LECTURE 3 – IMPACT OF NUTRITION CARE IN SURGERY 1 Slide 1 Impact of nutrition care in surgery Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training How does nutrition make a difference in the surgical process? Slide 2 Objectives • To discuss the impact of surgery on body composition, endocrine, and metabolic status • To discuss the use of nutrition in modifying the impact of surgery on the patient The objectives of this presentation are: • To discuss the impact of surgery on body composition, endocrine, and metabolic status • To discuss the use of nutrition in modifying the impact of surgery on the patient
Transcript
LECTURE 3 – IMPACT OF NUTRITION CARE IN SURGERY
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Slide 1
Impact of nutrition care in surgery
Surgical Nutrition Training ModuleLevel 1
Philippine Society of General SurgeonsCommittee on Surgical Training
How does nutrition make a difference in the surgical process?
Slide 2
Objectives
• To discuss the impact of surgery on body composition, endocrine, and metabolic status
• To discuss the use of nutrition in modifying the impact of surgery on the patient
The objectives of this presentation are: • To discuss the impact of surgery on body composition, endocrine, and metabolic status • To discuss the use of nutrition in modifying the impact of surgery on the patient
LECTURE 3 – IMPACT OF NUTRITION CARE IN SURGERY
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Slide 3
Surgery affects body composition and function (response to injury)
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
When surgery is performed the inflammatory process is immediately activated. Metabolic and endocrine response to the inflammatory process occur and depending on the nutritional status and over-all health of the patient, the quality of the resolution of the inflammatory process, wound healing, and recovery will vary. Well nourished patients will have a normal recovery process whereas the malnourished will have complications depending on the severity of malnutrition, adequacy of intake, body composition, pre-operative preparation, and type and quality of management.
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Slide 4
Nutrition management
COMPOSITION1. Carbohydrates2. Lipids
LCT (structural) MCT (energy) Fish Oils (immuno-
modulation)3. Protein
BCAA Glutamine
4. Vitamins/Trace elements5. Antioxidants
1. Sustains cellular metabolism and functions (MACRO & MICRONUTRIENTS)
2. Sustains mucosal cell quality and function (=GLUTAMINE)
3. Mucosal immunity sustained (GLUTAMINE & FISH OILS)
• Requires protocols for access, feeding patterns, delivery• Needs calorie and protein counting practice• Strict fluid balance• MAY BE ENTERAL AND /OR PARENTERAL NUTRITION
Nutrition management means: • Providing all the needed nutrients for the surgery recovery process. These are:
• Carbohydrates, fats, and protein (=macronutrients) • Vitamins and trace elements (=micronutrients) • Pharmaconutrients (=glutamine, fish oils, antioxidants)
• These nutrients will provide the necessary substrates needed when the patient goes to the SIRS or CARS phase of critical care surgical patients
• The basic processes are: • Following guidelines or protocols in clinical nutrition • Calorie counting practice especially on the first 7 post-operative days • Giving early enteral nutrition and supplemental parenteral nutrition
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Slide 5
Surgery causes immunosuppression
It is now realized that surgery induces immunosuppression. This would lead to infection complications in severely malnourished patients. The major mechanism is the resulting arginine deficiency caused by the arginase1 expressing granulocytes stimulated by the inflammation process during surgery. Arginase deficiency results to decreased T-lymphocyte growth and function leading to a major cellular immunosuppression.
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Slide 6
Nutrition management
This condition is counteracted by the supplementation of fish oils that inhibit the activity of arginase 1 and glutamine supplementation which enhances T-cell proliferation. • Banzal V et al. JPEN 2005. • Asprer JM et al. Nutrition 2006. • Morlion B et al. Ann Surg 1998.
Calder Philip, Polyunsaturated fatty acids, inflammation, and immunity : Nutrition, immune functions and health; Euroconferences, Paris; June 9-10, 2005
NFKB
Phospholipase A2 ← INJURY
CELL MEMBRANE – LIPID LAYER
DHADHA
How does the fish oils exert their beneficial effect by counteracting immunosuppression? By immunomodulation. These are the pathways of the different PUFAs what affects them and degree of inflammatory reaction that arises from their activity. Note the lower degree of inflammatory response from EPA, DHA and their effect on NFKB. • Calder Philip, Polyunsaturated fatty acids, inflammation, and immunity: Nutrition, immune
functions and health; Euroconferences, Paris; June 9-10, 2005.
