Dr man wo tsang metabolic peri-operative management
Metabolic Peri-operative management Dr Tsang Man Wo Specialist in Endocrinology, Diabetes & Metabolism MBBS,MRCP,FRCP(L.,E.,G.)FHKCP,FHKAM Consultant ,Department of M&G, UCH Hon. Associate Prof ., University of Hon g KongHon. Associate Prof., Chinese University of Hong Kong
Objectives• Traditional peri-operational mn : – Nil Per Oral ( NPO)• Metabolic nutritional management: – Novel pre op nutritional support vs fasting as pre op preparation. – Early vs delay post op nutritional support• Current guidelines – pre operation – post operation• advantages and mechanism of action
Objectives• Traditional peri-operational mn : – Nil Per Oral ( NPO)• Metabolic nutritional management: – Novel pre op nutritional support vs fasting as pre op reparation. – Early vs delay post op nutritional support• Current guidelines – pre operation – post operation• advantages and mechanism of action
Routine Preoperative Preparation for Surgery • fasting • History • Physical examination ( esp:nutritional assessment) • Special investigation • Informed consent • Marking the site/side of operation • Thromboembolic prophylaxis • Antibiotic prophylaxis
NPO• Fasting over night allows sufficient time to empty a stomach before induction: – Clear fluids are empty rapidly (T1/2 » 30 minutes). – Solids stay in stomach longer (T1/2 » 1-2 hours)• Prevent death from aspiration post op
Journal of Gastroenterology and Hepatology 21 (2006) 1832–1838
Journal of Gastroenterology and Hepatology 21(2006) 1832–1838
Cochrane Database of Systematic Reviews 2003 • Papers compare a shortened fluid fast with a standard fast. • 1. Aspiration/regurgitation – No aspiration or regurgitation was reported by trials that compared the preoperative intake of a low volume of fluid • 2. compared a shortened fluid fast to a standard fast by measuring – thirst, Yes – hunger, Yes – pain, – nausea, no difference – vomiting and no differenceBrady M, Kinn S & Stuart P. Preoperative fasting for adults to preventperioperative complications.; 2003(4).
There is good evidence to support fasting preoperativelyfor 2 hr for fluids and 6 hr for solids.Best Practice & Research Clinical AnaesthesiologyVol. 20, No. 3, pp. 457e469, 2006
• The fasting protocol is not based on “EBM”• thirsty (fasting) affect the well being in part the children• in modern day withdrawal syndrome of coffee• moreover it is not physiological for the body to prepare for t he stress.
Fed state Fast stateScandinavian Journal of Nutrition 2004; 48 (2): 77 /82
Site of insulin resistance after surgery; the contribution of hypocaloric nutritionand bed rest. Clin Sci 1997; 93:137-
Objectives• Traditional peri-operational mn : – Nil Per Oral ( NPO)• Metabolic nutritional management: – Novel pre op nutritional support vs fasting – Early vs delay post op nutritional support• Current guidelines – pre operation – post operation• advantages and mechanism of action
Overview of the interplay between surgery, the inflammatoryresponse, endocrine reactions, complications and metabolism. E.g. IL-6 E.g. catecholamine Glucagon Insulin, cortisolScandinavian Journal of Nutrition 2004; 48 (2): 77 /82
Figure 1. Time course for postoperative insulin resistance. Relative insulinsensitivity (%) in patients undergoing open cholecystectomy, calculated aspostoperative insulin sensitivity/preoperative insulin sensitivity×100. Insulinsensitivity was determined within 5 days preoperatively and at days 1 (n=9), 5, 9and 20 (n=5) postoperatively. *P<0.05 and **P<0.01
Figure 2. Reduction in insulin sensitivity after different surgical procedures. Relative insulinsensitivity (%), calculated as postoperative insulin sensitivity/ preoperative insulinsensitivity×100 in patients undergoing elective surgery. Surgical procedures were: laparoscopiccholecystectomy (Lap chol, n =6), inguinal hernia repair (Hernia, n =7), opencholecystectomy (Op chol, n =13), and major colorectal surgery (Colorectal, n =7). Differencesbetween groups, P<0.001, analysis of variance.
