Transcript Pre-Rehab Nutrition - WiSPEN - The Wisconsin Society for

Pre “Rehab” Nutrition
Beth Hall RD, CSO, LN
Billings Clinic
2014
Prehab Enteral Nutrition
1. Identify 3 nutrition interventions from the
ERAS protocol
2. Identify the nutrition triggers from Strong
for Surgery
3. Identify high risk surgical populations that
may benefit from early nutrition support
“Prehabilitation”
• Metabolic Assessment1-4
– Glycemic Control (HgA1C >7-8%) 1
– Weight loss ( BMI >35) 1
• Surgical complications are 12 X in obese pts1
• Individual exercise program
• Preserve lean body mass
– Smoking Cessation
• 30 day cessation reduced site dehiscence from
approximately 12% to 2%1-4
– Immune enhancing nutrition 5-7 days3,4
• 36% reduction in infectious complications
• 18% reducation in non-infectious complications
ERAS
• Enhanced Recovery After Surgery
• Perioperative Care to improve outcomes
after major surgery1,5
• Decreased length of stay by 2-3 days1,5
• Decreased complications by 30-50%1,5
ERAS SURGICAL POPULATOINS
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Bladder6-8
Colonic/Colorectal9,10
Esophageal11
Head and Neck Cancer12
Hepatic13
Gastrectomy (Laprascopic)14
Gynecological Cancer/Hysterectomy15,16
Pancreaticoduodenectomy17,18
ERAS OVERVIEW5
(Ljunqvist, 2014)
Nutritional Prehab ERAS
• NPO 6 hrs pre-op solids, 2 hrs clear liquids4,5,9
• Oral Rehydration Solution
– 120 g CHO drink night before and 2-3 hrs presurgery (09 Guidelines) 5
– 800 mL CHO drink night before and 400 mL 2-3
hrs (12.6 g CHO/100 mL) 5,10
– Nutrition status optimized with liberal nutrition
support
• Nutritional supplements
Post-operative Nutrition ERAS
• Oral fluids as tolerated on the day of the
surgery and built up to oral diet over nexct
24 hours 5,9
• Goal to meet nutritional needs within 72
hours 5,9
• Avoid excessive IVF (1.5-2.5 L/day should
be adequate) 5,9
Strong for Surgery
http://www.becertain.org/strong_for_surgery
Strong for Surgery
Nutrition Parameters:
STRONG FOR SURGERY
RD CONSULT FOR YES
BMI less than 19
C/S
Weight loss 8 # or more over 3
months
Less than 50% of 2 or less meals per
day
C/S
C/S
Is the patient un able to take food
C/S
Is patient having a complex surgery
C/S, Nutritional Supplement
http://www.becertain.org/strong_for_surgery
CASE REVIEW
CASE REVIEW
High Risk Prehab Nutrition
• Colorectal 5-7 days pre-op
• Whipple 5-7 days pre-op
• Esophagectomy – 2 weeks pre-op
• Obesity pre-op – 1 – 3 months pre-op
• All feeding tubes 5-7 days pre-op
CASE REVIEW
High Risk Prehab Nutrition
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Bezoars
Celiac Disease
Cancer
Cirrhosis
Colostomy
Crohn’s Disease
Divertulosis
Dysphagia
Eating Disorders
• Esophagectomy
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Esophagitis
Feeding tube
Fistulas
Gastrectomy
• Gastroenteritis
High Risk Prehab Nutrition
• Gastroparesis
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GERD
Ileostomy - 3 month care
Inflammatory Bowel Disease
Lactose Intolerance
• Malabsorption
• Malnutrition
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Parenteral Nutrition
Pre-operative weight loss
Short Bowel Syndrome
SMA
Ulcerative Colitis
Whipple
Wounds
Presurgical Weight Loss
• BMI has been associated to surgical
wound complications 1,19,20
• Obesity defined at % body fat has been
associated with a 5-fold increase in
surgical site infections19
– Using BIA 69% were identified as obese
• Reference Measurement - Men (0.85) Women
(0.88)
– Using BMI 38% were identified as obese
IBD Prehab EN
• Surgical Consult = Nutrition Consult
• Considerations from the British Dietetic
Association21:
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When medical therapy is contraindicated
Patients of physicians choose this treatment option
