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.

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

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

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.

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.

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): 445-54

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

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.

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.

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.

Malnutrition syndrome: features Obesity: WHO (World Health Organization) criteria BMI (Body Mass Index) = Weight in kg / Height in meter / Height in meter 30 - 34.9 Obese class 1 35 - 39.9 Obese class 2 40 and above Obese class 3 40 - 50 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: 30 - 34.9 Obese class 1 35 - 39.9 Obese class 2 40 and above Obese class 3 40 - 50 Morbidly Obese > 50 Super-Obese

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.

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

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

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.

effect of surgery on the patient What are the effects of surgery on the patient? effect of surgery on the patient

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

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.

↑Energy needs = ↑ free radicals Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003. 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.

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.

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.

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; 440-446. 2. Detsky AS et al. JAMA 1994; 271(1): 54-58. Detsky et al. JPEN 1987 Detsky et al. JAMA 1994

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.

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

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

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

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

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 1974 to 1997 ranges between 27% to 50% emphasizing the problem of malnutrition in the patient care institutions

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.

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.

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.

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 2000-2003. Clin Nutr 2006; 25(1):91-101 . 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 2000-2003. Clin Nutr 2006; 25(1):91-101 .

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?

conclusion

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