Nutrisi Perioperatifdan

MalignancyJ.Iswanto

SurabayaSurgicalUpdate2017Shangri-LaHotel11Maret 2017

Surabaya

Introduction•MalnourishedorNutritionalriskpatientisassociatedwithhigherpost-operativemorbidityandmortalityfollowingelectivesurgery,ahigherLOS,andincreasedofhospitalcost.• Prevalenceofmalnutrition:

*30- 40%ofadmittedpatients.*40%ofsurgicalpatients.

• Nutritionaltherapyisessentialinhospitalizedpatients.

AbdulLatiff,NSM,Ahmad,N;Islahudin,F :Trop.JPharmRes.,2016,:15(6):1321.

Cerantola.Yetal:PerioperativeNutritioninabdominalsurgery.Recommendationandreality,Gastroenterol.Res.AndPractice,2011:1.

TheMetabolicStressResponsetoSurgeryandTrauma

TheMetabolicStressResponsetoSurgeryandTrauma

• Neurohormonal response• Inflammatoryresponse• Metabolicresponse

*Ebbphase*Flowphase*Anabolicphase

Brunicardi etal.Schwartz’sPrinciplesofSurgery10th edition.2010.McGrawHill.Chapter2.p18

Perioperative careissues

• Excessivcrystalloidfluidadministrationduringandaftersurgery,inpatientsunderwentmajorGI-surgery,wouldresultinweightgaincausededema.• Itwouldrecentlycausepostoperativeileus anddelayedgastricemptying• Itissuggestedforfluidrestrictiontotheamountneededformaintainingsaltandwaterbalance.

Weimann,Braga,Harsanyi etal.:ESPENGuidelinesonEnteral Nutrition,ClinicalNutrition,2006(25):228.

Preadmissioncounselling

Selective bowel-prep

CHO- loading/no fasting

No - premed

No NG tubes

Thoracic epidural Anaesthesia

Short-acting Anaesthetic agent

Avoidance ofSodium/fluid overload

Short incisionsWarm air bodyheating in theatre

Standard mobilisation

Non-opial oralAnalgetics/NSA ID`s

Prevention of nausea and vomiting

Stimulation of gut motility

Early removal ofcatheters/drains

Perioperativeoral nutrition

Audit of compliance/outcomes

ERAS

Evidence-based practice

KCHFearon,2005.

Physiologicchangesinsurgicalpatients

• Intestinalpermeabilityinincrease2– 4-foldintheimmediatepostoperativeperiod.• Nutritionaldepletionisassociatedwithincreaseinintestinalpermeabilityandadecreaseofvillousheight.• Increaseintestinalpermeabilityrelatedtofailureofthefunctiongutbarriertoexcludeendogenousbacteriaandtoxins• ThisgutfailurecauseSIRS,SepsisandMOF.

Ward,N:Nutritionalsupporttopatientsundergoinggastrointestinalsurgery,NutritionJ,2003;2:2.

Woundhealing

• Acomplexprocessofcellularandbiochemicalevents,thataredependentonthenutritionalsubstrateavailable.• Woundhealingphaseisenergydemanding.• Woundhealingconsistofcellproliferation,proteinsynthesisandenzymeactivityrequiresenergyandbuildingsubstrates.• Woundhealingneedsmacronutrient:proteinorAA,CHandfats,electrolyteaswellasmicronutrient• Malnutritionaffectsallphaseofwoundhealing

Wild,Rahbarnia,Kellner,Sobotka :Basicsinnutritionandwoundhealing,Nutrition2010(26):865

AbdulLatiff,NSM,Ahmad,N;Islahudin,F :Trop.JPharmRes.,2016,:15(6):1321

UndernutritionandWoundhealing

• Delayedneovascularizationanddecreasedcollagensynthesis.• Prolongphaseofinflammatiom• Decresed phagocytosisbyleucocytes• DysfunctionofBandTcells• Decreasedmechanicalstrengthoftheskin.