Prevalence of hyperglycaemia(>10 mmol/l)Cook, C.B., G.L. Kongable, D.J. Potter, et al., J Hosp Med,2009; 4(9): p. E7-E14.
Umpierrez GE, Isaacs SD, Bazargan N, et al. J Clin Endocrinol Metab.2002;87(3):978–82.
Implication• impaired neutrophil function,• risk for infections,• hospital LOS, and mortality Moghissi, E.S., M.T. Korytkowski, M. DiNardo, et al., Diabetes Care, 2009; 32(6): p. 1119–31.
Postoperative insulin sensitivity andlength of hospital stay.
Infection: surgical site• Orthopaedic patients#: – spinal surgery, diabetes and hyperglycemia in the preoperative or postoperative time periods were independently associated with increased risk – lower extremity total joint arthroplasty , uncontrolled diabetes mellitus had significantly increased odds of surgical and systemic complications, higher mortality, and increased LOS during hospitalization in the postoperative period.• Colorectal procedures@ – A cohort study of patients with diabetes found that a mean 48-hour postoperative capillary glucose greater than 11.0 mmol/L (200 mg/dL) was independently associated with• Hepato-biliary-pancreatic cancer% – infection rates directly correlated with the degree of hyperglycemia encountered during the postoperative period # J Bone Joint Surg Am. 2009;91 (7):1621–9. @ J Bone Joint Surg Am. 2008;90(1):62–9. % Japan. J Hosp Infect. 2008;68(3):230–3.
Minimizing stress Improve outcome • Minimally invasive surgery • Laproscopic surgery • Epidural anaesthesia • Patient education • Medical nutritional support Improve outcome
Metabolic preparation before surgery• CHO metabolism at the onset of surgical trauma was an important determinant of the magnitude of the metabolic stress reactions.• Manipulation of metabolism using simple CHO intake would result in a different reaction if given before the onset of the surgical stress rather than after the stress had begun.
J. Clin. Invest.Volume 77, AprilW. J. Kingston, J. N. Livingston, and R. T. Moxley III 1986, 1153-1162
Endocrine changes with CHO inake• 1. Insulin release > reduce endogenous glucose production /release, GLUTs protein in sensitive peripheral tissue, induction of enzymes for glycogen synthesis securing storage of excess glucose.
insulin may modulates the role of stress hormones .• 2.Insulin metabolic effect will be counter acted by Antagonizing hormones : catehcolamines , glucagon , cortisol, if CHO ( induce insulin release ) is given after stress reaction .
• 3.preoperative carbohydrate loading, causing a release of insulin, will result in higher levels of free insulin-like growth factor-1• Helpful in burn patient• Improved protein catabolism• These help to explain why metabolism is far less catabolic in the postoperative situation in patients given preoperative carbohydrates instead of undergoing an overnight fast
Effects of Preoperative Oral CarbohydrateSupplementation on Postoperative Metabolic Stress Response of Patients Undergoing Elective Abdominal Surgery
Clinical effect of preoperative CHO treatment• Reduce cardiac complications after cardiac surgery – [Scand J Nutr 2000; 44: 3/7.]• Muscle strength was better retained up to 1 month after colorectal surgery. Due to reduced post op loss of nitrogen with CHO preparation . – [Acta Anaesthesiol Scand 2003; 47:191/9.]• Improved patient well being : reduced post op N/V – [Clinical Nutrition 1999; 18(Suppl 1): 80.]• enhance recovery from surgery – [Clin Nutr 2001; 20(Suppl 1):167/71]
Novel way of preparation for surgery• Pre-op CHO treatment is a simple and safe treatment, which allows most patients – to be fed immediately after surgery w/o major concerns regarding to hyperglycaemia – to have improved nitrogen balance – to have less reduce muscle strength Faster recovery from surgery
CHO loading e.g ( 12.5%) , maltodextran,osmolarity 285 mOsm• 800 ml, on evening before operation.• 400 ml (12.%) , 2-3 hr before operation
Objectives• Traditional peri-operational mn : – Nil Per Oral ( NPO)• Pre-op Metabolic nutritional management: – Novel vs fasting – Current guidelines• Post-op Metabolic nutritional management – Early vs delay post op nutritional support – proposed algorithm
Problems post op• hypercatabolic state• “energy debit”• infection• long ICU stay
Early nutrition support in the intensive care unit 1363-1950 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Post op :When ?• First 24–48 h following admission to an ICU• [ Canadian Clinical Practice Guidelines for Nutrition Support]Curr Op Crit Care 2005; 11:461–467.
