Malnutrition in Surgery. Symposium organized by the Committee on Critical Care Philippine College of Surgeons

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1 Malnutrition in Surgery Symposium organized by the Committee on Critical Care Philippine College of Surgeons

2 Objectives To discuss malnutrition To discuss the effect of malnutrition in surgery To discuss ways of correcting malnutrition in surgery to improve outcome(s) To discuss why early enteral feeding is crucial to improved surgical outcome(s)

3 What is malnutrition?

4 Chronic infections e.g. TB Chronic poor intake Extreme poverty

5 Diabetes Chronic systemic disease (e.g. autoimmune disease) Cancer

6 Critical care Trauma Post- surgical complications Infection, sepsis

7 Sarcopenic obesity (=too much fat, loss of protein) Selective intake (=vitamin and/or trace element deficiency)

9 Why is there a need to address malnutrition in surgery?

The modified SGA form of PhilSPEN SGA A (normal) B (mild/mod malnutrition) C (severe malnutrition) Nutrition Risk Score: 1-3: Low Risk 4-6: Moderate Risk 7-9 High Risk Sensitivity: 94.

10 The modified SGA form of PhilSPEN SGA A (normal) B (mild/mod malnutrition) C (severe malnutrition) Nutrition Risk Score: 1-3: Low Risk 4-6: Moderate Risk 7-9 High Risk Sensitivity: 94.7% Specificity: 96.2% Positive Predictive Value: 95.7% Lacuesta- Corro L et al. The results of the validation process of a Modified SGA (Subjective Global Assessment) Nutrition Assessment and Risk Level Tool designed by the Clinical Nutrition Service of St. Luke smedical Center, a tertiarycare hospital in the Philippines. (Article 12 POJ_0002.html) Issue February December2014: 1-7 (n=179)

11 Severe malnutrition and high risk status Bernardino J. The prognostic capacity of the Nutrition Risk Score and SGA grade of the PhilSPEN modified SGA (Subjective Global Assessment) on mortality outcomes An Initial Report. PhilSPEN Online J Enteral Parenter Nutr (Article 29; Issue July December 2016: Available at:

Malnutrition and surgical outcomes SGA A (normal) B (mild/mod malnutrition) C (severe malnutrition) Nutrition Risk Score: 1-3: Low Risk 4-6: Moderate Risk 7-9 High Risk Ocampo R B, Kadatuan Y,

12 Malnutrition and surgical outcomes SGA A (normal) B (mild/mod malnutrition) C (severe malnutrition) Nutrition Risk Score: 1-3: Low Risk 4-6: Moderate Risk 7-9 High Risk Ocampo R B, Kadatuan Y, Torillo MR, Camarse CM. Predicting post- operative complications based on Surgical nutritional risk level using the SNRAF in colon cancer Patients - a Chinese General Hospital & Medical Center experience. Phil J Surg Specialties Available at:

13 Malnutrition and surgical outcomes Detsky et al. JPEN 1987 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. JAMA 1994

14 Malnutrition correction and outcome(s) Del Rosario et al. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients nutritionally assessed as high or low risk. PhilSPEN Online J Parenter Enteral Nutrition; (Article 9 POJ_0006.html) Issue January January 2012: Available at:

15 Basis for addressing malnutrition in surgery

16 Total cells in the body Body Compartment Total cells in the body Skeletal muscle cells Cardiac muscle cells Number/Percent of cells in the body 37 trillion * Glucose Transporter IV (GLUT4) 14.8 trillion (40%) Present/active in 40% of cells in the body Fat cells 7.4 trillion (20%) Present/active in 20% of cells in the body * Bianconi E et al. An estimation of the number of cells in the human body. Ann Hum Biol Nov- Dec; 40(6):

17 Body compartments: nutrition standpoint Technically body composition can be simplified to consist of: Protein (15% of weight) Fat (25% of weight) Water (60% of weight)

