1 / 35

Nutritional Aspects of ERP

Nutritional Aspects of ERP. Pete Turner Specialist Nutritional Support Dietitian. Programme. ERP philosophy NBM Preoperative Carbohydrate Loading Malnutrition and surgery Screening - MUST Treatment plan. Enhanced Recovery Programme (ERP).

duane
Download Presentation

Nutritional Aspects of ERP

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Nutritional Aspects of ERP Pete Turner Specialist Nutritional Support Dietitian

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

  3. 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

  4. 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

  5. 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

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

  7. Sodium • Excess sodium • Oedema • Bowel oedema • Delayed bowel function • Ileus (Lobo et al 2002, Lancet 25;359, 1812-8) • Guidelines on Intravenous Fluid Therapy in Adult Surgical Patients – GIFTASUP (www.bapen.org.uk)

  8. Preoperative Carbohydrate (CHO) • Beneficial to anyone undergoing major surgery • Traditional preoperative fast harmful • 12 – 16 hours NBM • Metabolism changes to “starved” state

  9. Starved State • 12 hrs – 20 days • Increased Glucagon • Increased Cortisol • Catabolism • Gluconeogenesis • Insulin resistance

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

  11. 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

  12. CHO loading • Decreased catabolism • Decreased hyperglycaemia • Preserved muscle mass • Improved grip strength • Reduced LOS • Reduced Anxiety

  13. LOS Study meta-analysis • Ljungqvist et al 1998 Clin Nutr 17, Suppl1:3. • 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)

  14. Not Just Colorectal Urology Pancreatic Hip replacement Knee replacement

  15. All elective surgery

  16. 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?

  17. 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

  18. Balanced oral nutritional supplements Fortisip Fresubin Ensure Plus Milkshake Clinutren NICE CG32 Grade A

  19. 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

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

  21. Cost of Malnutrition • Annual cost of obesity to NHS? • £4.2 billion (DOH 2011) • Annual cost of malnutrition to NHS? • £13 billion (BAPEN 2009)

  22. 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 <18.9 increased mortality

  23. 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

  24. 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

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

  26. 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

  27. 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”

  28. Artificial Nutrition

  29. Portable Pumps

  30. TPN

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

  32. 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@rlbuht.nhs.uk

More Related