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Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
Utilizing ERAS to improve diet advancement post op
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Utilizing ERAS to improve diet advancement post op

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Presentation highlighting how dietitians can make use of ERAS principles to get patients fed sooner.

Presentation highlighting how dietitians can make use of ERAS principles to get patients fed sooner.

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  • 24/07/2012
  • 24/07/2012
  • Percentage change in body weight in the control and treatment groups on admission to hospital, at inclusion in the study, and then at two weekly intervals for 10 weeks. studied 101 patients: 52 were randomised to the treatment group (TG) and prescribed a 1.5 kcal/ml nutritional supplement; 49 patients were randomised to the control group (CG) and continued with routine nutritional management. 24/07/2012
  • Sixty-one patients, treated according to the ERAS program, were matched with 122 historical controls who had conventional postoperative care   matched cohort study was performed. ERAS intravenous fluid administration aimed at a urine production of at least 0.5 ml/kg and the total fluid intake should not exceed 2 l/24 h. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793377/ 24/07/2012
  • 40 patients undergoing elective colorectal surgery were randomly allocated to an intervention group receiving comprehensive information on the importance of mobilization, balanced anesthesia, and postoperative analgesia including epidural local anesthetics and enforced postoperative mobilization or a control group receiving anesthesia without epidural local anesthetics, postoperative analgesia with epidural morphine, and mobilization without fixed goals. The ambulation time improved substantially within 22 h in the intervention group versus 3 h in the control group on day 1 ( P  = 0.0004) and within 8 h versus 2 h on day 4 ( P  = 0.0003). http://www.nutritionjrnl.com/article/S0899-9007(01)00748-1/abstract 24/07/2012
  • Barriers to early enteral feeding include fear of GI morbidity, anastomotic disruption or leak but have not been proven valid in clinical or experimental trials. A clear liquid diet is the most frequently ordered first postoperative meal regardless of early or delayed administration. Although generally well tolerated, this diet fails to provide adequate nutrients to the postsurgical patient. In contrast, advancement to a regular diet as the initial meal has been shown to be well tolerated and provides significantly more nutrients than a clear liquid diet. This article reviews basic GI physiology, including motility, nutrient absorption, and the changes that occur in regulation and function of the GI tract following surgery, as well as clinical data regarding postoperative GI function and diet advancement. 24/07/2012
  • 24/07/2012
  • 24/07/2012
  • Odds ratios (ORs) for mortality. Values in the left panel are observed counts for early and traditional feeding, ORs, and lower (L) and upper (U) limits of 95% confidence intervals (CIs) for ORs of the outcome variable. In the graph, squares indicate point estimates of treatment effect (ORs for early vs traditional groups), with the size of the squares representing the weight attributed to each study. The horizontal lines represent 95% CIs for ORs of individual studies. The pooled estimate for the mortality rate is the pooled OR, obtained by combining all ORs of the 15 studies using the inverse variance weighted method. The 95% CI for the pooled estimate is represented by the diamond, and the length of the diamond depicts the width of the CI. Values to the left of the vertical line favor early feeding. 24/07/2012
  • Odds ratios (ORs) for anastomotic leak. Values in the left panel are observed counts for early and traditional feeding, OR, and lower (L) and upper (U) limits of 95% (CIs) for ORs of the outcome variable. In the graph, squares indicate point estimates of treatment effect (ORs for early vs traditional groups), with the size of the squares representing the weight attributed to each study. The horizontal lines represent 95% CIs for ORs of individual studies. The pooled estimate for the anastomotic leak rate is the pooled OR, obtained by combining all ORs of the 13 studies using the inverse-variance weighted method. The 95% CI for the pooled estimate is represented by the diamond, and the length of the diamond depicts the width of the CI. Values to the left of the vertical line favor early feeding. 24/07/2012