18 Lean body mass components

19 Wound Healing

Wound Healing Malnutrition Poor protein reserves Less energy supply Fat > higher inflammatory state Resolution Poor intake Poor nutrient supply Poor quality of wound healing Other complications

20 Wound Healing Malnutrition Poor protein reserves Less energy supply Fat > higher inflammatory state Resolution Poor intake Poor nutrient supply Poor quality of wound healing Other complications like dehiscence, ulcers, fistulas Neutrophils Macrophages > active resolution Collagen Basement membrane Angiogenesis RESOLUTION PROCESS Success > good wound healing Failure > poor healing / sepsis

Resolution is an active process The pro- inflammatory mechanisms probably are counterbalanced by endogenous anti- inflammatory signals that serve to temper the severity and limit the duration of the

21 Resolution is an active process The pro- inflammatory mechanisms probably are counterbalanced by endogenous anti- inflammatory signals that serve to temper the severity and limit the duration of the early phases, which leads to their resolution, an active rather than a passive process. The resolution of the inflammatory response is mainly mediated by families of local- activity mediators that are biosynthesized from essential fatty acids eicosapentaenoic acid and docosahexaenoic acid. These resolution mediators were termed resolvins and protectins. Inflammation resolution is also mediated by lipoxins, trihydroxystearin- containing eicosanoids that are generated within the vascular lumen through platelet- leukocyte interactions WOUND- HEALING- 3Nov pdf

22 What happens when malnutrition is not addressed?

23 Calorie and protein reserves Nutrient Reserve How long do these last? Carbohydrate Liver glycogen hours Muscle glycogen 48 hours Protein Skeletal muscle (for a 70 kg person) 20 days Fat All fat tissues (for a 70 kg person) 85 days

24 Nutrient metabolism and reserves When not fed after 24 hours the body starts to lose protein (= gluconeogenesis) Gluconeogenesis

25 Weight loss and mortality

26 Sarcopenia SARCOPENIA COMPLICATIONS Sarcopenia: Vandewoude M. Abbott Symposium, ESPEN Goteborg, Sweden.

27 Cancer Cachexia

28 Weight loss in cancer

29 Lean body mass loss and mortality

30 Protein requirements in surgery and trauma

Body will always attempt to preserve protein Protein preservation phase http://www.medscape.

31 Body will always attempt to preserve protein Protein preservation phase Demling RH. Eplasty. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9.

32 Priorities: Basic function vs. wound healing Demling RH. Eplasty. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9. Epub 2009 Feb 3.

Effects of not adequately addressing nutritional needs for wound healing Poor immune defense leading to Surgical site infection Chronic infections Recurrent infections Active resolution process is

33 Effects of not adequately addressing nutritional needs for wound healing Poor immune defense leading to Surgical site infection Chronic infections Recurrent infections Active resolution process is slowed down leading to: Poor take of anastomosis Dehiscence Fistulas Slow healing leading to chronic wound state: Non- healing wound Ulcers Recurrent ulcers Poor quality of the wound as to strength and function Hideous scars

34 What to do?

35 Decision(s) when to do surgery Elective surgery Not malnourished > minimum risk If malnourished > nutritional build up (? Days: recommended 7-10 days; practical: 3 days, then post- operative nutrition) Can ERAS principles be applied? Emergency surgery If can be optimized (usually perfusion and oxygenation) delay a little bit, then do surgery Critical care Nutritional build up Optimize microcirculation Then surgery if needed

36 Preoperative phase: what to do Nutritional assessment Moderately malnourished: 3-5 days build up Severely malnourished: 7-10 days build up What to prescribe? Energy: 30 kcal/kg actual body weight (ideal body weight if obese) > if severely malnourished and elderly you may start at 20 kcal/kg then gradually increase within three days to reach target Protein: g/kg body weight Carbohydrate: 60% of the non- protein calories Fat: 40% of non- protein calories Multivitamins and trace elements daily Lean body mass enhancers and immunonutrition

