Surgery  Review:  Surgical  nutri2on,    

Fluids  and  electrolytes  (Part  2)  

   

May  23,  2014    

PRACTICAL  SURGERY  

Pre-­‐opera1ve  checklist  •  Check  nutri1onal  and  fluid  status  (nutri1onal  assessment)  

•  Check  fluid  and  electrolyte  status  (=homeostasis):  – Na,  K,  Cl  (then  may  add  Mg,  Ca  if  needed)  – Glucose,  BUN,  serum  osmolality  –  Fluid  intake  and  output  record  

•  Wound  healing  capacity  –  Energy  and  protein  requirements  – Micronutrient  requirements  – Need  for  pharmaconutri1on  

1.  DETECT  MALNUTRITION  

Nutri1on  screening  &  assessment  Nutri2on  screening   Nutri2onal  assessment  

Malnutri1on  and  complica1ons  Surgical  pa2ents  •  9%  of  moderately  

malnourished  pa1ents  →  major  complica1ons  

•  42%  of  severely  malnourished  pa1ents  →  major  complica1ons  

•  Severely  malnourished  pa2ents  are  four  2mes  more  likely  to  suffer  postopera2ve  complica2ons  than  well-­‐nourished  pa2ents  

Detsky  et  al.  JAMA  1994    Detsky  et  al.  JPEN  1987  

Malnutri1on  and  complica1ons  

Malnutri1on  and  cost  Malnutri1on    is  associated  with  increased  cost  and  the  higher  the  risk  the  

higher  the  number  of  complica1ons  plus  cost  

Reilly  JJ,  Hull  SF,  Albert  N,  Waller  A,  Bringardener  S.  Economic  impact  of  malnutri1on:  a  model  system  for  hospitalized  pa1ents.  JPEN  1988;  12(4):371-­‐6.  

2.  DETERMINE  REQUIREMENTS  

Nutri1on  Care  Plan  Form  

How  much  calories?  Usual:  20-­‐25  kcal/kg/day  

Very  sick:  15-­‐20  kcal/kg/day  

Jeejeebhoy  K.  4th    Asia  Pacific  Parenteral  Nutri1on  Workshop.  June  7-­‐9,  2009;  Kuala  Lumpur,  Malaysia  

How  much  protein?  

How  much  carbohydrate  and  fat?  

3.  DETERMINE  ROUTE  OF  FEEDING  

Feeding  algorithm  Can the GIT be used?

Yes No

Parenteral nutrition Oral

< 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.

malnutri2on  Scheduled  •   esophageal  resec2on  •   gastrectomy  •   pancrea2coduodenectomy  

Enteral  nutri2on  for  10-­‐14  days  

oral  immunonutri2on  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  nutri2on   immunonutri2on  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  

yes  no  supplemental  enteral  diet  

Surgical  nutri1on  pathways:    Pre-­‐opera1ve  phase  

Normal  to  moderate  malnutri1on  

SURGERY  

Severe  Malnutri1on   •     Esophageal  resec1on  •     Gastrectomy  •     Pancrea1coduodenectomy  

Parenteral  nutri1on  +  Omega-­‐3-­‐Fany  Acids  +  An1oxidants    (+  glutamine);  6-­‐7  days  

Nutri1onal  Assessment  

ESPEN  Guidelines  on  Parenteral  Nutri1on  (2009)  

Condi1on:  When  oral  or  enteral    feeding  not  possible  

Enteral  nutri1on  STOMACH   JEJUNUM  

Nasogastric  tube   Nasojejunal  tube  

PEG   PEJ  

BUTTON  

PLG  

JET-­‐PEG  

PLJ  

NCJ  

PSJ  

PFJ  

PSG  

PFG  

Witzel,  Stamm,  Janeway  

Loser  C  et  al.  ESPEN  guidelines  on  ar8ficial  enteral  nutri8on  –  Percutaneous  endoscopic  gastrostomy  

(PEG)  

E:  Endoscopic  G:  Gastrostomy  J:  Jejunostomy  

L:  Laparoscopic  NC:  Needle  Catheter  S:  Sonographic   F:  Fluoroscopic  

Parenteral  nutri1on  

•  Central  PN   •  Peripheral  /  peripheral  central  PN  (PICC)  

PICC  =peripherally  inserted    central  catheter  

EARLY  ENTERAL  NUTRITION  

   • Enteral  feeding  24  to  72  hours  aqer  surgery  or  when  pa1ent  is  hemodynamically  stable  

