Nutritional Issues. Perioperative Nutritional Interventions. A challenging case you are likely familiar with

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1 Perioperative Nutritional Interventions Lygia Stewart MD, John Maa MD, and Annette Romani RD UCSF Post-Graduate Course Nutritional Issues Who needs nutritional supplementation? Oral, feeding tube, or TPN? Pre-op nutrition Post-op nutrition Immunonutrition Arginine, RNA, fish oil, vitamins, etc. A challenging case you are likely familiar with 60 year old man S/P radical prostatectomy, neobladder, and radiation resulting in an enterocutaneous fistula S/P two attempts at takedown, now on TPN for over a year. The plan was to reattempt takedown once his albumin reached 3, but despite anabolic steroids, distal feeding, changes in TPN formulation and supplements, unable to raise the serum albumin above 2.6, prealb 14, or lower CRP below 30. 1

2 Nutritional Status Difficult to quantitate Guidelines 10% Weight loss 15% decreased immune function Albumin Low albumin correlates with increased morbidity Inflammatory disorders also decrease serum albumin Prealbumin better predictor Muscle function, transferrin, skinfold thickness, Crheight index, DCH, SAG, total lymphocyte count Serum Albumin and Complications Esophagus Stomach Pancreas Colon Kudsk KA et al, JPEN 2003; 27: 1-9 Assessing Energy Requirements Kcal /kg (based on clinical judgment) Harris-Benedict Equation Mifflin St-Jeor Equation Ireton-Jones Equation Penn State Equation Indirect Calorimetry Mifflin- St. Jeor Equation Use when BMI > 30 Calculates REE Men: 9.99 x actual wt.(kg) x height (cm) x age + 5 Women: 9.99 x actual wt(kg) x height(cm) x age -161 Multiply REE by stress factors Penn State Equation Provides most accurate assessment of metabolic rate in critically ill patients Least reliable in elderly obese patients (over 60, BMI > 30) The largest & most complete validation study of metabolic rate in critically ill patients yet published 2

3 Situations Where Measurement of Energy Expenditure Unreliable FiO 2 >60% Chest tubes with air leak Tracheotomy tubes with incompetent or non-existent tracheal cuff Patients receiving inconsistent inspired oxygen (variable levels of inspired O 2 ) During hemodialysis Immunonutrition Formula enriched Arginine promotes wound healing, enhances T-cell function, and improves bacterial clearance. ω-3 fatty acids (fish oil) anti-inflammatory, vasodilatory, immunomodulatory modulate the synthesis of various eicosanoids. Dietary ribonucleic acid (RNA) Maintenance of normal immune functions T-cell mediated immune responses Glutamine - Promotes protein synthesis in gut mucosa and precursor for glutathione Immunonutrition vs Standard Enteral Formulas 22 RCT s 2419 patients Decreased infectious complications P < Greater effect in surgical patients Mortality not significantly different Heyland DK, et al, JAMA. 2001; 286:

4 Pre-OP TPN Pooled Data 13 studies 1250 pts malnourished TPN 7-10 days Pooled data favors pre-op TPN 10% risk reduction Klein S et al, NIH, Amer Society Parenteral Enteral Nutrition, Amer Society Clinical Nutrition. JPEN 1997; 21: Post-OP TPN Pooled Data 8 studies 754 pts Pooled data Post-op TPN is worse 10% increase in morbidity Klein S et al, NIH, Amer Society Parenteral Enteral Nutrition, Amer Society Clinical Nutrition. JPEN 1997; 21: Enteral Nutrition 4

5 Enteral / Standard Nutrition vs TPN Risk of Infection: enteral or standard nutrition vs TPN Braunschweig CL, et al, Am J Clin Nutr. 2001; 74: RCT s 1828 patients Less Morbidity with Enteral or Standard compared to TPN TPN Hyperglycemia More infections More costly Mortality not different Preoperative Enteral Nutrition vs None Prospective Randomized Studies Percent Shukla Flynn Shukla Foschi Infections Mortality Pre-op Nutrion Control All studies done In the late 80 s Post-op Enteral Nutrition vs NPO Meta-Analysis 11 studies 837 patients Enteral vs NPO Elective GI Surg Most (8/11) studies % colorectal Enteral better No risk anastomotic dehiscence with feeding Lewis SJ, et al, BMJ 2001; 323: 1-5 5

6 Conclusions Need to develop dietary strategies to optimize patient readiness for the surgical procedure What is easy? Pre-op enteral nutrition Pre-op immunonutrition Early diet post-op whenever possible 6