Dr Alisa Crouch Geriatrician The Prince Charles …...Goals •Haematinics and anaemia management...

Nutrition and haematinics in the

perioperative periodDr Alisa Crouch

Geriatrician

The Prince Charles Hospital, Brisbane

Why me?

• Geriatrician working in hip fracture care

• Successful intervention technique in this difficult

group

• Currently involved in RCT for preoperative

carbohydrate loading in emergency surgery for

NOF

Goals• Haematinics and anaemia management preop

• Look at recent recommendations for nutrition in periop period and evidence behind them

• AKA – How it might help you and yours

• Practicalities.

• How we try to make it work in the real world.

What I will not be covering

• Preoperative weight loss in obesity

• Details of parenteral nutrition

• Specific patient type recommendations

Haematinics and anaemia

• Iron

• B12

• Folate

• (Also needs Vit C, B1 and B6)

• Identification of cause is important

Risks of perioperative anaemia

Risks of anaemia

◦ Mortality and morbidity increases

Risks of transfusion

◦ “standard” – haemolytic, TRALI,etc

◦ Mortality, length of stay

Musallam KM, Tamim HM, Richards T, Spahn DR, Rosendaal FR, Habbal A et al. Preoperative anaemia and

postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 2011; 378: 1396–1407

Bernard AC, Davenport DL, Chang PK, Vaughan TB, Zwischenberger JB. Intraoperative transfusion of 1 U to 2

U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and

sepsis in general surgery patients. J Am Coll Surg 2009; 208: 931–937.

Iron replacement• Oral replacement.–Has a place but slow and side effects limit

• Infusion– Effective

– Some risks

• +/- EPO– Potential side effects hypertension, thrombosis

Canning ML, Gilmore KA Iron staining following an intravenous iron infusion. Med J Aust 2017;207(2):58

Process

• Bloods reviewed at time of waitlisting

• Liaise with GP if bloods not done

• Nurse lead

• PART of the story – also need to manage intraoperative blood loss, anticoagulation, transfusion protocols…..

Peri-operative nutrition

Duke Clinical Research Institute

Protein / calorie deficits

• Increased morbidity and mortality

• Increased length of stay

• Less likely to be discharged home

• Inflammatory response – catabolism –glycogen, fat, protein with subsequent muscle loss

SunZ,et al. (2015)Nutritional Risk Screening2002 as a Predictor of Postoperative Outcomes in

Patients Undergoing Abdominal Surgery: A Systematic Review and Meta-Analysis of Prospective

Cohort Studies.PLoSONE10(7):e0132857.doi:10.1371/ journal.pone.0132857

Severe nutritional risk Wt loss >10-15% within 6 months

BMI <18.5 kg/m2

SGA Grade C or NRS >5

Serum albumin <30g/L (no renal or hepatic dysfunction)

3 times complication rates and mortality.

Weimann A, et al. ESPEN Guideline: Clinical nutrition in surgery. Clinical nutrition 36(2017); 623-650

ESPEN 2017 guidelines• Integration of nutrition into overall management

• Avoid long periods of fasting

• Re-establishment of oral feeding as early as possible

• Start nutritional therapy early – as soon as risk becomes apparent

• Metabolic control

• ↓ factors that exacerbate catabolism or reduce GI function

• ↓ time on paralytic agents for ventilator Mx

• Early mobilisation

Weimann A, et al. ESPEN Guideline: Clinical nutrition in surgery. Clinical Nutrition 36(2017); 623-650

Nutrition Care Process and Model Part I:The 2008 UpdateJuly 2008 Volume 108 Number 7, Journal of the AMERICAN DIETETIC ASSOCIATION

Patient Comes to clinic after colonoscopy

Scans for staging

Multidisciplinary meeting with oncologists

Decision made for resection

Listed

Booked

PreAC

Admitted for OT

6. Assess nutritional status before and after

major surgery

Think about thiamine and multivitamins for

malnourished

Are they malnourished?

Subjective Global Assessment (SGA)

Nutritional Risk Screening (NRS 2002)

Malnutrition Universal Screening Tool (MUST)

Nutritional Risk Index (NRI)

Mini-Nutritional Assessment (MNA)

◦ Also in short form

Screening ≠ Diagnosis

Increased risk shown in nutritional

supplementation in all comers NRS ≥3 for

those not actually malnourished.

Grass et al. Preoperative nutritional risk screening by the specialist instead of the nutritional risk

score might prevent excess nutrition: a mulitvariate analysis of nutritional risk factors. Nutrition

Journal (2015) 14:37

14. Patients with severe nutritional risk shall

receive nutritional therapy prior to

surgery (A) even if this results in delays.

Period of 7-10 days may be appropriate

(O)

15. Whenever feasible oral or enteral preferred

Requirements• Healthy adult – Energy 25-30 kcal/kg

– Protein 0.8-1.5 g/kg (1-1.5 for older)

• Hypermetabolic– Energy 30-35 kcal/kg

– Protein 1.2-1.5 g/kg

• Cancer cachexia– Energy ≥30 kcal/kg

– Protein 1.4-2 g/kg

Carlia F, Gillisb C, Scheede-Bergdahl C. Promoting a culture of prehabilitation for the surgical cancer patient.

