Malnutrition  in  Surgery

Symposium  organized  by  the  Committee  on  Critical  CarePhilippine  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?

Lacuesta-‐Corro L et al. The results of the validation processof a Modified SGA (Subjective Global Assessment) NutritionAssessment and Risk Level Tool designed by the ClinicalNutrition Service of St. Luke’sMedical Center, a tertiary carehospital in the Philippines. (Article 12 | POJ_0002.html)Issue February 2012 -‐ December 2014: 1-‐7 (n=179)

Sensitivity:  94.7%Specificity:  96.2%

Positive  Predictive  Value:  95.7%

The  modified  SGA  form  of  PhilSPENSGA• A  (normal)• B  (mild/mod  malnutrition)• C  (severe  malnutrition)

Nutrition  Risk  Score:• 1-‐3:  Low  Risk• 4-‐6:  Moderate  Risk• 7-‐9  High  Risk

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  ParenterNutr(Article  29;  Issue  July  2016  -‐ December  2016:  134-‐136.  Available  at:  http://www.dpsys120991.com/POJ_0023.html

Malnutrition  and  surgical  outcomes

OcampoR  B,  Kadatuan Y,  TorilloMR,    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

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

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  well-‐nourished  patients

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

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

Malnutrition  correction  and  outcome(s)

Basis  for  addressing  malnutrition  in  surgery

Total  cells  in  the  bodyBody  Compartment Number/Percent  of  

cells in  the  body  Glucose  Transporter

IV  (GLUT4)

Total  cells  in  the  body

37 trillion  *

Skeletal  muscle  cellsCardiac  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  HealingMalnutrition• Poor  protein  reserves• Less  energy  supply• Fat  >  higher  inflammatory  state

Poor  intake• Poor  nutrient  supply• Poor  quality  of  wound  healing• Other  complications  like  

dehiscence,  ulcers,  fistulas

Resolution

• Neutrophils• Macrophages  >  

active  resolution

• Collagen• Basement  membrane• Angiogenesis  

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,  trihydroxystearin-‐containing  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  reservesNutrient Reserve How long  do  these  last?Carbohydrate Liver  glycogen 24  – 48 hours

Muscle  glycogen 48  hoursProtein Skeletal muscle (for  a  70  kg  person)  

20  daysFat All  fat  tissues (for  a  70  kg person)

85  days

Nutrient  metabolism  and  reserves

Gluconeogenesis  

When  not  fed  after  24  hours  the  body  starts  to  lose  protein  (=  gluconeogenesis)

Weight  loss  and  mortality

SarcopeniaCOMPLICATIONSSARCOPENIA

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

http://www.medscape.org/viewarticle/432384_4Demling RH.  Eplasty. Nutrition,  anabolism,  and  the wound   healing process:  an  overview.  Eplasty 2009;9:e9.

Protein  preservation  phase

Demling RH.  Eplasty. Nutrition,  anabolism,  and  the wound  healing process:  an  overview.  Eplasty 2009;9:e9.  Epub 2009 Feb  3.

Priorities:  Basic  function  vs.  wound  healing

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  decisionsStatus Option/access Condition DecisionERAS  >  normal  GIT

• Oral Intakewithin  24-‐48  hours

• Discharge early

ERAS  >  poor  appetite

• Oral Intake <  70% • PN: AA  soln,  Lipid  soln,  3-‐in-‐1  for  one  or  two  days

Pre-‐op: severely  malnourished

• Build up:  7-‐10  days• May  opt  for  3  days

Oral  intake  possible, but  inadequate

• Full diet  +  oral  supplement  +  PN  (3-‐in-‐1  TNA)  +  immunonutrition

• intra-‐op:  enteral  access?Need  to  do  surgery  immediately

• NGT post-‐op• Need  to  place  access?  

Gastrostomy?  Jejunostomy?

Enteral nutrition  possible  but  inadequate  intake

• EN:  tube  feed  within  24-‐48  hours;  when  inadequate  give  PN

• PN: Protein  soln only  or  protein  solnand/or  lipid  emulsion  or  “All  in  One”

Post-‐operativewith  enteral  access

• Enteral  nutrition EN goal • EN priority• if  intake  <  60%  give  supplemt PN

Critical  careStatus Option/access Condition DecisionICU • 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    • IV  infusion• medications• oral  feeding• EN• PN• albumin• blood/others  

OUTPUT• urine• insensible  loss• drains• stool

Fluid  balance  =  “0”Nutrient  balance  =  positive  (75%)

Value  of  nutrition  and  fluid  audit

Why  the  need  for  early  enteral  feeding?