Glycemia –targted specialized nutrition(Pre-diabetes and Diabetes) Table 6 Overweight/ Use calorie replacements* as part of a reduced calorie meal plan. (Grade C; LOE 3) Obese Calorie goals: <250 lb= 1200 to 1500 calories >250lb = 1500 to 1800 calories Calorie replacement goals: 2 to 3 calorie replacements per day to be incorporated into an a reduced calorie meal plan, as a meal replacement, partial meal replacement or snack. Use of calorie replacement/calorie supplement should be based on clinical Controlled Diabetes judgment and individual assessment ** (Grade D; expert opinion) A1c<7% Normal Weight 1 to 2 calorie replacements per day to be incorporated into an a reduced calorie Uncontrolled Diabetes meal plan, as a meal replacement, partial meal replacement or snack. A1c>7% (Grade D; LOE4) Use nutrition supplement*** 1-3 units/day per clinical judgment based on desired rate of weight gain andUnderweight clinical tolerance. (Grade D; LOE4) *Calorie replacement are nutritional products used as a meal replacement, partial meal replacement or snack to replace calories in the diet. Calorie replacements provide approximately 100 to 300 kcal per serving. **Individuals who may have muscle mass and/or function loss and/or micronutrient deficiency may benefit from a nutrition supplement. Individuals who need support with weight maintanenece and/or a healthy meal plan could benefit from calorie replacement. *** Nutritional supplements are complete and balanced nutritional products with ≥ 200 calories per serving used in addition to a typical meal
Mechanism of action of early (enteral )feeding• Attenuation of hypercatabolic response after trauma• improving wound healing• improving immune response• GI mucosal integrity
Proposed Algorithm Nutritional assessment Severe Malnourished Yes NOEarly within 24 hr Within day 3 20-25 kcal/kg/d 1.2-1.5 g protein/kg/day By combined enteral and parenteral nutrition as needed. Monitoring to avoid overfeeding /underfeeding Curr Opi Cli Nutr & Meta Care 2008,11,666-670
Over vs under feeding with early nutrition support • Overfeeding : • Underfeeding: – glucose overload – infection – ICU complication – fatty liver – ICU days – inc infection – inc mortality Enteral Isocaloric feeding : Parenteral 25 kcal/kg/day * Combined* American College of Chest Physician
• Guidelines that were published earlier this year suggest that when enteral feeding is not possible, parenteral nutrition should be initiated within 7 days (according to one guideline# or within 3 days (according to another guideline@.)• Among patients who have protein-energy malnutrition at the time of admission to the ICU, the American clinical practice guidelines suggest that parenteral nutrition should be initiated without delay.# #Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009; 33:277–316 @Singer P, Berger MM, Van den Berghe G, et al. ESPEN guidelines on parenteral nutrition:intensive care. Clin Nutr. 2009; 28:387–400.
Impact of Glycemic Control and Clinical Outcome
• blood glucose ≤110 mg/dL (6.1 mmol/L) reduced morbidity and mortality among critically ill patients in the SICU when compared to those who were conventionally managed.van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the criticallyill patients. N Engl J Med. 2001;345 (19):1359–67.
• in hyperglycemic cardiac surgery patients treated with intravenous (IV) insulin infusions the first 3 postoperative days demonstrating reductions in absolute and risk-adjusted mortality of 57% and 50%, respectively.Furnary AP, Gao G, Grunkemeier GL, et al. J Thorac Cardiovasc Surg.2003;125(5):1007–21.