  • Days to passing flatus. Values in the left panel are sample size (N), mean (standard deviation), weighted mean difference (WMD), and lower (L) and upper (U) limits of 95% confidence interval (CI) for mean of the outcome variable. In the graph, squares indicate point estimates of treatment effect (mean difference, ie, mean for early feeding group of patients minus mean for traditional group of patients), with the size of the squares representing the weight attributed to each study. The horizontal lines represent 95% CI for the mean differences of individual studies. The pooled estimate of the days to passing flatus is the WMD. It is obtained by combining all mean differences using the inverse-variance weighted method. The 95% CI for the overall mean based on the pooled estimate is represented by the diamond, and the length of the diamond depicts the width of the CI. Values to the left of the vertical line favor early feeding. 24/07/2012
  • Length of stay (days). Values in the left panel are sample size (N), mean (standard deviation), weighted mean difference (WMD), and lower (L) and upper (U) limits of 95% confidence interval (CI) for mean of the outcome variable. In the graph, squares indicate point estimates of treatment effect (mean difference, ie, mean for early feeding group of patients minus mean for traditional group of patients), with the size of the squares representing the weight attributed to each study. The horizontal lines represent 95% CI for the mean differences of individual studies. The pooled estimate of the length of stay (days) is the WMD. It is obtained by combining all mean differences using the inverse-variance weighted method. The 95% CI for the overall mean based on the pooled estimate is represented by the diamond, and the length of the diamond depicts the width of the CI. Values to the left of the vertical line favor early feeding. 24/07/2012
  • Odds ratio (OR) for complications (nausea and vomiting excluded). Values in the left panel are observed counts for early and traditional feeding, OR, and lower (L) and upper (U) limits of 95% confidence intervals (CIs) for ORs of the outcome variable. In the graph, squares indicate point estimates of treatment effect (OR for early vs traditional groups), with the size of the squares representing the weight attributed to each study. The horizontal lines represent 95% CIs for ORs of individual studies. The pooled estimate for the complication rate is the pooled OR, obtained by combining all ORs of the 15 studies using the inverse-variance weighted method. The 95% CI for the pooled estimate is represented by the diamond, and the length of the diamond depicts the width of the CI. Values to the left of the vertical line favor early feeding. 24/07/2012
  • Transcript

    • 1. Utilising ERAS to improvemeal advancement postoperatively.Nathan Billing-Surgical Dietitian
    • 2. Acknowledgement Some slides taken from others presentationsfound online. Emma Osland Carli Schwartz Other slides from AERAS study group slides Mattias Soop
    • 3. Overview Overview of Enhanced recovery programs Increasing intake after surgery Key Nutritional components of ERAS Early Oral Feeding – Identifying issues Traditional vs Early post operative dietadvancement Clear Oral fluids versus Free Oral Fluids Providing guidance to surgical team Rationalisation of diets available ? Recommended for diet advancement
    • 4. Enhanced Recovery Program Pioneered by Henrik Kehlet group in Denmark Identified factors which delay postoperativerecovery Pain Gut dysfunction Immobilization Combined a series of interventions to reduceperioperative stress and organ dysfunction11. Kehlet H. Multimodal approach to control postoperative pathophysiology andrehabilitation. Br J Anaesth 1997; 78:606–617.
    • 5. Recovery After SurgeryWhat are we trying to achieve? Reduce the surgical stress response andsupport basic body functions by 1, 2– Use of optimised analgesia– Early mobilisation– Early return to normal diet These interventions have been shown toimprove postoperative outcomes 3,41. Fearon, et al, Clinical Nutrition 2005; 24: 466–477.2. Kehlet, Lancet 2008; 371: 791–793.3. Khoo, et al, Annals of Surgery 2007; 245: 867–872.4. Wind, et al. British Journal of Surgery 2006; 93: 800–809.
