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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