Nutritional Aspects of ERP Pete Turner Specialist Nutritional Support Dietitian

Programme ERP philosophy NBM Preoperative Carbohydrate Loading Malnutrition and surgery Screening - MUST Treatment plan

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

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

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

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)

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)

Preoperative Carbohydrate (CHO) Beneficial to anyone undergoing major surgery Traditional preoperative fast harmful 12 – 16 hours NBM Metabolism changes to “starved” state

Starved State 12 hrs – 20 days Increased Glucagon Increased Cortisol Catabolism Gluconeogenesis Insulin resistance

Surgery Inflammatory response Increased cortisol, cytokines Catabolism, gluconeogenesis Insulin resistance Hyperglycaemia Exacerbated by starvation

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

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

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)

Not Just Colorectal Urology Pancreatic Hip replacement Knee replacement

All elective surgery

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?

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

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

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

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

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

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

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

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

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

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

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”

Artificial Nutrition

Portable Pumps

TPN

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

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