Nutrition management in surgical patients

Nutrition management in surgical patients

1. Nutritional Assessment & Management in Surgical Patients Hanan Alebachew MD,FCS(ECSA) (Assistant professor of surgery) Endocrine and Breast surgery fellow Department of surgery SPHMMC 2023

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4. Introduction Definition Deficiency or excess or imbalance of energy, protein and other nutrients Causes measurable adverse effects on tissue or body form (body shape, size and composition), function, and clinical outcome Etiology Starvation –related Chronic disease-related Acute disease or injury-related with marked inflammatory response 7/31/2023 4

5. Cont …. Daily requirement of energy 20-25kcal/kg Daily requirement Carbohydrate 7.2gm/kg….. 4kal/gm Protein0.8gm/kg……….4kcal/g Fat 1gm/kg……………….9kal/gm 7/31/2023 5

6. Calorie content per gram of nutrients

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8. NUTRITION IN THE SURGICAL PATIENT The goal of nutritional support in the surgical patient is to prevent or reverse the catabolic effects of disease or injury. Although several important biologic parameters have been used to measure the efficacy of nutritional regimens, the ultimate validation for nutritional support in surgical patients should be improvement in clinical outcome and restoration of function 7/31/2023 8

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10. Surgery & Nutrition 7/31/2023 10

11. Energy requirement

12. Enhanced Recovery after Surgery (ERAS) Minimize stress and to facilitate the return of function Components Preoperative preparation and medication Fluid balance Anesthesia and postoperative analgesia Pre- and postoperative nutrition Mobilization 7/31/2023 12

13. Introduction Cont’d… Etiology Starvation –related Chronic disease-related Acute disease or injury-related with marked inflammatory response Patients at risk - surgery, oncology, geriatrics, and intensive care medicine Significant impact for the hospital complication rate: severity of the disease, age >70 years, surgery and cancer Prevalence of malnutrition reach 50% (surgical patients) 7/31/2023 13

14. Introduction Cont’d… Unrecognized & underestimated Leading cause of mortality & morbidity Increased postoperative complications Prolonged hospital stay Poor wound healing Increased incidence of pressure ulcers Impaired muscular and respiratory functions Increased susceptibility to infection Increased mortality 7/31/2023 14

15. Surgery & Nutrition Cont’d… Success of surgery does not depend exclusively on technical surgical skills, but also on metabolic interventional therapy Balance the extent of surgery according to nutritional state, inflammatory activity and anticipated host response Limiting the extent of the surgical trauma Minimize intraoperative manipulation & excess fluid administration 7/31/2023 15

16. Nutritional Assessment Early recognition of malnutrition prior to admission or within 24-48hrs Components History Physical Examination Anthropometric measures Specific signs Laboratory( biochemical) tests 7/31/2023 16

17. Nutritional Assessment History Presence of weight loss Chronic illnesses, Dietary habits Medications Phy sical examination Loss of muscle and adipose tissues Skin & hair Oral Lips/mucous membranes Anthropometric data Weight change, skinfold thickness, and arm circumference muscle area 7/31/2023 17

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19. Nutritional Asses. Cont’d… Biomarkers (laboratory tests) Albumin level 3gm/dl Prealbumin level 12mg/dl Total lymphocyte count 1800/mm3 Transferrin level 150mmol Specific nutrient level 7/31/2023 19

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21. Nutritional Asses. Cont’d… Preoperative serum albumin define severe nutritional risk by the presence of at least one of the following criteria: Weight loss >10-15% within 6 months BMI <18.5 kg/m2 Subjective Global Assessment (SGA) Grade C or NRS >5 NRS nutrition screening tool (BMI, weight loss with in 3 month, decrease dietary intake 1 wk., ICU Pt.) Preoperative serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction) 7/31/2023 21

22. Nutritional Asses. Cont’d… Three main screening tools Nutritional Risk Screening(NRS) Malnutrition Universal Screening Tool (MUST) Mini Nutritional Assessment (MNA) 7/31/2023 22

23. Nutritional Asses. Cont’d… ESPEN has recently defined diagnostic criteria for malnutrition according to two options Option 1 : BMI <18.5 kg/m2 Option 2 : combined: weight loss >10% or >5% over 3 months and reduced BMI* or a low fat free mass index (FFMI)** * Reduced BMI is <20 or <22 kg/m2 in patients younger and older than 70 years, respectively **Low FFMI is <15 and <17 kg/m2 in females and males, respectively 7/31/2023 23