Wild,Rahbarnia,Kellner,Sobotka :Basicsinnutritionandwoundhealing,Nutrition2010(26):862

NutritionalAssessment

NutritionalAssessment

Protein

• Lymphocytes,leukocytes,phagocytes,monocytes,macrophages,immunesystemcellsarecomprisedofproteins.• Woundhealingneedssupplyofproteins.• Lackofproteindecreasesthesynthesisofcollagenandtheproductionoffibroblasts.• Methionine,andcysteinehaveroleincollagensynthesis.• Argininehaveamajorinfluenceontheproliferationofcollagenaccretionandimmunereaction.

Wild,Rahbarnia,Kellner,Sobotka :Basicsinnutritionandwoundhealing,Nutrition2010(26):862

MacronutrientsduringStress

Protein• Requirementsrangefrom1.2-2.0g/kg/dayduringstress• Comprise20%-30%oftotalcaloriesduringstress

BartonRG.Nutr Clin Pract 1994;9:127-139ASPENBoardofDirectors.JPEN2002;26Suppl 1:22SA

Carbohydrate:50– 60%oftotalenergy.

EnteralNutrition• Monosaccharides:glucose,fructose• Disaccharides:Sucrose• Oligosaccharides:Maltodextrin• Polysaccharides:Starch

ParenteralNutrition• Glucose.• Fructose• Sorbitolandxylitol(polyols).• Infusionrateglucose:≤4– 5mg/KgBW/min± 0.25– 0.3g/Kg/h.

Carpentier,Sobotka,Soeters :Carbohydrates,inBasicsinClinicalNutrition,4th Ed.Galen– ESPEN2011,254-5.

Lipids- Fattyacids

• Importantcomponentsofcellmembranes.• Subtrates foreicosanoidsynthesis,whichpromotestheinflammatoryprocess.• Shirgel etal,(2008):gelemulsionof ω-3FApromotestissuerepair,dermalangiogenesisandwoundhealing.• 20– 40%oftotalenergyintake.• Maximumrecommendationforintravenouslipidinfusion:1.0– 1.5g/kg/day

Wild,Rahbarnia,Kellner,Sobotka :Basicsinnutritionandwoundhealing,Nutrition2010(26):862

Lipids:

EnteralNutrition• Triglycerides• Phospholipids• Lipid-solublevitamins• Sterol• Commercialformula:30– 40%• MCT• ω-3FAinImmuneEnhancingEnteralFormula.

ParenteralNutrition• Modelofintestinalchylomicron• Core:Triglycerides+lipid-solublevitamins(some)• Surface:phospholipids,freecholesterol,lipid-solublevitamins.

Carpentier,Sobotka :Lipids,inBasicsinClinicalNutrition,4th Ed.Galen– ESPEN2011,258- 60.

VitaminC

• Forhydroxylationofprolineandlysineinthesynthesisofcollagen.• Foroptimalimmuneresponse,cellmitosis,andmonocytemigrationintothewoundtissue.• Monocytetransformsintomacrophagesduringinflammatoryphase.

Wild,Rahbarnia,Kellner,Sobotka :Basicsinnutritionandwoundhealing,Nutrition2010(26):862

Zinc.

• Zincisco-factorformanyenzymaticreations,thatinvolvedinthebiosynthesisofRNA,DNAandproteins.• Zincisessentialforallproliferatingcells.• Lowzincstatusdecreasestheclosureofwound

Wild,Rahbarnia,Kellner,Sobotka :Basicsinnutritionandwoundhealing,Nutrition2010(26):862

Iron

• Cofactorofprolylandlysyl hydrolysisenzymes,whichisessentialforthethe synthesisofcollagen.• Symptomsofirondeficiency:mildfatiguetoexhaustion,pallor,soretounge,digestivetractdisturbances.• PartofHemoglobinplaysanimportantroleintheOxygentransportforwoundhealing.