Corticosteroids should be avoided (young adults)
Patients present with or are at high risk for malnutrition
IBD Prehab EN
• EEN remission rates 50-80% in children
and young adults22
• Partial EN with an alternative diet (50%)
led to 70% remission rate22
• Partial EN with a free diet led to a 15%
remission rate22
IBD Prehab EN and Labs
• CBC
• Iron deficiency
– Serum Fe
– TIBC
– Ferritin
IBD Prehab EN and Labs
• Vitamin D may impact response to IBD
treatment23-26
– Desired level <30
– Repletion 50,000 q wk x 8 wk, 1-2 x mo, 3 month
checks
– Maintenance 1000 IU/day
• Calcium25
– Calcium citrate divided into dosing 2-3 times per day
– 1200-1500 mg/day
IBD Prehab EN and Labs
• Zinc25
– More often with high output fistulas and parenteral
nutrition dependence related to short bowel syndrome
– 12 mg of zinc should be added for each liter lost
• Magnesium25
– Oral options; Mg gluconate, Mg sulfate, Mg
oxide, Mg chloride
– For severe depletion IV replacement with slow
infusion to improve
IBD Prehab Nutrition
• Vitamin B1225
– Normal Range (200-900 ng/L)
– Repletion
• 1000mcg (IM injection)
• 1000 mcg (subcutaneous injection weekly)
• Oral synthetic B12 (1000-2000mcg/day)
• Folate25
– 1 mg oral folic acid daily in patients with high
homocysteine level and those on
methotrexate
CASE REVIEW
Prophylactic Feeding Tubes
• Prehab EN is critical in the cancer
population
– Head and Neck Cancer
– Esophageal Cancer
– Pancreatic Cancer Tx plan whipple and
chemoradiation
Billings Clinic Cancer Center Head and Neck Cancer EN Risk Assessment
Stage T3 or T4 and/or N2 or N3
High Risk
Moderate Risk
10-15% in 6 months
10% in 6 months
Mild Risk
Malnutrition
Weight loss
Including Pretreatment
5% in 1 month
BMI
<16
16-17.9
18-20
Albumin
<2.1 g/dL
2.1-2.7 g/dL
2.8-3.5 g/dL
Prealbumin
< 5mg/dL
5-10 mg/dL
10-15 mg/dL
Penetration/Aspiration Scale*
Level ≥ 5
Level ≥ 3
Level ≥ 2
Dysphagia*
Grade ≥3
Grade ≥2
Grade 2
Location
Bilateral neck disease planning
treatment
Oropharynx, hypopharynx, larynx,
nasopharynx, or base of the
tongue
Performance Status*
ECOG score ≥3
ECOG ≥2
ECOG ≥2
Karnofsky < 80
Karnofsky < 80
Karnofsky < 80
Limited Care Giver Support
VEGFR medications
Tracheotomy
Pharyngeal Tumor Site
If all 3 present 75% risk:
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Smokes 20 cigarettes per day
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Cancer Stage 3-4
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Poor Performance Status
Other
CASE REVIEW
References
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1.
Martindale RG, McClave SA, Taylor B, Lawson CM. Perioperative nutrition: what is the current landscape?
JPEN J Parenter Enteral Nutr. Sep 2013;37(5 Suppl):5S-20S.
2.
Drover JW, Dhaliwal R, Weitzel L, Wischmeyer PE, Ochoa JB, Heyland DK. Perioperative use of argininesupplemented diets: a systematic review of the evidence. J Am Coll Surg. Mar 2011;212(3):385-399, 399 e381.
3.
Marimuthu K, Varadhan KK, Ljungqvist O, Lobo DN. A meta-analysis of the effect of combinations of
immune modulating nutrients on outcome in patients undergoing major open gastrointestinal surgery. Ann Surg.
Jun 2012;255(6):1060-1068.
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McClave SA, Kozar R, Martindale RG, et al. Summary points and consensus recommendations from the
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6.
Patel HR, Cerantola Y, Valerio M, et al. Enhanced recovery after surgery: are we ready, and can we afford
not to implement these pathways for patients undergoing radical cystectomy? Eur Urol. Feb 2014;65(2):263-266.
7.
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Blom RL, van Heijl M, Bemelman WA, et al. Initial experiences of an enhanced recovery protocol in
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