Gastrointestinal  PeptidesGastric  acid,  pepsin,  mucosa  growth/repair

Glycogenolysis,  gluconeogenesis,   lipolysis

ébicarbonate  secretion  (panc duct,  bile  duct)

(1)  Muscle  contraction  

Stimulates  insulin  secretion   (gliptin)

ésecretion  of  electrolytes  and  water;  relaxessmooth  muscle  including  sphincters

éGI  motility,  êileal blood  flow

Inhibits  food  intake,  gastric  inhibitory  peptide

égrowth  hormone,   central   control  of  food   intake

(2)  Muscle  contraction  

Gastrin  secretion

Inhibits  gastrin,  secretin,  VIP,  GIP,  motilin

ésecretion  of  chloride   to  lumen

Gallbladder  contraction,  épancreatic  juice  rich  in  enzymes

Glucagon  (GLP-‐1,  GLP-‐2)  -‐ Glycogenolysis,  gluconeogenesis,   lipolysis

GanongWF.  Review  of  Medical  Physiology,  22nd edition,  2005.

[M]  =  mucosa[N]  =  nerve[Me/o]  =  enterochromaffin cells

[M]

[M]

[M]

[M]

[N]

[M]

[M]

[M]

[Me/o]

[N]

[M]

[N]

[M]

[M]

[M]Feed  within  24  to  48  hours  post-‐op

Maintenance

Motility

MetabolismMaintenance

Gastrointestinal  PeptidesGastric  acid,  pepsin,  mucosa  growth/repair

Glycogenolysis,  gluconeogenesis,   lipolysis

ébicarbonate  secretion  (panc duct,  bile  duct)

(1)  Muscle  contraction  

Stimulates  insulin  secretion   (gliptin)

ésecretion  of  electrolytes  and  water;  relaxessmooth  muscle  including  sphincters

éGI  motility,  êileal blood  flow

Inhibits  food  intake,  gastric  inhibitory  peptide

égrowth  hormone,   central   control  of  food   intake

(2)  Muscle  contraction  

Gastrin  secretion

Inhibits  gastrin,  secretin,  VIP,  GIP,  motilin

ésecretion  of  chloride   to  lumen

Gallbladder  contraction,  épancreatic  juice  rich  in  enzymes

Glucagon  (GLP-‐1,  GLP-‐2)  -‐ Glycogenolysis,  gluconeogenesis,   lipolysis

Ganong WF.  Review  of  Medical  Physiology,   22nd edition,   2005.

[M]

[M]

[M]

[M]

[N]

[M]

[M]

[M]

[Me/o]

[N]

[M]

[N]

[M]

[M]

[M]

BENEFITS  of  FEEDING• Early  bowel  motility  

recovery• Gut  mucosa  defense  is  

maintained• Gut  microbiome is  

maintained• Faster  wound  healing• Preserved  immune  status

[M]  =  mucosa[N]  =  nerve[Me/o]  =  enterochromaffin cells

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

Hours Early  EN:  Guideline   Evidence<  48  hours 1  Canadian Evidence  of  trend<  24  hours 2  ACCEPT Significant  evidence<  24  hours 3  Australian/New  Zealand Significant  evidence<  24  hours 4  ESPEN Significant  evidence<  48  hours 5  ASPEN Evidence  of  trend

Grade  B  recommendation

1. Heyland DK  et  al.  J  Parenter Enter  Nutr 2003.2. Martin  CM  et  al.  CMAJ  2004.3. Doig GS  and  Simpson  F.  EvidenceBased.net4. Kreymann KG  et  al.  Clinical  Nutrition  20065. 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  >            é 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  HClè 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  è shortening  height  of  villus

• But:  mucosa  perfusion  is  still  adequate• êoxygen  >  éAdenosine  (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• Combination:

• 3-‐in-‐1  or  “All  in  One” +  vitamins  and  trace  elements• 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

AMINOPLASMAL

LIPOFUNDIN/LIPIDEM

NUTRIFLEX

TRACUTIL

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

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