4Malnutrition does it matter? A malnourished patient will have 3 times the number of complications and 4 times the risk of death from the same surgery compared to a well nourished patient (NICE 2006)
5Definition of Malnutrition There is no universally accepted definition of malnutrition but the following is increasingly being used from RCP 2002:A state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome‘Malnutrition’ refers to both under and over-nutrition (but more commonly used for under-nutrition)
6The Extent of ‘The Problem’  Estimated > 3 million people in the UK are at risk of malnutrition at any one time (Elia & Russell, 2009)Under-recognised & under-treatedPublic health expenditure on disease-related malnutrition in the UK (2007) > 13 billion per annum (Elia & Russell, 2009)Elia M, Russell CA. Combating malnutrition: Recommendations for action: A report from the Advisory Group on Malnutrition led by BAPEN,200980% of this expenditure was in England40% of adult hospital patients are overtly malnourished on admission. 8% categorised as severe.
7Who’s at risk? Patients with Altered Elderly Nutritional Requirements: Critical careSepsisCancerTraumaSurgeryRenal FailureLiver DiseaseGI & pancreatic disordersCOPDPregnancyElderlyChronic ill-health e.g. diabetes, renal, COPD, neuroCancerDeprivation / povertyGI disorders / post GI surgeryAlcoholicsDrug Dependency
8Effects of Undernutrition PsychiatricAnhedoniaDepressionConfusionAnorexia?Micronutrient deficiencyImmunityIncreased infection riskImpaired wound healingRespiratoryDecreased tidal volumesReduced muscle bulkLoss of adaptive response to hypoxiaCardiacReduced cardiac outputCCFHepaticFatty LiverNecrosis/ FibrosisRenalReduced Na & H2O excretionGutReduced immunityReduced integrityOedemaOtherReduced muscle strengthNeurological weaknessInability to regulate temperature
9ESPEN guidelines for enteral nutrition in surgery Patients who are significantly malnourished and are due to undergo major surgery should be considered for preoperative nutrition support, this may involve tube feeding for days pre-op (ESPEN 2006)Oral intake should be resumed as soon as possible after surgery, usually within 24hrs, with monitoringEnteral tube feeding should be given without delay post op for any patient who it is anticipated will be unable to eat for > 7days and for patients who cannot maintain oral intake >60% requirements for >10 daysPN should be reserved for malnourished patients who cannot be fed via the GIT for at least 7 days
10Nutritional requirements Typically quoted as 25 – 30kcal / kg calories however Dietitian will assess patients individual needsCalorie requirements affected by:Age, Gender, Activity level, Weight,Degree of stress associated with surgeryCalorific intake from other sources e.g. propofol in ITU
13AlbuminCommonly used by the medical profession as a marker for nutritional stateAlbumin is not a marker for nutritionAlbumin indicates disease state not nutritionPoor nutritional state can coexist with illness but albumin does not indicate malnutritionNo single biochemical marker can be used to assess nutrition
14David BlaineFast for 44 daysHe lost 25.5Kg(26.6%)At end BMI = 21.6Kgm-2Albumin 52.9 gl-1
16Other causes of Low Albumin CommonLeast CommonSepsis - CRP; ALBAcute & Chronic inflammatory conditionsCirrhosis/ Liver diseaseNephrotic syndromeMalabsorptionMalnutritionHypoalbuminaemia is an important prognostic indicator. The lower the level, the higher the mortality
17Pre-operative fasting Typically patients NBM from midnight prior to surgery. Advocated to ensure an empty stomach to risk of aspirationESPEN (2006) and NICE (2006): Safe for patients to eat up to 6 hours prior to surgery and drink fluids up to 2 hours prior to surgery (grade A evidence)This the need for IV fluids which helps prevent post op fluid and salt overload which adversely affects the GIT tract and ability to mobilise (Powell-Tuck 2011)
18Surgery & FastingCatabolismInsulin resistanceHyperglycaemiaLoss of fat & muscle stores
20Preoperative carb loading preOp (Nutricia) and preload (Vitaflo)4 x 200ml evening pre surgery,2 x 200ml up to 2hrs pre anaesthesia kcal, 25g (4.2g sugar) carbohydrate per cartonCreates a non starved metabolismModerates metabolic responseto surgery
