Nutritional Aspects of ERP

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

12. 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

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

14. 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)

15. Not Just Colorectal Urology Pancreatic Hip replacement Knee replacement

16. All elective surgery

17. 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?

18. 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

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

20. 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

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

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

23. 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

24. 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

25. 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

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

28. 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

30. 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”

31. Artificial Nutrition

32. Portable Pumps

33. TPN

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

35. 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