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25. Nutritional Therapy Provision of nutrition or nutrients to prevent or treat malnutrition Routs Orally (regular diet, therapeutic diet, e.g. fortified food, oral nutritional supplements) Enteral nutrition (EN) Parenteral nutrition (PN) Dietary advice or nutritional counselling is part of a nutrition therapy 7/31/2023 25

26. Nutritional Therapy Cont’d… Indications -prevention and treatment of catabolism and malnutrition Indicated even in patients without obvious disease-related malnutrition to attenuate the stress response and provide appropriate supplementation to mitigate the effects of postoperative catabolism The enteral route should always be preferred except for the following contraindications: Intestinal obstructions or ileus, Severe shock Intestinal ischemia High output fistula Severe intestinal hemorrhage 7/31/2023 26

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28. Nutritional Therapy Cont’d… Combination of enteral and parenteral nutrition Requirements cannot be met by oral and enteral intake alone (<50% of caloric requirement) for >7days 7/31/2023 28

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36. Nutritional Therapy Cont’d… Preoperative Nutrition Prehabilitation Preoperative bundle designed to prepare the body for the metabolic insult of the perioperative period Exercise tolerance and weight, nutrition, and glucose control 7/31/2023 36

37. Nutritional Therapy Cont’d… Energy Requirements Basal energy expenditure (BEE) Harris-Benedict equations (kcal/d) BEE (men) = 66.47 + 13.75 (W) + 5.0 (H) – 6.76 (A) BEE (women) = 655.1 + 9.56 (W) +1.85 (H) – 4.68 (A) Total requirement = BEE X Injury Factor X Activity Factor 25-30 kcal/kg per day will adequately meet energy requirements in most postsurgical patients 7/31/2023 37

38. Nutritional Therapy Cont’d… Injury Factor Peritonitis 1.15 Soft tissue trauma 1.15 Fracture 1.20 Fever (per oc rise) 1.13 Moderate infection 1.20 Severe infection 1.40 <20% BSA burns 1.50 20-40% BSA burns 1.80 >40% BSA burns 2.00 Activity Factor Bed bound 1.2 Ambulatory 1.3 7/31/2023 38

39. Nutritional Therapy Cont’d… Preoperative fasting from midnight is unnecessary in most patients Can drink clear fluids until two hours &Solids shall be allowed until six hours before anesthesia Oral preoperative carbohydrate Impact postoperative insulin resistance and hospital length of stay Reduce anxiety Two to three hours before surgery 7/31/2023 39

40. Nutritional Therapy Cont’d… Malnourished patient Mild-short term (7-10 days) nutritional conditioning Severe- longer periods and this should be combined with resistance exercise Preoperative enteral nutrition/oral nutritional -prior to hospital admission PN -malnutrition or severe nutritional risk where energy requirement cannot be adequately met by EN 7/31/2023 40

41. Nutritional Therapy Cont’d… Postoperative Nutrition Oral nutritional intake shall be continued after surgery without interruption (initiated within hours) Early tube feeding (within 24 h) Early oral nutrition cannot be started and oral intake will be inadequate (<50%) for more than 7 days Special risk groups- e.g. Patients undergoing major head and neck or gastrointestinal surgery for cancer 7/31/2023 41

42. Nutritional Therapy Cont’d… There is no evidence to support withholding enteric feedings for patients after bowel resection or for those with low-output enterocutaneous fistulas of <500 mL/d Recent systematic review of studies No effect on anastomotic leak and a reduction in mortality Early enteral feeding Reduced incidence of fistula formation in patients with open abdomen 7/31/2023 42

43. Nutritional Therapy Cont’d… Tube feeding Start with Low flow rate Long term TF (>4 weeks) -placement of a percutaneous tube (PEG) is recommended Nasojejunal and nasoduodenal tubes-accidental dislodgement Postoperative ileus Minimize opioid use & appropriate fluid management 7/31/2023 43

44. Nutritional Therapy Cont’d… Immunonutrition Refers to the supplementation of specific nutrients, including arginine, omega-3 fatty acids, nucleotides, and/or glutamine. influence the immune and inflammatory response to surgical stress as well as encourage protein synthesis Indication All patients undergoing major elective gastrointestinal surgery Malnourished Initiated 5 to 7 days preoperatively and continued postoperatively 7/31/2023 44

45. Summary 7/31/2023 45

46. References Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL. ESPEN guideline: clinical nutrition in surgery. Clinical nutrition. 2017 Jun 1;36(3):623-50. Schwartz principles of surgery, F. Charles Brunicardi , 11th edition Sabiston 20 th edition. Up to date 2018 7/31/2023 46

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