LLL ESPEN Nutrisi Perioperatif Modul 2 PDF
LLL ESPEN Nutrisi Perioperatif Modul 2 PDF
LLL ESPEN Nutrisi Perioperatif Modul 2 PDF
Module 17.2
Learning objectives
Contents
1. Introduction
2. Screening tools
3. Indications for nutritional support
4. Preoperative nutrition
4.1. Caloric deficiency
4.2. Metabolic conditioning
4.3. Immunological preconditioning
5. Postoperative nutrition
6. Indications for parenteral nutrition (PN)
6.1. Amino acids
6.2. Glucose
6.3. Lipids
6.4. Ratio of macronutrients
6.5. Caloric amount
6.6. Vitamins and trace elements
7. Monitoring
8. Follow-up
9. Post-discharge nutrition
10. Concluding remarks
11. Summary
12. References
Key messages
Nutritional status is a prognostic factor in surgical patients;
Nutritional screening is essential in order to identify patients at metabolic risk
early before surgery;
Nutritional support is required if a longer period of inadequate oral intake has to
be anticipated;
The enteral route should be preferred;
1. Introduction
Malnutrition is generally considered to be associated with starving and lack of food. Its
presence in a modern society with an increasing percentage of obese people is frequently
neither realized nor well understood. Undernutrition is more subtle than suggested by the
World Health Organization (WHO) definition with a body mass index (BMI) <18.5kg/m2.
Disease related weight loss in patients with overweight is not necessarily associated with
the low BMI of the definition of the WHO. However, this weight loss results in changes of
body composition inducing a loss of fat-free mass, thus bearing a „metabolic risk“ which
has to be kept in mind for patients undergoing major surgery, especially those with
cancer.
Therefore, ESPEN has recently defined diagnostic criteria for malnutrition according to
two options:
-option 1: BMI <18.5kg/ m2
-option 2: combined: weight loss >10% or >5% over 3 months and reduced BMI or a
low fat free mass index (FFMI).
Reduced BMI means <20 or <22 kg/m2 in patients younger and older than 70 years,
respectively. Low FFMI is <15 and <17kg/m2 in females and males, respectively (1).
Because under- and malnutrition are frequently not recognized and therefore untreated,
metabolic factors will be usually not considered for the critical analysis of surgical
morbidity and outcome. Many retrospective and prospective major trials have elucidated
the association with impaired nutritional status and postoperative complication rate and
mortality (2-4). Data from the European “NutritionDay“ in about 15000 patients clearly
showed that “metabolic risk“ is a factor of hospital mortality, particularly in the elderly
(5).
According to the prospective data from a multicentric trial most high risk patients will be
found in hospital in the departments of surgery, oncology, geriatrics, and intensive care
medicine. The univariate analysis revealed significant impact on the hospital complication
rate from: severity of the disease, age >70 years, surgery and cancer (3). Bearing in
mind the demographic development in the western world, surgeons will have to deal with
an accumulation of risk in the elderly undergoing major surgery for cancer.
Table 1
Nutritional aspects in the surgical patient
- Nutritional Risk Screening on admission or first contact
- Observation and documentation of oral intake
- Regular follow-up of weight and BMI
2. Screening Tools
Several screening tools are available. Well validated and officially recommended by
ESPEN with wide-spread use is the Nutritional Risk Screening (NRS), the so-called
Kondrup-NRS (6). Patients classified at risk by NRS have significantly higher complication
rates during their hospital stay (3).
Copyright © by ESPEN LLL Programme 2015
Table 2
Complication rates in patients classified by NRS risk
no complication % complication % (n) Total in % (n)
(n)
No risk 88.7 (3021) 11.4 (383) 100 (3404)
Risk 69.4 (1143) 30.6 (504) 100 (1647)
p < 0.001
According to Sorensen et al, 2008 (3)
Despite convincing and clear metabolic advantages of the ERAS concept, there is also a
risk from hypocaloric nutrition and delay of adequate nutritional support in unidentified
patients at metabolic risk and those developing postoperative complications.
The indications for nutritional support in surgery are the prevention and treatment of
undernutrition. During the perioperative period this is primarily the substitution of
calories for preservation of the nutritional status and prevention of undernutrition.
Nutritional intervention may also focus on improvement in outcome – for this indication
the criteria of success are complication rates, mortality, hospital length of stay and cost-
benefit ratio.
The following recommendations are in accordance with the ESPEN Guidelines for Enteral
and Parenteral Nutrition in Surgery from 2006 and 2009 (7, 13, 14). The algorithm is
also based on these recent guidelines.
Inadequate oral intake for more than 14 days is associated with a higher mortality.
Nutritional support is therefore indicated even in patients without obvious undernutrition,
if it is anticipated that the patient will be unable to eat for more than 7 days
Copyright © by ESPEN LLL Programme 2015
perioperatively. It is also indicated in patients who cannot maintain oral intake above 60-
75% of recommended intake for more than 10 days. In these situations nutritional
support (by the enteral route if possible) should be initiated without delay. Combination
with parenteral nutrition should be considered in patients in whom there is an indication
for nutritional support and in whom energy needs cannot be met (<60% of caloric
requirement) via the enteral route, e.g. in upper GI fistulae (7, 13, 15).
