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Surgery Review: Surgical nutri2on,
Fluids and electrolytes (Part 2)
May 23, 2014
PRACTICAL SURGERY
Pre-‐opera1ve checklist • Check nutri1onal and fluid status (nutri1onal assessment)
• Check fluid and electrolyte status (=homeostasis): – Na, K, Cl (then may add Mg, Ca if needed) – Glucose, BUN, serum osmolality – Fluid intake and output record
• Wound healing capacity – Energy and protein requirements – Micronutrient requirements – Need for pharmaconutri1on
1. DETECT MALNUTRITION
Nutri1on screening & assessment Nutri2on screening Nutri2onal assessment
Malnutri1on and complica1ons Surgical pa2ents • 9% of moderately
malnourished pa1ents → major complica1ons
• 42% of severely malnourished pa1ents → major complica1ons
• Severely malnourished pa2ents are four 2mes more likely to suffer postopera2ve complica2ons than well-‐nourished pa2ents
Detsky et al. JAMA 1994 Detsky et al. JPEN 1987
Malnutri1on and complica1ons
Malnutri1on and cost Malnutri1on is associated with increased cost and the higher the risk the
higher the number of complica1ons plus cost
Reilly JJ, Hull SF, Albert N, Waller A, Bringardener S. Economic impact of malnutri1on: a model system for hospitalized pa1ents. JPEN 1988; 12(4):371-‐6.
2. DETERMINE REQUIREMENTS
Nutri1on Care Plan Form
How much calories? Usual: 20-‐25 kcal/kg/day
Very sick: 15-‐20 kcal/kg/day
Jeejeebhoy K. 4th Asia Pacific Parenteral Nutri1on Workshop. June 7-‐9, 2009; Kuala Lumpur, Malaysia
How much protein?
How much carbohydrate and fat?
3. DETERMINE ROUTE OF FEEDING
Feeding algorithm Can the GIT be used?
Yes No
Parenteral nutrition Oral
< 75% intake
Tube feed
Short term Long term
Peripheral PN Central PN More than 3-4 weeks
No Yes
NGT
Nasoduodenal or nasojejunal
Gastrostomy
Jejunostomy
“inadequate intake”
“Inability to use the GIT”
A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and enteral
nutrition in adult and pediatric patients, III: nutritional assessment – adults. J
Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA.
malnutri2on Scheduled • esophageal resec2on • gastrectomy • pancrea2coduodenectomy
Enteral nutri2on for 10-‐14 days
oral immunonutri2on for 6-‐7 days
Early oral feeding within 7 days
yes no
within 4 days
yes
“Fast Track”
no
Parenteral hypocaloric
Adequate calorie intake within 14 days
Enteral access (NCJ)
yes no
enteral nutri2on immunonutri2on for 6-‐7 days
Oral intake of energy requirements
yes no
combined enteral / parenteral
no slight, moderate severe
SURGERY
PRE-‐OPERATIVE PHASE
POST-‐OP
EARLY DAY 1 -‐ 14
LATE DAY 14
Oral intake of energy requirements
yes no supplemental enteral diet
Surgical nutri1on pathways: Pre-‐opera1ve phase
Normal to moderate malnutri1on
SURGERY
Severe Malnutri1on • Esophageal resec1on • Gastrectomy • Pancrea1coduodenectomy
Parenteral nutri1on + Omega-‐3-‐Fany Acids + An1oxidants (+ glutamine); 6-‐7 days
Nutri1onal Assessment
ESPEN Guidelines on Parenteral Nutri1on (2009)
Condi1on: When oral or enteral feeding not possible