37 What are Lean Body Mass enhancers? Immune enhancers? Lean body mass enhancers High protein intake Branched chain AA (50% of total protein) Nutraceuticals HMB, glutamine, arginine combinations Fish oil (EPA/DHA) 1 g/day Exercise Impact of free radicals Not too much anti- oxidants Adequate intake Macro and micronutrients DAILY Insulin Immune enhancers: Glutamine 30% of total protein (intravenous) 50% or total protein (oral) Fish Oils (EPA/DHA) Arginine Antioxidants (vitamins and trace elements) Probiotics Early feeding

38 Feeding pathway

39 Feeding access: Intraoperative and postoperative decisions Status Option/access Condition Decision ERAS > normal GIT ERAS > poor appetite Pre- op: severely malnourished Need to do surgery immediately Post- operative with enteral access Oral Intake within hours Discharge early Oral Intake < 70% PN: AA soln, Lipid soln, 3- in- 1 for one or two days Build up: 7-10 days May opt for 3 days NGT post- op Need to place access? Gastrostomy? Jejunostomy? Oral intake possible, but inadequate Enteral nutrition possible but inadequate intake Full diet + oral supplement + PN (3- in- 1 TNA) + immunonutrition intra- op: enteral access? EN: tube feed within hours; when inadequate give PN PN: Protein soln only or protein soln and/or lipid emulsion or All in One Enteral nutrition EN goal EN priority if intake < 60% give supplemt PN

40 Critical care Status Option/access Condition Decision ICU Tube feed > NGT EN goal reached Enteral nutrition + immuno nutrition ICU Tube feed > NGT Intake < 70% Enteral nutrition + Supplemental PN (AA soln or Fat emulsion or usually 3- in- 1) + immuno nutrition

41 How do we know intake is adequate?

42 Calorie, protein and fluid intake/ balance form

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

44 Value of nutrition and fluid audit

45 Why the need for early enteral feeding?

46 Gastrointestinal Peptides [M] = mucosa [N] = nerve [Me/o] = entero chromaffin cells [M] [M] [M] [M] [M] [Me/o] [M] [N] [N] [M] [M] [N] [M] [M] [M] Gastric acid, pepsin, mucosa growth/repair Glycogenolysis, gluconeogenesis, lipolysis é bicarbonate secretion (panc duct, bile duct) Gallbladder contraction, é pancreatic juice rich in enzymes Stimulates insulin secretion (gliptin) (1) Muscle contraction é GI motility, ê ileal blood flow é secretion of electrolytes and water; relaxes smooth muscle including sphincters (2) Muscle contraction Glucagon (GLP- 1, GLP- 2) - Glycogenolysis, gluconeogenesis, lipolysis Inhibits gastrin, secretin, VIP, GIP, motilin Gastrin secretion Feed within 24 to 48 hours post- op é secretion of chloride to lumen Inhibits food intake, gastric inhibitory peptide é growth hormone, central control of food intake Ganong WF. Review of Medical Physiology, 22 nd edition, Metabolism Maintenance Motility Maintenance

47 Gastrointestinal Peptides [M] = mucosa [N] = nerve [Me/o] = entero chromaffin cells [M] [M] [M] [M] [M] [Me/o] [M] [N] [N] [M] [M] [N] [M] [M] [M] Gastric acid, pepsin, mucosa growth/repair Glycogenolysis, gluconeogenesis, lipolysis é bicarbonate secretion (panc duct, bile duct) Gallbladder contraction, é pancreatic juice rich in enzymes BENEFITS Stimulates insulin of secretion FEEDING (gliptin) (1) Muscle Early contraction bowel motility é GI motility, recovery ê ileal blood flow é secretion Gut mucosa of electrolytes defense and water; relaxes is smooth muscle including sphincters maintained (2) Muscle contraction Gut microbiome is Glucagon (GLP- 1, GLP- 2) - Glycogenolysis, gluconeogenesis, maintained lipolysis Inhibits Faster gastrin, wound secretin, VIP, healing GIP, motilin Preserved immune status Gastrin secretion é secretion of chloride to lumen Inhibits food intake, gastric inhibitory peptide é growth hormone, central control of food intake Ganong WF. Review of Medical Physiology, 22 nd edition, 2005.

