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)