• Provide  nutrients  required  during  metabolic  stress  

• Maintain  GI  integrity  • Reduce  morbidity  compared  with  parenteral  nutri1on  

• Reduce  cost  compared  with  parenteral  nutri1on  

Ra1onale  

Early  enteral  nutri1on  vs  standard  nutri1onal  support  on  mortality  

Comparison:  mortality  Outcome:  early  enteral  nutri1on  vs.  control  

Study   Treatment  n/N  

Control    n/N  

Cerra  et  al  1990  

Gonschlich  et  al,  1990  

Brown  et  al,  1994  Moore  et  al,  1994  Bower  et  al,  1996  Kudsk  et  al,  1996  

Engel  et  al,  1997  

Weimann  et  al,  1998  

1/11  

2/17  

0/19  1/51  

24/163  1/16  

7/18  

2/16  

1/9  

1/14  

0/18  2/47  

12/143  1/17  

5/18  

4/13  

0.01   0.1   10   100  Higher  for  control   Higher  for  treatment  

Ross  Products,  1996   20/87   8/83  

Mendez  et  al,  1997   1/22   1/21  Rodrigo  et  al,  1997   2/16   2/13  

Atkinson  et  al,  1998   96/197   86/193  

Galban  et  al,  2000   17/89   28/87  

Heyland  et  al.  JAMA,  2001  

Pooled  Risk  Ra2o  1  

4.  DETERMINE  ADEQUACY  OF  INTAKE  

Calorie  Count  

Monitor  actual  nutrient  intake  

Effect  of  nutri1on  intake  on  outcome  Nutrition care led to reduced morbidity and mortality of surgical patients assessed

as severely malnourished and high risk (n=103)

Effect of nutrition care on post-operative complications predicted by surgical nutrition risk assessment: St. Luke’s Medical Center experience. Del Rosario D, Inciong JF, et al. 2008.

Intra-­‐opera1ve  checklist  

•  Fluid  intake  – Monitor  and  es1mate  fluid  losses  – Only  infuse  what  is  required  – Determine  whether  to  give  balanced  electrolyte  solu1ons  or  colloids;  avoid  saline  and  “water  only”  infusions  like  D5W  or  D10W  

•  Nutri1on  access  – Determine  the  need  for  long  term  enteral  nutri1on  (jejunostomy:  surgical  jejunostomy  or  nasojejunostomy)  

How  much  fluid  loss  in  surgery?  Fluid  Loss   60  kg  wt  Insensible    perspira1on  

Ven1la1on  with  100%  water  =  almost  zero  loss  

0  ml  

Evapora1ve  loss   •  moderate  incisions  with  partly  exposed  but  non-­‐exteriorised  viscera  =  8.0  mlhour  

•  major  incisions  with  completely  exposed  and  exteriorised  viscera  =  32.2  mlhour  

8-­‐30  ml  per  hr  

Third  space  loss   •  Ascites  or  other    fluids  –  measurable  •  Volumes  up  to  15  mL/kg/hour  are  

recommended  in  the  first  hour  of  abdominal  surgery,  with  decreasing  volumes  in  subsequent  hours.  

•  Measure    •  300  ml  

Total     •  Within  one  hour  (crystalloids  not  recommended)  

350  first  hour  

Adapted  from:  Brandstrup  B.  Fluid  therapy  for  the  surgical  pa1ent.    Best  Pract    Res  Clin  Anaesthesiology  2006;  20(2):  265-­‐83  

Which  fluid  is  the  most  appropriate?  

31  

Fluid  management  Use Compartment Composition Examples

Volume Replacement

Intravascular fluid volume

Iso-oncotic Isotonic Iso-ionic

6% HES 130 in balanced solution

Fluid Replacement

Extracellular fluid volume

Isotonic Iso-ionic

Balanced solution: normal saline; ringer’s lactate

Electrolyte or osmotherapy (solutions for correction)

Total body fluid volume

According to need for correction

KCL Glucose 5% Mannitol

Reference:    Zander  R,  Adams  Ha,  Boldt  J.  2005;  40;  701-­‐719  

Post-­‐opera1ve  checklist  

•  Fluids  and  electrolytes  – Daily  accumulated  fluid  balance  – Goal:  “zero”  fluid  balance  – Serum  electrolytes  – Give  balanced  electrolyte  solu1ons    

