Nutrition screening and assessment of surgical patients Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training

Objectives To discuss body composition analysis in surgical patients To discuss ways to improve body composition and function to improve outcomes in surgery

Muscle and fat mass, all ages

Body compartments in health and disease WATER (60%) FAT (25%) PROTEIN (14%) WATER (72%) FAT (15%) PROTEIN (12%) WATER (70%) FAT (23%) PROTEIN (6%) CARBO + OTHER (1%) NORMALSTARVATIONCRITICAL CARE WATER (55%) FAT (30%) PROTEIN (14%) OBESE

Loss of lean body mass = ↑mortality Loss of Total LBM ComplicationsAssociated Mortality 10%Decreased immunity Increased infections 10% 20%Decrease in healing, increase In weakness, infection 30% Too weak to sit, pressure ulcers, Pneumonia, lack of healing 50% 40%Death, usually from pneumonia100% Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9. LBM=Lean Body Mass

Principles in surgical nutrition Surgery causes cellular damage and metabolic responses that increase energy and nutrient needs Immunosuppression increases susceptibility to bacterial and other infectious agent intrusion with their corresponding side effects Wound healing requires increased energy and nutrient needs Malnutrition affects surgical outcome(s) Optimum outcome is dependent on preparation, operative method, and adequate support

Malnutrition detection tools Nutrition screeningNutritional assessment

The surgical nutrition process All admitted patients are nutritionally screened All nutritionally at risk patients are assessed All high risk patients are given nutrition care plans Monitoring of the nutrition process is done Nutrition care plan modification / Discharge

STEP 1: NUTRITION SCREENING Goal: To identify the nutritionally at risk patients

The surgical nutrition process All admitted patients are nutritionally screened All nutritionally at risk patients are assessed All high risk patients are given nutrition care plans Monitoring of the nutrition process is done Nutrition care plan modification / Discharge

Height and weight taken from regularly calibrated instruments Basic data requirements Body Mass Index – <18.5 underweight – 18.5 – 24.9 normal – 25 – 29.9 overweight – 30+ obese Severe weight loss – >5% in 1 month – >7.5% in 3 months – >10% in 6 months Mid Arm Circumference – Male: <17.6 cm – Female: <17.1 cm

Nutrition Screening Form for Adult and Geriatric patients

Nutrition Screening Form for Pediatric patients - boys

Nutrition Screening Form for Pediatric patients - girls

Outcome: nutrition surveillance

NUTRITIONAL ASSESSMENT Goal: To identify the nutritionally HIGH RISK patients

The surgical nutrition process All admitted patients are nutritionally screened All nutritionally at risk patients are assessed All high risk patients are given nutrition care plans Monitoring of the nutrition process is done Nutrition care plan modification / Discharge

Nutritional Assessment and Risk Level Form

Outcome: complication prediction Predicting post-operative complications based on surgical nutritional risk level using the SNRAF in colon cancer patients - a Chinese General Hospital & Medical Center experience. Ocampo R B, Kadatuan Y, Torillo MR, Camarse CM, Malilay RB, Cheu G, Llido LO, Gilbuena AA. Yr 2007.

A filtering process

CASE DISCUSSION: NUTRITION SCREENING AND ASSESSMENT

Gastric CA FM, 68 y/o, admitted because of gastric mass and admitted to undergo gastrectomy Ht m; Wt. 46 kg; BMI=16.9 Previous wt 4 months - 52 kg; % weight loss = 11% Ancillary procedures: – Chest Xray: old (?) PTB – ECG: Normal heart – CBC: Hb=10; WBC=6,000; Platelets=250,000; N%=70; L%=10 – Electrolytes: Na=130; K=3.2 – BUN =25; Creatinine=1.2 – Albumin - 3

Nutrition screening 1.Is the BMI 30? 2.Has the patient lost weight within the last three (3) months? 3.Did the patient have a reduced dietary intake in the last week? 4.Is the patient severely ill (e.g. in intensive therapy) 1.Is the BMI 30? 2.Has the patient lost weight within the last three (3) months? 3.Did the patient have a reduced dietary intake in the last week? 4.Is the patient severely ill (e.g. in intensive therapy) 1.YES: BMI = YES: lost weight (11% in the last 4 months) 3.YES: reduced dietary intake 4.NO: not severely ill NUTRITION SCREEN RESULT: NUTRITIONALLY AT RISK 1.YES: BMI = YES: lost weight (11% in the last 4 months) 3.YES: reduced dietary intake 4.NO: not severely ill NUTRITION SCREEN RESULT: NUTRITIONALLY AT RISK

Nutritional assessment/Risk Level SGA: Weight loss: >10% and gastro symptoms = (grade C) (3 pts) → severe malnutrition BMI=16.9 (2 pts) Albumin=3 (less than 3: 2 pts) TLC=600 (less than 900: 2 pts) Total Risk Score=9 Nutritional Assessment = Severe malnutrition Risk Level =High Risk of developing nutrition related complications

Final decision Nutrition build up of this patient is mandatory for at least 5 to 10 days Other options: – Do surgery then continuous post-operative nutrition maintenance and build up – Needs a Nutrition Care Plan Rationale: body composition and reserves cannot provide optimum condition for good healing and fast recovery plus reduction of complications (infection, dehiscence, fistula formation)

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