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Slide 8
Fish Oils: impact on liver function
Gura K et al. Safety and Efficacy of a Fish-Oil-Based Fat Emulsion in the Treatment of Parenteral Nutrition -Associated Liver Disease. Pediatrics 2008; 121: e678-68.
The impact of fish oils to modulate the inflammatory process and optimize cell function is shown in this report on liver transplant candidates who developed parenteral nutrition associated liver disease (PNALD). The use of fish oils to supplement the fat requirements resulted to remission of the bile cholestasis and eventual recovery of liver function. • Gura K et al. Safety and Efficacy of a Fish-Oil-Based Fat Emulsion in the Treatment of
For severely malnourished surgical patients the current guidelines (ESPEN and ASPEN) are recommending nutritional build up prior to surgery. Feeding pathways have been developed to achieve this purpose.
This algorithm recommends not just nutritional build up for severely malnourished patients for 5 to 7 days, it also re commends immunonutrition for these major surgeries: esophageal resection, gastrectomy, and pancreaticoduodenectomy. The issue of early feeding and the placement of jejunostomy is also included in the algorithm.
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Slide 11
Feeding algorithmCan the GIT be used?
Yes No
Parenteral nutritionOral
< 75% intake
Tube feed
Short term Long term
Peripheral PN Central PN
More than 3-4 weeks
No Yes
NGT
Nasoduodenal
or nasojejunal
Gastrostomy
Jejunostomy
“inadequate intake”
“Inability to use the GIT”
A.S.P.E.N. Board of Directors. Guidelines
for the use of parenteral and enteral
nutrition in adult and pediatric patients,
III: nutritional assessment – adults. J
Parenter Enteral Nutr 2002; 26 (1 suppl):
9SA-12SA.
The standard feeding algorithm published in 1994 by ASPEN (American Society of Parenteral and Enteral Nutrition) is still valid up to today. Here the gut is the primary route for feeding and parenteral nutrition is supplemented when the gut cannot be used or when the oral/enteral intake can only manage less than 70% of the patient’s required/computed intake. NGT’s are only sustained for two to three weeks after which a gastrostomy (percutaneous or surgical) is recommended. • A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in
Achieving adequate intake in the postoperative period was able to show improvement in mortality and morbidity outcomes in surgical patients. In this study no significant difference is seen in the mortality rates of the patients whether high or low risk. • Del Rosario D. et al. The effect of adequate energy and protein intake on morbidity and
mortality in surgical patients nutritionally assessed as high or low risk. Nutrition (under review).
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Slide 13
Nutrition team and intake
Llido et al. Nutrition team supervision improves intake of critical care
patients in a private tertiary care hospital in the Philippines: report from
years 2000 to 2011 (for submission)
Another factor that helps sustain adequate intake in surgical patients especially the high risk ones is the role of the nutrition team. In this report the nutrition team was able to achieve adequate intake in the critical care patients in the first 72 hours and sustain this result within the first week of nutrition management. • Llido et al. Nutrition team supervision improves intake of critical care patients in a private
tertiary care hospital in the Philippines: report from years 2000 to 2011 (for submission)
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Slide 14
Surgery induces insulin resistance
Insulin signaling blocked
↓ GLUT4 activity↑ blood glucose
Witasp A et al. Expression of inflammatory and insulin signaling genes in adipose tissue in response to elective surgery. J Clin Endocrinol Metab 2010; 95(7): 3460–9.
[IRS1=insulin receptor substrate1; SOCS3, suppressor of cytokine signaling 3]
Insulin resistance during surgery is also observed. This study showed the mechanism behind the surgery induced insulin resistance. Witasp A et al. Expression of inflammatory and insulin signaling genes in adipose tissue in response to elective surgery. J Clin Endocrinol Metab 2010; 95(7): 3460–9.