•  Adequacy  of  nutrient  intake  – Early  enteral  nutri1on  – Daily  nutrient  balance  (=nutrient  intake)  – Good  glucose  control  

SURGICAL  COMPLICATIONS  

Common  peri-­‐opera1ve  surgical  complica1ons  

•  Fluid  and  electrolyte  problems  •  Wound  infec1on  and  sepsis  •  Wound  dehiscence  

Fluid  management  

•  Average  periopera1ve  fluid  infusion:  –  Intra-­‐op  =  3.5  to  7  liters  – 3  liters/day  for  the  next  3  to  4  days  – Average  gain  post-­‐op  =  3  to  6  kg  weight  gain  

•  Leads  to:  – Delay  of  gastrointes1nal  func1on  –  Impair  wound  anastomosis  healing  – Affects  1ssue  oxygena1on  – Prolonged  hospital  stay  

Lassen  et  al.  Arch  Surg  2009  

Fluid  and  electrolyte  imbalance  INJURY  =  SURGERY  

↑albumin  escape    from  intravascular  

space  

Inflammatory  mediators   ↑vasodila1on  effect    of  anesthe1c  agents  

↑K+  release    from  cells  

↓K+  and  ↑  Na  intracellular  

Sick  cell  syndrome  of  cri1cal  illness  

↑hypotonic  fluid    infusion  

90%  cause  of  hyponatremia  in  

surgery  

Fluid  Reten2on  +    Electrolyte  Imbalance  

Lobo  D,  Macafee  DL,  Allison  S.  How  periopera1ve  fluid  balance  influences  postopera1ve  outcomes.  Best  Pract  Res  Clin  Anaesthesiology  2006;  20(3):  439–55.  

Ileus  and  dehiscence  Salt  and  water  overload  

↑intra-­‐abdominal  pressure  

↓mesentery  blood  flow  

Intes1nal  edema  

↓1ssue  OH-­‐proline  

STAT3  ac1va1on  ↓myosin  phosphoryla1on  

ILEUS  

Impaired  wound  healing  

DEHISCENCE  

Intramucosal    acidosis  

↓muscle  contrac1lity  

Chowdhury  and  Lobo.  Curr  Opinion  Clin  Nutr  Metab  2011    

Anastomosis  leak  

•  Points  to  bowel  prepara1on:  – meta-­‐analyses  show  that  bowel  prepara1on  is  not  beneficial  

–  in  elec1ve  colonic  surgery,  and  2  smaller  recent  RCTs  suggest  that  it  increases  the  risk  for  anastomo1c  leak  

– Promote  longer  ileus  dura1on  

•  Points  to  fluid  management  Lassen  K  et  al.  Consensus  Review  of  Op1mal  Periopera1ve  Care  in  Colorectal  Surgery:  Enhanced  Recovery  Aqer  Surgery  (ERAS)  Group  Recommenda1ons.  

Arch  Surg  2009;  144  (10):  961-­‐9.  

What  is  the  worst  fluid  to  give?  

Plasma   0.9%  saline  Na  (mmol/L)   135  –  145   154  Cl  (mmol/L)   95  –  105   154  K  (mmol/L)   3.5  –  5.3   0  HCO3  (mmol/L)

 24  –  32   0  

Osmolality  (mOsm/kg)   275  –  295   308  pH   7.35  –  7.45   5.4  

Lobo  D,  Macafee  D,  and  Allison  S.  How  periopera1ve  fluid  balance  influences  postopera1ve  outcomes.  Best  Pract  Res  Clin  Anaesthesiology  2006;  20(3):  

439-­‐55.  

Inflamma1on:  surgery  

ADAPTED  FROM:  

Inflamma1on:  sepsis  

Inflamma1on  &  organ  failure  in  the  ICU  

SIRS TNFα, IL-1β, IL-6, IL-12, IFNγ, IL-3

IL-10, IL-4, IL-1ra, Monocyte HLA-DR

suppression

CARS

days

Insult (trauma, sepsis)

Infla

mm

ator

y ba

lanc

e

AN

TI

PR

O

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

Goal  of  nutri2on/  pharmaconutri2on  

Inflamma1on  &  organ  failure  in  the  ICU  

SIRS TNFα, IL-1β, IL-6, IL-12, IFNγ, IL-3

IL-10, IL-4, IL-1ra, Monocyte HLA-DR

suppression

CARS

days

Insult (trauma, sepsis)