Enteral nutri1on STOMACH JEJUNUM
Nasogastric tube Nasojejunal tube
PEG PEJ
BUTTON
PLG
JET-‐PEG
PLJ
NCJ
PSJ
PFJ
PSG
PFG
Witzel, Stamm, Janeway
Loser C et al. ESPEN guidelines on ar8ficial enteral nutri8on – Percutaneous endoscopic gastrostomy
(PEG)
E: Endoscopic G: Gastrostomy J: Jejunostomy
L: Laparoscopic NC: Needle Catheter S: Sonographic F: Fluoroscopic
Parenteral nutri1on
• Central PN • Peripheral / peripheral central PN (PICC)
PICC =peripherally inserted central catheter
EARLY ENTERAL NUTRITION
• Enteral feeding 24 to 72 hours aqer surgery or when pa1ent is hemodynamically stable
• Provide nutrients required during metabolic stress
• Maintain GI integrity • Reduce morbidity compared with parenteral nutri1on
• Reduce cost compared with parenteral nutri1on
Ra1onale
Early enteral nutri1on vs standard nutri1onal support on mortality
Comparison: mortality Outcome: early enteral nutri1on vs. control
Study Treatment n/N
Control n/N
Cerra et al 1990
Gonschlich et al, 1990
Brown et al, 1994 Moore et al, 1994 Bower et al, 1996 Kudsk et al, 1996
Engel et al, 1997
Weimann et al, 1998
1/11
2/17
0/19 1/51
24/163 1/16
7/18
2/16
1/9
1/14
0/18 2/47
12/143 1/17
5/18
4/13
0.01 0.1 10 100 Higher for control Higher for treatment
Ross Products, 1996 20/87 8/83
Mendez et al, 1997 1/22 1/21 Rodrigo et al, 1997 2/16 2/13
Atkinson et al, 1998 96/197 86/193
Galban et al, 2000 17/89 28/87
Heyland et al. JAMA, 2001
Pooled Risk Ra2o 1
4. DETERMINE ADEQUACY OF INTAKE
Calorie Count
Monitor actual nutrient intake
Effect of nutri1on intake on outcome Nutrition care led to reduced morbidity and mortality of surgical patients assessed
as severely malnourished and high risk (n=103)
Effect of nutrition care on post-operative complications predicted by surgical nutrition risk assessment: St. Luke’s Medical Center experience. Del Rosario D, Inciong JF, et al. 2008.
Intra-‐opera1ve checklist
• Fluid intake – Monitor and es1mate fluid losses – Only infuse what is required – Determine whether to give balanced electrolyte solu1ons or colloids; avoid saline and “water only” infusions like D5W or D10W
• Nutri1on access – Determine the need for long term enteral nutri1on (jejunostomy: surgical jejunostomy or nasojejunostomy)
How much fluid loss in surgery? Fluid Loss 60 kg wt Insensible perspira1on
Ven1la1on with 100% water = almost zero loss
0 ml
Evapora1ve loss • moderate incisions with partly exposed but non-‐exteriorised viscera = 8.0 mlhour
• major incisions with completely exposed and exteriorised viscera = 32.2 mlhour
8-‐30 ml per hr
Third space loss • Ascites or other fluids – measurable • Volumes up to 15 mL/kg/hour are
recommended in the first hour of abdominal surgery, with decreasing volumes in subsequent hours.
• Measure • 300 ml
Total • Within one hour (crystalloids not recommended)
350 first hour
Adapted from: Brandstrup B. Fluid therapy for the surgical pa1ent. Best Pract Res Clin Anaesthesiology 2006; 20(2): 265-‐83
Which fluid is the most appropriate?
