
How long do these last?
Carbohydrate Liver glycogen
24 – 48 hours
Muscle glycogen 48 hours
Protein
Skeletal muscle (for a 70 kg person)
20 days
Fat
All fat tissues
(for a 70 kg person)
85 days
Nutrient metabolism and reserves
When not fed after 24 hours
the body starts to lose protein
(= gluconeogenesis)
Gluconeogenesis
Weight loss and mortality
Sarcopenia
SARCOPENIA
COMPLICATIONS
Sarcopenia: Vandewoude M. Abbott Symposium, ESPEN 2011. Goteborg, Sweden.
Cancer Cachexia
Weight loss in cancer
Lean body mass loss and mortality
Protein requirements in surgery and trauma
Body will always attempt to preserve protein
Protein preservation phase
http://www.medscape.org/viewarticle/432384_4
Demling RH. Eplasty. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9.
Priorities: Basic function vs. wound healing
Demling RH. Eplasty. Nutrition,
anabolism, and the wound
healing process: an overview.
Eplasty 2009;9:e9.
Epub 2009 Feb 3.
Effects of not adequately addressing
nutritional needs for wound healing
• Poor immune defense leading to
• Surgical site infection
• Chronic infections
• Recurrent infections
• Active resolution process is slowed down leading to:
• Poor take of anastomosis
• Dehiscence
• Fistulas
• Slow healing leading to chronic wound state:
• Non-healing wound
• Ulcers
• Recurrent ulcers
• Poor quality of the wound as to strength and function
• Hideous scars
What to do?
Decision(s) when to do surgery
• Elective surgery
• Not malnourished > minimum risk
• If malnourished > nutritional build up (? Days: recommended 7-10 days; practical: 3
days, then post-operative nutrition)
• Can ERAS principles be applied?
• Emergency surgery
• If can be optimized (usually perfusion and oxygenation) delay a little bit, then do
surgery
• Critical care
• Nutritional build up
• Optimize microcirculation
• Then surgery if needed
Preoperative phase: what to do
• Nutritional assessment
• Moderately malnourished: 3-5 days build up
• Severely malnourished: 7-10 days build up
• What to prescribe?
• Energy: 30 kcal/kg actual body weight (ideal body weight if obese) > if
severely malnourished and elderly you may start at 20 kcal/kg then gradually
increase within three days to reach target
• Protein: 1.2 – 1.5 g/kg body weight
• Carbohydrate: 60% of the non-protein calories
• Fat: 40% of non-protein calories
• Multivitamins and trace elements daily
• Lean body mass enhancers and immunonutrition
What are Lean Body Mass enhancers? Immune
enhancers?
Lean body mass enhancers
• High protein intake
• Branched chain AA (50% of total protein)
• Nutraceuticals
• HMB, glutamine, arginine combinations
• Fish oil (EPA/DHA) – 1 g/day
• Exercise
• Impact of free radicals
• Not too much anti-oxidants
• Adequate intake
• Macro and micronutrients DAILY
• Insulin
Immune enhancers:
• Glutamine
• 30% of total protein (intravenous)
• 50% or total protein (oral)
• Fish Oils (EPA/DHA)
• Arginine
• Antioxidants (vitamins and trace
elements)
• Probiotics
• Early feeding
Feeding pathway
Feeding access: Intraoperative and
postoperative decisions
Status
ERAS > normal
GIT
ERAS > poor
appetite
Option/access
• Oral
Pre-op: severely
malnourished
• Build up: 7-10 days
• May opt for 3 days
Need to do
surgery
immediately
Post-operative
with enteral
access
• Oral
Condition
Decision
Intake within 24- • Discharge early
48 hours
Intake < 70%
• PN: AA soln, Lipid soln, 3-in-1 for
one or two days
Oral intake
possible, but
inadequate
• NGT post-op
Enteral nutrition
• Need to place access? possible but
Gastrostomy?
inadequate
Jejunostomy?
intake
• Full diet + oral supplement + PN (3in-1 TNA) + immunonutrition
• intra-op: enteral access?
• EN: tube feed within 24-48 hours;
when inadequate give PN
• PN: Protein soln only or protein soln
and/or lipid emulsion or “All in
One”
• Enteral nutrition
• EN priority
• if intake < 60% give supplemt PN
EN goal
Critical care
Status
Option/access
Condition
Decision
ICU
• Tube feed > NGT
EN goal reached
• Enteral nutrition + immuno nutrition
ICU
• Tube feed > NGT
Intake < 70%
• Enteral nutrition + Supplemental PN (AA
soln or Fat emulsion or usually 3-in-1) +
immuno nutrition
How do we know intake is adequate?
Calorie,
protein and
fluid intake/
balance
form
Nutrient
intake
monitor
form
INTAKE
OUTPUT
• IV infusion
• urine
• medications • insensible loss
• oral feeding • drains
• EN
• stool
• PN
• albumin
• blood/others
Fluid balance = “0”
Nutrient balance = positive (75%)
Value of nutrition and fluid audit
Why the need for early enteral feeding?
Gastrointestinal Peptides
[M] = mucosa
[N] = nerve
[Me/o] = entero
chromaffin cells
[M]
Gastric acid, pepsin, mucosa growth/repair
[M]
Glycogenolysis, gluconeogenesis, lipolysis
[M]
bicarbonate secretion (panc duct, bile duct)
[M]
Gallbladder contraction, pancreatic juice
rich in enzymes
[M]
Stimulates insulin secretion (gliptin)
[Me/o]
(1) Muscle contraction
[M]
GI motility, ileal blood flow
[N]
secretion of electrolytes and water; relaxes
smooth muscle including sphincters
[N]
(2) Muscle contraction
[M]
Glucagon (GLP-1, GLP-2) - Glycogenolysis,
gluconeogenesis, lipolysis
[M]
Inhibits gastrin, secretin, VIP, GIP, motilin
[N]
Gastrin secretion
[M]
secretion of chloride to lumen
[M]
[M]
Metabolism
Maintenance
Motility
Feed within 24 to 48 hours post-op
Inhibits food intake, gastric inhibitory peptide
growth hormone, central control of food intake
Ganong WF. Review of Medical Physiology, 22nd edition, 2005.
