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NUTRITION IN FAST TRACK SURGEY Atta-ur-Rehman, Ph.D (Clinical Nutrition) King Khalid National Guard Hospital,Jeddah KSA.:

NUTRITION IN FAST TRACK SURGEY Atta-ur-Rehman, Ph.D (Clinical Nutrition) King Khalid National Guard Hospital,Jeddah KSA.

PowerPoint Presentation:

PROTECTIVE & DESTRUCTIVE A STRESS RESPONSE WHAT HAPPENS IN HOSPITALIZED PATIENTS ? Trauma Sepsis Surgery Cancer Chronic Infections Burns Fractures

Metabolic Response to Illness:

Metabolic Response to Illness Time Energy Expenditure Ebb Phase Flow Phase Cutherbertson, Tilstone, Adv Clin Chem 1969.

Metabolic Response to Illness:

28 24 20 16 12 8 4 0 10 20 30 40 Major Burn Skeletal Trauma Severe Sepsis Infection Days Nitrogen Excretion (g/day) Normal Range Metabolic Response to Illness Elective Operation

Metabolic Response to Starvation & Illness:

Metabolic Response to Starvation & Illness Starvation Injury or Illness Metabolic Rate   Body Fuels conserved wasted Body Protein conserved wasted Urinary Nitrogen   Weight Loss slow rapid The body adapts to starvation but not when accompanied by critical injury or illness .

Neuroendocrine Response:

Neuroendocrine Response Endocrine Response Fatty Acids Glucose Glucose Fat Deposits Liver & Muscle (Glycogen) Muscle (Amino Acids)

PowerPoint Presentation:

FATE OF PROTEIN METABOLISM CORTISOL LIVER ( Gluconeogenesis) Synthesis of new glucose Substrate for wound healing Acute Phase proteins needed during stress Skeletal amino acids Mobilized / efflux ACUTE PHASE PROTEINS Immunoglobulins, leukocytes, lymphocytes to fight infection Hemoglobin, albumin to replace blood loss Enzymes necessary for protein synthesis Mobilization results in rapid loss of lean body mass & increase negative nitrogen balance

PowerPoint Presentation:

IF ALLOWED TO PROCEED UNABATED THE NET PROTEIN CATABOLISM RESULTS IN CRITICAL ORGAN FAILURE Rapid loss of lean body mass NET RESULT IS A NEGATIVE NITROGEN BALANCE AS PROTEIN CATABOLISM EXCEEDS PROTEIN SYNTHESIS BY LIVER FATE OF PROTEIN METABOLISM

PowerPoint Presentation:

Hyperglycemia, a common response to catabolism Results from increased hepatic gluconeogenesis Decreased glucose uptake by insulin dependent tissues Decreased glucose incorporation into fatty acids The persistent hyperglycemia Injury induced insulin resistance FATE OF CARBOHYDRATE METABOLISM

PowerPoint Presentation:

FATE OF CARBOHYDRATE METABOLISM Glucagon secretion is increased Insulin release is blocked by epinephrine HEPATIC GLUCOSE PRODUCTION "PSEUDO DIABETIC STATE" (STRESS DIABETES) The wound uses glucose extensively as an energy source GLUCONEOGENESIS (Liver) - meets glucose needs ANOREXIA - side effect of high blood glucose

PowerPoint Presentation:

ENERGY/ PROTEIN NEEDS GOAL The goal of nutritional support is to supply enough protein to promote anabolism , along with sufficient calories to ensure that protein will not be used as a source of energy

PowerPoint Presentation:

Therefore providing optimal nutrition support to the patients, keeping in mind the increased requirements for energy, protein, electrolytes, fluids is imperative. CONCLUSION

Recovery After Surgery :

Recovery After Surgery What are we trying to achieve? Patient mobile (back to preop level) GI function back to normal – Able to eat normally – Bowel movements No pain on oral analgesics

Recovery After Surgery:

Recovery After Surgery Nutritional goals Return to normal food asap Energy and protein requirements Able to handle feeding Normal GI function

Question # 1:

Question # 1 One of the following is not proven 1. Overnight fasting is the safest way to prepare for surgery 2. 3 kg weight gain after surgery is undesirable 3. Insulin resistance is undesirable after surgery 4. Bowel cleansing increases the risk for anastomotic leaks in colon resection 5. Patients can eat normal food the day after colon resection

Outlines:

Outlines What are the problems? – Fluid balance – Catabolism _Interactions between fluids and nutrition _Integration of treatments _Proposals for protocols

What are the issues? :

What are the issues? fluids & nutrition Fluids – Fluid imbalance pre – per – post op Nutrition – Inadequate nutrition – Metabolic derangements – Poor pain control

The problem in nutrition:

The problem in nutrition Metabolic derangements Effect of treating insulin resistance 1548 consecutive postop ICU patients Glucose 4.5-6.1 mM vs. treat >12 mM Mortality ICU 43% Mortality in hospital 34% G van den Berghe, N Engl J Med 2001

Insulin normalize metabolism:

Insulin normalize metabolism Postop insulin to glucose 6 mmol/l normalized: FFA Urea excretion Substrate utilization after major surgery Brandi LS et al: Clin Sci 1990

Back to eating food :

Back to eating food Two main problems Gut is not working – Fluids – Drains, tubes – Pain Catabolism ”blocks use” of nutrients

Back to eating food:

Back to eating food Two main problems Gut is not working Catabolism blocks use of nutrients How did we do yesterday (i.e. 2003)?

