Presentation on theme: "Fluids, electrolytes, nutrition in surgery"— Presentation transcript:
1Fluids, electrolytes, nutrition in surgery PSGS ReviewBonaventure Plaza, Greenhills, San Juan3-4 PM; April 27, 2012
2Case62 y/o maleHeight=1.6 m, weight=52 kg, weight two months ago=60 kgAnorexia, vomiting; weight lossDiagnosis: head of pancreas cancerReferred for surgery:Labs: Hb=11, WBC=5600, N=60%, L=6%, platelet=240k; Na=135 mmol/L; K=3.2 mmol/L; glucose=160 mg/dL; BUN=6 mmol/L; albumin=3 gm/dL; creatinine=1.1 mg/dL
3Questions Will you operate on this patient tomorrow? If you plan to build up – how?Route? Duration? What to give?How will you know your build-up attempts are okay?During surgery:Will you monitor the fluid input?How will you give the fluids? Will you leave everything to the anesthesiologist?What are your choices of fluids?Will you place a jejunostomy?
4Questions In the post-operative period: Will you place an NGT? Will you place drains?Will you place on NPO? How long?How often will you check the electrolytes? Glucose?When will you start enteral feeding? Oral feeding?How? When?Will you give parenteral nutrition? When?
6Essentials for wound healing HomeostasisNormal ECF and ICFOptimum balance mechanismsOptimum cell structure and functionAdequate energy provisionOptimum antioxidant activityAdequate nutritionMacronutrientsMicronutrientsAdequate perfusionAdequate oxygenationAdequate waste removal
7Homeostasis Essential for optimum body function Fluids, electrolytes, acids and bases must be balancedBalance = a set desired levelMore than desired level = increasing excretionBelow desired level = increasing absorption
8Cell structure and function Illustrations from Guyton’s Textbook of PhysiologySTRUCTUREFUNCTIONStructure MaintenanceMacronutrientsMicronutrientscomponentsenergy
9The cell: basic components DetailsWater70% to 85% except in fat cellsIonsmajor → potassium, magnesium, phosphate, bicarbonate; minor → sodium, chloride and calciumProtein20% to 30% of cell massStructuralFunctionalLipids(mainly phospholipids and cholesterol): 2% of cell massCarbohydratessmall part but has major role in metabolism
10100 trillion cells Nervous system Musculoskeletal system Cardiovascular systemRespiratory systemGastrointestinal systemGenitourinary systemReproductive systemEndocrine systemHemopoietic system
11Body composition and water Human body composition (% of weight):Water: 60%ECF (extracellular fluid): 20%Intravascular fluidExtravascular interstital fluidICF (intracellular fluid): 40%Mass: 40%Lean body massFat massTBF = ICF + ECF = 42 liters (60% of weight)ECF = 14 litersPlasmaInterstitial FluidICF = 28 litersComputation of usual fluid requirement per day:30 ml/kgor 1.5 to 2.5 L/day
12Normal routes of water gain and loss at room temp (=230C) Water intakeml/dayWater lossFluid1200Insensible700In Food1000Sweat100Metabolicallyproducedfrom food300Feces200Urine1500Total2500From: Berne R, ed. Physiology 5th ed. St. Louis, Missouri: Mosby 2004: p. 662.
13Electrolytes Chemicals that can carry an electrical charge Dissolved in the body fluidsFluid and electrolyte levels are interdependentElectrolyte increases, water is addedElectrolyte decreases, water is removed
14Positive Ions Electrolyte Extracellular mEq/L Intracellular Function Sodium14210Fluid balanceOsmotic pressurePotassium5100Neuromuscular excitabilityAcid base balanceCalcium-BonesBlood clottingMagnesium2123EnzymesTotal154205
15Negative Ions Electrolyte Extracellular mEq/L Intracellular Function Chloride1052Fluid balanceOsmotic pressureBicarbonate248Acid base balanceProteins1655Phosphate149Energy storageSulfate1-Protein metabolismTotal154205
16Osmolality Normal cellular function requires normal serum osmolality Water homeostasis maintains serum osmolalityThe contributing factors to serum osmolality are: Na, glucose, and BUNSodium is the major contributor (accounts for 90% of extracellular osmolality)Acute changes in serum osmolality will cause rapid changes in cell volume
17How to compute for plasma osmolality 2 x [Na] + [glucose]/18 + [BUN]/2.8Na = 140 mmol/LGlucose = 110 mg/dLBUN = 20 mg/dLOsmolality = (2x140) + (110/18) + (20/2.8)Osmolality =Osmolality = mmol/L(Normal = 275 to 295 mmol/L or mOsm/kg)Division of glucose and BUN by 18 and 2.8 converts these to mmol/L
27Surgery induced immunosuppression Ogawa K et al. Suppression of cellular immunity by surgical stress.Surgery 2000; 127 (3):Surgical stress↓Lymphocyte number and functionup to 2 weeks post-op↓T-helper cells↓Cytotoxic T-cells↓NK cells↓IL2 receptor+ cells↑T-suppressor cells↑cortisol↑immuno - suppressive acidic protein??