Maintenance
Gastrointestinal Peptides
[M] = mucosa
[N] = nerve
[Me/o] = entero
chromaffin cells
[M]
Gastric acid, pepsin, mucosa growth/repair
[M]
Glycogenolysis, gluconeogenesis, lipolysis
[M]
[M]
bicarbonate secretion (panc duct, bile duct)
Gallbladder contraction, pancreatic juice
rich in enzymes
[N]
Stimulates insulin
(gliptin)
BENEFITS
ofsecretion
FEEDING
contraction
•(1) Muscle
Early
bowel motility
GI motility,
recovery
ileal blood flow
of electrolytesdefense
and water; relaxes
•secretion
Gut mucosa
is
smooth muscle including sphincters
maintained
(2) Muscle contraction
•Glucagon
Gut(GLP-1,
microbiome
is
GLP-2) - Glycogenolysis,
gluconeogenesis,
lipolysis
maintained
gastrin, wound
secretin, VIP,healing
GIP, motilin
•Inhibits
Faster
•Gastrin
Preserved
immune status
secretion
[M]
secretion of chloride to lumen
[M]
Inhibits food intake, gastric inhibitory peptide
[M]
[Me/o]
[M]
[N]
[N]
[M]
[M]
[M]
growth hormone, central control of food intake
Ganong WF. Review of Medical Physiology, 22nd edition, 2005.
Gut associated lymphoid tissues
Relationship of GALT and MALT
When the gut is okay, the pulmonary system will also be okay
Early enteral nutrition guidelines for critical
care patients
Grade B recommendation
Hours
Early EN: Guideline
Evidence
< 48 hours
1 Canadian
Evidence of trend
< 24 hours
2 ACCEPT
Significant evidence
< 24 hours
3 Australian/New
< 24 hours
4 ESPEN
Significant evidence
< 48 hours
5 ASPEN
Evidence of trend
1.
2.
3.
4.
5.
Zealand Significant evidence
Heyland DK et al. J Parenter Enter Nutr 2003.
Martin CM et al. CMAJ 2004.
Doig GS and Simpson F. EvidenceBased.net
Kreymann KG et al. Clinical Nutrition 2006
McClave SA et al. J Parenter Enter Nutr 2009.
What happens when you don’t feed your
patient?
“NPO” orders: effect on metabolism
• No intake for 24 hrs > no more liver glycogen
• No intake >24 hours > start losing protein
• No intake for 48 hours to 5 days > maximum protein loss > gut
mucosa deterioration >  inflammatory status
• No intake on the 6th to 7th day
• Protein preservation
• Ketoadaptation > Fat starts to be the main source of energy
“NPO” orders: effect on immune defense
• Stomach: low secretion of HCl  less bactericidal activity
• Small intestine:
• Diminished mucosa defense system
• Diminished secretion of secretory IgA
• Diminished activity of GALT due to lesser perfusion and stimulation secondary to lower
mucosal activity
• Small intestine: Diminished digestive/absorptive capacity
• Slower rate of mucosa re-epithelialization  shortening height of villus
• But: mucosa perfusion is still adequate
• oxygen > Adenosine (vasodilator) > perfusion
When to give parenteral nutrition?
Parenteral nutrition: Indications
• Supplemental parenteral nutrition:
• When oral/enteral nutrition is inadequate
• Total parenteral nutrition: oral or tube feeding not possible
• Intestinal obstruction
• Severe ileus
• Initial phase of short bowel syndrome
Parenteral nutrition: Points to remember
• All three macronutrients should be supplied daily
• If oral or tube feeding and there is an insufficient macronutrient – give by PN
• Micronutrients should be given daily
• Vitamins – water and fat soluble
• Trace elements
• Note the deficiencies and give corresponding corrections
• Pharmaconutrients like glutamine or fish oil have better results with
parenteral nutrition
Parenteral nutrition: Delivery
• Most common: Peripheral parenteral nutrition (800 to 900
mOsm/L)
• Single:
• Amino acid solution (suggestion > branched chain amino
acid rich)
• Fatty acid emulsion > MCT, LCT, Fish Oils, Olive Oil
AMINOPLASMAL
• Combination:
• 3-in-1 or “All in One” + vitamins and trace elements
LIPOFUNDIN/LIPIDEM
• Selected: central parenteral nutrition (> 900 mOsm/L)
• Usually combination:
• 3-in-1 or “All in One” + vitamins and trace elements
• Compounded + vitamins and trace elements
• Route: Internal Jugular (IJ) catheter, subclavian
catheter, PICC line
TRACUTIL
NUTRIFLEX
Concluding statements
Review: nutrition principles
• Identify malnutrition and do the needed corrections
• Severity of lean body mass loss is associated with increased mortality
> bring them back first nutritionally before doing any surgery
• Do not let the patient go to starvation state (=NPO beyond 24 hours)
and lose protein in the post-operative phase
• The gut should be utilized as early as possible
• Adequacy of intake is directly related to reduction of mortality
• If intake through the gut or “enteral nutrition” is inadequate do not
hesitate to immediately give parenteral nutrition
Thank You
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