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

• 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 pre-

surgery (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

C/S

Less than 50% of 2 or less meals per day

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

• Bezoars• Celiac Disease • Cancer• Cirrhosis• Colostomy • Crohn’s Disease • Divertulosis • Dysphagia• Eating Disorders

• Esophagectomy

• Esophagitis

• Feeding tube

• Fistulas

• Gastrectomy

• Gastroenteritis

High Risk Prehab Nutrition

• Gastroparesis

• GERD

• Ileostomy - 3 month care

• Inflammatory Bowel Disease

• Lactose Intolerance

• Malabsorption

• Malnutrition

• 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:– 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

• 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 EN and Labs

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

High Risk Moderate Risk Mild Risk

Malnutrition

Weight lossIncluding Pretreatment

10-15% in 6 months 10% in 6 months

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

Other Limited Care Giver Support VEGFR medications

Tracheotomy Pharyngeal Tumor Site

If all 3 present 75% risk: 1. Smokes 20 cigarettes per day

1. Cancer Stage 3-4

1. Poor Performance Status

Billings Clinic Cancer Center Head and Neck Cancer EN Risk AssessmentStage T3 or T4 and/or N2 or N3

CASE REVIEW

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