ACTA ONCOLOGICA, 2017 VOL. 56, NO. 2, 128–133

Immediate Pre op (NB ERAS)

1. If no specific aspiration risk:

–Clear fluids until 2 hours pre op

–Solids until 6 hours pre op (Grade A)

2. Preop carbohydrate treatment night

before and 2 hours before surgery

(Grade B)Amer MA et al. Network meta-analysis of the effect of preoperative carbohydrate loading on recovery after

elective surgery. Br J Surg 2017; 104:187-97

Liu VX et al. Enhanced recovery after surgery program implementation in 2 surgical populations in an

integrated health care delivery system. JAMA Surg. 2017 July 19; 152(7) e171032

Post op

3. In general oral nutritional intake shall be

continued after surgery without interuption

4. Adapt oral intake to individual and surgery

5. Oral intake (including clear fluids) should be

initiated within hours of surgery for most

Nutritional therapy

7. Nutritional therapy indicated in patient with malnutrition and those at nutritional risk.

- Also if anticipated unable to eat for more than 5 days or not above 50% recommended for 7 days

- Enteral route where possible

8. If req. cannot be met by oral route combination of enteral and parenteral nutrition

13. Peri- or postop immunonutrients should

be given in malnourished patients

undergoing major cancer surgery (B)

- No clear evidence for these vs

standard nutritional supps exclusively (O)

Immunonutrition?• Enteral diet with additional arginine,

glutamine, omega 3, and/or RNA

• Theorised to alter immune function and cytokine production

• Several negative studies in well nourished patients

• Care in sepsis (REDOXX study)

Concerns?

Disclosure of interests

C. Mariette: Clinical trials: as principal investigator,

coordinator or principal experimenter (Nestlé,

Merck-Serono); Occasional work: advisory

activities (Nestlé, Takeda); Conferences: invitation

as speaker (Nestlé, Roche, Sanofi, Takeda).

Care in the critically ill

ICU cohort 300 patients.

Enteral immunonutrition vs high protein

◦ No change in rates of infection

◦ No change in length of stay

◦ Increased 6 month mortality in “medical” pts

◦ No benefits, some potential risks

Van Zanten ARH, et al. High Protein Immune-Modulating Enteral Nutrition and Risk of Infection in the ICU.

JAMA.2014;312(5):514-524.doi:10.1001/jama.2014.7698

More recommendations14. Needs not met with normal food – oral

nutritional supplement encourage unrelated to nutritional status

22. - 26. Details of tube types and feed types

27. Regular reassessment of nutritional state

28.-33. Transplant specific

34.-37. Bariatric surgery specific

What have we done about it? Multidisciplinary, multimodal, systematic nutrition care

◦ Blanket dietician review

◦ “medicalisation”of nutrition – recognising malnutrition as a

disease and nutrition as the clinical intervention

◦ Coordinated multidisciplinary approach and delegation of care

◦ Enhanced food services system

◦ Improving nutrition knowledge and awareness

Team involvement in identifying issues

◦ Pragmatic action research

Elective considerations

Identification of those at risk

Selection of screening tools

Timely reviews

Think about thiamine supplementation

also

Food for thought… Screen for malnutrition using a validated tool as

soon as possible

Feed at risk patients early – go hard with protein

Starve your patients sparingly

Avoid restrictive diets including delayed or staged diet upgrades.

When the gut works, use it (but there is a place for PN)

Use funky nutrition to generate interest but don’t forget the basics.

Thanks to

Dr Jack Bell

Sally Fraser

Michelle Dwyer

QUESTIONS?

References• Perioperative nutrition

• Wojda TR, et al. Perioperative Nutrition Support for Surgical Patients: Aspects and Commentary. Curr Surg Rep (2015);3:27

• Miller KR, et al. An Evidence-Based Approach to Perioperative Nurtition Support in the Elective Surgical Patient. J Parenter Enteral Nutr. 2013;37:39S-50S

• Bell J et al. Multidisciplinary, multi-modal nutritional care in acute hip fracture inpatients – Results of a pragmatic intervention. Clinical Nutrition (2014) 33;6; 1101–1107

• Bell J et al. Developing and evaluating interventions that are applicable and relevant to inpatients and those who care for them; a multiphase, pragmatic action research approach. BMC Medical Research Methodology 2014 https://doi.org/10.1186/1471-2288-14-98

• Anaemia

– Ng O, Keeler BD, Mishra A, Simpson A, Neal K, Brookes MJ, Acheson AG. Iron therapy for pre-operative anaemia. CochraneDatabaseof SystematicReviews 2015, Issue 12. Art.No.: CD011588. DOI: 10.1002/14651858.CD011588.pub2.

9. If PN all-in-one should be preferred over

multi-bottle system

10. SOP for nutritional support to secure

effective nutritional support therapy.

11. Glutamine supplementation can be

considered with PN

12. Consider including omega-3 fatty acids in

PN (B)

13. Peri- or postop immunonutrients should

be given in malnourished patients

undergoing major cancer surgery (B)

- No clear evidence for these vs standard

nutritional supps exclusively (O)

ERAS

Preop carb loading

◦ Variably implemented

◦ Positive trials for time to flatus in abdo surg

◦ Many trials with small numbers

◦ Can be difficult for emergency lists

Prevalence on admission: 52%

Incidence (during acute

Malnutrition – Undertreated

What have we done about it?Clinical practice improvements identified, developed and implemented by the

treating team using pragmatic action research approach

Multidisciplinary, multimodal, systematic nutrition care

Proactive nutrition assessment & intervention; all patients

‘Medicalisation’ of nutrition – recognising malnutrition as a disease, and

nutrition as the clinical intervention

Coordinated multidisciplinary approach and delegation of care

Enhanced foodservices system

Improving nutrition knowledge and awareness

Bell et al (2014) Clinical NutritionBell et al (2014) BMC Medical Research Methodology

Anaemia of Chronic Inflammation

Adapted from:

http://www.melbournehaematology.com.au/pdfs/guidelin

es/melbourne-haematology-guidelines-iron-studies.pdf

https://www.researchgate.net/figure/261957307_fig1_Iro

n-is-bound-and-transported-in-the-body-via-transferrin-

and-stored-in-ferritin (Iron)