Nutritional Aspects of ERP

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Nutritional Aspects of ERP

• Pete Turner
• Specialist Nutritional Support Dietitian

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Programme

• ERP philosophy
• NBM
• Preoperative Carbohydrate Loading
• Malnutrition and surgery
• Screening - MUST
• Treatment plan

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Enhanced Recovery Programme (ERP)

• Multifactorial approach to optimise recovery from
  surgery and reduce length of stay
• Optimal anaesthesia and analgesia
• Appropriate fluid management
• Early postoperative mobilisation
• Nutritional Aspects
• Good evidence in colorectal surgery growing
  evidence in other surgery

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Nutritional Aspects of ERP

• Avoidance of nil by mouth (NBM)
• Appropriate fluids
• Preoperative carbohydrate loading
• Early postoperative nutrition
• ERP should include
• Screening for risk of malnutrition
• Preoperative nutritional support for those at
  risk

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Avoiding Preoperative NBM

• ESPEN Grade A evidence (Clinical Nutrition(25)
  2006)
• Avoids dehydration
• Require less iv fluids
• Avoid sodium overload
• Quicker recovery
• GIFTASUP
• ESA 2011

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Sodium

• Basal Sodium Requirements?
• 1mmol/kg/day
• How much Na in 1000mls saline?
• 150mmol
• How much Na in 1000mls Hartmanns?
• 131mmol
• Oedema
• GIFTASUP (www.bapen.org.uk)

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Sodium

• Excess sodium
• Oedema
• Bowel oedema
• Delayed bowel function
• Ileus (Lobo et al 2002, Lancet 25359, 1812-8)
• Guidelines on Intravenous Fluid Therapy in Adult
  Surgical Patients GIFTASUP (www.bapen.org.uk)

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Preoperative Carbohydrate (CHO)

• Beneficial to anyone undergoing major surgery
• Traditional preoperative fast harmful
• 12 16 hours NBM
• Metabolism changes to starved state

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Starved State

• 12 hrs 20 days
• Increased Glucagon
• Increased Cortisol
• Catabolism
• Gluconeogenesis
• Insulin resistance

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Surgery

• Inflammatory response
• Increased cortisol, cytokines
• Catabolism, gluconeogenesis
• Insulin resistance
• Hyperglycaemia
• Exacerbated by starvation

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CHO loading

• 50g glucose polymer
• 2 servings night before surgery
• 1 Serving 2 hours before surgery
• Block metabolic changes to starvation
• Safe (ESPEN 2006 Grade A)
• PreLoad Vitaflo
• PreOp - Nutricia

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CHO loading

• Decreased catabolism
• Decreased hyperglycaemia
• Preserved muscle mass
• Improved grip strength
• Reduced LOS
• Reduced Anxiety

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LOS Study meta-analysis

• Ljungqvist et al 1998 Clin Nutr 17, Suppl13.
• Meta-analysis of 3 RCTs
• Preoperative CHO vs overnight fast
• 20 reduction in LOS
• Preop CHO beneficial to all patients undergoing
  major surgery (ESPEN Grade B)

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Not Just Colorectal

• Urology
• Pancreatic
• Hip replacement
• Knee replacement

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All elective surgery
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Contraindications?

• Diabetes?
• Safe in type II in hospital (Gustafsson et al
  2008, Acta Anaesthesiol Scand 52(7), 946-51)
• Alcoholics Wernicke Korsakoff syndrome?
• Severely malnourished
• Refeeding syndrome?
• Emergency surgery?

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Post Operative - ACRU

• Ensure Plus
• Nutritionally balanced
• Used 4 hrs post op on ACRU
• Well tolerated
• Stop day 4 in well nourished
• Continue in malnourished

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Balanced oral nutritional supplements

• Fortisip
• Fresubin
• Ensure Plus Milkshake
• Clinutren
• NICE CG32 Grade A

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Early Post Operative Nutrition

• NICE CG32
• Promote gut function
• Attenuate stress response
• Prevent bacterial translocation
• Immune function - GALT
• Reduced anastamotic dehiscence
• NICE Grade A evidence in malnutrition

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Malnutrition

• 1 in 5 malnourished (Edington 2000)
• Increased LOS
• More infections
• More antibiotics
• BAPEN NSW 2007 RLBUHT

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Cost of Malnutrition

• Annual cost of obesity to NHS?
• 4.2 billion (DOH 2011)
• Annual cost of malnutrition to NHS?
• 13 billion (BAPEN 2009)

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Malnutrition and Surgery

• NICE 2006 CG 32
• 3 times as many post operative complications
• 4 times greater risk of death at surgery
• Increased infection
• Poor wound healing
• Depression
• Hip fracture BMI lt18.9 increased mortality

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Enhanced Recovery Malnutrition

• Does ER include preoperative treatment of
  malnutrition?
• ESPEN 2006 Grade A
• BAPEN Council
• Mike Stroud NICE
• Professor Marinos Elia Govt policy
• www.bapen.org.uk Malnutrition Matters

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What can we do?

• Screen at Preop OPD NICE CG 32
• Malnutrition Universal Screening Tool (MUST)
• OSCAR
• Management guidelines
• Dietetic referral
• Preoperative sip feeds
• Southampton Mike Stroud

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MUST

• Malnutrition Universal Screening Tool
• BAPEN
• Identifies Malnourished
• At risk of Malnutrition
• Validated
• NICE CG 32
• NHS litigation agency

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MUST Management Plan

• MUST Score
• 0 Low risk. Routine Care
• 1 Medium risk. High protein diet sheet
• 2 High Risk.
• High protein diet sheet
• Dietitian
• Oral Nutritional Supplements

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How long?

• ESPEN 10 -14 days (Grade A)
• NICE CG 32
• Most trials showing benefit from short-term
• nutrition support, do so despite too little
• nutrition being given for too short a time
  for
• the benefit to accrue from maintaining or
• improving body energy and protein stores

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Artificial Nutrition
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Portable Pumps
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TPN
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Conclusions

• Preoperative starvation is harmful
• Preoperative CHO loading is beneficial
• Most major surgery
• Safe in elective surgery

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Conclusions

• High incidence of malnutrition
• Greatly increases risk of surgery
• Morbidity and mortality
• Preoperative treatment effective
• ESPEN, NICE CG32
• European UK experts include in ER
• Evidence peter.turner_at_rlbuht.nhs.uk