    • 6. Multimodal steps of ERAS protocol• Optimised health /medical condition• Informed decision andpatient education• Pre operative health &risk assessment• Optimised hydration &nutrition• Reduced starvation• Patient information andexpectation managed• Discharge planning• No / Reduced bowelprep (bowel surgery)• Minimally invasivesurgery• Use of transverseincisions• No nasogastric tubes(bowel surgery)• Use of Localanaesthetic withsedation• Epidural management(inc thoracic)• Optimised fluidmanagement• Planned mobilisation• Rapid hydration &nourishment• Appropriate IV therapy• No wound drains• No NG ( bowel surgery)• Catheters removed early• Regular oral analgesia –paracetamol andNSAIDS• Avoidance of opiate-based analgesia wherepossible or administeredtopically• Estimateddischarge date asplanned• Full informationand ongoingsupport• Allied Healthprofessionalfollow up whererequired• Personal followup from clinicalteam (home calls)Pre Operative Intra Operative Post Operative Discharge
    • 7. Increasing oral intake after surgeryDay 0 patients receive Sandwich for day of surgery 2 x supplements post operativelyDay 1 onwards patients receive progress to standard diet 3 x supplements post operatively
    • 8. Use of nutritional supplements in malnourishedpatients post operatively (600kcal/day)Beattie A Het al. Gut 2000;46:813-818©2000 by BMJ Publishing Group Ltd and British Society of Gastroenterology
    • 9. Fluid input:ERAS vs Conventional CareTeeuwen, et al, J Gastrointestinal Surgery 2010; 14:pp88–95.61 ERAS patients vs 122 historical matched controlsERAS total IV fluid intake ≠ > 2 l/24 h
    • 10. Effect of mobilization on oralintake00.20.40.60.81Intervention ControlMean Protein intake Patients in interventiongroup encouraged toactive mobilization fromday 1 Control mobilized intraditional mannerwithout specific aims Main part of meals waseaten while sitting at atable and not in a bed020406080Intervention ControlMean Energy IntakeHenriksen, et al, Nutrition 2002; 18(3): pp:263–267.Kj/kg/dayg/kg/day
    • 11. Importance of team approach Agreement betweenanaesthesia andsurgical teams FTE requirementimportance of ERASnurse Need surgeon buy in
    • 12. ERAS alone is not enoughInfluence of compliancewith the separate careelements on length of stayon various components onlength of hospital stayHazzard ratio above 1indicates a better chance ofearly discharge whereas avalue below 1 indicates alower chance.Maessen, et al, British Journal of Surgery 2007; 94: pp224-231.
    • 13. Oral feedingNutrition 2002; 18:944-948Factors that limit or promote post operative feeding
    • 14. Feeding the patient:Postoperative Nutrient Provision
    • 15. Traditional Postoperative DietAdvancementTraditional practice NBM prior to surgery NBM and gastricdecompression untilbowel function resumedpost surgery Diet progression oncegut working Clear fluids  free fluids  soft/light diet  full dietRationale Initially adopted to combatpost operative vomitingand subsequent concerns Aspiration pneumonia Increase abdominalpressure  anastomoticrupture Also thought to “protectthe anastomosis” byallowing gut rest andavoiding food passing thesurgical site
    • 16. Clear Oral Fluids vsFree Oral Fluids Aim: To provide a dietof liquid foods thatrequire no chewing. Includes more proteinhigh in saturated fatand low in fibre, andmay require vitaminand mineralsupplementation.ClearOral Fluids Free Oral fluids Aim: To replace ormaintain the body’swater balance andleave minimumresidue in theintestinal tract Meets anaesthesiafasting guidelines Inadequate in allnutrients
