Presentation on theme: "Malnutrition in surgical patients"— Presentation transcript:
1 Malnutrition in surgical patients Surgical Nutrition Training ModuleLevel 1Philippine Society of General SurgeonsCommittee on Surgical TrainingMalnutrition in surgical patients.This reality has not been given emphasis in the past surgical training modules thus it was decided by the Committee on Surgical Training of the Philippine Society of General Surgeons to develop a surgical nutrition training module for all residents, fellows, and consultants in general surgery in order to include the surgical nutrition care process in the daily practice of the general surgeon.This is the basic surgical nutrition training module which is the first part and the second part is the advanced surgical nutrition training module.
2 ObjectivesTo define malnutrition and discuss its impact on the surgical patientTo identify malnutrition in hospitalized surgical patientsThe objectives of this presentation are:To define malnutrition and discuss its impact on the surgical patientTo identify malnutrition in hospitalized surgical patients
3 Malnutrition is a syndrome Malnutrition is a syndrome. It is a collection of signs and symptoms that depicts the over-all manifestation of malnutrition which is either undernutrition or overnutrition.Malnutrition is a syndrome
4 Malnutrition syndrome: features Wasting / marasmusCachexiaProtein-energy malnutritionSarcopeniaFailure to thriveObesityThese are the features of the malnutrition syndrome:Wasting / marasmusCachexiaProtein-energy malnutritionSarcopeniaFailure to thriveObesityGordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
5 Malnutrition syndrome: features Wasting/marasmusLoss of body cell mass without underlying inflammatory condition; Pure starvationCachexiaLoss of body cell mass with underlying inflammatory condition; Cytokine mediatedCancer: moderate to advanced stageWasting/marasmusLoss of body cell mass without underlying inflammatory condition;Pure starvationCachexiaLoss of body cell mass with underlying inflammatory condition;Cytokine mediatedCancer: moderate to advanced stageGordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
6 Cancer Cachexia Cancer cachexia is induced by two areas: The tumor which produces two identified tumor derived enzymesProteolysis inducing factor (PIF) which causes proteolysis from the muscle stores thus losing amino acidsLipid Mobilizing Factor (LMF) which causes lipolysis from the fat reserves resulting to fatty acid utilizationThe normal tissues which induce increased inflammation due to either cell ischemia or destruction which release cytokines like TNFα or pro-inflammatory interleukinsBozzetti F. et al. ESPEN guidelines in parenteral nutriton: non-surgical oncology. Clin Nutr 2009; 28(4):
7 Inflammation in cachexia These are the inflammatory cytokines released both by the cancer and normal cellsPro-inflammatory: interleukin 1, interleukin 6, interleukin 8, and TNFαAnti-inflammatory: interleukin 4, interleukin 10, TGFThe end result is an increase in the loss of protein and fat which are ultimately converted to energy which is reflected by an increased energy expenditureThe overall effect is an increase in the complication rate
8 Malnutrition syndrome: features Protein-energy malnutritionIn modern healthcare this is often acute metabolic derangement driven by pro-inflammatory state; not classic PEM with clinical and metabolic evidence for reduced intake of protein and energyProtein-energy malnutritionToday this is attributed to acute metabolic derangement driven by pro-inflammatory state; not classic PEM with clinical and metabolic evidence for reduced intake of protein and energyGordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
9 Malnutrition syndrome: features Sarcopenia (mostly geriatric)Age related loss of muscle; often with inflammation / cachexia overlapFailure to thriveClassic pediatric growth failure syndromeNow also applied in clinical practice to undernourished older persons in functional or cognitive decline (Alzheimer’s disease)Sarcopenia (mostly geriatric)Age related loss of muscle; often with inflammation / cachexia overlapFailure to thriveClassic pediatric growth failure syndromeNow also applied in clinical practice to undernourished older persons in functional or cognitive decline (Alzheimer’s disease)Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
10 Sarcopenia 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.
11 Malnutrition syndrome: features Obesity: WHO (World Health Organization) criteriaBMI (Body Mass Index) = Weight in kg / Height in meter / Height in meterObese class 1Obese class 240 and above Obese class 3Morbidly Obese> 50 Super-ObeseObesity: WHO (World Health Organization) criteriaBMI (Body Mass Index) = Weight in kg / Height in meter / Height in meterBMI values and nutritional status:Obese class 1Obese class 240 and above Obese class 3Morbidly Obese> 50 Super-Obese
12 Malnutrition syndrome: summary UNDERNUTRITIONchronic starvation without inflammationchronic disease with inflammationacute injury/disease with inflammationOBESITYBMI > 30MacronutrientdeficiencyMicronutrientMetabolic SyndromeMALNUTRITIONHegazi R et al. TNT version 3, 2011This summary of the malnutrition syndrome shows the two major types of body composition abnormalities:Undernutrition – with or without inflammationOvernutrition – with or without metabolic syndromeBoth may have either macro or micronutrient deficiencyHegazi R et al. TNT version 3, 2011.
