Malnutrition in surgical patients

Surgical Nutrition Training ModuleLevel 1

Philippine Society of General SurgeonsCommittee on Surgical Training

Objectives

• To define malnutrition and discuss its impact on the surgical patient

• To identify malnutrition in hospitalized surgical patients

MALNUTRITION IS A SYNDROME

Malnutrition syndrome: features

• Wasting / marasmus• Cachexia• Protein-energy malnutrition• Sarcopenia• Failure to thrive• Obesity

Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.

Malnutrition syndrome: features

• Wasting/marasmus– Loss of body cell mass without underlying

inflammatory condition; Pure starvation• Cachexia– Loss of body cell mass with underlying

inflammatory condition; Cytokine mediated– Cancer: moderate to advanced stage

Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.

Cancer Cachexia

Inflammation in cachexia

Malnutrition syndrome: features

• Protein-energy malnutrition– In modern healthcare this is often acute metabolic

derangement driven by pro-inflammatory state; not classic PEM with clinical and metabolic evidence for reduced intake of protein and energy

Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.

Malnutrition syndrome: features

• Sarcopenia (mostly geriatric)– Age related loss of muscle; often with

inflammation / cachexia overlap• Failure to thrive– Classic pediatric growth failure syndrome– Now also applied in clinical practice to

undernourished older persons in functional or cognitive decline (Alzheimer’s disease)

Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.

SarcopeniaCOMPLICATIONS

Malnutrition syndrome: features

• Obesity: WHO (World Health Organization) criteria– BMI (Body Mass Index) = Weight in kg / Height in

meter / Height in meter• 30 - 34.9 Obese class 1• 35 - 39.9 Obese class 2• 40 and above Obese class 3• 40 - 50 Morbidly Obese• > 50 Super-Obese

Malnutrition syndrome: summary

UNDERNUTRITION• chronic starvation without inflammation• chronic disease with inflammation• acute injury/disease with inflammation

OBESITYBMI > 30

Macronutrient deficiency

Micronutrient deficiency

Metabolic Syndrome

MALNUTRITION

Hegazi R et al. TNT version 3, 2011

Malnutrition process

• It is a continuum– Starts with poor intake– Effect of initiation and progress of the disease

process: severity of disease and adequacy of intake

– Effect of efforts to correct both body composition and disease process

Malnutrition concerns

• Lean body mass– Structure and function– Body composition capacity for healing and

recovery– Quality of life

• Energy reserves– Function– Optimal utilization of substrates and protein

synthesis

Malnutrition syndrome: features and effects

• Wasting / marasmus• Cachexia• Protein-energy

malnutrition• Sarcopenia• Failure to thrive• Obesity

• Loss of lean body mass• Structural and

functional impairment• Energy utilization

problems• Antioxidant capabilities• Increased complications

and mortality

Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.

EFFECT OF SURGERY ON THE PATIENT

Surgery = 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

Surgery, wound healing, and nutritional status

SURGERY

INFLAMMATION

↑WBC + ↑ENERGY

↑CELL MULTIPLICATION + ↑NUTRIENT NEEDS

WOUND HEALING

NORMAL POOR ± COMPLICATIONS

No Malnutrition Malnutrition

↑Energy needs = ↑ free radicals

Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003.

Role of nutrition in surgery

LIPIDS

MUSCLEMALTGALT

CARBO

Alanine

WBC, RBC, FIBROBLASTS

All WBC, RBC, FACTORSBone Marrow

MALT, GALTB-cells

T-cells

PlateletsGlutamine

Organs Affected• epithelium• connective tissue• angiogenesis• complement system

INFLAMMATIONANTIOXIDANTSWOUND HEALINGINFECTION CONTROL

Body composition

NEED TO KEEP ALL NUTRIENTS IN STEADY SUPPLY AS NEEDED

Nutrition and wound healing

Wound healing

Surgery Nutritional status

Severe malnutrition

Good Prolonged

Complications

Normal

Body reserves:• skeletal muscle – alanine and glutamine• fat reserves – energy (long term)

Malnutrition in surgical patientsSurgical 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 1994 Detsky et al. JPEN 1987

Malnutrition and costsMalnutrition is associated with increased cost and the higher the risk the

higher the number of complications plus cost

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

Malnutrition: effects on surgery

• Slow wound healing.• Reduced muscle strength.• Decrease in respiratory muscle strength • Impaired cardiac function• Immune hypofunction and dysfunction• Higher morbidity and mortality• Poor quality of life

PREVALENCE OF MALNUTRITION

Malnutrition detection toolsNutrition screening Nutritional assessment

Nutritional Assessment

and Risk Level Form

Hospital malnutrition: global

Year Author Location Prevalence1974 Bistrian US 50%1977 Hill England 44%1979 Weinsier US 48%1984 Agradi Italy 34%1993 Larsson Sweden 27%1994 McWhirter Scotland 40%1995 Fernando Philippines 48%1997 Waitzberg Brazil 47%

Malnutrition in the PhilippinesHospital BMI

<18.5BMI>30

SGA “C”

1. Marikina, Rizal (Amang Rodriguez Medical Center) 38% 15% -2. Lipa City, Batangas (Mary Mediatrix Med Center) 18% 5% -3. Quezon City (St. Luke’s Medical Center) 6% 12% -4. Manila (Philippine General Hospital) - - 42%5. Pasig (The Medical City) 4% 14% -6. Alabang (Asian Hospital Medical Center) 8% 20% -7. Cabanatuan City (Premiere Medical Center) 15% 9% -8. Mandaluyong (St. Martin De Porres Hospital 12% 8% -Mean 14.4% 11.8%

Malnutrition in the units

Nutritionally at risk patients

Llido L. The impact of computerization of the nutrition support process in the nutrition support program in a tertiary care hospital in the Philippines: report

for the years 2000-2003. Clin Nutr 2006; 25(1):91-101 .

WHAT IS THE PREVALENCE OF MALNUTRITION AMONG SURGICAL

PATIENTS IN YOUR CENTER?

CONCLUSION

Malnutrition

• Is a syndrome• Its presence in surgical patients influences

outcome• Detection and management is a priority in

surgical patients• Is prevalent in the surgical patient population