    • 17. Early Postoperative FeedingEarly post-op feeding Clear fluids to 3-4hrspre-anaesthetic Fluids or diet from firstpostoperative dayirrespective ofresumption of bowelfunction No NGT post op Often in the context ofmultimodal approachincluding earlier mobilisation, non-opioid analgesia, key-hole surgeryRationale Gut secretes and reabsorbs~7L fluid/d irrespective oforal intake, so “protecting theanastomosis” is based on afalse premise Many patients alreadymalnourished  morepostoperative complications Nausea/vomiting is muchless of a problem with newanaesthetic agents Some evidence that earlyfeeding reduces the body’sstress response tosurgery/trauma
    • 18. The research … Increasing numbers of studies investigating thistopic dating from 1978 Tube feeding  early liquids  early solids Individual studies do not demonstrate majoradverse outcomes with early feeding Some suggestion of organisational benefits May decrease length of hospital stay and cost oftreatment Reported adverse outcomes Nausea, vomiting, NG reinsertion (common)
    • 19. Previously conducted meta-analysesNutritional issues• Inclusion of immune-modulating EN products• Inclusion of studies feeding both proximal and distal toanastomoses• Nutrition provided at 24hrs post op may have included clearfluids  little nutritional valueGeneral issues Appears to contain inconsistencies in inclusion criteria of studiesincludedCriteria for this meta-analysis Early feeding provision of diet (excluding COFS) and enteralfeeding given within 24 hours postoperatively. Traditional postoperative management = withholding nutritionprovision until bowel function had resumed, as evidenced byeither passage of flatus or bowel motion
    • 20. Early vs Traditional PostOp feeding• Fifteen studies involving a total of 1240 patients were analysed in meta-analysis.• To investigate impact of early feeding vs traditional postoperative feeding and• Mortality• Anastamotic Leaks• Days to passing Flatus• Length of stay• Postoperative Complications
    • 21. Results - MortalityOsland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 481
    • 22. Results – Anastamotic LeaksOsland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 481
    • 23. Results – Days to passing flatusOsland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 482
    • 24. Results – Length of StayOsland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 483
    • 25. Results – PostoperativeComplications (Nausea and Vomitingexcluded)Studypre 2000SagarRyanSchroederBinderowBeier-HolgersenCarrOrtizHartsellNessimStewartsubtotalpost 2000Han-GeurtsDelaneyLuchaZhouHan-GeurtssubtotalPOOLEDEarly3 of 152 of 74 of 160 of 328 of 300 of 1417 of 931 of 293 of 2710 of 4048 of 30312 of 567 of 311 of 2623 of 16122 of 4665 of 320113 of 623Traditional5 of 157 of 77 of 160 of 3219 of 304 of 1418 of 951 of 294 of 2712 of 4077 of 30513 of 4910 of 331 of 2570 of 15520 of 50114 of 312191 of 617OR0.530.030.4610.220.080.9610.750.780.550.760.690.960.211.370.620.55L0.0800.070.020.0500.240.070.110.170.340.180.140.070.060.330.260.35U3.780.942.9161.411.082.063.7713.425.013.560.93.273.3812.990.745.611.510.870.1 2.0 4.0 6.0favour Early favour TraditionalOsland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 479
    • 26. Conclusions of Meta-analyisis No merit in withholding nutrition providedproximal to the anastomosis until bowelfunction is resumed. Statistically significant reductions in totalcomplications in the postoperative course withearly feeding. No negative effect of early feeding wasdemonstrated with regard to in hospitalmortality, anastomotic dehiscence, LOS, andtime to recovery of bowel function
    • 27. Recommending Diet Advancement Advance diet to full liquids followed by solidfoods, depending on patient’s tolerance. Consider the patient’s disease state and anycomplications that may have come about sincesurgery. Liaise closely with surgical teams Provide guidance of meal choices available in yourkitchen. Define meal advancement. Standardize practices.
