Download Impact of nutrition care in surgery

Impact of nutrition care in
surgery
Surgical Nutrition Training Module
Level 1
Philippine Society of General Surgeons
Committee 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
COMPOSITION
1. Carbohydrates
2. Lipids
 LCT (structural)
 MCT (energy)
 Fish Oils (immunomodulation)
3. Protein
 BCAA
 Glutamine
4. Vitamins/Trace elements
5. 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
PRE-OPERATIVE PHASE
severe
Scheduled
• esophageal resection
• gastrectomy
• pancreaticoduodenectomy
Enteral nutrition
for 10-14 days
oral immunonutrition
for 6-7 days
malnutrition
no
slight, moderate
SURGERY
Early oral feeding within 7 days
POST-OP
EARLY DAY 1 - 14
no
yes
Enteral access (NCJ)
within 4 days
enteral nutrition
Oral intake of energy requirements
no
yes
immunonutrition for 6-7 days
yes
“Fast Track”
no
Parenteral hypocaloric
combined enteral / parenteral
Adequate calorie intake within 14 days
LATE DAY 14
yes
no
Oral intake of energy requirements
supplemental enteral diet
no
yes
Feeding algorithm
Can the GIT be used?
“Inability to use the GIT”
Yes
No
“inadequate intake”
Parenteral nutrition
Oral
Tube feed
< 75% intake
Short term
Long term
Peripheral PN
Central PN
More than 3-4 weeks
Yes
No
NGT
Gastrostomy
Nasoduodenal
or nasojejunal
Jejunostomy
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 resistance
Insulin 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 nutrition
Standard content
High dose nutrition
Standard content
Cancer patient
Weight loss
Cancer patient
Weight loss
Hardly any
weight change
Weight change
Life span
Better function
BEFORE
New drugs
Surgery
EN/PN
Pharmaconutrition
Aggressive mgt
Supportive/function
Exercise
TODAY
Fish oils and cancer
Antioxidants
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.
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.
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
Inflammatory mediators
↑K+ release
from cells
↑vasodilation effect
of anesthetic agents
↑albumin escape
from intravascular
space
↑hypotonic fluid
infusion
90% cause of
hyponatremia in
surgery
↓K+ and ↑ Na
intracellular
Sick cell syndrome
of critical illness
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 dehiscence
Salt and water overload
↑intra-abdominal pressure
Intestinal edema
↓mesentery blood flow
↓tissue OH-proline
STAT3 activation
↓myosin phosphorylation
Intramucosal
acidosis
Impaired wound healing
↓muscle contractility
ILEUS
DEHISCENCE
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 assessorblinded multicenter trial. Annals of Surgery 2003; 238: 641–648.
SURGICAL CRITICAL CARE
Inflammation phases of injury
↑inflammation→organ dysfunction
↑immunosuppression→infection→organ dysfunction
24 hours
Moore FA. Presidential address: imagination trumps knowledge.
Am J Surg 2010: 200: 671-7.
Inflammation and organ failure in the ICU
Inflammatory balance
SIRS
TNF, IL-1,
IL-6, IL-12,
IFN, IL-3
Tissue inflammation, Early
organ failure and death
Pharmaconutrition
Early feeding
days
IL-10, IL-4, IL-1ra,
Monocyte HLA-DR
suppression
CARS
Insult
(trauma, sepsis)
1. EPA/DHA
(fish oils)
2. Glutamine
3. Antioxidants
4. Arginine
5. Vitamins
6. Trace
elements
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
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