22Nutrition screen on admission ElectiveEmergencyNutrition screen on admissionNutrition screening in OPC+/-ERAS protocolHigh RiskLow RiskHigh RiskLow RiskPost operative nutrition supportRescreen weeklyPre-op nutrition support & goal setting
23Options for nutrition support Oral nutrition supportEnteral tube feedingNasogastricNasojejunalPEG / RIGJejunostomyParenteral feedingAim for the least invasive method requiredto achieve goals
24Oral nutrition support High calorie, high protein dietSnacks, puddingsMajority of patients can resume a normal diet within hours of surgeryAvoid unnecessary restrictions
25Oral nutritional supplements Not all the same!Patient preferences keyConsideration should be given to what product best addresses the identified nutritional deficiencies prior to prescribingCo-morbidities will also affect choice e.g. CMP allergy, diabetes, fat malabsorption, renal disease, coeliac diseaseOngoing monitoring of patients is essential to establish when nutritional goals have been met and nutritional support can be stoppedNot all patients need supplements forever!!
27Puree diet example Breakfast: Porridge & Cup of tea (all) Mid Morning: Cup of Coffee & SquashLunch: Beef Casserole meal (all)Crème Caramel (all)Orange JuiceMid Afternoon: SquashEvening Meal: Salmon Bake Meal (all)Raspberry Mousse (all)SquashSupper: Cup of teaWhat do you think of this intake??
28Puree diet example Total: 1270kcal 52.5g protein 1135ml fluid This will be inadequate for most post operative patientsBe aware that patients can have difficulty achievingadequate intakes on altered consistency diet and fluidas choices are more limited and less nutrient richRequire additional snacks or puddings and manyrequire oral nutritional supplements when on thistexture
29Enteral feedingEnteral feeding refers to the delivery of nutritionally complete feed containing protein, carbohydrate, fat, water, minerals and vitamins directly into the stomach, duodenum or jejunum.NICE 2006
30Enteral feeding For those unable to take orally for >7 days or are unable to take sufficient amounts (>60%) and forwhom more invasive nutritional support is anappropriate part of the treatment plan ESPEN 2006Polymeric feeds first line, reflects normal dietary intakeSpecialist feeds for use in certain conditions e.g. renal, malabsorption, sodium or fluid restrictionVarious “core” feeds availablefibre and fibre free versions0.8-2kcal / mlNutritionally complete in set amount of caloriesGluten & lactose free majority of productsContain milk protein except Soya based feedsVegetarian issue – carminic acid – in ONS, fish oils.Depends on company / product used, Dietitian will advise
31Nasogastric - indications Patients at high risk of aspiration, swallowing problems, unconscious.Supplementary to oral nutrition – poor appetite, increased nutritional requirements.Supplementary to parenteral nutrition.
32Nasal Bridal A nasal bridal is a device to secure a NG or NJ tube to the nasal septum2 high grade magnets are inserted via each nostril these connect around the nasal septum allowing the looping of a thin strip of gauze/tape around the nasal septum which is then fixed to the NG / NJ tube with a clip.
33Gastrostomy feedingThe placement of a tube through the abdominal wall directly into the stomach for either temporary or permanent delivery of enteral feed (Payne-James et al 2001).PEG, RIG, Surgical gastrostomy – be clear on what type of tube it isHead & Neck cancer
34Indications / contraindications Long term nutrition support requiredSwallowing impairmentContraindicationsAbsoluteTotal gastrectomyPortal hypertension with gastric varicesRelativeUnfit for procedurePartial gastrectomyPDAscitesActive gastric ulcer
35Jejunal FeedingPlacement of a tube into the small bowel, either via the nasal cavity (NJ), surgically placed (surgical jejunostomy), or occasionally via PEG tube (PEJ). It is a method of feeding patients who are unable to maintain or improve their nutritional status by oral intake and in whom gastric feeding is contraindicated or has been unsuccessful.
