NHD CPD eArticle
NETWORK HEALTH DIGEST
Naomi Johnson Scientific and Regulatory Manager, BSNA
Naomi has a First Class Honours degree in Nutritional Science and an MSc in Public Health Nutrition. She has worked in the nutrition industry for several years. www.bsna.co.uk
Volume 8.02 - 15th February 2018
ENHANCED RECOVERY AFTER SURGERY: THE ROLE OF NUTRITION
IN ASSOCIATION WITH THE BSNA
‘Failing to prepare is preparing to fail’, a statement which is all too true when considering patient outcomes post-surgery. For any patient undergoing surgery, recovery and avoidance of complications are key objectives. The preand post-operative health and diet of the patient is an integral part of this . . . While there are nu m erou s factors w hich w ill influ ence recovery p ost-su rgery (i.e. u nd erlying d isease, extent of su rgery, age and p sychological w ellbeing), nu tritional intervention can p lay an integral role, w ith the correct nu trition an essential part of the recovery process. Malnutrition can negatively affect wound healing by prolonging inflammatory pathways, and in patients with undernutrition who present for surgery, there is a higher risk of post-operative complications including morbidity and mortality.1,2 More than three million people in the UK are malnourished at any one time, with an estimated 30% of people admitted to acute hospitals and care homes at risk of malnourishment.3,4 A su rvey by BAPEN (British Association for Parenteral and Enteral N u trition) of UK hospitals fou nd that ad u lts ad mitted to hospital w ere more u nd erw eight (<20kg/ m 2) w hen com p ared w ith the general p opu lation.5 The European Society for Clinical N utrition and Metabolism (ESPEN ) guid ance recommend s that nutrition support should be used in patients w ith severe nutritional risk 10-14 days prior to surgery; inad equate oral intake during this period is associated w ith a higher
mortality rate.6 For those patients at severe nutritional risk, a delay to surgery and administration of tube feeding and/ or oral nutritional supplements (ONS) is advised (with exception to intestinal obstruction, severe shock and intestinal ischemia). Use of tube feeding and/ or ONS is also indicated in those patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days and those who will be unable to eat for more than seven days peri-operatively (even if und ernutrition is not obvious). Parenteral nutrition (PN) is indicated in patients for whom enteral nutrition (EN ) may not be appropriate, such as in intestinal obstruction or failure.6 PN can also be used to complement EN, in those patients consuming <60% of calorific requirements. In upper GI cancer patients at severe nutritional risk, use of PN , pre-operatively, has been show n to reduce complications.7 PRE-OPERATIVE NUTRITIONAL CONSIDERATIONS
The overall health and nutritional status of the patient prior to surgery w ill vary significantly. Underw eight, malnutrition, sarcopenia, cachexia and atrophy may already be present pre-surgery due to factors such as aging, disease
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NHD CPD eArticle and inactivity.8 Surgical nutrition stud ies have identified weight loss (>10%) and low albumin (<30g/ l) as risk factors for ad verse outcomes.9 Skeletal muscle plays an essential role in health; loss of aerobic capacity, reduced strength, weakness, fatigue, insulin resistance, falls and fear of falling, frailty disability and mortality are all associated w ith skeletal muscle loss.10 An interru p tion in nu tritional intake can be negatively implicated in health ou tcom es; increased metabolic stress, hyp erglycaem ia and insulin resistance are all ind icated in preoperative fasting.6,11 Therefore, w hilst p reoperative fasting is still com m on p ractice, it is now consid ered unnecessary for m ost patients (althou gh this is contraind icated in those at risk of aspiration). When an earlier retu rn to gastrointestinal function is facilitated , patientsâ€™ tolerance to normal food and even enteral feed ing can also be im proved .12 In a system atic review of patients w ho had elective gastrointestinal surgery, septic complications and length of hospital stay w ere red u ced in those w ho received early EN .13 It shou ld be noted , how ever, that risks are associated w ith both enteral feed ing and its early use. BAPEN gu id elines p rovid e ad vice on best practice for the ad ministration of m ed ication via enteral tu bes.14 Surgery can have a huge impact on the body, resulting in a cascad e of metabolic changes. When an injury occurs, afferent neuronal impulses activate an endocrine response.15 This stress response to surgery results in a rise in stress hormones and inflammatory markers, w hich present as immune system suppression and increased cortisol secretions w hich w ill impact both carbohydrate, fat and protein metabolism. Insulin resistance is a sign of surgical stress, w ith more extensive surgery associated w ith greater levels of insulin resistance - an independ ent risk factor that influences length of stay and
