ESPEN Congress Vienna 2009 Nutrition after discharge from hospital: The surgeon s responsability O. Ljungqvist (Sweden)
Nutrition after discharge from hospital: The surgeon s responsability Olle Ljungqvist Professor of Surgery Karolinska Institutet Stockholm, Sweden ESPEN 2009 Vienna
Critical illness Trauma/Infection Acute Stress Response Iatrogenic Factors Immunological Response Neuroendocrine Response Metabolic Response
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 2009 4
Recovery After Surgery Starts before surgery! Prepare your unit to be able to Prepare the patient Mentally Physically Olle Ljungqvist 21 september 2009 5
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
Change in body weight 0 Baseline Body weight change (%) -2-4 -6-8 -10 Intervention Oral Supplement Control -12 Inclusion postop Admission 2 4 6 8 10 Time of assessment (weeks) Beattie et al 2000, Gut 46, 813-8
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 2009 8
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 2009 9
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 2009 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 2009 11
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 2009 12
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 2009 13
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 2009 14 Lobo D, Lancet 2002: 359; 1812-1818
Fluids New Meta analysis Any restriction Morbidity 0.44 (0.22, 0.77) p= 0.005 Perioperative restriction Morbidity 0.35 (0.18, 0.70) p= 0.003 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
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 2009 16
Back to eating food Two main problems Gut is not working Fluids Drains, tubes Pain Catabolism blocks use of nutrients Olle Ljungqvist 21 september 2009 17
Effects of Bowel preparation on body weight & fluids Bowel prep: Bisacodyl and sodium phosphate Body weight - 1.2 kg Osmolality 297 -> 300 mosm/kg Fluid intake to cover losses: 2.5-3 L Holte K, Dis Colon Rectum 2004; 47, 1397-1402 Olle Ljungqvist 21 september 2009 18
Bowel preparation increases the risk of anastomotic leakage N = 1454, OR 1.75 (1.05 2.70), p = 0.032 Slim K et al BJS 2004; 91, 1125-1130 Olle Ljungqvist 21 september 2009 19
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 2009 20
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 2009 21
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 2009 22
Preoperative Fasting Giftasup 2009
Postoperative metabolic derangements Olle Ljungqvist 21 september 2009 24
Metabolic response to surgery in traditional perioperative care 100 Postoperative change (%) 80 60 40 20 0-20 -40-60 -80 N losses N balance Energy exp Glucose Insulin Insulin sens Traditional Olle Ljungqvist 21 september 2009 25 Ljungqvist, Fearon, Little in Nutrition Society text book 2005
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 2009 26
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 2009 27
+ + 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 2009 28
Pattern of complications Postop (days) Diabetes (years) Bacteremia Ventilatory support Renal failure Polyneuropathy Infections Muscle weakness Renal failure Polyneuropathy Olle Ljungqvist 21 september 2009 29
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 2009 30
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 2009 31 Gustafsson U et al, in press BJS 2009
Caloric intake Gustafsson U et al, in press BJS 2009
Glucose in colorectal surgery Gustafsson U et al, in press BJS 2009
CRP postop day 1 * * P< 0.05 Gustafsson U et al, in press BJS 2009
Postoperative complications Percent (%) 50 40 30 20 10 0 High OR 3.2* Low OR 2.3 High Low Complications, total Infections Gustafsson U et al, in press BJS 2009
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 2009 36
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 2009 37
Avoiding insulin resistance and hyperglycemia Minimal invasive surgery Epidural Anesthesia Pain relief Metabolic preparation Olle Ljungqvist 21 september 2009 38
Insulin sensitivity and minimal invasive surgery Insulin sensitivity (%) 100 80 60 40 20 0 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 2009 39
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) 0-0.5-1 -1.5-2 -2.5 * Cholecystektomy Hip replacement Colorectal Combined (meta) *P<0.05 mean (SEM) Olle Ljungqvist 21 september 2009 40 *Hausel, BJS 2005; #Hausel Anesth Analg 2001; Ljungqvist Clin Nutr 2001
Preoperative carbohydrates reduces protein losses and improves muscle strenght Urea losses (mmol/kg/d) 6 5 4 3 2 1 0 Postoperative muscle strength (%) 0-2 -4-6 -8-10 -12-14 -16 Control CHO P<0.05 P<0.05 Mean (SEM) Olle Ljungqvist 21 september 2009 41 Crowe, BJS 1984; Henriksen Acta Anaesth Scand 2003
Preoperative Carbohydrates Giftasup 2009
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 2009 43
Postoperative sip feeds improves nutritional intake Olle Ljungqvist 21 september 2009 44 Henriksen Nutrition 2003
ERAS: oral intake development (mean intake postop day 1-4)
Metabolic response to surgery in traditional perioperative care 100 Postoperative change (%) 80 60 40 20 0-20 -40-60 -80 N losses N balance Energy exp Glucose Insulin Insulin sens Traditional Olle Ljungqvist 21 september 2009 46 Ljungqvist, Fearon, Little in Nutrition Society text book 2005
Metabolic response to surgery traditional periop care vs ERAS 100 Postoperative change (%) 80 60 40 20 0-20 -40-60 -80 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 2009 47
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 2009 48