31
Fluid management Use Compartment Composition Examples
Volume Replacement
Intravascular fluid volume
Iso-oncotic Isotonic Iso-ionic
6% HES 130 in balanced solution
Fluid Replacement
Extracellular fluid volume
Isotonic Iso-ionic
Balanced solution: normal saline; ringer’s lactate
Electrolyte or osmotherapy (solutions for correction)
Total body fluid volume
According to need for correction
KCL Glucose 5% Mannitol
Reference: Zander R, Adams Ha, Boldt J. 2005; 40; 701-‐719
Post-‐opera1ve checklist
• Fluids and electrolytes – Daily accumulated fluid balance – Goal: “zero” fluid balance – Serum electrolytes – Give balanced electrolyte solu1ons
• Adequacy of nutrient intake – Early enteral nutri1on – Daily nutrient balance (=nutrient intake) – Good glucose control
SURGICAL COMPLICATIONS
Common peri-‐opera1ve surgical complica1ons
• Fluid and electrolyte problems • Wound infec1on and sepsis • Wound dehiscence
Fluid management
• Average periopera1ve fluid infusion: – Intra-‐op = 3.5 to 7 liters – 3 liters/day for the next 3 to 4 days – Average gain post-‐op = 3 to 6 kg weight gain
• Leads to: – Delay of gastrointes1nal func1on – Impair wound anastomosis healing – Affects 1ssue oxygena1on – Prolonged hospital stay
Lassen et al. Arch Surg 2009
Fluid and electrolyte imbalance INJURY = SURGERY
↑albumin escape from intravascular
space
Inflammatory mediators ↑vasodila1on effect of anesthe1c agents
↑K+ release from cells
↓K+ and ↑ Na intracellular
Sick cell syndrome of cri1cal illness
↑hypotonic fluid infusion
90% cause of hyponatremia in
surgery
Fluid Reten2on + Electrolyte Imbalance
Lobo D, Macafee DL, Allison S. How periopera1ve fluid balance influences postopera1ve outcomes. Best Pract Res Clin Anaesthesiology 2006; 20(3): 439–55.
Ileus and dehiscence Salt and water overload
↑intra-‐abdominal pressure
↓mesentery blood flow
Intes1nal edema
↓1ssue OH-‐proline
STAT3 ac1va1on ↓myosin phosphoryla1on
ILEUS
Impaired wound healing
DEHISCENCE
Intramucosal acidosis
↓muscle contrac1lity
Chowdhury and Lobo. Curr Opinion Clin Nutr Metab 2011
Anastomosis leak
• Points to bowel prepara1on: – meta-‐analyses show that bowel prepara1on is not beneficial
– in elec1ve colonic surgery, and 2 smaller recent RCTs suggest that it increases the risk for anastomo1c leak
– Promote longer ileus dura1on
• Points to fluid management Lassen K et al. Consensus Review of Op1mal Periopera1ve Care in Colorectal Surgery: Enhanced Recovery Aqer Surgery (ERAS) Group Recommenda1ons.
Arch Surg 2009; 144 (10): 961-‐9.
What is the worst fluid to give?
Plasma 0.9% saline Na (mmol/L) 135 – 145 154 Cl (mmol/L) 95 – 105 154 K (mmol/L) 3.5 – 5.3 0 HCO3 (mmol/L)
24 – 32 0
Osmolality (mOsm/kg) 275 – 295 308 pH 7.35 – 7.45 5.4
Lobo D, Macafee D, and Allison S. How periopera1ve fluid balance influences postopera1ve outcomes. Best Pract Res Clin Anaesthesiology 2006; 20(3):
439-‐55.