13 Malnutrition process It is a continuum Starts with poor intake Effect of initiation and progress of the disease process: severity of disease and adequacy of intakeEffect of efforts to correct both body composition and disease processThe malnutrition process is a continuumStarts with poor intakeEffect of initiation and progress of the disease process: severity of disease and adequacy of intakeEffect of efforts to correct both body composition and disease processThis shows the need to intervene nutritionally as soon as possible in order to avoid more serious complications
14 Malnutrition concerns Lean body massStructure and functionBody composition capacity for healing and recoveryQuality of lifeEnergy reservesFunctionOptimal utilization of substrates and protein synthesisThese are the malnutrition concerns (major areas for intervention)Lean body massTo assess structure and functionTo assist/improve body composition capacity for healing and recoveryTo aim for good quality of lifeEnergy reservesTo sustain/optimize functionTo aim for optimal utilization of substrates and protein synthesis
15 Malnutrition syndrome: features and effects Wasting / marasmusCachexiaProtein-energy malnutritionSarcopeniaFailure to thriveObesityLoss of lean body massStructural and functional impairmentEnergy utilization problemsAntioxidant capabilitiesIncreased complications and mortalityThese are the effects of the malnutrition syndrome:Loss of lean body massStructural and functional impairmentEnergy utilization problemsAntioxidant capabilitiesIncreased complications and mortalityGordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
16 effect of surgery on the patient What are the effects of surgery on the patient?effect of surgery on the patient
17 Surgery = injury SURGERY INFLAMMATION Metabolic response Endocrine responsePOST-SURGERY STATUSResolution of inflammationWound healingRecoveryCOMPLICATIONSMalnutritionInadequate intakeCurrent body compositionPre-op preparation (NPO, antibiotic, fluid balance)Post-op managementSurgery is an injury process.Injury causes the inflammatory process to be activated in the local and systemic areas thus involving the cellular metabolism and functions that are programmed to bring about healing.The availability of the needed nutrients with interactions with other components of care (fluids and antibiotics) play a major role in the quality of recovery or healing especially the presence or absence of complications
18 Surgery, wound healing, and nutritional status INFLAMMATION↑WBC + ↑ENERGY↑CELL MULTIPLICATION + ↑NUTRIENT NEEDSWOUND HEALINGNORMALPOOR ± COMPLICATIONSNo MalnutritionMalnutritionThe inflammation status during and after surgery brings about increased nutrient and energy requirements which are the reflections of cellular multiplication and tissue anabolism. Nutritional status is a major factor in the healing process with malnutrition resulting to poor healing and increased complications.
19 ↑Energy needs = ↑ free radicals Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editorsWound healing is an energy requiring process which is increased and the mitochondria and all of the cellular organelles which are involved in energy production and utilization will produce a lot of free radicals which if not neutralized will cause cell damage/death. Thus antioxidants are found in every corner of the cell which make the healing process optimal and effective.
20 Role of nutrition in surgery LIPIDSMUSCLEMALTGALTCARBOAlanineWBC, RBC, FIBROBLASTSAll WBC, RBC, FACTORSBone MarrowMALT, GALTB-cellsT-cellsPlateletsGlutamineOrgans Affectedepitheliumconnective tissueangiogenesiscomplement systemINFLAMMATIONANTIOXIDANTSWOUND HEALINGINFECTION CONTROLBody compositionNEED TO KEEP ALL NUTRIENTS IN STEADY SUPPLY AS NEEDEDThese are the areas where a lot of activity is happening during the process of healing after injury. Inflammation involves the complement, hemopoietic and immune system which are fully dependent on the major reserves (fat and protein) for full function. Keeping all the nutrients flowing will ensure the completion of the healing process which also includes resolution of any complication that arise.