Wild,Rahbarnialner,Sobotka :Basicsinnutritionandwoundhealing,Nutrition2010(26):862

KeyVitaminsandMinerals

VitaminA Woundhealing andtissuerepairVitaminC Collagensynthesis,woundhealingBVitamins Metabolism,carbohydrateutilizationPyridoxine EssentialforproteinsynthesisZinc Woundhealing,immunefunction,

proteinsynthesisVitaminE AntioxidantFolicAcid,Iron,B12 Requiredforsynthesisand

replacementofredbloodcells

TNTManualversion2.

SpecialNutrients

• Glutamine:0.2-0.4g/KgBW/d(L-Glutamine=0.3-06g/KgBW/dalanyl-Glutamine-peptide)• ω-3fattyacids:EPAandDHA.• Fishoil• Arginine• Nucleotides• Antioxidants:vitaminC,250– 1000mg/d,VitaminE,100–500mg/d,β-carotene5-10mg/d,selenium100-200mg/d.

BasicsinClinicalNutritionESPEN,4th.Ed.P.290,292,296,449.

Singer,Berger,vandenBerghe etal:ESPENGuidelinesofPN:Intensivecare.

RoleofArginineinMetabolicStress

• Providessubstratestoimmunesystem• Increasesnitrogenretentionaftermetabolicstress• Improveswoundhealinginanimalsmodels• Stimulatessecretionofgrowthhormoneandisaprecursorforpolyaminesandnitricoxide• Notappropriateforsepticorinflammatorypatients

“givingargininetoasepticpatientislikeputtinggasolineonanalreadyburningfire.

B.Mizock,MedicalIntensiveCareUnit,CookCountyHospital,Chicago,ILBarbul A.JPEN 1986;10:227-238;Barbul A,etal.J.Surg Res1980;29:228-235

PerioperativeNutritionalSupport

• Totalcalorie20– 25Kcal/KgBW/day.• ESPENrecommendations:rarely>30– 35Kcal/KgBW/day.• Protein1.2– 2g/KgBW/day.

• Glucose(CH)50– 60%oftotalenergyintake.(~7g/KgBW/d)• Rateofglucoseinfusionmaynotmorethan4– 5mg/KgBW/min.• Lipids20– 40%oftotalcalorieintake.• Rateofinfusionoflipidsemulsion:LCT≤0.1g/Kg/handMCT≤0.15g/KgBW/h.• Vitamins,mineralandtraceelementassameasRDA.

BasicsinClinicalNutrition,ESPEN,4th Ed.p.255,260-1,

Terapi Nutrisi pada Malignancy

CancerCachexiaisdefined:• Multifactorialsyndromedefinedbyanongoinglossofskeletalmusclemass(withorwithoutlossoffatmass)thatcannotbefullyreversedbyconventionalnutritionalsupportandleadstoprogressivefunctionalimpairment.• Itspathophysiologyischaracterizedbyanegativeproteinandenergybalancedrivenbyavariablecombinationofreducedfoodintakeandabnormalmetabolism.• Cytokinesareamajordrivingforceinthedevelopmentofcancercachexia,suchas:TNF-α,IL-2,IL-8,IFN-γ.

Fearon,K;Strasser .F;Anker.S,Detal:DefinitionandclassificationofCancerCachexia:AnInternationalConsensus.LancetOncol,2011;12:489-95.(www.ncbi.nlm.nih.gov/pubmed)

Bozzetti,F:CancerCachexiain:BasicsinClinicalNutritionEd.Sobotka .L,4th Ed.ESPEN2011p.584.

Normal Death

Precachexia

- Weightloss≤5%

- Anorexia

- MetabolicChange

Cachexia

- WeightLoss>5%- WeightLoss>2%

+BMI<20kg/m2+Sarcopenia.

