Transcript Malnutrition in surgical patients

Malnutrition in surgical patients
Surgical Nutrition Training Module
Level 1
Philippine Society of General Surgeons
Committee on Surgical Training
Objectives
• To define malnutrition and discuss its impact
on the surgical patient
• To identify malnutrition in hospitalized
surgical patients
MALNUTRITION IS A SYNDROME
Malnutrition syndrome: features
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Wasting / marasmus
Cachexia
Protein-energy malnutrition
Sarcopenia
Failure to thrive
Obesity
Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
Malnutrition syndrome: features
• Wasting/marasmus
– Loss of body cell mass without underlying
inflammatory condition; Pure starvation
• Cachexia
– Loss of body cell mass with underlying
inflammatory condition; Cytokine mediated
– Cancer: moderate to advanced stage
Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
Cancer Cachexia
Inflammation in cachexia
Malnutrition syndrome: features
• Protein-energy malnutrition
– In modern healthcare this is often acute metabolic
derangement driven by pro-inflammatory state;
not classic PEM with clinical and metabolic
evidence for reduced intake of protein and energy
Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
Malnutrition syndrome: features
• Sarcopenia (mostly geriatric)
– Age related loss of muscle; often with
inflammation / cachexia overlap
• Failure to thrive
– Classic pediatric growth failure syndrome
– Now also applied in clinical practice to
undernourished older persons in functional or
cognitive decline (Alzheimer’s disease)
Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
Sarcopenia
COMPLICATIONS
Malnutrition syndrome: features
• Obesity: WHO (World Health Organization)
criteria
– BMI (Body Mass Index) = Weight in kg / Height in
meter / Height in meter
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30 - 34.9
35 - 39.9
40 and above
40 - 50
> 50
Obese class 1
Obese class 2
Obese class 3
Morbidly Obese
Super-Obese
Malnutrition syndrome: summary
MALNUTRITION
UNDERNUTRITION
• chronic starvation without inflammation
• chronic disease with inflammation
• acute injury/disease with inflammation
Macronutrient
deficiency
Micronutrient
deficiency
OBESITY
BMI > 30
Metabolic Syndrome
Hegazi R et al. TNT version 3, 2011
Malnutrition process
• It is a continuum
– Starts with poor intake
– Effect of initiation and progress of the disease
process: severity of disease and adequacy of
intake
– Effect of efforts to correct both body composition
and disease process
Malnutrition concerns
• Lean body mass
– Structure and function
– Body composition capacity for healing and
recovery
– Quality of life
• Energy reserves
– Function
– Optimal utilization of substrates and protein
synthesis
Malnutrition syndrome: features and
effects
• Wasting / marasmus
• Cachexia
• Protein-energy
malnutrition
• Sarcopenia
• Failure to thrive
• Obesity
• Loss of lean body mass
• Structural and
functional impairment
• Energy utilization
problems
• Antioxidant capabilities
• Increased complications
and mortality
Gordon Jensen. International Guidelines: malnutrition syndrome; ASPEN Congress 2008, Chicago.
EFFECT OF SURGERY ON THE
PATIENT
Surgery = injury
SURGERY
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INFLAMMATION
Metabolic response
Endocrine response
POST-SURGERY STATUS
• Resolution of inflammation
• Wound healing
• Recovery
COMPLICATIONS
• Malnutrition
• Inadequate intake
• Current body composition
• Pre-op preparation (NPO,
antibiotic, fluid balance)
• Post-op management
Surgery, wound healing, and
nutritional status
SURGERY
INFLAMMATION
↑WBC + ↑ENERGY
↑CELL MULTIPLICATION + ↑NUTRIENT NEEDS
WOUND HEALING
No Malnutrition
NORMAL
POOR ± COMPLICATIONS
Malnutrition
↑Energy needs = ↑ free radicals
Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. 2003.
Role of nutrition in surgery
WBC, RBC, FIBROBLASTS
CARBO
Bone Marrow
All WBC, RBC, FACTORS
LIPIDS
B-cells
MUSCLE
MALT
GALT
Body
composition
Alanine
MALT, GALT
Glutamine
T-cells
Platelets
Organs Affected
• epithelium
• connective tissue
• angiogenesis
• complement system
INFLAMMATION
ANTIOXIDANTS
WOUND HEALING
INFECTION CONTROL
NEED TO KEEP ALL NUTRIENTS IN STEADY SUPPLY AS NEEDED
Nutrition and wound healing
Nutritional status
Surgery
Normal
Wound healing
Good
Severe malnutrition
Prolonged
Complications
Body reserves:
• skeletal muscle – alanine and glutamine
• fat reserves – energy (long term)
Malnutrition in surgical patients
Surgical patients
• 9% of moderately
malnourished patients →
major complications
• 42% of severely
malnourished patients →
major complications
• Severely malnourished
patients are four times
more likely to suffer
postoperative
complications than wellnourished patients
Detsky et al. JPEN 1987
Detsky et al. JAMA 1994
Malnutrition and costs
Malnutrition is associated with increased cost and the higher the risk the
higher the number of complications plus cost
Reilly JJ, Hull SF, Albert N, Waller A, Bringardener S. Economic impact of malnutrition: a
model system for hospitalized patients. JPEN 1988; 12(4):371-6.
Malnutrition: effects on surgery
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Slow wound healing.
Reduced muscle strength.
Decrease in respiratory muscle strength
Impaired cardiac function
Immune hypofunction and dysfunction
Higher morbidity and mortality
Poor quality of life
PREVALENCE OF MALNUTRITION
Malnutrition detection tools
Nutrition screening
Nutritional assessment
Nutritional
Assessment
and Risk Level
Form
Hospital malnutrition: global
Year
1974
1977
1979
1984
1993
1994
1995
1997
Author
Bistrian
Hill
Weinsier
Agradi
Larsson
McWhirter
Fernando
Waitzberg
Location
US
England
US
Italy
Sweden
Scotland
Philippines
Brazil
Prevalence
50%
44%
48%
34%
27%
40%
48%
47%
Malnutrition in the Philippines
Hospital
BMI
<18.5
BMI
>30
SGA
“C”
1. Marikina, Rizal (Amang Rodriguez Medical Center)
38%
15%
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2. Lipa City, Batangas (Mary Mediatrix Med Center)
18%
5%
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3. Quezon City (St. Luke’s Medical Center)
6%
12%
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42%
5. Pasig (The Medical City)
4%
14%
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6. Alabang (Asian Hospital Medical Center)
8%
20%
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7. Cabanatuan City (Premiere Medical Center)
15%
9%
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8. Mandaluyong (St. Martin De Porres Hospital
12%
8%
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4. Manila (Philippine General Hospital)
Mean
14.4% 11.8%
Malnutrition in the units
Nutritionally at risk patients
Llido L. The impact of computerization of the nutrition support process in the
nutrition support program in a tertiary care hospital in the Philippines: report
for the years 2000-2003. Clin Nutr 2006; 25(1):91-101 .
WHAT IS THE PREVALENCE OF
MALNUTRITION AMONG SURGICAL
PATIENTS IN YOUR CENTER?
CONCLUSION
Malnutrition
• Is a syndrome
• Its presence in surgical patients influences
outcome
• Detection and management is a priority in
surgical patients
• Is prevalent in the surgical patient population