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

4. 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

5. 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

6. Traditional
Fasting
Patient involvement – passive

7. 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

8. Where Are We Now

9. 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

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

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

12. Fearon et al, 2005 Clin Nut
24:

13. 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

14. 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 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 60
patients. 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

15. 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

16. 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.

17. Fast Track vs Traditional

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

19. 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:

20. 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:

21. What role the Dietitian ?

22. 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

23. Preoperative vs Discharge BMI2

24. Anthropometry changes
AMC
TSF *
*p<0.05

26. 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

27. 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

28. 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).

29. 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.

30. 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.

31. 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.

32. 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.

34. 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