30Pre-operative checklist Check nutritional and fluid status (nutritional assessment)Check fluid and electrolyte status (=homeostasis):Na, K, Cl (then may add Mg, Ca if needed)Glucose, BUN, serum osmolalityFluid intake and output recordWound healing capacityEnergy and protein requirementsMicronutrient requirementsNeed for pharmaconutrition
33Malnutrition and complications Surgical patients9% of moderately malnourished patients → major complications42% of severely malnourished patients → major complicationsSeverely malnourished patients are four times more likely to suffer postoperative complications than well-nourished patientsFOR EXAMPLE: In 1987, Detsky published a study of 202 patients hospitalized for major gastrointestinal tract surgery. Thirty-one percent of these patients had some degree of malnutrition, and 10% suffered from severe malnutrition.This suggests that despite medical and technological progress, the prevalence of malnutrition among hospitalized patients is still consistently and significantly present. These data may be old (1987) but the situation continues to be consistent throughout the world. (1)In Detsky’s study of surgical patients, 42% of those severely malnourished and 9% of those moderately malnourished suffered major complications. Severely malnourished patients are four times more likely to suffer postoperative complications than well-nourished patients (2)References:1. Detsky AS et al. JPEN J Parenter Enteral Nutr 1987; Detsky AS et al. JAMA 1994; 271(1):Detsky et al. JPEN 1987Detsky et al. JAMA 1994
35Malnutrition and costMalnutrition is associated with increased cost and the higher the risk the higher the number of complications plus costFinally malnutrition and increased cost due to increased complications and length of hospital stay is one of the major reasons why nutrition should be a major component of surgical careReilly JJ, Hull SF, Albert N, Waller A, Bringardener S. Economic impact of malnutrition: a model system for hospitalized patients. JPEN 1988; 12(4):371-6.
43Feeding algorithm Can the GIT be used? Yes No Parenteral nutrition Oral< 75% intakeTube feedShort termLong termPeripheral PNCentral PNMore than 3-4 weeksNGTNasoduodenal or nasojejunalGastrostomyJejunostomy“inadequate intake”“Inability to use the GIT”A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients, III: nutritional assessment – adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA.
44PRE-OPERATIVE PHASE SURGERY malnutrition Scheduled esophageal resectiongastrectomypancreaticoduodenectomyEnteral nutrition for daysoral immunonutrition for 6-7 daysEarly oral feeding within 7 daysyesnowithin 4 days“Fast Track”Parenteral hypocaloricAdequate calorie intake within 14 daysEnteral access (NCJ)enteral nutritionimmunonutrition for 6-7 daysOral intake of energy requirementscombined enteral / parenteralslight, moderatesevereSURGERYPRE-OPERATIVE PHASEPOST-OPEARLY DAYLATE DAY 14supplemental enteral diet
45Surgical nutrition pathways: Pre-operative phase Condition: When oral or enteral feeding not possibleNormal to moderate malnutritionSURGERYSevere MalnutritionEsophageal resectionGastrectomyPancreaticoduodenectomyParenteral nutrition + Omega-3-Fatty Acids + Antioxidants (+ glutamine); 6-7 daysNutritional AssessmentESPEN Guidelines on Parenteral Nutrition (2009)
49RationaleEnteral feeding 24 to 72 hours after surgery or when patient is hemodynamically stableProvide nutrients required during metabolic stressMaintain GI integrityReduce morbidity compared with parenteral nutritionReduce cost compared with parenteral nutrition
