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Malnutrition in surgical patients Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training.

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Presentation on theme: "Malnutrition in surgical patients Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training."— Presentation transcript:

1 Malnutrition in surgical patients Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training

2 Objectives To define malnutrition and discuss its impact on the surgical patient To identify malnutrition in hospitalized surgical patients

3 MALNUTRITION IS A SYNDROME

4 Malnutrition syndrome: features Wasting / marasmus Cachexia Protein-energy malnutrition Sarcopenia Failure to thrive Obesity Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.

5 Malnutrition syndrome: features Wasting/marasmus – Loss of body cell mass without underlying inflammatory condition; Pure starvation Cachexia – Loss of body cell mass with underlying inflammatory condition; Cytokine mediated – Cancer: moderate to advanced stage Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.

6 Cancer Cachexia

7 Inflammation in cachexia

8 Malnutrition syndrome: features Protein-energy malnutrition – In 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 energy 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 overlap Failure to thrive – Classic pediatric growth failure syndrome – Now 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.

10 Sarcopenia COMPLICATIONS

11 Malnutrition syndrome: features Obesity: WHO (World Health Organization) criteria – BMI (Body Mass Index) = Weight in kg / Height in meter / Height in meter Obese class Obese class 2 40 and aboveObese class Morbidly Obese > 50Super-Obese

12 Malnutrition syndrome: summary UNDERNUTRITION chronic starvation without inflammation chronic disease with inflammation acute injury/disease with inflammation UNDERNUTRITION chronic starvation without inflammation chronic disease with inflammation acute injury/disease with inflammation OBESITY BMI > 30 OBESITY BMI > 30 Macronutrient deficiency Macronutrient deficiency Micronutrient deficiency Micronutrient deficiency Metabolic Syndrome MALNUTRITION Hegazi 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 intake – Effect of efforts to correct both body composition and disease process

14 Malnutrition concerns Lean body mass – Structure and function – Body composition capacity for healing and recovery – Quality of life Energy reserves – Function – Optimal utilization of substrates and protein synthesis

15 Malnutrition syndrome: features and effects Wasting / marasmus Cachexia Protein-energy malnutrition Sarcopenia Failure to thrive Obesity Wasting / marasmus Cachexia Protein-energy malnutrition Sarcopenia Failure to thrive Obesity Loss of lean body mass Structural and functional impairment Energy utilization problems Antioxidant capabilities Increased complications and mortality Loss of lean body mass Structural and functional impairment Energy utilization problems Antioxidant capabilities Increased complications and mortality Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.

16 EFFECT OF SURGERY ON THE PATIENT

17 Surgery = injury SURGERY INFLAMMATION Metabolic response Endocrine response INFLAMMATION Metabolic response Endocrine response POST-SURGERY STATUS Resolution of inflammation Wound healing Recovery POST-SURGERY STATUS Resolution of inflammation Wound healing Recovery COMPLICATIONS Malnutrition Inadequate intake Current body composition Pre-op preparation (NPO, antibiotic, fluid balance) Post-op management COMPLICATIONS Malnutrition Inadequate intake Current body composition Pre-op preparation (NPO, antibiotic, fluid balance) Post-op management

18 Surgery, wound healing, and nutritional status SURGERY INFLAMMATION ↑WBC + ↑ENERGY ↑CELL MULTIPLICATION + ↑NUTRIENT NEEDS WOUND HEALING NORMAL POOR ± COMPLICATIONS No MalnutritionMalnutrition

19 ↑Energy needs = ↑ free radicals Robbins Basic Pathology 7 th edition. Kumar, Cotran, Robbins editors

20 Role of nutrition in surgery LIPIDS MUSCLE MALT GALT CARBO Alanine WBC, RBC, FIBROBLASTS All WBC, RBC, FACTORS Bone Marrow MALT, GALT B-cells T-cells Platelets Glutamine Organs Affected epithelium connective tissue angiogenesis complement system INFLAMMATION ANTIOXIDANTS WOUND HEALING INFECTION CONTROL Body composition NEED TO KEEP ALL NUTRIENTS IN STEADY SUPPLY AS NEEDED

21 Nutrition and wound healing Wound healing Surgery Nutritional status Severe malnutrition Good Prolonged Complications Normal Body reserves: skeletal muscle – alanine and glutamine fat reserves – energy (long term) Body reserves: skeletal muscle – alanine and glutamine fat reserves – energy (long term)

22 Malnutrition in surgical patients 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 Detsky et al. JPEN 1987

23 Malnutrition and costs Malnutrition is associated with increased cost and the higher the risk the higher the number of complications plus cost Reilly 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 strength Impaired cardiac function Immune hypofunction and dysfunction Higher morbidity and mortality Poor quality of life

25 PREVALENCE OF MALNUTRITION

26 Malnutrition detection tools Nutrition screeningNutritional assessment

27 Nutritional Assessment and Risk Level Form

28 Hospital malnutrition: global YearAuthorLocationPrevalence 1974BistrianUS50% 1977HillEngland44% 1979WeinsierUS48% 1984AgradiItaly34% 1993LarssonSweden27% 1994McWhirterScotland40% 1995FernandoPhilippines48% 1997WaitzbergBrazil47%

29 Malnutrition in the Philippines HospitalBMI <18.5 BMI >30 SGA “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)15%9%- 8. Mandaluyong (St. Martin De Porres Hospital12%8%- Mean14.4%11.8%

30

31 Malnutrition in the units

32 Nutritionally at risk 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):

33 WHAT IS THE PREVALENCE OF MALNUTRITION AMONG SURGICAL PATIENTS IN YOUR CENTER?

34 CONCLUSION

35 Malnutrition Is a syndrome Its presence in surgical patients influences outcome Detection and management is a priority in surgical patients Is prevalent in the surgical patient population


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