• The Portland Diabetes Project demonstrated reductions in mortality, surgical site infection, and hospital LOS after cardiothoracic surgery in patients treated with ITT to maintain blood glucose less than 150 mg/dL(8.3 mmol/l) regardless of their ICU or non-ICU status.Furnary AP, Wu Y. Endocr Pract. 2006;12 Suppl 3:22–6.
Controversies of IIT on blood glucose target• Tight glucose control ( 4.4-6.1 mmol/l) should not applied to all patients.• Patients with brain injury, AMI, severe sepsis are susceptible to hypoglycaemia
Way forwad• ? Nutritional pharmacology : – glutamine , – antioxidant and gamma-linolenic acid in ARDS or severe sepsis
Conclusion• To obtain satisfactory results in general surgery requires a careful approach to the preoperative preparation of patients .• Specific patients groups have specific needs• high risk patients should be identified early and appropriate measures taken to reduce complication
Minimizing stress Improve outcome • Minimally invasive surgery • Laproscopic surgery • Epidural anaesthesia • Patient education • Medical nutritional support Improve outcome
Algorithm Development &Transcultural Medical Nutrition for Prediabetes and Diabetes Management Represents a consensus of experienced practitioners, researchers, and academicians; Supported by evidence and opinion that was graded forquality according to the standards expressed in the ACE and ADAHelps identify patients with one or more risk factors, both prediabetes and diabetesHelps to address conditions that are mitigated with dietary modification include overweight or obesity, hypertension, and dyslipidemia.
Transcultural Medical Nutrition Algorithm New for Prediabetes and Type 2 Diabetes Actions Comments Ethno-cultural Lifestyle Input Prediabetes is established by: IFG = 100-125 mg/dL, IGT = 140-1991) Geographic location and 2) Ethno-cultural classification mg/dL, and/or A1c = 5.7-6.4%. Diabetes is established by: FPG ≥126 mg/dL; casual PG ≥200 mg/dL; 2 hr OGTT: ≥200 mg/dL; A1c: ≥6.5%. (A1c alone is not recommended to diagnose diabetes) Individual Risk Stratification Location, ethnicity, and culture individualize recommendations.Family history of high-risk dietary patterns and premature cardiovascular disease, less than Inputs will inform other areas of the algorithm.recommended physical activity, abnormal anthropometrics (BMI/WC/WHR over normal ranges for Anthropometrics include weight, BMI, waist circumference,locale), hypertension, dyslipidemia, any cardiovascular event, any liver disease, microalbuminuria and/or waist-hip ratio according to local preference/custom.over normal range, risky alcohol intake, any sleep disturbance, any chronic illness See body composition parameters in Tables 1 and 2. Low Risk High Risk Excessive daily alcohol consumption is defined as >2 drinks for men and >1 drink for women. General Recommendations Individual risk stratification directs lifestyle interventions forCounseling, physical activity, and healthy eating consistent with current clinical practice guidelines or improved glycemic control and decreased risks for progression,evidence (Tables 3-5) complications and mortality. +/- Insufficient physical activity is <30 min/day and/or <5 days/week. Overweight/Obesity Low-risk patients with prediabetes or type 2 diabetes have no Physical activity consistent with guidelines (Table 3) adverse conditions other than an impaired glycemic profile and should follow established general recommendations for lifestyle Weight loss consistent with guidelines (Table 4) interventions plus nutritional therapy per AACE/ADA guidelines. MNT consistent with guidelines (Table 4) High-risk patients have ≥1 risk factors that require specific Formula/Caloric supplementation or replacement consistent interventions to reduce progression, complications, and with options and strategies (Table 5) mortality. Conditions amenable to lifestyle change include Consider bariatric surgery (Table 6) overweight/obesity, hypertension, and dyslipidemia. +/- Hypertension Hypertension is defined as blood pressure >130/80 mm Hg. Antihypertensive diet consistent with DASH and sodium 2.4 g Na+ = 6 g salt (≈ 1 teaspoon) restriction of <1.5 g/day (Table 7) 1.5 g Na+ = 3.7 g salt (≈ 2/3 teaspoon). +/- The nutritional management of obesity and that of dyslipidemia Dyslipidemia are similar (Table 4). Lipid-modifying diet (Table 4) When hypertension and dyslipidemia complicate prediabetes and diabetes, interventions are additive and intensified. Follow-up Evaluation (1-3 months)History, physical (anthropometrics, blood pressure); chemistries (glucose, A1c, lipids, urinary Follow-up evaluation is scheduled according to patient needsalb/creatinine, liver enzymes); urinalysis and local practice. At Goals Not At Goals Mechanick JI, et al. Maintain physical activity, meal plan, Intensify physical activity, meal plan, and medical nutrition therapy and medical nutrition therapy Curr Diab Rep. 2012. Feb 9.
