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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 http://www.ddplnet.com