4Response to Surgery and Fasting Endocrine responseGlucagonInsulinMetabolic responseGlycogen breakdownProtein breakdownLipolysisInsulin resistanceThis table serves to outline the most important metabolic changes seen relating to surgical stress and those relating to fasting.The endocrine response as we know involves an increase in production of glucagon with a concomitant reduction in production of insulin.The metabolic responses involve an increase in glycogen, protein and fat breakdown, while there is a notable increase in insulin resistance.All of these responses are also seen with respect to fasting causing them all to be exaggerated in the fasted patient undergoing surgery.Fasting further increases the effects of surgical stress.Insulin: Anabolic hormone (Glycogen synthesis, Protein synthesis) and Blood glucose lowering effectInsulin Resistance: A reduced biologic response to insulin (Hyperglycaemia), and Absence or reduction in anabolic processes, and Protein breakdownFasting further increases metabolic response to surgeryInsulin resistance is a useful metabolic marker
5Effects of Cytokines on Nutritional Status Immune cells activatedCytokines producedAppetiteReducedIL1bTNFaIL6Altered fuel mixGluconeogenisislipolysisSURGERYBecause of the presence of the tumour the immune cells (and subsequently other cells) release the proinflammatory cytokines. Production of IL1 in particular causes a reduction in appetite (anorexia). We have already discussed the implications of anorexia.As well as reducing appetite cytokines particularly PIF (proteolysis inducing factor) begin to mobilise muscle or lean body mass. This leads to overt changes in body composition which may progress to significant levels of wasting in cancer patients.Fat mobilisedMuscle mobilisedLBMWEIGHT LOSS
7Traditional Post-opOpiate analgesia patient unable to sit up and take fluids for several hours (no fluid pre-op).Also contribute to ileus, N&V.NBM ?3-5/7 Further starvationImmobilisationPatient expectations – passive in their careexpect to be hospitalised 10/7lengthy recovery
13Insulin Resistance Following Elective Surgery Enhanced by fastingSymptoms similar to type 2 diabetesReduced by regional anaesthetic and minimally invasive techniquesRelated to magnitude of surgeryCan remain for about 3 weeksAssociated with length of stayInsulin resistance is associated with length of hospital stay
14Insulin Resistance and Length of Stay Log length of stay (Days)Post-op Insulin sensitivity(% pre-op)1.41.21.00.188.8.131.52.0-0.220406080100R=0.53p<0.0001n=60One issue which seems to be of particular interest to people in the current climate of healthcare economics is that of the effect on length of stay.In this paper published in 1999 Thorell et al tested whether post-op insulin resistance is related to clinical outcome. They did this by combining data from a series of studies in which identical methods were used to assess insulin sensitivity and related them to length of stay.All the studies took place between in the same hospital in Sweden. The investigators had no control over the clinical management of the patients and these were discharged as soon as they were deemed fit.The reduction in insulin sensitivity on the first post-op day was compared with the length of hospital stay after the operation.It was found that the degree of post-op insulin resistance was significantly correlated with the length of stay p=To allow for the multiple confounding factors affecting the length of stay of these patients a multiple regression analysis was performed in the same 60patients. The overall predictive value of the regression model was 71% p<Thus measures of insulin resistance not only provide estimates of metabolic disturbance related to degree of stress but also offer a measure of a parameter that has implications for outcome in terms of length of stay.Thorell et al, Curr Opin Clin Nutr Metab Care 1999
15Preop CHO loading-Clinical Research A pre-operative fast is not ideal to prepare a patient for surgical stress since:it is uncomfortableIt contributes to an additional catabolic stress and worsens recoveryHypothesis:The negative effects of pre-operative fasting can be reduced by pre-operative carbohydrate loadingImprove post-operative insulin sensitivityReduce post-operative insulin resistanceImprove patient well beingImprove recovery and reduce length of stayThe underlying hypothesis in the development of a pre-operative carbohydrate drink is that:many of the negative endocrine and metabolic effects relating to fasting can be reduced by carbohydrate loadingthe improvement in the pre-operative metabolic state will reduce the reactions to physical stress.Thus we expect to see animprovement in post-operative insulin sensitivityreduction in post-operative insulin resistanceimproved recovery and hence a reduced length of stayimprovement in patient well-beingI would like to talk briefly about each of these claims
16Preoperative oral carbohydrate administration It has been demonstrated that CHO fluids provided 2-3 hours before induction of anaesthesia- attenuate early postoperative metabolic stress.- improve insulin resistance.- reduce recovery time.
18Length of Hospital Stay in Colorectal Surgery **** p>0.01n=33Length of StayFearon and Luff, 2003
19Fast Track vs Traditional n=451 (Traditional n=333 (4 countries), Fast Track n=118 (Denmark))Retrospective case note review.Patients underwent laparotomy for colorectal resection.No difference in morbidity or 30 day mortality between centres.The median length of stay was 2days in Fast Track and 7-9 days in Traditional (p<0.05).Readmission rate was 22% in Fast Track cf 2-16% Traditional (p<0.05).Nygren et al, 2005 Clin Nutr. 24:
20Early Oral Nutrition After Elective Colorectal Surgery Influence of balanced analgesia and enforced mobilisation.- Mobility significantly improved (5.5 hrs/day vs 1.7 hrs/day).- Nutritional intake greater.- No significant loss of body compositionHenriksen et al, 2002 Nutrition18:
26Preoperative oral carbohydrate administration The provision of utilisable energy can minimise the loss of lean body mass.What remains to be elucidated is whether:This attenuation of lean body mass can improve sustainable improvement of function
27Dietitians taking this Forward ? Henriksen et al (2002) provided 200ml ONS to intervention group 1day pre-op and 7 days post-op. Assumption made that patients compliant.Alluded to other factors that may have improved intake- patient involvement- early mobilisation
28Nutrition as Component ER As with pharmacological interventions this nutritional approach relies strongly on patient compliance however the commitment from patients to adhere to prescribed nutritional regimens is poor (Bruce et al, 2003; Akner and Cederholm, 2001; Lawson et al, 2000).
29Appropriately Involve Patient Where do we Start ? Patient’s perception of dietetic consultation.How does the patient value nutrition as a component of their nutritional care?Determine the patient’s knowledge and understanding of key nutritional concepts.Explicitly identify what contribution the patient can make to their nutritional care.
30Patient Perception of Dietetic Consultation Rate nutrition as factor in recovery (VAS) and justify.What advice given and asked in their view advice acceptableDid patient feel able to contribute to dietary targets set ? How could patient involvement be improved?Out-patient review mode and media of consultation.
31Do Patients Understand Key Nutritional Concepts? Health literacy importance element in achieving compliance.Use body map as tool to allow patient to patient’s understanding of the relationship between pathophysiology/recovery.Non- threatening multiple choice questions and ask for justification for their selection.
32Where are we GoingExamine the use of multimodal accelerated recovery programme in elderly #NOF patients.- pre-op carbohydrate loading.- anaesthesia and pain control.- training programme.- nutrition.- active patient involvement.- monitor in the rehabilitation phase of care.
34Team Dietitians - Emma Kehoe, Project Lead. - Jackie Bird, Patient Involvement.Clinicians – Dr Alan Davidson, Dr Eric GardinerPhysiologist – Dr Isobel Davidson.Physiotherapist – Dr Sarah Mitchell.OT – Claire Ritchie.Cosultant – Christine Russell