Actions Comments Diabetes /PreDiabetes Ethno-cultural Lifestyle Input Diabetes is established by: FPG ≥126 mg/dL; casual PG ≥200 mg/dL; 2 hr OGTT: ≥200 mg/dL;1) Geographic location and 2) Ethno-cultural classification A1c: ≥6.5%. (A1c alone is not recommended to diagnose diabetes.) Individual Risk Stratification Location, ethnicity, and culture individualizeFamily history of high-risk dietary patterns and premature cardiovascular disease, less recommendations. Inputs will populate otherthan recommended physical activity, abnormal anthropometrics (BMI/WC/WHR over areas of the algorithm.normal ranges for locale), hypertension, dyslipidemia, any cardiovascular event, any liverdisease, microalbuminuria over normal range, risky alcohol intake, any sleep disturbance, Anthropometrics include weight, BMI, waistany chronic illness circumference, and/or waist-hip ratio according to local preference/custom. See body composition parameters in Tables 1 and 2. Low Risk High Risk Excessive daily alcohol consumption is defined as >2 drinks for men and >1 drink for women General Recommendations Individual risk stratification directs lifestyle interventions for improved glycemic control andProfessional counseling, physical activity, and healthy eating consistent with current decreased risk for complications and mortality.clinical practice guidelines or evidence (Tables 3-5) Insufficient physical activity is <30 min/day +/- and/or <5 days/week. Overweight/Obesity Low-risk patients with diabetes have no adverse Physical activity consistent with guidelines (Table 3) conditions other than an impaired glycemic Weight loss consistent with guidelines (Table 4) profile and should follow established general MNT consistent with guidelines (Table 4) recommendations for lifestyle interventions plus nutrition therapy per AACE/ADA guidelines. Formula/Caloric supplementation or replacement consistent High-risk patients with diabetes have ≥1 risk with options and strategies (Table 5) factors that require specific interventions to Consider bariatric surgery (Table 6) reduce complications. Conditions amenable to lifestyle change include overweight/obesity, hypertension, and dyslipidemia. +/- 60
Actions Comments Hypertension is defined as blood pressure Hypertension >130/80 mm Hg. Antihypertensive diet consistent with DASH and sodium restriction of <1.5 g/day (Table 7) 2.4 g Na+ = 6 g salt (≈ 1 teaspoon) 1.5 g Na+ = 3.7 g salt (≈ 2/3 teaspoon). +/- The nutrition management of obesity and that of dyslipidemia are similar (Table 4). Dyslipidemia When hypertension and dyslipidemia complicate Lipid-modifying diet (Table 4) prediabetes and diabetes, interventions are additive and intensified. Follow-up Evaluation (1-3 months)History, physical (anthropometrics, blood pressure); chemistries (glucose, A1c, lipids,urinary albumin/creatinine, liver enzymes); urinalysis Follow-up evaluation is scheduled according to At Goals Not at Goals patient needs and local practice.Maintain physical activity, meal plan, Intensify physical activity, meal plan, andand medical nutrition therapy medical nutrition therapy. Improve compliance 61
The inflammatory reflex Kevin J. Tracey Nature 420, 853-859(19 December 2002
Malnutrition• Mild to moderate – Weight loss 6-12% of normal, albumin 3.5g/dl, transferrin 200 mg/dl• Severe - weight loss >12%, low protein• NG versus TPN• Protein levels – Normal 0.8 g/kg/day – Ill 1.2 to 2.0 g/kg/day