PROTEIN AND CALORIE

REQUIREMENTS

THE SURGICAL PATIENT

Prof Christian Simoens, MD, PhD

Head of the Department of Abdominal Surgery

UZ Brussel

SURGICAL METABOLISM AND NUTRITION

Energy utilization

In short- and long-term starvation

Inflammatory response (SIRS-CARS)

In critical situation

ERAS guidelines

Nutritional support in the surgical patient

SHORT-TERM FASTING

glycogen

gluconeogenesis

oxidation

protein

triglycerides

brain

RBC

WBC

Nerve

Kidney (m)

Heart

Kidney (c)

Muscle

glucoseAmino

Acids(ala, gln)

glycerol

FFA

Pyruvate

lactateketones

muscle

Ad tissue

Liver

REE ↓ 30%

8-30 g N/day

Glucose ↓

FFA ↑

LONG-TERM FASTING

glycogen

gluconeogenesis

oxidation

protein

triglycerides

brain

RBC

WBC

Nerve

Kidney

HeartRenal cortex

Muscle

glucoseAmino

acids

glycerol

FFA

Pyruvate

lactate

ketones

muscle

Ad tissue

Liver

gluconeogenesis

kidney

REE %

2--5g N/day

Glucose ↓

FFA ↑↑

INFLAMMATORY RESPONS TO INJURY

DAMPs

PAMPs

Myeloid cells

Somatic cells

endothelium

SIRS

CARS

ORGAN DAMAGE

MOF

Homeostasis and

tissue repair

Pituitary

Adrenal

CNSGH

Aldosterone

insuline

Infl cytokines

TNF-α, IL, IFN

Inflammatory

response

ACTH

glucocorticoids

Epi, norepi

acetylcholine

DAMP damage-associated molecule patterns

PAMP pathogen-associated molecule patterns

CNS central nervous system

SIRS systemic inflammatory response syndrome

CARS counterregulatory anti-inflammatory response syndrome

SIRS - CARS

MOF

recovery

SIRS

CARS

ENERGY METABOLISM FOLLOWING INJURY

glycogen

gluconeogenesis

oxidation

protein

triglycerides

Wound

RBC

WBC

Nerve

Kidney

Heart

Kidney

Muscle

glucoseAmino

acids

glycerol

FFA

Pyruvate

lactate

ketones

muscle

Ad tissue

Liver

gluconeogenesis

kidney

REE ↑↑ 10-80%

15-30g N/day

Glucose ↑↑

FFA ↑↑

50-80%

WHAT IS MALNUTRITION?

There is no universally accepted definition

Malnutrition ? nutritional risk ?

~40% of patients undergoing major surgery should be at nutritional risk

~8% severely malnourished

5,4% average weight loss during hospitalisation

Malnutrition is often either not recognized or not viewed as clinicallysignificant by many surgeons

McWirther JP et al, BMJ 1994;308:945

Hiesmayr M et al, Cl Nutr 2009;28:484

IMPACT OF MALNUTRITION

Independent risk factor for poor postoperative

outcome

↓ lean muscle mass

Alterations in respiratory mecanics

Impaired immune functions

Intestinal atrophy

↑ infectious complications

poor wound healing, ↑ anastomotic leakage

↑ LOS, ↑ Costs

↑ mortality

SCREENING OF MALNUTRITION

All patients are screened on admission. Role of dietitian in the

assessment of nutritional requirements and the identification

of appropriate nutritional options

NRS (Nutritional Risk Score)

1. BMI, weight loss, food intake

2. disease severity, age

NRS ≥ 3 increased postoperative complications

Anthropometric tests

Biochemical parameters (e.g. albumine, prealbumine)

Nutrition des patients chirurgicaux11 3-5-2018

Nutrition des patients chirurgicaux12 3-5-2018

SUIVI DE L’ÉTAT NUTRITIONNEL CHEZ LES PATIENTS CHIRURGICAUX

INDICATIONS FOR NS IN SURGICAL PATIENTS

NS in the surgical patient aims to meet the energy requirements for essential metabolic processes and tissue repair and to prevent or reverse the catabolic effects of disease or injury

Only a minority of surgical patients will need routine NS

Enhanced Recovery After Surgery (ERAS) guidelines Measures aiming to attenuate the metabolic stress induced

by starvation and surgery.

ERAS was first developped for colon surgery but now extendsto other GI interventions and even to other surgicaldisciplines.

ERAS GUIDELINES /1

Avoid mechanical bowel preparation

Dehydration, fluid and electrolyte abnormalities

Increased risk for anastomotic leakage

(Preserve colonic microbiome

Role of the microbiome in glucose metabolism, immune

functions, fuel for colonocytes,…)

Lassen K et al, Arch Surg; 144: 961

ERAS GUIDELINES /2

Avoid preoperative fasting from midnight

Allow intake of clear fluids 2h and solid foods 6h before

induction

ERAS GUIDELINES /3

Preoperative carbohydrate loading

↓ preoperative thirst, hunger and anxiety

↓ postoperative insuline resistance

↓ protein loss

shorter hospital stay

ERAS GUIDELINES /4

Avoid opioids, long-acting sedatives and hypnotics

Avoid general anesthesia by gas inhalation

Epidural anesthesia

Prevention and treatment of nausea and vomiting

Avoid routine naso-gastric intubation

Effect of epidural analgesia on postoperative insulin resistance as

evaluated by insulin clamp technique

I. Uchida, T. Asoh, C. Shirasaka, H. Tsuji. Br J Surg 1988

ERAS GUIDELINES /5

Avoid perioperative IV fluid overload

Delayed return to normal gastro-intestinal function

↑ risk of anastomotic leakage

Early oral or enteral feeding

(Prefer protective colostoma to ileostoma)