36Indications for jejunal feeding Previously documented gastroparesisGastric stasis due to paralysing agents required for ventilationPersisting delayed gastric emptying despite medical managementSevere acute pancreatitisUpper GI surgeryPancreatic or duodenal injuryHepato-biliary surgeryCancer of the oesophagus or stomach where NG or gastrostomy feeding is inappropriateUpper GI fistula
37Complications of EN Nausea and vomiting Abdominal distension Diarrhoea ConstipationOesophagitisAspirationBlocked tubeComplications during tube insertion
38Parenteral nutrition (PN) Administration of nutrients, fluids and electrolytes directly into a central or peripheral veinTraditionally associated with complicationsHowever PN used appropriately, with close attention to glycaemic control and avoidance of overfeeding can safely deliver adequate nutrition
39Who needs it?Patients who are malnourished or who are likely to become malnourished and where the GI tract is not fully functional or is inaccessible (NICE 2006)PN anticipated to be needed >7/7TPN should be avoided where aggressive nutritional support not indicated or where the risks outweigh the benefits
40If the gut works, use it! If the gut works a little, use it a little
41Indications Short bowel syndrome Prolonged paralytic ileus (>7/7)Bowel obstruction or pseudo-obstructionMotility disorders e.g. sclerodermaGastrointestinal fistulaeAdhesionsAnastamotic leakRadiation gastroenteritisMucositis, oesophagitis or intractable vomiting secondary to chemotherapySevere acute inflammatory bowel diseaseGI perforationSevere acute pancreatitisPost op extensive bowel surgery
42Parenteral Nutrition Bags made up by aseptic lab Mixture of glucose, lipid, amino acids, electrolytes, fluid, vitamins, minerals and trace elementsModifications can be made if clinically indicatedIf EN commences can reduce PN gradually as EN increases
43Refeeding syndromePatients who have had a prolonged period with little/no nutrition >10/7, low BMI, >10% unintentional wt loss, electrolyte disturbances, alcoholics pose risk of refeeding syndrome when any feeding commencedSevere electrolyte & metabolic abnormalities can occur as a result of feeding but difficult to separate from abnormalities associated with critical illnessPrevent by slow feeding, vitamin supplementation and electrolyte correctionEnsure patients are assessed by a dietitian to ascertain risk level and appropriate plan is made
45Conclusion Malnutrition significantly affects outcomes from surgery Identification of malnourished patients enables appropriate treatments to be initiated to promote the rapid recovery and discharge of surgical patientsIncreasing use of ERAS protocols and cessation of prolonged fasting pre-op improves outcomesNutrition support should be provided for patients identified at risk of malnutrition from nutrition screening aiming for the least invasive route
46ReferencesAnderson MR, O’Connor M, Mayer P, O’Mahony D, Woodward J, Kane,K. (2003). The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high- risk dysphagia stroke patients. Clinical Nutrition. Vol 23. No 4ERAS society guidelines (joint publications with ESPEN):ESPEN (2006). Guidelines on enteral nutrition: surgery including organ transplantation. Clinical Nutrition 25: 224 – 244ESPEN (2009). Guidelines on parenteral nutrition: surgery. Clinical Nutrition 28:Gustafsson UO, Nygren J, Thorell A, Soop M, Hellström PM, Ljungqvist O, Hagström-Toft E. (2008). Pre-operative carbohydrate loading on postoperative hyperglycaemia in hip fracture patients: A randomised control clinical study. Acta Anaesthesiol Scand Aug;52(7):946-51NICE (2006) Nutrition Support in Adults: oral supplements, enteral and parenteral feeding. NICEPowell-Tuck et al. (2011) British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP). BAPEN