50Early enteral nutrition vs standard nutritional support on mortality Comparison: mortalityOutcome: early enteral nutrition vs. controlStudyTreatment n/NControln/NCerra et al 1990Gottschlich et al, 1990Brown et al, 1994Moore et al, 1994Bower et al, 1996Kudsk et al, 1996Engel et al, 1997Weimann et al, 19981/112/170/191/5124/1631/167/182/161/91/140/182/4712/1431/175/184/130.010.110100Higher for controlHigher for treatmentRoss Products, 199620/878/83Mendez et al, 19971/221/21Rodrigo et al, 19972/13Atkinson et al, 199896/19786/193Galban et al, 200017/8928/87Heyland et al. JAMA, 2001Pooled Risk Ratio1
54Effect of nutrition intake on outcome Nutrition care led to reduced morbidity and mortality of surgical patients assessed as severely malnourished and high risk (n=103)Effect of nutrition care on post-operative complications predicted by surgical nutrition risk assessment: St. Luke’s Medical Center experience. Del Rosario D, Inciong JF, et al
55Intra-operative checklist Fluid intakeMonitor and estimate fluid lossesOnly infuse what is requiredDetermine whether to give balanced electrolyte solutions or colloids; avoid saline and “water only” infusions like D5W or D10WNutrition accessDetermine the need for long term enteral nutrition (jejunostomy: surgical jejunostomy or nasojejunostomy)
56How much fluid loss in surgery? 60 kg wtInsensibleperspirationVentilation with 100% water = almost zero loss0 mlEvaporative lossmoderate incisions with partly exposed but non-exteriorised viscera = 8.0 mlhourmajor incisions with completely exposed and exteriorised viscera = 32.2 mlhour8-30 ml per hrThird space lossAscites or other fluids – measurableVolumes up to 15 mL/kg/hour are recommended in the first hour of abdominal surgery, with decreasing volumes in subsequent hours.Measure300 mlTotalWithin one hour (crystalloids not recommended)350 first hourAdapted from: Brandstrup B. Fluid therapy for the surgical patient.Best Pract Res Clin Anaesthesiology 2006; 20(2):
58Fluid management Use Compartment Composition Examples Volume ReplacementIntravascular fluid volumeIso-oncoticIsotonicIso-ionic6% HES 130 in balanced solutionFluid ReplacementExtracellular fluid volumeBalanced solution: normal saline; ringer’s lactateElectrolyte or osmotherapy(solutions for correction)Total body fluid volumeAccording to need for correctionKCLGlucose 5%MannitolReference: Zander R, Adams Ha, Boldt J. 2005; 40;58
59Post-operative checklist Fluids and electrolytesDaily accumulated fluid balanceGoal: “zero” fluid balanceSerum electrolytesGive balanced electrolyte solutionsAdequacy of nutrient intakeEarly enteral nutritionDaily nutrient balance (=nutrient intake)Good glucose control
61Common peri-operative surgical complications Fluid and electrolyte problemsWound infection and sepsisWound dehiscence
62Fluid management Average perioperative fluid infusion: Leads to: Intra-op = 3.5 to 7 liters3 liters/day for the next 3 to 4 daysAverage gain post-op = 3 to 6 kg weight gainLeads to:Delay of gastrointestinal functionImpair wound anastomosis healingAffects tissue oxygenationProlonged hospital stayLassen et al. Arch Surg 2009
63Fluid and electrolyte imbalance INJURY = SURGERY↑albumin escapefrom intravascular spaceInflammatory mediators↑vasodilation effectof anesthetic agents↑K+ releasefrom cells↓K+ and ↑ NaintracellularSick cell syndromeof critical illness↑hypotonic fluidinfusion90% cause of hyponatremia in surgeryFluid Retention +Electrolyte ImbalanceLobo D, Macafee DL, Allison S. How perioperative fluid balance influences postoperative outcomes. Best Pract Res Clin Anaesthesiology 2006; 20(3): 439–55.