ERAS GUIDELINES /6

Avoid drains (peritoneal cavity)

Prevention of postoperative ileus

Early mobilisation

ENERGY – PROTEIN REQUIREMENTS

Harris-Benedict

BEE (♂)= 66.47+13.75(W)+5.0(H)-6.76(A) kcal/day

BEE (♀)= 655.1+9.56(W)+1.85(H)-4.68(A) kcal/day

- calculated BEE x 1.2 - 2 (depending on severity of injury)

Approximative estimation of requirements

Energy: 25-30kcal/kg.day (severe stress 30-40kcal/kg.day)

1.2 – 1.5 g/kg.day protein

(nonprotein calorie : nitrogen ratio of 150:1)

Indirect calorimetry in selected patients

Weimann A. Cl Nutr 2006; 25: 224

Braga M. Cl Nutr 2009; 28: 378

ROUTES FOR NS

Oral nutritional support

Enteral tube feeding

Nasogastric, nasojejunal, PEG

jejunostomy

Parenteral feeding

Prefer enteral routeLower cost, no risk associated with IV route (vascular access, infections,…), maintained

mucosal defenses, maintained IGA and cytokines production, no bacterial overgrowth

TIMING OF NUTRITIONAL SUPPORTPREOPERATIVE NS

Patients with severe nutritional risk

Oral or enteral NS for 10-14 days (A)

or 7–10 days TPN if EN contra-indicated) (A)

Consider feeding jejunostomy (e.g. neo-adjuvant radio-

chemotherapy in obstructive esofageal cancer patients)

Pre-op oral nutritional supplements in mildly to

moderately malnourished patients

Preoperative carbohydrate load

Immunonutrition (arginine,nucleotides, n-3FA) (A)

5-7 days preoperatively to all cancer patients (and prolonged for 5-7 days postoperatively)

Weimann A. Cl Nutr 2006; 25: 224

Braga M. Cl Nutr 2009; 28: 378

TIMING OF NUTRITIONAL SUPPORTPOSTOPERATIVE NS (ORAL)

Early oral food intake (A)

Within 24h

to reach nutritional target within 5-7days

~ type of surgery

Nutritional supplements (2x200ml) untill adequate

food intake

Weimann A. Cl Nutr 2006; 25: 224

Braga M. Cl Nutr 2009; 28: 378

TIMING OF NUTRITIONAL SUPPORTPOSTOPERATIVE NS (ENTERAL)

Early tube feeding (< 24 hours) (NJT, PEG) (A)

patients at nutritional risk

severe surgery

if anticipated oral intake <60% of target for >10days

consider placement of jejunostomy at time of

surgery

Weimann A. Cl Nutr 2006; 25: 224

Braga M. Cl Nutr 2009; 28: 378

TIMING OF NUTRITIONAL SUPPORTPOSTOPERATIVE NS (PARENTERAL)

Indications for post-operative parenteral nutrition

severely malnourished patients (A)

when postoperative complication impairing

gastrointestinal function for > 7days (A)

combination EN and PN if nutritional target cannot be

met by EN alone (<60%)

Avoid overnutrition! ↑ O2 consumption, ↑ CO2 production, need for ventilatory support, fatty liver,

↓ WBC function, hyperglycemia, ↑ infections

Weimann A. Cl Nutr 2006; 25: 224

Braga M. Cl Nutr 2009; 28: 378

TYPE OF FORMULAS (ORAL – ENTERAL)

ONS

High calory, high protein diets

Enteral feeding

Standard whole protein formulas appropriate for most

patients (C)

High-calorie, high protein, elemental, renal, pulmonary,

hepatic formulas

EN with immuno-stimulating substrates (A)

Glutamine?, arginine?

Weimann A. Cl Nutr 2006; 25: 224

Braga M. Cl Nutr 2009; 28: 378

TPN COMPOSITION

Standard (3in1) mixtures appropriate for most

patients (50/30/20)

Administered over 24h (glucose control)

High output fistulas

Metabolic and electrolyte disturbances

May necessitate supplementation Na, Mg, vitamins,…

TPN COMPOSITION

Choice of lipid

n-6 FA (soy oil) pro-inflammatory, immunosuppression

MCFA (coconut oil) rapidly cleared from plasma and promptly oxidized

n-9 FA (olive oil) slower plasma clearance, ↑anti-oxydant defenses

n-3 FA (fish oil) anti-inflammatory, ↓cardiac arrhythmias

Amino-acids

Dipeptiven? (alanyl-glutamine)

Vitamins and trace elements

Supplemented on a daily basis

MONITORING NUTRITIONAL STATUS

Daily monitoring of diatary intakes

Weight

Weekly nutritional screening and/or re-assessment

Clinical parameters

Blood analyses

Glucose, triglycerides

Hematology, CRP

Liver function, renal function

Albumine, transferrin

Ionogram, P, K, Mg

REFEEDING SYNDROME

Initiation of EN or PN in a malnourished patient

Electrolyte abnormalities (PO4--, Mg++, K+)

Thiamine deficiency

Na+ and water retention (oedema)

Heart failure, respiratory failure, delirium, death

Slow increase of calorie intake in patients at risk

Close electrolyte monitoring (supplementation as

required)

OPTIMAL DURATION OF NS

Well nourished patients: untill normal feeding

Malnourished patients: ONS for 8 weeks

SUMMARY

Malnutrition substantially increase postoperative

morbidity and mortality

An appropriate postoperative NS has beneficial

effects on postoperative outcome

The implementation of ERAS guidelines has

substantially decreased postoperative morbidity

In malnourished patients the nutritional status

should first be corrected and surgery delayed