ESPEN Congress Vienna Nutrition after discharge from hospital: The surgeon s responsability. O. Ljungqvist (Sweden)

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1 ESPEN Congress Vienna 2009 Nutrition after discharge from hospital: The surgeon s responsability O. Ljungqvist (Sweden)

2 Nutrition after discharge from hospital: The surgeon s responsability Olle Ljungqvist Professor of Surgery Karolinska Institutet Stockholm, Sweden ESPEN 2009 Vienna

3 Critical illness Trauma/Infection Acute Stress Response Iatrogenic Factors Immunological Response Neuroendocrine Response Metabolic Response

4 Recovery After Surgery What are we trying to achieve? Patient mobile (back to preop level) GI function back to normal Able to eat normally Bowel movements No pain on oral analgesics Olle Ljungqvist 21 september

5 Recovery After Surgery Starts before surgery! Prepare your unit to be able to Prepare the patient Mentally Physically Olle Ljungqvist 21 september

6 Role of post-op oral nutritional Supplements in malnourished patients N=109 patients randomised N=54 Control N=55 Treatment (600kcal, 24gP in 400mls) N=49 Completed N=52 Completed Beattie et al 2000, Gut 46, 813-8

7 Change in body weight 0 Baseline Body weight change (%) Intervention Oral Supplement Control -12 Inclusion postop Admission Time of assessment (weeks) Beattie et al 2000, Gut 46, 813-8

8 Enhanced Recovery After Surgery Audit compliance and outcome Patients journey C l i n i c Preop Surgery H D U Ward Home Anesthesia Recovery Audit compliance & outcomes Olle Ljungqvist 21 september

9 Enhanced Recovery After Surgery Study Group N: Univ Tromsö / A Revhaug, K Lassen SCO: Univ Edinburgh/ K Fearon UK: Univ Nottingham/ D Lobo UK: St Marks/ R Kennedy NL: Maastricht/ M vmeyenfeldt, C dejong DE: Charité/ W Schwenk, C Spies NZ: North Shore Auckland/ M Soop SE: Ersta/KI/ J Nygren, J Hausel, O Ljungqvist Olle Ljungqvist 21 september

10 Peri-op fluid management Epidural Anaesthesia Remifentanyl Pre-op councelling DVT prophylaxis No - premed No bowel prep Early mobilisation ERAS CHO - loading/ no fasting Perioperative Nutrition Incisions Bairhugger Oral analgesics/ NSAID s Prevention of ileus/ prokinetics No NG tubes Early removal of catheters/drains Olle Ljungqvist 21 september

11 Peri-op fluid management Epidural Anaesthesia Remifentanyl Pre-op councelling DVT prophylaxis No - premed No bowel prep Early mobilisation ERAS CHO - loading/ no fasting Perioperative Nutrition Incisions Bairhugger Oral analgesics/ NSAID s Prevention of ileus/ prokinetics No NG tubes Early removal of catheters/drains Olle Ljungqvist 21 september

12 What are the issues? fluids & nutrition Fluids Fluid imbalance pre per post op Nutrition & Metabolism Inadequate nutrition Metabolic derangements Poor pain control Olle Ljungqvist 21 september

13 Making the gut work after surgery Fluid balance Avoid fluid accumulation in the gut Pain control Medications to support gut function (& metabolism) Olle Ljungqvist 21 september

14 Overloading with fluids and salt reduces GI motility The problem with fluids & nutrition Body weight Gastric emptying Passage of Gas: 2 days faster; Stools: 3 days faster Olle Ljungqvist 21 september Lobo D, Lancet 2002: 359;

15 Fluids New Meta analysis Any restriction Morbidity 0.44 (0.22, 0.77) p= Perioperative restriction Morbidity 0.35 (0.18, 0.70) p= Intraoperative restriction Morbidity 0.46 (0.21, 0,99) p= 0.05 Goal directed fluid vs cardiovascular Morbidity 0.43 (0.26, 0.71) p= 0.01 No difference in mortality in any analysis Rahbari NN, BJS 2009: 96: 331

16 What are the issues? fluids & nutrition Fluids Fluid imbalance pre per post op Nutrition & Metabolism Inadequate nutrition Metabolic derangements Poor pain control Olle Ljungqvist 21 september

17 Back to eating food Two main problems Gut is not working Fluids Drains, tubes Pain Catabolism blocks use of nutrients Olle Ljungqvist 21 september

18 Effects of Bowel preparation on body weight & fluids Bowel prep: Bisacodyl and sodium phosphate Body weight kg Osmolality 297 -> 300 mosm/kg Fluid intake to cover losses: L Holte K, Dis Colon Rectum 2004; 47, Olle Ljungqvist 21 september

19 Bowel preparation increases the risk of anastomotic leakage N = 1454, OR 1.75 ( ), p = Slim K et al BJS 2004; 91, Olle Ljungqvist 21 september

20 Epidural analgesia vs iv opiates EDA gives better pain relief than iv opiates 10 Pain score (VAS cm) 5 Iv opiates EDA 0 POD 1 AM POD 1 PM POD 2 AM POD 2 PM POD 3 AM POD 3 PM P<0.001 EDA vs opiates all times points Mean (SEM) Rigg Lancet 2002 Olle Ljungqvist 21 september

21 Epidural analgesia vs opiates GI function EDA results in less GI paralysis (vs iv opiater) Jorgensen Cochr Database Syst Rev 2004 Olle Ljungqvist 21 september

22 Naso Gastric Tubes Meta-analys of 26 staudies: Postoperative NG tube after abdominal surgery increases the risk for: Fever Lungatelectasies Pneumonia Delayed food intake Cheatham Ann Surg 1995 Olle Ljungqvist 21 september