    • 28. Liasing with Surgical teams What does “E & D as tolerated” mean? Review of diet codes available for usei.e. Light diet vs Low Residue Diet vs Post Op Diet When to use Modified consistency diets e.g. Upper GI surgery vs Lower GI surgeryUpper GI surgery could have impact on peristalsis somay require liquid or pureed meals ?Sham feeding (i.e. Chewing gum)
    • 29. Type of Surgery /Underlying ConditionRecommendeddiet post opRationaleRecurrent Small bowelobstructionLow residue diet A diet low in fibre to minimise chance of furtherobstructions occurringUpperGI surgery:•Nissens Fundoplication•Oesophagectomy•Ivor Lewis GastrectomyLiquid DietorPureed DietorLow residue dietAs this surgery would have an impact on themechanical ability to swallow feed and lead to adegree of dysphagia. A liquid or pureed diet isrecommended initially to help minimisedifficulties in swallowingSmall bowel resections  Liquid DietorLow residue dietorStandard dietAs this surgery may result in anastamotic joinsin small intestine low residue foods arerecommended to minimise pressure on thesejoins initially.Colorectal surgery Standard dietorHigh Energy proteindietAs this surgery involves the lower GI tract, mostfood is well digested by the time it reaches thecolon and regardless of the type of food shouldbe pretty well digestedCholecystectomy Standard diet As gut motility or function has not been alteredby surgery no special requirements or surgeryNon Gut surgery Standard diet As gut motility or function has not been alteredby surgery no special requirements or surgeryAlternative to E+D as tolerated?
    • 30. Tailor made protocolsSpecific surgeries /conditions that will have own specialist diet progressionpathway and dietetic inputBariatric Surgery•Gastric Bypass (Roux en Y)•Gastric Sleeve•Duodenal SwitchWater onlyOptifastFluid dietPureed dietPatients need to adjust to smaller stomachvolume and advance their diet slowly aftersurgery. There is close working with surgeonsand set plans for these patients in place.Chylous ascites and Chyle leaks Specialist diet withreduced fat and highMCT contentDietary chylomicrons are absorbed in the smallintestines and gradually pass along largeromental lymphatics. Reducing the intake of fathas been shown to be beneficial at minimisingPancreatic surgery orotherfistulasPotential enteral NJfeeding and orIVN/TPNStimulation of pancreatic or other GI secretionsmay be an issue and may need to be minimised.Dietitian input is recommended.As perSurgeon
    • 31. Questions References: Anderson et al. Early enteral nutrition within 24h of colorectal surgery versus later commencement offeeding for postoperative complications. Cochrane Database Syst Rev, 2006 (4): CD002080. Franklin, G.A., McClave, S.A., Hurt, R.T., Lowen, C.C., Stout, A.E, et al., 2011. Physician- DeliveredMalnutrition: Why do patients receive nothing by mouth or a clear liquid diet in a university hospitalsetting? Journal of Parental and Enteral Nutrition. 35(3):pp337-342. Hancock, S., Cresci, G., Martindale, R., 2002. The clear Liquid Diet: When is it appropriate? CurrentGastroenterology reports. 4: pp324-331. Jeffery, K.M., Harkins, B., Cresci, G.A., Martindale, R.G., 1996. The clear liquid diet is no longer anecessity in the routine postoperative management of surgical patients. The American Surgeon62(3):167-70. Kawamura, Y.J., Kuwahara Y., Mizokami K., et al., 2010. Patient’s appetite is a good indicator forpostoperative feeding: a proposal for individualized postoperative feeding after surgery for coloncancer. Int JColorectal Dis.;25:pp239-243. Lewis et al. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: a systematicreview and meta-analysis of controlled trials. BMJ, 2001, 323 (7316) 773-776 Lewis et al. Early enteral nutrition within 24h of intestinal surgery versus later commencement offeeding: A systematic review and meta-analysis. JGastrointest Surg, July 16 2008 Story, S.K., Chamberlain, R.S,. 2009 A Comprehensive Review of Evidence-Based Strategies toPrevent and Treat Postoperative Ileus. Digestive Surgery 2009; 26:265–275. Warren, J., Bhalla, V., Cresci, G., 2011. Postoperative Diet Advancement: Surgical Dogma vsEvidence based Medicine. Nutrition in Clinical Practice. 26(2): pp115-125.

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