64Impaired wound healing Ileus and dehiscenceSalt and water overload↑intra-abdominal pressure↓mesentery blood flowIntestinal edema↓tissue OH-prolineSTAT3 activation↓myosin phosphorylationILEUSImpaired wound healingDEHISCENCEIntramucosalacidosis↓muscle contractilityChowdhury and Lobo. Curr Opinion Clin Nutr Metab 2011
65Anastomosis leak Points to bowel preparation: meta-analyses show that bowel preparation is not beneficialin elective colonic surgery, and 2 smaller recent RCTs suggest that it increases the risk for anastomotic leakPromote longer ileus durationPoints to fluid managementLassen K et al. Consensus Review of Optimal Perioperative Care in Colorectal Surgery: Enhanced Recovery After Surgery (ERAS) Group Recommendations. Arch Surg 2009; 144 (10):
66What is the worst fluid to give? Plasma0.9% salineNa (mmol/L)135 – 145154Cl (mmol/L)95 – 105K (mmol/L)3.5 – 5.3HCO3 (mmol/L)24 – 32Osmolality (mOsm/kg)275 – 295308pH7.35 – 7.455.4Lobo D, Macafee D, and Allison S. How perioperative fluid balance influencespostoperative outcomes. Best Pract Res Clin Anaesthesiology 2006; 20(3):
69Inflammation & organ failure in the ICU SIRSTNF, IL-1, IL-6, IL-12, IFN, IL-3IL-10, IL-4, IL-1ra, Monocyte HLA-DR suppressionCARSdaysInsult(trauma, sepsis)Inflammatory balanceANTIPROTissue inflammation, Early organ failure and deathweeksImmunosuppression2nd InfectionsDelayed MOF and deathGriffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle Nutrition Workshop SeriesGoal of nutrition/ pharmaconutrition
70Inflammation & organ failure in the ICU SIRSTNF, IL-1, IL-6, IL-12, IFN, IL-3IL-10, IL-4, IL-1ra, Monocyte HLA-DR suppressionCARSdaysInsult(trauma, sepsis)Inflammatory balanceANTIPROTissue inflammation, Early organ failure and deathweeksImmunosuppression2nd InfectionsDelayed MOF and deathGriffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle Nutrition Workshop SeriesGoal of nutrition/ pharmaconutritionEarly enteral nutritionSupplement with parenteral nutritionPharmaconutrition: Fish oils and glutamineZero fluid balance
71Sarcopenia in elderly COMPLICATIONS This presentation of the progression of sarcopenia when the patient ages and the succeeding complications of effect of disuse and disease shows the effects on malnutrition development on both function and status.Reference: Sarcopenia. Vandewoude M. Abbot symposium on sarcopenia, ESPEN 2011; Goteborg, Sweden.
72Sarcopenia in elderly COMPLICATIONS Early enteral nutrition Supplement with parenteral nutritionAdequate nutrient intakePharmaconutrition: Fish oils and glutamineZero fluid balanceThis presentation of the progression of sarcopenia when the patient ages and the succeeding complications of effect of disuse and disease shows the effects on malnutrition development on both function and status.Reference: Sarcopenia. Vandewoude M. Abbot symposium on sarcopenia, ESPEN 2011; Goteborg, Sweden.
76Surgical case62 y/o maleHeight=1.6 m, weight=52 kg, weight two months ago=60 kgAnorexia, vomiting; weight lossDiagnosis: head of pancreas cancerReferred for surgery:Labs: Hb=11, WBC=5600, N=60%, L=6%, platelet=240k; Na=135 mmol/L; K=3.2 mmol/L; glucose=160 mg/dL; BUN=6 mmol/L; albumin=3 gm/dL; creatinine=1.1 mg/dL
77Questions Will you operate on this patient tomorrow? Yes if emergency needed, but needs intraop enteral access and will give early enteral nutritionNo; optimize patient through nutrition and fluid management
78Available data BMI=21 Weight loss in two months=13% Cancer, head of pancreasAlbumin=3 gm/dLTotal lymphocyte count (TLC)=336Na=135, K=3.2Compute for the osmolality([2x135] + [160/18] +  = mOsm/kg H2O)
79QuestionIf you plan to build up the patient how?
80Build up Total fluid (ml)/day = 52 kg x 30 ml/day = 1560-1600 ml/day Total calories/day = 52 kg x 30 kcal/day = 1560 kcal/dayTotal protein/day = 52 kg x 1.5 gm/day = 78 gm/dayTotal carbo and fat: get the non-protein calories: 1560 – (78x4kcal/gm) = 1248 NPCCarbo (60%): 1248 x 0.60 = kcal/(4kcal/g) = 187 gmFat (40%): 1248 x 0.40 = kcal/(9kcal/g) = 55.5 gmVitamins and trace elements?
81Build up What is the route? Duration of build up? Oral? Tube feed? Parenteral nutrition? Combination?Duration of build up?How to ensure adequate intake?Measure calorie count dailyMonitor and ensure normalization of the electrolyte and fluid status
82Build up What are the indicators of build up success? Normalization of abnormal values?TLC? Albumin? Na? K?“zero” fluid balance?Adequate nutrition intake?
83Intra-operative Will you monitor the fluid input? How much fluid loss do you expect?Will you leave everything to the anesthesiologist?What are your choices of fluids?Will you place a jejunostomy?
84Post-operative Will you place an NGT? Will you place drains? How will you monitor the post-op course?Will you place on NPO? How long?How often will you check the electrolytes? Glucose?When will you start enteral feeding? Oral feeding?How? When?Will you give parenteral nutrition?
85Take home message Fluid and nutritional status Fluid and electrolyte balanceNutrient balance/adequate nutrient intake