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Fasting (within 2-3 days acceptable)
Awad S et al. The effects of fasting and refeeding with a ‘metabolic preconditioning’ drink on substrate reserves and mononuclear cell
Early oral supplementation in surgical patients where reducing the period of non-feeding improves liver glycogen reserves is one of the first procedures of the practice of early recovery after surgery (ERAS) that reduces the effect of surgery induced insulin resistance. Awad S et al. The effects of fasting and refeeding with a ‘metabolic preconditioning’ drink on substrate reserves and mononuclear cell mitochondrial function. Clin Nutr 2010; 29: 538–44
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Slide 16
Cancer Cachexia
Cancer cachexia is another challenge for the surgeon. This pathophysiology mechanism shows the two major factors which cause continuing weight loss inspite of increased nutrient delivery in cancer cachexia patients. The tumor produces factors that increases fat and protein loss (LMF and PIF). The host response to the tumor is the production of cytokines that induce loss of appetite and increased satiety and add to this a rise in energy expenditure by the host (=increased inflammation status). These two pronged insults results to the status of cancer cachexia. • Bozzetti F et al. ESPEN guidelines in parenteral nutrition: non-surgical oncology. Clin Nutr
New drugsSurgeryEN/PNPharmaconutritionAggressive mgtSupportive/functionExercise
TODAY
The new approach in nutrition in cancer cachexia patients consists of the following: • High dose nutrition – enteral and/or parenteral nutrition (this focuses on the normal cells) • Surgery to remove the tumor or tumor bulk (to reduce the weight losing tumor factors) • Drugs to counteract the weight loss and the effect of cachexia factors • Pharmaconutrition that also counteracts the effect of the cachexia factors • Exercise to stimulate protein synthesis
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This is the effect of enteral nutrition (oral supplements and tube feed) on lean body mass of cancer cachexia patients (= reversal of progressive loss of lean body mass). • Fearon et al. Effect of a protein and energy dense n-3-fatty acid enriched oral supplement on
loss of weight and lean tissue in cancer cachexia: a randomized double blind trial. Gut 2003; 52: 1479-86.
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Slide 19
Fish oils and cancer
This report shows the optimal dose of fish oils for cancer cachexia management. It is in the range of 0.1 to 0.2 gm/kg ideal body weight or 4 to 16 gm/day.
Slide 20
The impact of omega-3-fatty acids on the inflammatory response to cancer surgery with improvement of cell function shows the capability of pharmaconutrition to influence the clinical course of cancer cachexia. In this report liver function is better with fish oil supplementation rather than with pure omega-6-fatty acid infusion. • Heller et al. Int J Cancer 2004.
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Slide 21
Antioxidants
Nathens AB, Neff MJ, Jurkovich GJ, Klotz P, Farver K, Ruzinski JT, Radella F, Garcia I, Maier RV. Randomized, prospective trial of antioxidant supplementation in critically ill surgical
patients. Ann Surg. 2002; 236(6): 814-22.
1. α-tocopherol 1,000 IU (20 mL) q 8h per naso- or orogastric tube
2. ascorbic acid 1,000 mg given IV in 100 mL D5W q 8h for the shorter of the duration of admission to the ICU or 28 days.
The supplementation of antioxidants also improves surgical outcome through improvement of the increased antioxidant functions of the mitochondria and cytoplasmic membranes thus maintaining the optimum level of free radicals that sustain new protein synthesis. • Nathens AB et al. Ann Surg 2002.
– Antioxidants (vitamin C, Vitamin E, zinc, copper, selenium)
• Strict fluid management– Saline and balanced salt solutions
• Early enteral feeding
To summarize: improving surgical outcomes through nutrition is achieved through: • Achieving adequate intake with macronutrients, micronutrients, and pharmaconutrients • Strict fluid management with use of appropriate solutions • Early enteral feeding Slide 23
Nutrition and fluid management go together
INJURY = SURGERY
↑albumin escapefrom intravascular
space
Inflammatory mediators ↑vasodilation effect of anesthetic agents
↑K+ release from cells
↓K+ and ↑ Naintracellular
Sick cell syndromeof critical illness
↑hypotonic fluidinfusion
90% cause of hyponatremia in
surgery
Fluid Retention + Electrolyte Imbalance
Lobo D, Macafee DL, Allison S. How perioperative fluid balance influences postoperative outcomes. Best Pract Res Clin Anaesthesiology 2006; 20(3): 439–55.
Nutrition and fluid management go together. A poorly managed fluid resuscitation would lead to cells that are not optimized for nutrition management and function – these are either swollen or shrunk showing symptoms of the “sick cell syndrome”. An added problem will be interstitial edema and poor microcirculation environment.
