Pre-operative CHO loading an integral component of peri-operative care - Only the Beginning-

2. Pre-operative CHO loading an integral component of peri-operative care- Only the Beginning-

4. Response to Surgery and Fasting Fasting further increases metabolic response to surgery Insulin resistance is a useful metabolic marker

5. Effects of Cytokines on Nutritional Status Immune cells activated Cytokines produced Appetite Reduced IL1b TNFa IL6 Altered fuel mix Gluconeogenisis lipolysis SURGERY Fat mobilised Muscle mobilised LBM WEIGHT LOSS

6. Traditional Fasting Patient involvement – passive

7. Traditional Post-op • Opiate analgesia patient unable to sit up and take fluids for several hours (no fluid pre-op). Also contribute to ileus, N&V. • NBM ?3-5/7 Further starvation Immobilisation • Patient expectations – passive in their care expect to be hospitalised 10/7 lengthy recovery

8. Where Are We Now

9. Multimodel Strategies to Improve Surgical Outcome • Patient info • Anxiety/Fear • Optimise nutrition Delayed • Organ dysfunction • Modify alcohol/smoking • Hypothermia • Neuraxial blockade • Nausea, vomiting, ileus, • semi- starvation • Laprascopic surgery Accelerated • Normothermia • Hypoxemia • Nausea and ileus prevention • Early enteral feeding • Sleep disturbance • Undisturbed sleep • Drains, NG tubes, • catheters • Opiate sparing analgesia Adapted Kehlet, 2000

10. Patterns of Recovery Rate of Return of Function Enhanced Recovery Traditional Care Days Weeks Adapted Luff,2003

11. Where are we now –CHO loading has influenced traditional peri-operative care in colorectal surgery - Fast track peri-operative care.

12. Fearon et al, 2005 Clin Nut 24: 466-467

13. Insulin Resistance Following Elective Surgery • Enhanced by fasting • Symptoms similar to type 2 diabetes • Reduced by regional anaesthetic and minimally invasive techniques • Related to magnitude of surgery • Can remain for about 3 weeks • Associated with length of stay

14. 100 R=0.53 p<0.0001 n=60 80 60 Post-op Insulin sensitivity (% pre-op) 40 20 0 -0.2 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 Log length of stay (Days) Insulin Resistance and Length of Stay Thorell et al, Curr Opin Clin Nutr Metab Care 1999

15. Preop CHO loading-Clinical Research • A pre-operative fast is not ideal to prepare a patient for surgical stress since: • it is uncomfortable • It contributes to an additional catabolic stress and worsens recovery • Hypothesis: The negative effects of pre-operative fasting can be reduced by pre-operative carbohydrate loading • Improve post-operative insulin sensitivity • Reduce post-operative insulin resistance • Improve patient well being • Improve recovery and reduce length of stay

16. Preoperative oral carbohydrate administration • It has been demonstrated that CHO fluids provided 2-3 hours before induction of anaesthesia - attenuate early postoperative metabolic stress. - improve insulin resistance. - reduce recovery time.

17. Fast Track vs Traditional

18. Length of Hospital Stay in Colorectal Surgery n=48 ** ** p>0.01 n=33 Length of Stay Fearon and Luff, 2003

19. Fast Track vs Traditional • n=451 (Traditional n=333 (4 countries), Fast Track n=118 (Denmark)) • Retrospective case note review. • Patients underwent laparotomy for colorectal resection. • No difference in morbidity or 30 day mortality between centres. • The median length of stay was 2days in Fast Track and 7-9 days in Traditional (p<0.05). • Readmission rate was 22% in Fast Track cf 2-16% Traditional (p<0.05). • Nygren et al, 2005 Clin Nutr. 24: 455-61

20. Early Oral Nutrition After Elective Colorectal Surgery • Influence of balanced analgesia and enforced mobilisation. - Mobility significantly improved (5.5 hrs/day vs 1.7 hrs/day). - Nutritional intake greater. - No significant loss of body composition Henriksen et al, 2002 Nutrition 18: 263-267

21. What role the Dietitian ?

22. New Approach to Pre-op Management (n=65) Pre Surgery Discharge Weight BMI Anthropometry (TSF/AMC) 800mls placebo/CHOD 2-3hours pre-surgery 400mls placebo/CHOD Weight BMI Anthropometry (TSF/AMC) LOS

23. Preoperative vs Discharge BMI 2

24. Anthropometry changes AMC TSF * *p<0.05

26. Preoperative oral carbohydrate administration • The provision of utilisable energy can minimise the loss of lean body mass. What remains to be elucidated is whether: • This attenuation of lean body mass can improve sustainable improvement of function

27. Dietitians taking this Forward ? • Henriksen et al (2002) provided 200ml ONS to intervention group 1day pre-op and 7 days post-op. Assumption made that patients compliant. • Alluded to other factors that may have improved intake - patient involvement - early mobilisation

28. Nutrition as Component ER • As with pharmacological interventions this nutritional approach relies strongly on patient compliance however the commitment from patients to adhere to prescribed nutritional regimens is poor (Bruce et al, 2003; Akner and Cederholm, 2001; Lawson et al, 2000).

29. Appropriately Involve PatientWhere do we Start ? • Patient’s perception of dietetic consultation. • How does the patient value nutrition as a component of their nutritional care? • Determine the patient’s knowledge and understanding of key nutritional concepts. • Explicitly identify what contribution the patient can make to their nutritional care.

30. Patient Perception of Dietetic Consultation • Rate nutrition as factor in recovery (VAS) and justify. • What advice given and asked in their view advice acceptable • Did patient feel able to contribute to dietary targets set ? How could patient involvement be improved? • Out-patient review mode and media of consultation.

31. Do Patients Understand Key Nutritional Concepts? • Health literacy importance element in achieving compliance. • Use body map as tool to allow patient to patient’s understanding of the relationship between pathophysiology/recovery. • Non- threatening multiple choice questions and ask for justification for their selection.

32. Where are we Going • Examine the use of multimodal accelerated recovery programme in elderly #NOF patients. - pre-op carbohydrate loading. - anaesthesia and pain control. - training programme. - nutrition. - active patient involvement. - monitor in the rehabilitation phase of care.

34. Team Dietitians - Emma Kehoe, Project Lead. - Jackie Bird, Patient Involvement. Clinicians – Dr Alan Davidson, Dr Eric Gardiner Physiologist – Dr Isobel Davidson. Physiotherapist – Dr Sarah Mitchell. OT – Claire Ritchie. Cosultant – Christine Russell