23 Preoperative Fasting Giftasup 2009

24 Postoperative metabolic derangements Olle Ljungqvist 21 september

25 Metabolic response to surgery in traditional perioperative care 100 Postoperative change (%) N losses N balance Energy exp Glucose Insulin Insulin sens Traditional Olle Ljungqvist 21 september Ljungqvist, Fearon, Little in Nutrition Society text book 2005

26 Insulin normalize metabolism Postop insulin to glucose 6 mmol/l normalized: FFA Urea excretion Substrate utilization after major surgery Brandi LS et al: Clin Sci 1990 Olle Ljungqvist 21 september

27 Hyperglycemia in surgical stress Traditional belief: Hyperglycemia in the acutely stressed patient is not dangerous Glucose levels treated > 12 mmol/l Few studies on postoperative glucose levels Olle Ljungqvist 21 september

28 + + Insulin resistance Surgery & Type 2 diabetes Postop Type 2 DM Hyperglycemia + + Insulin sensitivity - - Glucose production + + Peripheral glucose uptake - - GLUT4 translocation - - Glycogen formation - - Adopted from Ljungqvist et al, Clin Nutr 2001 Olle Ljungqvist 21 september

29 Pattern of complications Postop (days) Diabetes (years) Bacteremia Ventilatory support Renal failure Polyneuropathy Infections Muscle weakness Renal failure Polyneuropathy Olle Ljungqvist 21 september

30 Glucose control & ICU studies current issues Mix of patients Surgical medical different entry circumstances not comparable or mixable Level of disease effects best at lower levels of stress Nutrition route and amount Massive evidence of harmful effects of hyperglycemia in diseases why different in ICU? Olle Ljungqvist 21 september

31 Glucose control & outcomes after surgery 120 Consecutive patients Colorectal surgery No history of diabetes Preop HbA1c 26% pathologically high Glucose 5 times daily postop CRP and complications (30 day follow up) Olle Ljungqvist 21 september Gustafsson U et al, in press BJS 2009

32 Caloric intake Gustafsson U et al, in press BJS 2009

33 Glucose in colorectal surgery Gustafsson U et al, in press BJS 2009

34 CRP postop day 1 * * P< 0.05 Gustafsson U et al, in press BJS 2009

35 Postoperative complications Percent (%) High OR 3.2* Low OR 2.3 High Low Complications, total Infections Gustafsson U et al, in press BJS 2009

36 Glucose control & Surgical stresses patient Hyperglycemia is undesirable Glucose control should be targetted Lower levels of stress benefit from glucose control Olle Ljungqvist 21 september

37 Glucose control & Surgical stresses patient What level should be targetted? Remains to be answered, But It seems reasonable that nutrition should not be withheld and that glucose control is good also after surgery Olle Ljungqvist 21 september

38 Avoiding insulin resistance and hyperglycemia Minimal invasive surgery Epidural Anesthesia Pain relief Metabolic preparation Olle Ljungqvist 21 september

39 Insulin sensitivity and minimal invasive surgery Insulin sensitivity (%) Lap Chol Hernia P < 0.001, ANOVA n = 6-13 Open Chol Major Colorectal Thorell et al: Curr Opin Clin Nutr Metab Care 1999 Olle Ljungqvist 21 september

40 Preoperative carbohydrates Preoperative carbohydrates reduces Preoperative discomfort Postoperative nausea Length of stay Preoperative effects#: thirst (P<0.05) hunger (P<0.05) anxiety (P<0.05) Postoperative effects: nausea and vomiting* Reduction in LOS (d) * Cholecystektomy Hip replacement Colorectal Combined (meta) *P<0.05 mean (SEM) Olle Ljungqvist 21 september *Hausel, BJS 2005; #Hausel Anesth Analg 2001; Ljungqvist Clin Nutr 2001

41 Preoperative carbohydrates reduces protein losses and improves muscle strenght Urea losses (mmol/kg/d) Postoperative muscle strength (%) Control CHO P<0.05 P<0.05 Mean (SEM) Olle Ljungqvist 21 september Crowe, BJS 1984; Henriksen Acta Anaesth Scand 2003

42 Preoperative Carbohydrates Giftasup 2009

43 Preop Carbohydrates & diabetes 400 ml 12.5% carbohydrate drink + Normal morning medication: Same gastric emptying as healthy Higher glucose peak = safe to use U Gustafsson et al, Acta Anaesthesiol Scand 2008 Olle Ljungqvist 21 september

44 Postoperative sip feeds improves nutritional intake Olle Ljungqvist 21 september Henriksen Nutrition 2003

45 ERAS: oral intake development (mean intake postop day 1-4)

46 Metabolic response to surgery in traditional perioperative care 100 Postoperative change (%) N losses N balance Energy exp Glucose Insulin Insulin sens Traditional Olle Ljungqvist 21 september Ljungqvist, Fearon, Little in Nutrition Society text book 2005

47 Metabolic response to surgery traditional periop care vs ERAS 100 Postoperative change (%) N losses N balance Energy exp Glucose Insulin Insulin sens Traditional Enhanced-recovery Ljungqvist, Fearon, Little in Nutrition Society text book 2005 Olle Ljungqvist 21 september

48 Conclusions Balanced fluid and sodium target no change in body weight Make the gut work fluids, EDA, feed Avoid metabolic stress EDA, Preop CHO, Early postop feeding Serve normal food early, add sip feeds Any doubt about intake: order supplements for at least 2-3 weeks Olle Ljungqvist 21 september

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