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Slide 24
Problems with saline
A lot of surgical patients receive saline. This data shows that saline compared to plasma is not physiologic and should not be used in pre and post-operative states. The ideal solutions are the balanced electrolyte solutions.
Slide 25
Appropriate fluid management
These data compares plasma with the resuscitating fluids: saline and balanced electrolyte solutions (Hartmann’s and Plasmalyte). It is the balanced electrolyte solutions that come closest to the plasma composition.
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Ileus and dehiscenceSalt and water overload
↑intra-abdominal pressure
↓mesentery blood flow
Intestinal edema
↓tissue OH-proline
STAT3 activation↓myosin phosphorylation
ILEUS
Impaired wound healing
DEHISCENCE
Intramucosalacidosis
↓muscle contractility
Chowdhury and Lobo. Curr Opinion Clin Nutr Metab 2011
A simple salt and water overload is enough to induce ileus and dehiscence in the post-operative period causing unnecessary complications like prolonged gut recovery or anastomotic leaks which progress to more serious outcomes when not aggressively managed. Chowdhury and Lobo. Curr Opinion Clin Nutr Metab 2011
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Slide 27
Effect of positive fluid balance
Brandstrup B et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-
blinded multicenter trial. Annals of Surgery 2003; 238: 641–648.
This study shows the value of restricted fluid management versus the standard fluid management in respect to the presence of major and minor complications. The body needs fluids that are close to the plasma composition and it cannot handle huge amounts of extra fluids. • Brandstrup B et al. Effects of intravenous fluid restriction on postoperative complications:
comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Annals of Surgery 2003; 238: 641–648.
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SURGICAL CRITICAL CARE
Nutrition in surgical critical care situations plays a crucial role in the recovery, morbidity, and mortality of the patient.
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Slide 29
Inflammation phases of injury
Moore FA. Presidential address: imagination trumps knowledge. Am J Surg 2010: 200: 671-7.
24 hours
↑inflammation→organ dysfunction
↑immunosuppression→infection→organ dysfunction
When a patient goes into a critical care state like the development of sepsis, the inflammatory environment runs two major courses: there is a severe pro-inflammatory phase which is reflective of the second hit phenomenon of the reperfusion process on the patient and there is a concomittant anti-inflammatory phase which has a slower pace of development. SIRS (severe inflammatory response syndrome) occurs during the first week and manifested by single or multi-organ dysfunction which when uncontrolled goes to fulminant organ failure and death. CARS (counter anti-inflammatory response sydrome) becomes manifest on the second week as a series of infections and when not managed well the patient goes into a slow indolent death.
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Slide 30
Inflammation and organ failure in the ICU
SIRSTNF , IL-1 ,
IL-6, IL-12,
IFN , IL-3
IL-10, IL-4, IL-1ra,
Monocyte HLA-DR
suppression
CARS
days
Insult(trauma, sepsis)
Infl
amm
ato
ry b
alan
ce
Tissue inflammation, Early organ failure and death
weeks
Immunosuppression
2nd Infections Delayed MOF and death
Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle
SIRS and CARS can be managed by the following strategies: • Early enteral nutrition which reduces the capacity of the gut to develop the “first hit” status
through maintenance of the mucosal and immune protective status • Fish oils modulate the pro-inflammatory phase by lessening the degree or intensity of the
inflammatory response. • Giving glutamine which helps in supplying the needed nutrient and energy requirements for
an increased metabolic requirement. This need is also seen in the immunosuppression phase. This time the fish oil infusion helps lessen the immune suppression phase while glutamine again improves the immune capability phase
• Finally a good fluid management with avoidance of fluid overload Slide 31
CONCLUSION
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In conclusion:
Slide 32
Nutrition care in surgery
• improves outcomes in surgery by addressing pathophysiologic changes induced by injury on the cellular and organ-system levels.
• This is achieved through:
– Appropriate fluid management
– Early enteral nutrition
– Adequate nutrient intake
– Pharmaconutrients
• Nutrition care in surgery improves outcomes by addressing the pathophysiologic changes induced by injury and utilizing basic and new concepts in immunology and pharmacoutrition to improve the recovery process.
• This is achieved through: • Appropriate fluid management • Early enteral nutrition • Adequate nutrient intake • Pharmaconutrients