21 Nutrition and wound healing SurgeryNutritional statusSevere malnutritionGoodProlongedComplicationsNormalBody reserves:skeletal muscle – alanine and glutaminefat reserves – energy (long term)To summarize, the outcome of surgery is mainly dictated by the amount of reserves the body has which is quantified/qualified by the process of nutritional assessment. The quality of outcome, morbidity or mortality is mainly influenced by the patient’s nutritional status.
22 Malnutrition in surgical patients 9% 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. Twenty seven percent of these patients had some degree of malnutrition, and 9% 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
23 Malnutrition and costs Malnutrition 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.
24 Malnutrition: effects on surgery Slow wound healing.Reduced muscle strength.Decrease in respiratory muscle strengthImpaired cardiac functionImmune hypofunction and dysfunctionHigher morbidity and mortalityPoor quality of lifeTo appreciate the value of nutritional assessment we need to know the consequences of malnutrition: These are:1. Slow wound healing which results to complications and longer hospital stay2. Reduced muscle strength which also leads to longer hospitalization3. Decrease in respiratory muscle strength with slower recovery due to poor tissue oxygenation4. Impaired cardiac function which leads to hypoperfusion, weakness and slow recovery5. Immune hypofunction and dysfunction leading to increased infection and complications6. Higher morbidity and mortality which is the result of the above conditions7. Poor quality of life which is the ultimate complaint of the patientThus knowing that a patient has a poor nutritional status will guide us in avoiding the above complications of malnutrition
25 Prevalence of malnutrition What is the prevalence of malnutrition in the hospital? Among surgical patients? Which are the severely malnourished and how did they fare after surgery? Is malnutrition a major factor in the outcomes?Prevalence of malnutrition
26 Malnutrition detection tools Nutrition screeningNutritional assessmentMalnutrition detection for patients on admission or for surgery is currently based on two processes:Nutrition screening – rapid and encompassingNutrition assessment – rapid and substantial
27 Nutritional Assessment and Risk Level Form This is the Nutrition Assessment and Risk Level form.
28 Hospital malnutrition: global YearAuthorLocationPrevalence1974BistrianUS50%1977HillEngland44%1979Weinsier48%1984AgradiItaly34%1993LarssonSweden27%1994McWhirterScotland40%1995FernandoPhilippines1997WaitzbergBrazil47%Global hospital malnutrition as shown from to 1997 ranges between 27% to 50% emphasizing the problem of malnutrition in the patient care institutions
29 Malnutrition in the Philippines HospitalBMI <18.5BMI >30SGA “C”1. Marikina, Rizal (Amang Rodriguez Medical Center)38%15%-2. Lipa City, Batangas (Mary Mediatrix Med Center)18%5%3. Quezon City (St. Luke’s Medical Center)6%12%4. Manila (Philippine General Hospital)42%5. Pasig (The Medical City)4%14%6. Alabang (Asian Hospital Medical Center)8%20%7. Cabanatuan City (Premiere Medical Center)9%8. Mandaluyong (St. Martin De Porres HospitalMean14.4%11.8%Malnutrition is present in every hospital which reported their prevalence of malnutrition to the Philippine Society of Parenteral and Enteral Nutrition (PHILSPEN). Note the undernutrition or overnutrition prevalence, but what is significant here is the presence of severe malnutrition in 42% of patients in the country’s biggest government hospital.
30 The prevalence of malnutrition in the surgical and oncology sections is substantial in the different time frames of examination – 52% and 25% in the surgical unit and 64% to 53% in the cancer center.
31 Malnutrition in the units The prevalence of malnutrition determination showed that every unit has a malnourished patient and this includes the cancer, general surgery, and orthopedic units.
32 Nutritionally at risk patients Nutritionally high risk patients identified through a nutrition assessment process include cancer and surgical patients.Llido L. The impact of computerization of the nutrition support process in the nutrition support program in a tertiary care hospital in the Philippines: report for the years Clin Nutr 2006; 25(1):Llido L. The impact of computerization of the nutrition support process in the nutrition support program in a tertiary care hospital in the Philippines: report for the years Clin Nutr 2006; 25(1):
33 What is the prevalence of malnutrition among surgical patients in your center? This is the crux of the matter – what is the prevalence of malnutrition among surgical patients in your institution?
35 Malnutrition Is a syndrome Its presence in surgical patients influences outcomeDetection and management is a priority in surgical patientsIs prevalent in the surgical patient populationIn conclusion:Malnutrition is a syndromeIts presence in surgical patients influences outcomeDetection and management of malnutrition is a priority in surgical patientsMalnutrition is prevalent in the surgical patient population