Review and Updates in Surgical Nutri5on

Transcription

1 31th PSGS Post Graduate Course 70 th Annual Philippine College of Surgeons Clinical Congress Review and Updates in Surgical Nutri5on PART 2 Luisito O. Llido, MD, FPCS, DPBCN, FPSGS Sub- Commi9ee on Surgical Nutri@on Commi9ee on Research PSGS

2 Aim for adequate intake = 75% of computed requirements

3 The Philippine hospital skeleton

4 care elderly are not receiving adequate calories even on the 3 rd day of admission Umali et al. Recommended and actual calorie intakes of intensive care unit pa@ents in a ter@ary care hospital in the Philippines. Nutri@on 2006.

5 care elderly are receiving very low protein even on the 3 rd day of admission 21% 22% 24%

6 Calorie, protein, fluid balance form

7 Nutrient monitor form INTAKE IV infusion medica5ons oral feeding EN PN albumin blood/others OUTPUT urine insensible loss drains stool Fluid balance = 0 Nutrient balance = posi5ve (75%)

8 Fluid and nutrient balance

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10 intake and morbidity

11 intake and risk

12 Adequate intake, ICU = é discharged alive 71% N=80 29% 74% 26% Manuales G et al. Impact of nutri@on team on intake and mortality outcome of ICU pa@ents, St. Luke s Medical Center Available at: : h9p://

13 Adequate intake, surgery = ê mortality St., Luke s Medical Center, General Surgery (From admission to discharge) Del Rosario et al. Available at: h9p://

14 Team = Adequate Intake (n=80) Manuales et al. Available at: h9p://

15 Team Diagnosis Management Overall plan Screening Enteral Parenteral Monitoring Enteral Monitoring Parenteral Monitoring

16 team: clinical pathway All admi9ed are screened by the nurses All at risk are assessed by the die55ans All high risk are given care plans by the clinical physicians Monitoring (nurses, die55ans, pharmacists, physicians) care plan / Discharge

17 Get the pa5ent out of bed as early as possible!

18 Effect of on Lean Body Mass

19 Factors favoring early Pre- op carbohydrate loading é Muscle glycogen ê Proteolysis é Muscle Epidural anesthesia ê Pain ê Muscle weakness ê / stress Early feeding é Gut é Muscle Adequate nutrients

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21 Cri5cal care nutri5on Pharmaconutri5on

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23 Fully gut will provide general immune competence (=best source: enteral feed)

24 ANTI PRO and organ failure in the ICU Inflammatory balance Insult (trauma, sepsis) SIRS TNFα, IL-1β, IL-6, IL-12, IFNγ, IL-3 days IL-10, IL-4, IL-1ra, Monocyte HLA-DR suppression CARS Tissue Early organ failure and death Pharmaconutri5on Early feeding weeks Immunosuppression 1. EPA/DHA (fish oils) 2. Glutamine 3. An5oxidants 4. Arginine 5. Vitamins 6. Trace elements 2 nd Infec@ons Delayed MOF and death Griffiths, R. Specialized nutri7on support in the cri7cally ill: For whom and when? Clinical Nutri7on: Early Interven7on; Nestle Nutri7on Workshop Series

25 HMB, glutamine, arginine HMB (β- hydroxy- β- methyl- butyric acid) reduces Improves protein synthesis Improves capacity Glutamine Improves WBC oxidant precursor Arginine Improves Enhances T- cell Fish Oil (EPA/DHA) Protein synthesis Metabolism enhancement improvement Pressure ulcer healing Organ improvement Immune

26 IMD diet) N=146 EPA=500mg- 1gm/day GLA=500mg/day Gadek et al. Effect of enteral feeding with EPA, GLA, and in with ARDS. Crit Care Med 1999; 27:

27 EPA/DHA = 1-2gm/day

28 Glutamine Saline group Glutamine group Animal study, sepsis model (cecal * P < 0.05 GLN = gm/kg/day Singleton KD and Wischmeyer P. Glutamine A9enuates Inflamma@on and NF- kb Ac@va@on Via Cullin- 1 Deneddyla@on. Biochem Biophys Res Commun August 29; 373(3):

29 Glutamine Legend: HV = acid aspira@on, high volume HVG = acid aspira@on, high volume + GLN LV = acid aspira@on, low volume LVG = acid aspira@on, low volume + GLN * P < 0.05 GLN = gm/kg/day * animal study Lai CC, Liu WL, Chen CM. Glutamine A9enuates Acute Lung Injury Caused by Acid Aspira@on. Nutrients 2014, 6, ;

30 Colon, fiber, immune defense

31 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 D 5 W q 8h for the shorter of the dura@on 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, prospec@ve trial of an@oxidant supplementa@on in cri@cally ill surgical pa@ents. Ann Surg. 2002; 236(6):

32 Lean body mass enhancers Adequate protein BCAA Adequate energy: Carbohydrate Lipid (50% SFA, MCT/ 50% PUFA) Pulse Exercise Fish oils Glutamine HMB Arginine

33 GUT RESECTION/BYPASS

34 Gut Near to Total Gastrectomy anastomosis Jejunostomy Ileostomy Small bowel Enterocutaneous fistula

35 of micronutrients

36 Effects of short bowel Surgical of small bowel outcome: 50%- 60% jejunal well tolerated >30% ileal poorly tolerated < 60% small bowel les severe End jejunostomy severe fluid loss Magnesium, calcium, and zinc deficiency common * Jeejeebhoy K. Micronutrients. 4 th Asia Pacific Parenteral Nutri@on Workshop June 2009; Kuala Lumpur, Malaysia

37 Short bowel failure) Outcome and electrolyte acute renal failure Poor intake of protein and energy Poor quality of life morbidity and mortality

38 Management phase: stabilize the vital and perfusion to the bowel Parenteral (complete) Stable phase: of parenteral and enteral Match fluid and electrolyte losses with adequate replacements Adequate intake Use of pharmaconutrients

39 Review checklist ERAS protocol Measures to achieve adequate intake care issues Short bowel issues

40 THANK YOU