- Oftenreducedfoodintake

- SystemicInflammation

RefractoryCachexia

- VariabledegreeofCachexia

- Cancerdiseasebothprocatabolic andnotresponsivetoanticancertreatment

- Lowperformancestatus- <3monthsexpected

survival

Sauer,A.CandVoss,A.C:ImprovingOutcomeswithNutritioninPatientswithCancer,whitepaper.AbbotOnLine,Fearon,K;Strasser .F;Anker.S,Detal:DefinitionandclassificationofCancerCachexia:AnInternationalConsensus.LancetOncol,2011;12:489-95(Original)

CancerCachexia

• StageI:weightloss<10%,andnosymptoms• StageII:weightloss<10%andormoresymptoms• StageIII:weightloss≥10%andnosymptom• StageIV:weightloss≥10%andoneormoresymptoms.

Bozzetti,F:CancerCachexiain: BasicsinClinicalNutritionEd.Sobotka .L,4th Ed.ESPEN2011p.584.

IndicationNutritionforCancerpatient.ESPENrecommendation:• Toreduceoperativeriskby:

- correctingmalnutrition- potentiatingimmuneresponse- maintainingthegutactivity

• Toincreasepatient’stolerancetoaggressivecancertreatmentinmalnourishedpatients.• Tomaintainpatient’sliveifthereisintestinalfailurecausedof-radiationtherapy,surgicaltherapy,bowelobstruction

Bozzetti,FandMeyenfeldt,MF:NutritionalsupportinCancerPatients,BASICSINCLINICALNUTRITION,4th Ed.,Editor:LubosSobotka,ESPEN2011.p576.

ESPEN:Glutamine

• ThereisinsufficientevidencetorecommendGlutaminesupplementationduringconventionalcytotoxicortargetedtherapy.• Levelofevidence:Low.• Strenght ofrecommendation:None.

26th ESPENCongress,Geneve,20

ESPENGuidelines:EnteralNutritionPerioperative• PatientwithseverenutritionalriskbenefitfromNutritionalsupport10– 14dpriortomajorsurgery,evenifsurgeryhastobedelayed.(GradeA).DuringRadiotherapy,Radio-chemotherapy,Chemotherapy:• RoutineENisnotrecommended.• Duringchemotherapy,routineENhasnoeffectontumorresponsetochemotherapyoronsideeffectsofchemotherapy.(GradeC)

Arends,J,Bodogy.G,Bozzetti .F:ESPENGuidelinesonEN:NonsurgicalOncology,Clin.Nutr.2006;25:245.

NutritionalSupportNutritionregimenwouldprovide30-35kcal/kgBW/dayAminoacid1-1.5 g/kgBW/dayLipidswithdoseof1g/KgBW/day,consistofLCT/MCT.(20– 40%oftotalcalorieintake).ω-3fattyacideicosapentaenoic acid(EPA)shouldbeaddedintheformula,becauseithasbeenrecognizedbeingcapableofblockingcytokineactivityVitamin,suchasVit.CandmineralaregivenapproximatelyequaltodailyRDA.Waterandelectrolyteshouldprovideformaintainingthewaterandelectrolytebalance.

Bozzetti,FandMeyenfeldt,MF:NutritionalsupportinCancerPatients,BASICSINCLINICALNUTRITION,4th Ed.,Editor:Lubos Sobotka,ESPEN2011.p573– 82..

AdvancedCancerNutritionalSupport

• Bragaetal:preoperativeoraladministrationofImmuneEnhancedNutritioncontains:Arginine,ω-3FA, Nucleotidefor5-7days,3x250mlreducedpostoperativemorbidity.• Routeofnutritioncanbe:Oral,EnteralNutrition,ParenteralNutritionorCombination• EN isprefered thenPN• Ethicalconsiderationwouldbeinvolvedespeciallyinterminalcancerpatient

Bozzetti,FandMeyenfeldt,MF:NutritionalsupportinCancerPatients,BASICSINCLINICALNUTRITION,4th Ed.,Editor:Lubos Sobotka,ESPEN2011.p575.

ProgramMannual TNTCourse