Pre-operative CHO loading an integral component of peri-operative care - Only the Beginning-

Response to Surgery and Fasting Endocrine response Glucagon  Insulin  Metabolic response Glycogen breakdown Protein breakdown Lipolysis Insulin resistance This 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 effect Insulin Resistance: A reduced biologic response to insulin (Hyperglycaemia), and Absence or reduction in anabolic processes, and Protein breakdown Fasting further increases metabolic response to surgery Insulin resistance is a useful metabolic marker

Effects of Cytokines on Nutritional Status Immune cells activated Cytokines produced Appetite Reduced IL1b TNFa IL6 Altered fuel mix Gluconeogenisis lipolysis SURGERY Because 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 mobilised Muscle mobilised LBM WEIGHT LOSS

Traditional Fasting Patient involvement – passive

Traditional Post-op Opiate 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 starvation Immobilisation Patient expectations – passive in their care expect to be hospitalised 10/7 lengthy recovery

Where Are We Now

Multimodel Strategies to Improve Surgical Outcome Patient info Anxiety/Fear Optimise nutrition Organ dysfunction Delayed Modify alcohol/smoking Hypothermia Neuraxial blockade Nausea, vomiting, ileus, semi- starvation Laprascopic surgery Accelerated Normothermia Hypoxemia Nausea and ileus prevention Early enteral feeding Sleep disturbance Undisturbed sleep Drains, NG tubes, catheters Opiate sparing analgesia Adapted Kehlet, 2000

Patterns of Recovery Rate of Return of Function Enhanced Recovery Traditional Care Days Weeks Adapted Luff,2003

Where are we now – CHO loading has influenced traditional peri-operative care in colorectal surgery - Fast track peri-operative care.

Fearon et al, 2005 Clin Nut 24: 466-467

Insulin Resistance Following Elective Surgery Enhanced by fasting Symptoms similar to type 2 diabetes Reduced by regional anaesthetic and minimally invasive techniques Related to magnitude of surgery Can remain for about 3 weeks Associated with length of stay Insulin resistance is associated with length of hospital stay

Insulin Resistance and Length of Stay Log length of stay (Days) Post-op Insulin sensitivity (% pre-op) 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 -0.2 20 40 60 80 100 R=0.53 p<0.0001 n=60 One 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 1990-1996 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=0.0001. To allow for the multiple confounding factors affecting the length of stay of these patients a multiple regression analysis was performed in the same 60 patients. The overall predictive value of the regression model was 71% p<0.0001. 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

Preop CHO loading-Clinical Research A pre-operative fast is not ideal to prepare a patient for surgical stress since: it is uncomfortable It contributes to an additional catabolic stress and worsens recovery Hypothesis: The negative effects of pre-operative fasting can be reduced by pre-operative carbohydrate loading Improve post-operative insulin sensitivity Reduce post-operative insulin resistance Improve patient well being Improve recovery and reduce length of stay The 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 loading the improvement in the pre-operative metabolic state will reduce the reactions to physical stress. Thus we expect to see an improvement in post-operative insulin sensitivity reduction in post-operative insulin resistance improved recovery and hence a reduced length of stay improvement in patient well-being I would like to talk briefly about each of these claims

Preoperative 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.

Fast Track vs Traditional

Length of Hospital Stay in Colorectal Surgery ** ** p>0.01 n=33 Length of Stay Fearon and Luff, 2003

Fast 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: 455-61

Early 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 composition Henriksen et al, 2002 Nutrition 18: 263-267

What role the Dietitian ?

New Approach to Pre-op Management (n=65) Pre Surgery Discharge Weight BMI Anthropometry (TSF/AMC) 800mls placebo/CHOD 2-3hours pre-surgery 400mls placebo/CHOD Weight BMI Anthropometry (TSF/AMC) LOS

Preoperative vs Discharge BMI 2

Anthropometry changes AMC TSF * *p<0.05

Preoperative 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

Dietitians 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

Nutrition 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).

Appropriately 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.

Patient Perception of Dietetic Consultation Rate nutrition as factor in recovery (VAS) and justify. What advice given and asked in their view advice acceptable Did patient feel able to contribute to dietary targets set ? How could patient involvement be improved? Out-patient review mode and media of consultation.

Do 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.

Where are we Going Examine 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.

Team Dietitians - Emma Kehoe, Project Lead. - Jackie Bird, Patient Involvement. Clinicians – Dr Alan Davidson, Dr Eric Gardiner Physiologist – Dr Isobel Davidson. Physiotherapist – Dr Sarah Mitchell. OT – Claire Ritchie. Cosultant – Christine Russell