Volume 8.02 - 15th February 2018
poor wound healing.16 Hormonal changes w ill lead to increased catabolism (to mobilise energy sources). Once surgery has commenced, blood glucose concentrations will rise: the extent of this varies according to the type and degree of surgery. Potential risks linked to perioperative hyperglycaemia includ e increased w ound infection and impaired w ound healing. Postoperative control of blood sugar levels is, therefore, essential to recovery and overall outcomes. POST-OPERATIVE NUTRITIONAL CONSIDERATIONS
Du ring period s of inactivity/ im m obility, su ch as post-su rgery, a loss of lean bod y m ass is im plicated in a red u ced ability to recover. This issu e is fu rther exacerbated w ith age. An old er cohort su bjected to 10 d ays of inactivity exp erienced app roxim ately a three-fold greater loss of lean leg m u scle m ass w hen com p ared to a you nger cohort exam ining p rotein synthesis and m u scle m ass in healthy ad u lts w ho w ere su bjected to bed rest for 28 d ays.5,17 From age 40, m u scles d o not respond to p rotein from the d iet as w ell as that of you nger cou nterparts.18 The right nutrition for mu scle health and recovery is, therefore, key. Post-operatively, for the m ajority of patients a stand ard w hole protein form u la is app rop riate, w hich m ay inclu d e im m u ne-m od u lating su bstrates (arginine, omega-3 fatty acid s and nu cleotid es) in enteral form .6 Extensive research exists on the role of ON S in old er p op u lations, w hich has show n to increase both bod y w eight and improve nutritional statu s.19 In those old er ind ivid u als w ho are malnou rished , an ON S high in protein and vitamin D in particu lar, can have a valu able role to play in im proved recovery. Patients with whole-bod y protein d epletion have been shown to have a marked increase in both major complications and d uration of post-
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During periods of inactivity/immobility, such as post-surgery, a loss of lean body mass is implicated in a reduced ability to recover.
operative stay.20 For both young and eld erly individuals it is well researched that mod erate-tolarge servings of protein or amino acid s increases muscle protein synthesis.21,22 In old er ad ults, high doses of protein (>25g) or essential amino acids (10-15g) have a similar ability to synthesise muscle protein compared to younger ones; lower doses (protein <20g; EAAs <8g) d o not achieve the same skeletal muscle response. However, single servings of >30g protein d o not stimulate a greater anabolic response between younger and old er adults.23 The American Society for Parenteral and Enteral Nutrition (ASPEN) has suggested 1.2-2.0g protein/ kg for those in the critical care setting, includ ing post-operative major surgery.24 In a prosp ective non-rand om ised stu d y, significant red u ctions in nosocom ial infections and overall com plications w ere show n in highrisk su rgery p atients (N RS 2002 ≥5) w ho received su fficient pre-operative nu trition therapy (>10kcal/ kg/ d for seven d ays) w hen com pared w ith patients w ho received insu fficient therapy.25 For low risk patients, no d ifferences w ere observed betw een su fficient and insu fficient EN .25 ‘Im m u ne m od u lating nu trition’ or ‘im m u nonu trition’ (a liqu id nu tritional su pp lem ent enriched w ith specific nu trients), given by the oral/ enteral rou te d u ring the p eri-operative period has d em onstrated a red u ction in postoperative infective com plications.26 Optim al rehabilitation and w ou nd healing is d epend ent on the bod y being in an anabolic state. For the m ajority of p atients u nd ergoing su rgery, a pre-op erative carbohyd rate d rink the night before (800m l) and a 400m l d rink tw o hou rs p rior to anaesthesia is generally ad vised .6
Red uced post-operative insu lin resistance and preservation of skeletal mu scle mass has been d emonstrated in colorectal patients and those w ith hip replacement w ho took a 12.5% hypo-osmolar carbohyd rate rich d rink preoperatively.27,28,29,30 Ad ditionally, pre-operative carbohydrate load ing reduces thirst, hunger and anxiety.29,30 The correct pre-operative preparation is essential to post-operative recovery; carbohydrate loading red uces insulin resistance and diminishes nitrogen and protein loss.31,32 Post-operatively it also helps to preserve skeletal muscle. ENHANCED RECOVERY AFTER SURGERY (ERAS) GUIDELINES