Inflamma1on: surgery
ADAPTED FROM:
Inflamma1on: sepsis
Inflamma1on & organ failure in the ICU
SIRS TNFα, IL-1β, IL-6, IL-12, IFNγ, IL-3
IL-10, IL-4, IL-1ra, Monocyte HLA-DR
suppression
CARS
days
Insult (trauma, sepsis)
Infla
mm
ator
y ba
lanc
e
AN
TI
PR
O
Tissue inflammation, Early organ failure and death
weeks
Immunosuppression
2nd Infections Delayed MOF and death
Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle
Nutrition Workshop Series
Goal of nutri2on/ pharmaconutri2on
Inflamma1on & organ failure in the ICU
SIRS TNFα, IL-1β, IL-6, IL-12, IFNγ, IL-3
IL-10, IL-4, IL-1ra, Monocyte HLA-DR
suppression
CARS
days
Insult (trauma, sepsis)
Infla
mm
ator
y ba
lanc
e
AN
TI
PR
O
Tissue inflammation, Early organ failure and death
weeks
Immunosuppression
2nd Infections Delayed MOF and death
Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle
Nutrition Workshop Series
Goal of nutri2on/ pharmaconutri2on
1. Early enteral nutri2on 2. Supplement with
parenteral nutri2on 3. Pharmaconutri2on: Fish
oils and glutamine 4. Zero fluid balance
Sarcopenia in elderly COMPLICATIONS
Sarcopenia in elderly COMPLICATIONS
1. Early enteral nutri2on 2. Supplement with
parenteral nutri2on 3. Adequate nutrient
intake 4. Pharmaconutri2on: Fish
oils and glutamine 5. Zero fluid balance
Cancer Cachexia
Cancer Cachexia
1. Early enteral nutri2on 2. Supplement with
parenteral nutri2on 3. Adequate nutrient
intake 4. Pharmaconutri2on: Fish
oils and glutamine 5. Zero fluid balance
CASE DISCUSSION
Surgical case • 62 y/o male • Height=1.6 m, weight=52 kg, weight two months ago=60 kg
• Anorexia, vomi1ng; weight loss • Diagnosis: head of pancreas cancer • Referred for surgery: • Labs: Hb=11, WBC=5600, N=60%, L=6%, platelet=240k; Na=135 mmol/L; K=3.2 mmol/L; glucose=160 mg/dL; BUN=6 mmol/L; albumin=3 gm/dL; crea1nine=1.1 mg/dL
Ques1ons
• Will you operate on this pa1ent tomorrow?
Available data
• BMI=21 • Weight loss in two months=13% • Cancer, head of pancreas • Albumin=3 gm/dL • Total lymphocyte count (TLC)=336 • Na=135, K=3.2 • Compute for the osmolality
– ([2x135] + [160/18] + [6] = 284.8 mOsm/kg H2O)
Ques1on
• If you plan to build up the pa1ent how?
Build up
• Total fluid (ml)/day = 52 kg x 30 ml/day = 1560-‐1600 ml/day
• Total calories/day = 52 kg x 30 kcal/day = 1560 kcal/day
• Total protein/day = 52 kg x 1.5 gm/day = 78 gm/day • Total carbo and fat: get the non-‐protein calories: 1560 – (78x4kcal/gm) = 1248 NPC – Carbo (60%): 1248 x 0.60 = 748.8 kcal/(4kcal/g) = 187 gm – Fat (40%): 1248 x 0.40 = 499.2 kcal/(9kcal/g) = 55.5 gm
• Vitamins and trace elements?
Build up
• What is the route? – Oral? Tube feed? Parenteral nutri1on? Combina1on?
• Dura1on of build up? • How to ensure adequate intake?
– Measure calorie count daily – Monitor and ensure normaliza1on of the electrolyte and fluid status
Build up
• What are the indicators of build up success? – Normaliza1on of abnormal values?
• TLC? Albumin? Na? K?
– “zero” fluid balance? – Adequate nutri1on intake?
Intra-‐opera1ve
• Will you monitor the fluid input? • How much fluid loss do you expect?
– Will you leave everything to the anesthesiologist?
• What are your choices of fluids? • Will you place a jejunostomy?
Post-‐opera1ve
• Will you place an NGT? • Will you place drains? • How will you monitor the post-‐op course?
– Will you place on NPO? How long? – How oqen will you check the electrolytes? Glucose?
• When will you start enteral feeding? Oral feeding? – How? When?
• Will you give parenteral nutri1on?
Take home message
• Fluid and nutri1onal status • Fluid and electrolyte balance • Nutrient balance/adequate nutrient intake
THANK YOU
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