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Impact of nutrition care in surgery

Impact of nutrition care in surgery. Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training. Objectives. To discuss the impact of surgery on body composition, endocrine, and metabolic status

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Impact of nutrition care in surgery

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  1. Impact of nutrition care in surgery Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training

  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

  3. Surgery affects body composition and function (response to 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

  4. Nutrition management • COMPOSITION • Carbohydrates • Lipids • LCT (structural) • MCT (energy) • Fish Oils (immuno-modulation) • Protein • BCAA • Glutamine • Vitamins/Trace elements • Antioxidants • Sustains cellular metabolism and functions (MACRO & MICRONUTRIENTS) • Sustains mucosal cell quality and function (=GLUTAMINE) • Mucosal immunity sustained (GLUTAMINE & FISH OILS) • Reverses CARS (FISH OILS, GLUTAMINE, ANTIOXIDANTS) • Requires protocols for access, feeding patterns, delivery • Needs calorie and protein counting practice • Strict fluid balance • MAY BE ENTERAL AND /OR PARENTERAL NUTRITION

  5. Surgery causes immunosuppression

  6. Nutrition management

  7. Eicosanoids

  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.

  9. Severely malnourished patiets • Nutritional build-up is required • Current ESPEN and ASPEN guidelines • Feeding pathways

  10. PRE-OPERATIVE PHASE • Scheduled • esophageal resection • gastrectomy • pancreaticoduodenectomy malnutrition no slight, moderate severe oral immunonutrition for 6-7 days Enteral nutrition for 10-14 days SURGERY Early oral feeding within 7 days POST-OP EARLY DAY 1 - 14 Enteral access (NCJ) no yes within 4 days enteral nutrition immunonutrition for 6-7 days Oral intake of energy requirements yes no yes no “Fast Track” Parenteral hypocaloric combined enteral / parenteral Adequate calorie intake within 14 days Oral intake of energy requirements LATE DAY 14 yes no supplemental enteral diet yes no

  11. Feeding algorithm Can the GIT be used? “Inability to use the GIT” Yes No “inadequate intake” Parenteral nutrition Oral Tube feed < 75% intake Short term Long term More than 3-4 weeks Central PN Peripheral PN Yes No NGT 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. Gastrostomy Nasoduodenal or nasojejunal Jejunostomy

  12. Outcome of surgical patients Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, 2008.

  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)

  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]

  15. 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 mitochondrial function. Clin Nutr 2010; 29: 538–44

  16. Cancer Cachexia

  17. New paradigm in nutrition oncology High dose nutrition Standard content High dose nutrition Standard content New drugs Surgery EN/PN Pharmaconutrition Aggressive mgt Supportive/function Exercise Cancer patient Weight loss Cancer patient Weight loss Hardly any weight change Weight change Life span Better function BEFORE TODAY

  18. Fish oils and cancer

  19. Antioxidants α-tocopherol 1,000 IU (20 mL) q 8h per naso- or orogastric tube 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. 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.

  20. Management: • Goal: adequate intake • Protein, carbohydrates, fat • Vitamins and trace elements • Fish oils (EPA/DHA) • Glutamine • Antioxidants (vitamin C, Vitamin E, zinc, copper, selenium) • Strict fluid management • Saline and balanced salt solutions • Early enteral feeding

  21. Nutrition and fluid management go together INJURY = SURGERY Inflammatory mediators ↑vasodilation effect of anesthetic agents ↑hypotonic fluid infusion ↑K+ release from cells ↑albumin escape from intravascular space 90% cause of hyponatremia in surgery ↓K+ and ↑ Na intracellular Sick cell syndrome of critical illness 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.

  22. Problems with saline

  23. Appropriate fluid management

  24. Ileus and dehiscence Salt and water overload ↑intra-abdominal pressure Intestinal edema ↓mesentery blood flow ↓tissue OH-proline STAT3 activation ↓myosin phosphorylation Intramucosal acidosis Impaired wound healing ↓muscle contractility DEHISCENCE ILEUS Chowdhury and Lobo. Curr Opinion Clin Nutr Metab 2011

  25. 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.

  26. Surgical critical care

  27. Inflammation phases of injury ↑inflammation→organ dysfunction ↑immunosuppression→infection→organ dysfunction 24 hours Moore FA. Presidential address: imagination trumps knowledge. Am J Surg 2010: 200: 671-7.

  28. Tissue inflammation, Early organ failure and death SIRS TNF, IL-1, IL-6, IL-12, IFN, IL-3 Pharmaconutrition PRO Early feeding days weeks Inflammatory balance ANTI IL-10, IL-4, IL-1ra, Monocyte HLA-DR suppression Immunosuppression Delayed MOF and death 2nd Infections CARS Insult (trauma, sepsis) Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle Nutrition Workshop Series Inflammation and organ failure in the ICU EPA/DHA (fish oils) Glutamine Antioxidants Arginine Vitamins Trace elements

  29. conclusion

  30. 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

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