48 Gut associated lymphoid tissues

49 Relationship of GALT and MALT When the gut is okay, the pulmonary system will also be okay

50 Early enteral nutrition guidelines for critical care patients Grade B recommendation Hours Early EN: Guideline Evidence < 48 hours 1 Canadian Evidence of trend < 24 hours 2 ACCEPT Significant evidence < 24 hours 3 Australian/New Zealand Significant evidence < 24 hours 4 ESPEN Significant evidence < 48 hours 5 ASPEN Evidence of trend 1. Heyland DK et al. J Parenter Enter Nutr Martin CM et al. CMAJ Doig GS and Simpson F. EvidenceBased.net 4. Kreymann KG et al. Clinical Nutrition McClave SA et al. J Parenter Enter Nutr 2009.

51 What happens when you don t feed your patient?

52 NPO orders: effect on metabolism No intake for 24 hrs > no more liver glycogen No intake >24 hours > start losing protein No intake for 48 hours to 5 days > maximum protein loss > gut mucosa deterioration > é inflammatory status No intake on the 6 th to 7 th day Protein preservation Ketoadaptation > Fat starts to be the main source of energy

53 NPO orders: effect on immune defense Stomach: low secretion of HCl è less bactericidal activity Small intestine: Diminished mucosa defense system Diminished secretion of secretory IgA Diminished activity of GALT due to lesser perfusion and stimulation secondary to lower mucosal activity Small intestine: Diminished digestive/absorptive capacity Slower rate of mucosa re- epithelialization è shortening height of villus But: mucosa perfusion is still adequate ê oxygen > é Adenosine (vasodilator) > perfusion

54 When to give parenteral nutrition?

55 Parenteral nutrition: Indications Supplemental parenteral nutrition: When oral/enteral nutrition is inadequate Total parenteral nutrition: oral or tube feeding not possible Intestinal obstruction Severe ileus Initial phase of short bowel syndrome

56 Parenteral nutrition: Points to remember All three macronutrients should be supplied daily If oral or tube feeding and there is an insufficient macronutrient give by PN Micronutrients should be given daily Vitamins water and fat soluble Trace elements Note the deficiencies and give corresponding corrections Pharmaconutrients like glutamine or fish oil have better results with parenteral nutrition

Parenteral nutrition: Delivery Most common: Peripheral parenteral

branched chain amino acid rich) Fatty acid emulsion > MCT, LCT, Fish

elements Selected: central parenteral nutrition (> 900 mosm/l) Usually

Compounded + vitamins and trace elements Route: Internal Jugular (IJ)

57 Parenteral nutrition: Delivery Most common: Peripheral parenteral nutrition (800 to 900 mosm/l) Single: Amino acid solution (suggestion > branched chain amino acid rich) Fatty acid emulsion > MCT, LCT, Fish Oils, Olive Oil Combination: 3- in- 1 or All in One + vitamins and trace elements Selected: central parenteral nutrition (> 900 mosm/l) Usually combination: 3- in- 1 or All in One + vitamins and trace elements Compounded + vitamins and trace elements Route: Internal Jugular (IJ) catheter, subclavian catheter, PICC line TRACUTIL AMINOPLASMAL LIPOFUNDIN/LIPIDEM NUTRIFLEX

58 Concluding statements

59 Review: nutrition principles Identify malnutrition and do the needed corrections Severity of lean body mass loss is associated with increased mortality > bring them back first nutritionally before doing any surgery Do not let the patient go to starvation state (=NPO beyond 24 hours) and lose protein in the post- operative phase The gut should be utilized as early as possible Adequacy of intake is directly related to reduction of mortality If intake through the gut or enteral nutrition is inadequate do not hesitate to immediately give parenteral nutrition

60 Thank You

Nutrition care plan for surgical patients. Objectives

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