Nutritional Aspects of ERP

Pete Turner

Specialist Nutritional Support Dietitian

Programme• ERP philosophy

• NBM

• Preoperative Carbohydrate Loading

• Malnutrition and surgery

• Screening - MUST

• Treatment plan

Enhanced Recovery Programme (ERP)• Multifactorial approach to optimise recovery from

surgery and reduce length of stay

• Optimal anaesthesia and analgesia

• Appropriate fluid management

• Early postoperative mobilisation

• Nutritional Aspects

• Good evidence in colorectal surgery – growing evidence in other surgery

Nutritional Aspects of ERP• Avoidance of nil by mouth (NBM)

• Appropriate fluids

• Preoperative carbohydrate loading

• Early postoperative nutrition

• ERP should include…

• Screening for risk of malnutrition

• Preoperative nutritional support for those at risk

Avoiding Preoperative NBM

• ESPEN – Grade A evidence (Clinical Nutrition(25) 2006)

• Avoids dehydration

• Require less iv fluids

• Avoid sodium overload

• Quicker recovery

• GIFTASUP

• ESA 2011

Sodium• Basal Sodium Requirements?

• 1mmol/kg/day

• How much Na in 1000mls saline?

• 150mmol

• How much Na in 1000mls Hartmann’s?

• 131mmol

• Oedema

• GIFTASUP (www.bapen.org.uk)

Sodium• Excess sodium

• Oedema

• Bowel oedema

• Delayed bowel function • Ileus (Lobo et al 2002, Lancet 25;359, 1812-8)

• Guidelines on Intravenous Fluid Therapy in Adult Surgical Patients – GIFTASUP (www.bapen.org.uk)

Preoperative Carbohydrate (CHO)

• Beneficial to anyone undergoing major surgery

• Traditional preoperative fast harmful

• 12 – 16 hours NBM

• Metabolism changes to “starved” state

Starved State

• 12 hrs – 20 days

• Increased Glucagon

• Increased Cortisol

• Catabolism

• Gluconeogenesis

• Insulin resistance

Surgery

• Inflammatory response

• Increased cortisol, cytokines

• Catabolism, gluconeogenesis

• Insulin resistance

• Hyperglycaemia

• Exacerbated by starvation

CHO loading• 50g glucose polymer

• 2 servings night before surgery

• 1 Serving 2 hours before surgery

• Block metabolic changes to starvation

• Safe (ESPEN 2006 Grade A)

• PreLoad – Vitaflo

• PreOp - Nutricia

CHO loading• Decreased catabolism

• Decreased hyperglycaemia

• Preserved muscle mass

• Improved grip strength

• Reduced LOS

• Reduced Anxiety

LOS Study meta-analysis

• Ljungqvist et al 1998 Clin Nutr 17, Suppl1:3.

• Meta-analysis of 3 RCTs

• Preoperative CHO vs overnight fast

• 20% reduction in LOS

• Preop CHO beneficial to all patients undergoing major surgery (ESPEN Grade B)

Not Just Colorectal

• Urology

• Pancreatic

• Hip replacement

• Knee replacement

All elective surgery

Contraindications?

• Diabetes?• Safe in type II in hospital (Gustafsson et al 2008, Acta

Anaesthesiol Scand 52(7), 946-51)

• Alcoholics – Wernicke Korsakoff syndrome?

• Severely malnourished

• Refeeding syndrome?

• Emergency surgery?

Post Operative - ACRU• Ensure Plus

• Nutritionally balanced

• Used 4 hrs post op on ACRU

• Well tolerated

• Stop day 4 in well nourished

• Continue in malnourished

Balanced oral nutritional supplements

• Fortisip

• Fresubin

• Ensure Plus Milkshake

• Clinutren

• NICE CG32 Grade A

Early Post Operative Nutrition

• NICE CG32

• Promote gut function

• Attenuate stress response

• Prevent bacterial translocation

• Immune function - GALT

• Reduced anastamotic dehiscence

• NICE – Grade A evidence in malnutrition

Malnutrition

• 1 in 5 malnourished (Edington 2000)

• Increased LOS

• More infections

• More antibiotics

• BAPEN NSW 2007 – RLBUHT

Cost of Malnutrition

• Annual cost of obesity to NHS?

• £4.2 billion (DOH 2011)

• Annual cost of malnutrition to NHS?

• £13 billion (BAPEN 2009)

Malnutrition and Surgery• NICE 2006 CG 32

• 3 times as many post operative complications

• 4 times greater risk of death at surgery

• Increased infection

• Poor wound healing

• Depression

• Hip fracture – BMI <18.9 increased mortality

Enhanced Recovery & Malnutrition

• Does ER include preoperative treatment of malnutrition?

• ESPEN 2006 – Grade A

• BAPEN Council

• Mike Stroud – NICE

• Professor Marinos Elia – Govt policy

• www.bapen.org.uk – Malnutrition Matters

What can we do?• Screen at Preop & OPD – NICE CG 32

• Malnutrition Universal Screening Tool (MUST)

• OSCAR

• Management guidelines

• Dietetic referral

• Preoperative sip feeds

• Southampton – Mike Stroud

MUST• Malnutrition Universal Screening Tool

• BAPEN

• Identifies Malnourished

• At risk of Malnutrition

• Validated

• NICE CG 32

• NHS litigation agency

MUST Management Plan• MUST Score

• 0 – Low risk. Routine Care

• 1 – Medium risk. High protein diet sheet

• 2 – High Risk.

• High protein diet sheet

• Dietitian

• Oral Nutritional Supplements

How long?

• ESPEN 10 -14 days (Grade A)

• NICE CG 32

• “Most trials showing benefit from short-term

nutrition support, do so despite ‘too little

nutrition’ being given for ‘too short a time’ for

the benefit to accrue from maintaining or

improving body energy and protein stores”

Artificial Nutrition

Portable Pumps

TPN

Conclusions• Preoperative starvation is harmful

• Preoperative CHO loading is beneficial

• Most major surgery

• Safe in elective surgery

Conclusions• High incidence of malnutrition

• Greatly increases risk of surgery

• Morbidity and mortality

• Preoperative treatment effective

• ESPEN, NICE CG32

• European & UK experts – include in ER

• Evidence – peter.turner@rlbuht.nhs.uk