SURGERY, CURRENT ISSUE IN
NUTRITION SUPPORT
NURUS SA’ADAH MOHD
FADZIL
0616952
UIAM DIETETICS
Introduction
Stress hormone & Catabolism of glycogen,
Surgery
inflammatory mediator fat & protein
dehydration,
weight loss, fatigue, Insulin resistance
poor wound Release of glucose,FFA & a.a
healing,
increased risk of
infectious
complication and a Recent study shows that measure to reduce stress of surgery can
reduction in lean minimise catabolism & support anabolism
body mass as a -this allow pt to recover faster & better
result of increased -such program are ERAS (enhanced recovery after surgery) that
nitrogen losses involved:
preop prep & medication+fluid balance+anaesthesia &
analgesia+ pre-post op nutrition + mobilization
(Weimann, A., et al,2006)
Surgery involves a deliberate injury to the body
The surgical insult results in several responses that cause a
change in metabolism towards catabolism(e-SPEN,2010).
Recovery from surgery requires a reversal of the trauma-
induced catabolism towards anabolism.
The adverse effects of malnutrition in surgical patients have
been documented from as early as 1936(Marion, J.O & Julie,
I.,2010).
Nutrition, the supply of energy and protein, represents an
essential part of the perioperative treatment.
To prevent complications associated with malnutrition,
nutrition screening, assessment and support must
become an integral part of the multidisciplinary care of
the surgical patient.
Low risk people
[Link]-operative
They can eat normal food up until the evening before surgery.
Patients undergoing intestinal resections have traditionally prepared
by bowel cleansing the day before surgery. The idea behind bowel
cleansing is that if the large bowel is free from stools, the risk of
postoperative infection may be reduced no benefit from the use
of this routine
Over the last decade many national anaesthesia societies have
changed preoperative fasting guidelines and now recommend free
intake of clear fluids up until 2–3 h before anaesthesia for elective
procedures has been proven safe and was brought about to
reduce the discomfort of thirst + dehydration (e-SPEN,2010).
Exception for those with risk of aspiration(GERD/Obese/delayed
gastric emptying)
Food is now allowed up to 6 hours before surgery and clear oral fluids or
carbohydrate loading drinks up to 2 hours before surgery.
an iso-osmolar carbohydrate rich drink given preoperatively is quickly
cleared from the stomach and, by the addition of carbohydrates,
preoperative hunger and anxiety is also reduced+ reduces postoperative
insulin resistance.
Preoperative intake of a carbohydrate drink (CHO) with 800 ml the night
before and 400 ml before surgery does not increase the risk of
aspiration(Brady M,et al.,2003, Soreide E,et al.,1997 & Hausel J,et al.,2001)
In colorectal patients, and those with hip replacement the intake of an
hypo-osmolar 12.5% carbohydrate rich drink has been shown to reduce
postoperative insulin resistance(Nygren J, et al.,1998 & Soop M,et al, 2004)
and preserve skeletal muscle mass(Yuill, K.A,et al., 2005)
This regime has been shown to reduce cardiac complications after cardiac
surgery in several studies.
For patients who are excluded from using the newer and
liberal fasting guidelines, i.v. glucose with or without
insulin has been shown to have the same effects.
Provided the glucose load is sufficient (5 mg/kg/min often
by use of 20% or 30% glucose solutions)
[Link]-operative
The routine to delay oral drinking or feeding until flatus or stools has been passedno
scientific support
There was also a fear that early feeding would cause a breakdown of the bowel
anastomosis. The ERAS program has challenged this and several researchers have
illustrated that both flatus and bowel sounds return sooner in those who are fed in
comparison to those starved postoperatively. The incidence of anastomotic
breakdown in the fed group was not significantly greater than the fasted group.
Minimising the development of catabolism and returning the patient from the
catabolic state to one of anabolism is an important part of this process in which
nutrition has a major role.
Kehlet and colleagues also points out the importance of maintaining gut function with
the use of local anaesthetics in epidural anaesthesia maintained for at least 2 days
after opiates have the side effect of enhancing postoperative ileuscolon resections.
This allows avoiding opiates as pain treatment since these measures makes it possible
for most postoperative patients to take oral feeding within hours after surgery and to
return to normal food intake within a day or two even after major gastrointestinal
surgery.
