1. Malnutrition in surgical patients
Surgical Nutrition Training Module
Level 1
Philippine Society of General Surgeons
Committee on Surgical Training
Malnutrition 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. Objectives
To define malnutrition and discuss its impact on the surgical patient
To identify malnutrition in hospitalized surgical patients
The objectives of this presentation are:
To define malnutrition and discuss its impact on the surgical patient
To 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 / marasmus
Cachexia
Protein-energy malnutrition
Sarcopenia
Failure to thrive
Obesity
These are the features of the malnutrition syndrome:
Wasting / marasmus
Cachexia
Protein-energy malnutrition
Sarcopenia
Failure to thrive
Obesity
Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
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
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.
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 enzymes
Proteolysis inducing factor (PIF) which causes proteolysis from the muscle stores thus losing amino acids
Lipid Mobilizing Factor (LMF) which causes lipolysis from the fat reserves resulting to fatty acid utilization
The normal tissues which induce increased inflammation due to either cell ischemia or destruction which release cytokines like TNFα or pro-inflammatory interleukins
Bozzetti 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 cells
Pro-inflammatory: interleukin 1, interleukin 6, interleukin 8, and TNFα
Anti-inflammatory: interleukin 4, interleukin 10, TGF
The 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 expenditure
The overall effect is an increase in the complication rate

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
Protein-energy malnutrition
Today 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 energy
Gordon 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 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)
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.
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) criteria
BMI (Body Mass Index) = Weight in kg / Height in meter / Height in meter
Obese class 1
Obese class 2
40 and above Obese class 3
Morbidly Obese
> 50 Super-Obese
Obesity: WHO (World Health Organization) criteria
BMI (Body Mass Index) = Weight in kg / Height in meter / Height in meter
BMI values and nutritional status:
Obese class 1
Obese class 2
40 and above Obese class 3
Morbidly Obese
> 50 Super-Obese

12. Malnutrition syndrome: summary
UNDERNUTRITION
chronic starvation without inflammation
chronic disease with inflammation
acute injury/disease with inflammation
OBESITY
BMI > 30
Macronutrient
deficiency
Micronutrient
Metabolic Syndrome
MALNUTRITION
Hegazi R et al. TNT version 3, 2011
This summary of the malnutrition syndrome shows the two major types of body composition abnormalities:
Undernutrition – with or without inflammation
Overnutrition – with or without metabolic syndrome
Both may have either macro or micronutrient deficiency
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
The malnutrition process 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
This shows the need to intervene nutritionally as soon as possible in order to avoid more serious complications

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
These are the malnutrition concerns (major areas for intervention)
Lean body mass
To assess structure and function
To assist/improve body composition capacity for healing and recovery
To aim for good quality of life
Energy reserves
To sustain/optimize function
To aim for optimal utilization of substrates and protein synthesis

15. Malnutrition syndrome: features and effects
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
These are the effects of the malnutrition syndrome:
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
What are the effects of surgery on the patient?
effect of surgery on the patient

17. Surgery = injury SURGERY INFLAMMATION Metabolic response
Endocrine response
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
Surgery 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 NEEDS
WOUND HEALING
NORMAL
POOR ± COMPLICATIONS
No Malnutrition
Malnutrition
The 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 editors
Wound 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
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
These 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
Surgery
Nutritional status
Severe malnutrition
Good
Prolonged
Complications
Normal
Body reserves:
skeletal muscle – alanine and glutamine
fat 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 complications
42% of severely malnourished patients → major complications
Severely malnourished patients are four times more likely to suffer postoperative complications than well-nourished patients
FOR 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 1987
Detsky 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 cost
Finally 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 care
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
To 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 stay
2. Reduced muscle strength which also leads to longer hospitalization
3. Decrease in respiratory muscle strength with slower recovery due to poor tissue oxygenation
4. Impaired cardiac function which leads to hypoperfusion, weakness and slow recovery
5. Immune hypofunction and dysfunction leading to increased infection and complications
6. Higher morbidity and mortality which is the result of the above conditions
7. Poor quality of life which is the ultimate complaint of the patient
Thus 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 screening
Nutritional assessment
Malnutrition detection for patients on admission or for surgery is currently based on two processes:
Nutrition screening – rapid and encompassing
Nutrition assessment – rapid and substantial

27. Nutritional Assessment and Risk Level Form
This is the Nutrition Assessment and Risk Level form.

28. Hospital malnutrition: global
Year
Author
Location
Prevalence
1974
Bistrian US
50%
1977
Hill
England
44%
1979
Weinsier
48%
1984
Agradi
Italy
34%
1993
Larsson
Sweden
27%
1994
McWhirter
Scotland
40%
1995
Fernando
Philippines
1997
Waitzberg
Brazil
47%
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
Hospital
BMI <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) 9%
8. Mandaluyong (St. Martin De Porres Hospital
Mean
14.4%
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?

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
In conclusion:
Malnutrition is a syndrome
Its presence in surgical patients influences outcome
Detection and management of malnutrition is a priority in surgical patients
Malnutrition is prevalent in the surgical patient population