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 (

7. Sodium Excess sodium Oedema Bowel oedema Delayed bowel function
Ileus (Lobo et al 2002, Lancet 25;359, )
Guidelines on Intravenous Fluid Therapy in Adult Surgical Patients – GIFTASUP (

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), )
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
– 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 –