Most patients undergoing surgery can commence oral feeding
within hours after the operation. Oral supplements are a very
useful prescription for patients who do not tolerate or only
partially cover their energy needs with hospital food. Enteral
feeding has also been shown to reduce postoperative
complications and reduce length of stay in a recent meta-
analysis.
A key factor for early oral or enteral feeding is a strict fluid and
electrolyte regimen. Overloading the patient with fluids and
salts perioperatively causes oedema and delayed GI motility.
Reducing maintenance fluids to 2000 ml and NaCl to 77 mmol
per day was shown by Lobo et al to substantially enhance
gastric motility and speed up recovery(e-SPEN,2010).
Early EN Meta analysis
Author/Journal Study parameter Study design Outcome
Marik,CCM.2001 Feeding<or>36 hr 15 studies ↓ infection
753 patients ↓ LOS
Lewis, BMJ.2001 NPO vs <24 hr 11 studies ↓ infection
837 patients ↓ LOS
↑vomit risk
[Link].2003 <24 to 48 hr 8 studies Trend to ↓
infection &
mortality
Lewis SJ. J GI Surg. <24 13 studies ↓ mortality
2008 1173 patients
Doig [Link] Care <24 5 studies ↓ infection
Med.2009 ↓ mortality
Malnourished People
The overall goal for the compromised patient or the
patient undergoing major surgery are the same as for the
uncomplicated patient – i.e. to promote more rapid
recovery.
In addition to these principles, high risk or malnourished
patients often present a greater level of complexity that
may demand other measures to be taken to ensure
adequate nutritional and metabolic support.
Several studies have demonstrated that a week or two of preoperative
feeding, enterally or parenterally improves the outcome from surgery in
patients with severe malnutrition. On the other hand its use in those with
normal nutritional status or only mild malnutrition PN is associated with
either no benefit or even an increase in complications.
There is some evidence of benefit from parenteral nutrition under the
following conditions:
– As a continuation of preoperative nutritional support in previously
malnourished patients.
– In patients with postoperative complications impairing gastrointestinal
function and preventing normal oral feeding for more than 7–10 days
postoperatively.
– In previously severely malnourished patients undergoing emergency
surgery.
– In previously well-nourished patients who have suffered major trauma
or critical illness and who are unable to tolerate enteral feeding.
evidence suggests that enteral feeding by the
nasogastric, nasoenteral and jejunal routes or a
combination of some enteral and supplementary
parenteral feeding are the preferred methods, although,
in the presence of prolonged gastrointestinal failure,
parenteral feeding may be life saving. There are also
some trials indicating that early and adequate oral
supplementation in the first week after surgery may
improve outcome, particularly in the malnourished(Doig
GS, et al.,2009).
Glucose control
There is growing and strong evidence that glucose levels
should be maintained at normal levels while feeding the
severely stressed surgical patient.
Van den Berghe and colleagues showed that
postoperative patients (mainly thoracic surgery) in need
of ventilatory support in an ICU setting benefited from
intensive insulin treatment to normalise glucose levels
(aiming at 4.5–6 mmol/l)(e-SPEN,2009)
Normalising glucose levels using insulin resulted in
marked reductions in septic episodes, renal failure, time
on the ventilator, polyneuropathy and also mortality.
In this study patients were fed and showing that insulin
action seems to be a key to successful immediate
postoperative feeding, but also to avoiding complications
that will cause further catabolism.
The use of insulin to maintain glucose control is likely to be a
better approach compared to semi-starvation through
carbohydrate restriction, which has been another approach,
suggested to avoid hyperglycaemia.
Whether the beneficial effects of insulin are confined to the
maintenance of normoglycaemia or include the previously
demonstrated reduction in net protein catabolism and cell
membrane function remains to be determined.
Prescription of feeding
First and foremost, perioperative care demands early intake of
normal food as a major aim. Regular hospital food should be the
first choice for nutrition in most postoperative patients. However,
it is essential to monitor and record the adequacy of such intake.
Broadly, however, for patients consuming some but not sufficient
regular food, sip feeds can be recommended.
For patients able to take only minor portions of normal food or
none at all, enteral tube feeding using a standard polymeric feed
should be used in most cases starting at 20 ml/hr and increasing
as tolerance improves.
Several positive trials of postoperative enteral feeding have used
quite low intakes of 18–20 kcal/kg body weight in the first few
days, with beneficial results, particularly in terms of infection.
