Malnutrition in surgical patients Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training
Objectives • To define malnutrition and discuss its impact on the surgical patient • To identify malnutrition in hospitalized surgical patients
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.
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.
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 MALNUTRITION • UNDERNUTRITION • chronic starvation without inflammation • chronic disease with inflammation • acute injury/disease with inflammation OBESITY BMI > 30 Macronutrient deficiency Micronutrient deficiency Metabolic Syndrome 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.
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 No Malnutrition Malnutrition NORMAL POOR ± COMPLICATIONS
↑Energy needs = ↑ free radicals Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003.
Role of nutrition in surgery WBC, RBC, FIBROBLASTS CARBO All WBC, RBC, FACTORS Bone Marrow LIPIDS B-cells Alanine MALT, GALT MUSCLE MALT GALT T-cells Glutamine Platelets • Organs Affected • epithelium • connective tissue • angiogenesis • complement system Body composition INFLAMMATION ANTIOXIDANTS WOUND HEALING INFECTION CONTROL NEED TO KEEP ALL NUTRIENTS IN STEADY SUPPLY AS NEEDED
Nutrition and wound healing Nutritional status Surgery Normal Severe malnutrition Wound healing Good Prolonged Complications • Body reserves: • skeletal muscle – alanine and glutamine • fat reserves – energy (long term)
Malnutrition in surgical patients 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. JPEN 1987 Detsky et al. JAMA 1994
Malnutrition and costs Malnutrition 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
Malnutrition detection tools Nutrition screening Nutritional assessment
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?
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