Infla

mm

ator

y ba

lanc

e

AN

TI

PR

O

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

Goal  of  nutri2on/  pharmaconutri2on  

1.   Early  enteral  nutri2on  2.   Supplement  with  

parenteral  nutri2on  3.   Pharmaconutri2on:  Fish  

oils  and  glutamine  4.   Zero  fluid  balance  

Sarcopenia  in  elderly  COMPLICATIONS  

Sarcopenia  in  elderly  COMPLICATIONS  

1.   Early  enteral  nutri2on  2.   Supplement  with  

parenteral  nutri2on  3.   Adequate  nutrient  

intake  4.   Pharmaconutri2on:  Fish  

oils  and  glutamine  5.   Zero  fluid  balance  

Cancer  Cachexia  

Cancer  Cachexia  

1.   Early  enteral  nutri2on  2.   Supplement  with  

parenteral  nutri2on  3.   Adequate  nutrient  

intake  4.   Pharmaconutri2on:  Fish  

oils  and  glutamine  5.   Zero  fluid  balance  

CASE  DISCUSSION  

Surgical  case  •  62  y/o  male  •  Height=1.6  m,  weight=52  kg,  weight  two  months  ago=60  kg  

•  Anorexia,  vomi1ng;  weight  loss  •  Diagnosis:  head  of  pancreas  cancer  •  Referred  for  surgery:  •  Labs:  Hb=11,  WBC=5600,  N=60%,  L=6%,  platelet=240k;  Na=135  mmol/L;  K=3.2  mmol/L;  glucose=160  mg/dL;  BUN=6  mmol/L;  albumin=3  gm/dL;  crea1nine=1.1  mg/dL  

Ques1ons  

•  Will  you  operate  on  this  pa1ent  tomorrow?  

Available  data  

•  BMI=21  •  Weight  loss  in  two  months=13%  •  Cancer,  head  of  pancreas  •  Albumin=3  gm/dL  •  Total  lymphocyte  count  (TLC)=336  •  Na=135,  K=3.2  •  Compute  for  the  osmolality    

–  ([2x135]  +  [160/18]  +  [6]  =  284.8  mOsm/kg  H2O)  

Ques1on  

•  If  you  plan  to  build  up  the  pa1ent  how?  

Build  up  

•  Total  fluid  (ml)/day  =  52  kg  x  30  ml/day  =  1560-­‐1600  ml/day  

•  Total  calories/day  =  52  kg  x  30  kcal/day  =  1560  kcal/day  

•  Total  protein/day  =  52  kg  x  1.5  gm/day  =  78  gm/day  •  Total  carbo  and  fat:  get  the  non-­‐protein  calories:  1560  –  (78x4kcal/gm)  =  1248  NPC  –  Carbo  (60%):  1248  x  0.60  =  748.8  kcal/(4kcal/g)  =  187  gm  –  Fat  (40%):  1248  x  0.40  =  499.2  kcal/(9kcal/g)  =  55.5  gm  

•  Vitamins  and  trace  elements?  

Build  up  

•  What  is  the  route?  – Oral?  Tube  feed?  Parenteral  nutri1on?  Combina1on?  

•  Dura1on  of  build  up?  •  How  to  ensure  adequate  intake?  

– Measure  calorie  count  daily  – Monitor  and  ensure  normaliza1on  of  the  electrolyte  and  fluid  status  

Build  up  

•  What  are  the  indicators  of  build  up  success?  – Normaliza1on  of  abnormal  values?  

•  TLC?  Albumin?  Na?  K?  

– “zero”  fluid  balance?  – Adequate  nutri1on  intake?  

Intra-­‐opera1ve  

•  Will  you  monitor  the  fluid  input?  •  How  much  fluid  loss  do  you  expect?    

– Will  you  leave  everything  to  the  anesthesiologist?  

•  What  are  your  choices  of  fluids?  •  Will  you  place  a  jejunostomy?  

Post-­‐opera1ve  

•  Will  you  place  an  NGT?  •  Will  you  place  drains?  •  How  will  you  monitor  the  post-­‐op  course?  

– Will  you  place  on  NPO?  How  long?  – How  oqen  will  you  check  the  electrolytes?  Glucose?  

•  When  will  you  start  enteral  feeding?  Oral  feeding?  – How?  When?  

•  Will  you  give  parenteral  nutri1on?  

Take  home  message  

•  Fluid  and  nutri1onal  status  •  Fluid  and  electrolyte  balance  •  Nutrient  balance/adequate  nutrient  intake  

THANK  YOU