Immune Modulating Formula
Some studies in major trauma, and in cancer surgery suggest that
immune-enhancing feeds may have some advantage over standard
feeds in these conditions.
In a series of recent studies it has been suggested that addition of
specific immune-enhancing nutrients such as arginine, u-3 fatty
acids, RNA, glutamine may be of benefit for the patient undergoing
major surgery(Olle, L. et al.,2010).
From the design of the studies it is however is not clear if the
effects where related to the addition of nutrients as such or the
addition of any one of the specific components.
A systematic review of the evidence found that there is a
substantial reduction in infectious complications and shorter
hospital length of stay associated with the use of arginine
supplementation, with no overall effect on mortality compared
with standard care(John,W.D,.et al, 2011)
Immune modulating formula should be used for
appropriate patient population (major elective
surgery,trauma,burn,head & neck cancer and critical ill pt
on mechanical ventilator), being cautious in pt with
severe sepsis
(For surgical ICU patient: Grade A)( For medical ICU
patient:Grade B)
(ASPEN,2009)
CPG on Immune Modulating formula in Surgical
Canadian ESPEN SCCM ASPEN Aus/NZ EAST 2004 ADA 2008
2007 2006 2009 2009 2003
Yes Yes Yes Yes N/A Yes N/A
Clinical evidence for enteral Nutritional Support with
glutamine: a systematic review, glutamine-enriched diets
showed good overall tolerance, improvement of
immunologic aspects in multiple trauma patients, cost
reduction in critically ill patients, and improvement of
mucositis in post-chemotherapy patients (grade B
recommendations)
The doses given and the duration of therapy varied widely
depending on the pathologic condition. Intake of 20 to 30 g/d,
early initiation of diet, and maintenance for 5 d or longer are
recommended (grade C recommendations).
(Abelardo, G.,et al, 2003)
GRV
CONSENSUS STATEMENT:2002 (JPEN,2002)
GRV> 500 cc Withold feed+reassess
GRV200-500 Careful bedsite evaluation
GRV<200 cc Appear to be well tolerated+on going evaluation
GRV: Published Guideline
ADA 2008 >250 cc
CCPG 2009 >550 cc
ESPEN 2006 Not address
ASPEN/SCCM >500 cc
2009
Parenteral Feeding
With parenteral nutrition, particular attention should be
paid to avoiding too little or too much salt and water and
to avoidance of hyperglycaemia. For many of these
patients, insulin may be needed to maintain
normoglycaemia.
Otherwise standard prescriptions can be used to give 25–
30 kcal/kg/day with 30–40% of total calories from fat.
Intakes of 0.15–0.2 gN/kg/day are usually adequate with
energy to nitrogen ratio of approximately 150:1.
The usual recommended amounts of mineral and
micronutrients should also be supplied.
Wound healing
For optimal wound healing to occur, the body needs to be well
nourished. This will enable synthesis of acute phase proteins,
white cells, fibroblasts collagen and other tissue components
which can be delivered to the wound to promote healing. If
these are not present, wound healing will be delayed and
dehiscence or anastomotic breakdowns may occur.
Large open abdominal wounds will require intensive nutrition
support. Protein intake should be optimized as losses from
larger open abdominal wounds are often underestimated.
There are also electrolyte, vitamin and mineral losses. Vitamin
and mineral levels should be checked especially zinc and
vitamin C.
If calorie and protein requirements cannot be met via diet and
sip feeds, a high-protein feed should be administered via a
nasogastric feeding tube. (Marion, J. & Julie, I. D., 2010)
Conclusion
Most patients undergoing surgery can return to normal oral feeding
immediately, or at any rate shortly after the operation.
Several old traditional routines need to be changed. Proper anaesthetic
techniques for pain control will help to facilitate a return to the use of the
oral route for feeding and avoid postoperative ileus.
Preoperative feeding improves the outcome from surgery in patients with
severe malnutrition and preoperative carbohydrates reduce postoperative
insulin resistance and protein catabolism in elective surgery.
Postoperative enteral nutrition reduces postoperative complications. There
is some evidence of benefit from postoperative enteral and/or parenteral
nutrition in previously malnourished patients, in those with postoperative
complications and after major trauma or burns.
So-called ‘immune-enhancing’ feeds have shown benefit in very severe
trauma and in patients undergoing major surgery for upper gastrointestinal
cancer.
Feeding should be part of an integrated protocol of management
throughout the patient’s clinical course