Whenever possible the enteral route is preferred. (7, 16-18). If necessary in the case of
limited gastrointestinal tolerance, enteral nutrition should be supplemented by combined
enteral / parenteral support. Parenteral nutrition is beneficial in undernourished patients
in whom enteral nutrition is not feasible or not tolerated, as well as in patients with
postoperative complications impairing gastrointestinal function who are unable to receive
and absorb adequate amounts of oral / enteral feeding for 7 days or more (13).
4. Preoperative Nutrition
There are different concepts of patient conditioning which may be combined as well.
These are:
- substitution of caloric deficiency in severe metabolic risk,
- metabolic conditioning (carbohydrate loading),
- immunological preconditioning.
5. Postoperative Nutrition
In general, interruption of nutritional intake is unnecessary after surgery. Oral intake
should however be adapted to individual tolerance and to the type of surgery carried out.
Usually, oral intake can be initiated within hours after surgery (7).
It is evidence based, that early oral and/or enteral food intake diminishes the risk for
infectious complications and favours a shorter hospital length of stay (16-18). After
surgery to the gastrointestinal tract no increase in the risk of developing anastomotic
leakage can be found. Therefore, there is no reasonable rationale for longer periods of
fasting after surgery. There is evidence that even after colorectal surgery with bowel
anastomoses oral nutrition can be started without delay. When anastomoses of the upper
GI tract have been performed, patients may drink as well as receiving enteral nutrition
delivered via a tube whose tip is placed distal to the anastomosis (7).
Even if oral feeding can be started within short term after surgery patients may benefit
from supplementary postoperative tube feeding: those after major cancer surgery of the
abdomen and head and neck – laryngectomy, pharyngectomy, oesophageal resection,
gastrectomy, pancreato-duodenectomy – as well as those after severe trauma. In these
patients it is reasonable to create safe enteral access by naso-jejunal tube or fine needle
catheter jejunostomy (NCJ) at the time of surgery. It has been shown that
decompression after gastrectomy with a nasojejunal tube, bears considerable discomfort
for many patients, and may be unnecessary (31). This is therefore another argument for
NCJ for feeding (33).
Enteral tube feeding can be started with low rates (5-10ml/h) within 24 hrs after surgery.
The administration rate should be cautiously increased stepwise by (for example) 10-
20ml/h each day. Gastrointestinal tolerance has to be monitored carefully, observing
gastric residual volume, the abdomen and peristalsis. In the case of haemodymanic
instability in the ICU the administration rate should be reduced to 5-10ml/h or even
stopped for a few hours.
For early enteral nutrition, especially in the Intensive Care Unit, a slow increase of
administration rate is recommended: for example, 50ml/h with incremental small steps
of 10-20ml/h over four days observing the enteral tolerance by abdominal distension and
gastric aspiration. Standard enteral (polymeric) diets may be used which have to be
appropriately added to by sufficient volumes of intravenous fluid (34). In high-risk
patients - as outlined before - immunonutrition should often now be preferred (7, 22,
35).
6.2. Glucose
“Intensified insulin therapy” has brought new metabolic awareness regarding
hyperglycaemia. A meta-analysis including data from 38 studies clearly showed the
evidence of insulin therapy for the decrease of mortality, in particular in surgical and
diabetic ICU patients (39). However, intensified insulin treatment bears a considerable
risk of hypoglycaemia and should be continuously performed with the equipment of an
ICU (40). On the normal ward for the avoidance of hyperglycaemia reduction of glucose
supply should be considered. At present, the optimal serum glucose level is considered to
be about 140 - 150 mg% (13, 14).
6.3. Lipids
After major abdominal surgery follow-up of nutritional status (minimum BMI) including
documentation of the amount of oral food intake is necessary. Dietary counselling is
recommended as well which is usually appreciated by the patient.
Table 3
Blood chemistry
- electrolytes
- blood glucose
- triglycerides
- creatinine
- liver enzymes
- serum lactate in the critically ill
8. Follow up
Although follow up of the nutritional status can be easily performed by the BMI this is not
sensitive for differences in body composition without change of BMI. Bioelectrical
Impedance Analysis (BIA) is a feasible noninvasive tool which is also convenient for
outpatients. The intraindividual course can be well documented in a three-compartment-
model including extracellular (ECM) and body cell mass (BCM) as well as fat mass (FM).
From body impedance, the fat free mass (FFM), the ratio of ECM/BCM and the phase
angle may be easily calculated providing reasonably reliable information about the cell
content in the body. Ideally, the first measurement will be performed before surgery.
11. Summary
Aiming enhanced recovery and the reduction of postoperative morbidity ERAS
programmes do not preclude the necessity of appropriate perioperative nutritional and
metabolic care. Early detection and observation of patients with nutritional risk remains
an essential part of perioperative management. Whenever possible, artificial nutritional
support should be avoided. However, if in high risk patients inadequate oral intake has to
be anticipated nutritional support should be started early via the enteral route, perhaps
in combination with parenteral nutrition. Long-term total parenteral nutrition will be
limited to special indications. This review includes support for the guideline
recommendations for surgical patients of the European Society for Clinical Nutrition and
Metabolism (ESPEN) (www.espen.org) from 2006 and 2009, of which update is in
progress.