Ad opted by a nu m ber of hosp itals, enhanced recovery after su rgery (ERAS) protocols have becom e a w id ely accepted toolkit.33 These gu id elines provid e evid ence-based recommend ations for ON S and EN in surgical patients. In a systematic review of six trials (3 RCTs and 2 CTs; n=512) u se of ERAS resu lted in red u ced hospital stays and a low er m orbid ity rate (RR: 0.54 [CI 0.42-1.69]), althou gh there w as no d ifference in read m ission and m ortality rate.6 The ERAS guidelines seek to minimise surgical stress, maintain nutritional status, reduce complications and optimise recovery rates. The ERAS programme considers key nutritional and metabolic aspects of pre and post-operative care, w hich integrate nutrition into the overall management of the patient, and includ e: • p re-operative nu trition;34 • avoid ance of long p eriod s of pre-op erative fasting;34
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NHD CPD eArticle • flu id intake and carbohyd rate load ing u p to tw o hou rs p re-op eratively;34 • re-establishment of oral feed ing as early as p ossible after su rgery (id eally the first p ostoperative d ay);34 • m etabolic control, e.g. of blood glu cose;34 • red u ction of factors w hich exacerbate stressrelated catabolism or im pair gastrointestinal fu nction.6 Recently published (ESPEN ) guid elines on nutrition in cancer patients strongly recom m end that all cancer patients u nd ergoing either
Volume 8.02 - 15th February 2018
curative or palliative surgery are managed using an ERAS programme.34 Successful ad option of an enhanced recovery app roach also requ ires inpu t from the multid isciplinary team ; ‘enhanced recovery is abou t the w hole team rather than an ind ivid u al’ at a su stained level.35 Im plem enting the m ost app rop riate pre-and post-surgery protocols ensu res that patients have the best possible chance of a su ccessfu l and speed y recovery. N u tritional screening and intervention can play a vital role in this, w ith ERAS programmes offering a measured clinical im pact on overall patient ou tcom es.
References 1 van Bokhorst-de van der Schueren MA, van Leeuwen PA, Sauerwein HP et al (1997). Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications. Head Neck 19(5): 419-25 2 Durkin MT, Mercer KG, McNulty MF, et al (1999). Vascular surgical society of Great Britain and Ireland: contribution of malnutrition to postoperative morbidity in vascular surgical patients. Br J Surg 86(5): 702 3 Elia M, Russell CA (eds) (2009). Combating malnutrition; recommendations for action. A report from the Advisory Group on Malnutrition, led by BAPEN. Redditch: BAPEN 4 BAPEN Quality Group (2010) Malnutrition Matters - Meeting Quality Standards in Nutritional Care: A Toolkit for Commissioners and Providers in England www.bapen. org.uk/pdfs/toolkit-for-commissioners.pdf (Accessed: October 2016) 5 Paddon-Jones D, Sheffield-Moore M, Urban RJ et al (2004). Essential amino acid and carbohydrate supplementation ameliorates muscle protein loss in humans during 28 days bedrest. J Clin Endocrinol Metab 89: 4351-4358 6 Weimann A, Braga M, Harsanyi L et al (2006). ESPEN Guidelines on Enteral Nutrition: Surgery including Organ Transplantation. Clin Nutr 25.224-244 7 The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group (1991). Perioperative total parenteral nutrition in surgical patients. N Engl J Med; 325:525e32 8 Evans WJ (2010). Skeletal muscle loss: cachexia, sarcopenia and inactivity. Am J Clin Nutr 91(4):1123S-1127S 9 Tyldesley S, Sheehan F, Munk P et al (1979). Prediction of operative morbidity and mortality by preoperative nutritional assessment. Surg Forum; 30:80e2 10 Fried L, Tangen CM, Walston J et al (2001). Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 56: M134-M135 11 Van den Berghe G, Wouters P, Weekers F et al (2001). Intensive insulin therapy in the critically ill patients. N Engl J Med. 345: 1359-67 12 Zaloga GP (1999). Early enteral nutritional support improves outcome: hypothesis or fact? Crit Care Med 27: 259-61 13 Lewis SJ, Egger M, Sylvester PA, Thomas S (2001). Early enteral feeding versus ‘nil by mouth’ after gastrointestinal surgery: systematic review and meta-analysis of controlled trials BMJ 323: 1-5 14 British Association for Parenteral and Enteral Nutrition (BAPEN). Administering drugs via enteral feeding tubes: a practical guide. www.BAPEN.org.uk/pdfs/d_and_e/ de_pract_guide.pdf (Accessed: Sept 2016) 15 Desborough JP (2000). The stress response to trauma and surgery. Br J Anaesth 85; 109-17 16 Ljungqvist O, Nygren J, Thorell A (2002). Modulation of post-operative insulin resistance by pre-operative carbohydrate loading. Proc Nutr Soc 61(3): 329-36 17 Kortebein P, Ferrando A, Lombeida J et al (2007). Effect of 10 days of bed rest on skeletal muscle in healthy older adults. JAMA 297: 1772-1774 18 Russell CA and Elia M (2011). Nutrition screening surveys in hospitals in the UK, 2007-2011. www.bapen.org.uk/pdfs/nsw/bapen-nsw-uk.pdf (Accessed: Sept 2016) 19 Milne AC, Potter J, Vivanti A, Avenell A (2009). Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev 15(2). CD003288 20 Hill GL (1994). Changes in body compositional and outcomes 21 Paddon-Jones D, Sheffield-Moore M, Katsanos CS et al (2006). Differential stimulation of muscle protein synthesis in elderly humans following isocaloric ingestion of amino acids or whey protein. Exp Gerontol 41: 215-219 22 Volpi E, Mittendorfer B, Wolf SE, Wolfe RR (1999). Oral amino acids stimulate muscle protein anabolism in the elderly despite higher first-pass splanchnic extraction. Am J Physiol Endocrinol 277:E513-E520 23 Symons TB, Sheffield-Moore M, Wolfe RR, Paddon-Jones D (2009). A moderate serving of high-quality protein maximally stimulates skeletal muscle protein synthesis in young and elderly subjects. J Am Diet Assoc 109:1582-1586 24 Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) (2016) Guidelines for the provision and assessment of nutrition support in the critically ill patient. J Parenteral Enteral Nutr 40(2): 159-211 25 Jie B, Jiang ZM, Nolan MT, Zhu SN, Yu K, Kondrup J (2012). Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition. 28(10): 1022-1027 26 Marimuthu K, Varadhan KK, Ljungqvist O, Lobo DN (2012). A meta-analysis of the effect of combinations of immune modulating nutrients on outcome in patients undergoing major open gastrointestinal surgery. Ann Surg 255: 1060e8 27 Nygren J, Soop M, Thorell A, Efendic S, Nair KS, Ljungqvist O (1998). Preoperative oral carbohydrate administration reduces ostoperative insulin resistance. Clin Nutr 17(2): 65-71 28 Yuill KA, Richardson RA, Davidson HI, Garden OJ, Parks RW (2005). The administration of an oral carbohydrate-containing fluid prior to major elective uppergastrointestinal surgery preserves skeletal muscle mass postoperatively - a randomised clinical trial. Clin Nutr 24(1): 32-7 29 Soop M, Nygren J, Thorell A et al (2004). Preoperative oral carbohydrate treatment attenuates endogenous glucose release three days after surgery. Clin Nutr 23: 733-41 30 Soop M, Myrenfors P, Nygren J et al (1998). Preoperative oral carbohydrate intake attenuates metabolic changes immediately after hip replacement. Clinical Nutrition 17(Supp 1): 3-4 31 Svanfeldt M, Thorell A, Hausel J et al (2007). Randomised clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. Br J Surg 94: 1342-50 32 Soop M, Carlson GL, Hopkinson J et al (2004). Randomised clinical trial of the effects of immediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol. Br J Surg 91: 1138-45 33 Fearon KCH, Ljungqvist O, Von Meyenfeldt M et al (2005). Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 245(3); 466-477 34 Arends J, Bachmann P, Baracos V et al (2016). ESPEN guidelines on nutrition in cancer patients. Clin Nutr (2016) 1-38 http://dx.doi.org/10.1016/j.clnu.2016.07.015 35 Moore A (2014). Enhanced perspective: Enhanced recovery programmes should be an integral part of a surgery patients’ care plan both before and after surgery. Health Service Journal. hsj.co.uk Copyright © 2018 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.
NHD CPD eArticle Volume 8.02 - 15th February 2018 NETWORK HEALTH DIGEST
Questions relating to: Enhanced recovery after surgery: the role of nutrition. Type your answers below, download and save or print for your records, or print and complete by hand. Q.1
Describe the factors which influence recovery post-surgery.
Outline the ESPEN guidance on nutrition support for patients who are at severe nutritional risk pre-surgery.
When is parenteral nutrition (PN) appropriate for patients at severe nutritional risk?
Why is pre-operative fasting now considered unnecessary?
What stress impact can surgery have on the body?
Explain why post-operative control of blood sugar levels is essential.
Why is a whole protein formula appropriate for patients after surgery?
How can a carbohydrate drink administered pre-operatively help with recovery after surgery?
Outline the key ERAS guidelines which are becoming a widely accepted in hospital settings.
Please type additional notes here . . .
Copyright ÂŠ 2018 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.
Enhanced recovery after surgery: the role of nutrition