Question # 2:

Question # 2 In my unit we routinely used Bowel cleansing for colon resections Overnight fasting for elective surgery NG tubes until bowel movements Opioids (not EDA) for postop pain relief 2 or more of the above

Current perioperative treatment:

Current perioperative treatment Survey in Sweden (+ N, DK, NL, Scotland) 2003 71% response rate overall (S = 69%) Practice in current use 70 yr otherwise healthy, colon resection for cancer Extracted data from Lassen et al: BMJ 2005

Current perioperative treatment:

Current perioperative treatment Bowel cleansing 97% oral Clear fluids 86% 2 h / 14% 3-4h Preop CHO 30% iv / 22% oral EDA 48h 92% NG tube postop 18% next morning Postop oral nutrition 25% (50% no) Extracted data from Lassen et al: BMJ 2005

Making the gut work after surgery:

Making the gut work after surgery Fluid balance Fluid accumulation in the gut Pain control Medications to support gut function

PowerPoint Presentation:

Bowel preparation increases the risk of anastomotic leakage N = 1454, OR 1.75 (1.05 – 2.70), p = 0.032 Slim K et al BJS 2004; 91, 1125-1130

Naso-gastric (NG) tubes:

Naso-gastric (NG) tubes Meta-analysis of 26 studies: postoperative NG tube after abdominal surgery increases the risk for: Fever Lungatelectasies Pneumonia Delayed food intake Cheatham Ann Surg 1995

Question # 3:

Question # 3 Glucose levels – what is correct? Is not a problem in uncomplicated medium size surgery Need to be controlled only in ICU Is a sign of metabolic derangements Below 10 mmol/l is probably not of any importance in surgical patients

Metabolic derangements :

Metabolic derangements Insulin resistance _ Hyperglycemia – Dramatic effects on outcomes – Insulin resistance is the key Protein economy Function

Hyperglycemia:

Hyperglycemia Chronic diabetes -> complications Infections Cardiovascular Renal failure Polyneuropathy Muscle weakness

Hyperglycemia in surgical stress:

Hyperglycemia in surgical stress Traditional belief: Hyperglycemia in the acutely stressed patient is ”not dangerous” Glucose levels treated > 12 mmol/l Few studies on postoperative glucose Levels

Hyperglycemia in surgical stress:

Hyperglycemia in surgical stress Present knowledge: Hyperglycemia in the acutely stressed patient is dangerous Glucose levels treated > 6 mmol/l Understanding of the role of glucose control and insulin in stress is improving

Aggressive insulin treatment in ICU:

Aggressive insulin treatment in ICU Prospective randomized trial 1548 consecutive postop ICU patients Target glucose 4.5-6.1 mM vs. treat >12mM Mortality ICU 43% Mortality in hospital 34% G van den Berghe, N Engl J Med 2001

Aggressive insulin treatment in ICU:

Aggressive insulin treatment in ICU Prospective randomized trial 1548 consecutive postop ICU patients Target glucose 4.5-6.1 mM vs. treat >12 mM Bacteremia 46% Ventilatory support 37% Renal failure 41% Polyneuropathy 44% G van den Berghe, N Engl J Med 2001

Pattern of complications:

Pattern of complications Postop (days) Diabetes (years) Bacteremia Infections Ventilatory support Muscle weakness Renal failure Polyneuropathy

Hyperglycemia:

Hyperglycemia Overload of substrates in mitochondria -> ROS ”Blocks” glycolysis and Krebs cycle -> gene expression -> cytokine production Insulin treatment reduces CRP levels Brownlee, Nature 2003

Glucose control:

Glucose control & surgical stressed patient Hyperglycemia is dangerous Glucose control should be targeted Lower levels of stress benefit from glucose control

Conclusions:

Conclusions Balanced fluid and sodium – target no change in body weight Make the gut work – fluids, EDA, feed Avoid metabolic stress – EDA, Preop CHO, Early postop feeding Serve normal food early, add sip feeds Build multiprofessional & multimodal perioperative care programs Add on: Monitor the pace of change

Question # 4:

Question # 4 After hearing this lecture I heard about our present periop protocol I think we need to make some changes I think this speaker is out of his mind I will make changes and this will be easy to do – the logic and proof is sound I will think about this and read some more

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