Nutritional Support

in Perioperative Period

Dennis Chrissandy W
Surgery Department
PRIMAYA HOSPITAL PASAR KEMIS
Tangerang - Indonesia
 Pain
Anaesthesia Hypoxemia

Systemic Overhydration
Inflammation
Dehydration
Immobilization
Stressors Starvation
Hypothermia
Tissue Injury
Opioids
Impaired
Blood
Tissue
Transfusion
Blood Loss Perfusion
 Stress Response

Stress hormones
and cytokines

• Catabolic Reaction  Loss of energy stores and Muscle breakdown

• Loss of normal anabolic action of insulin  Insulin Resistance
The surgical patient . . .
• Decreased intake
• Inadequate nutritional intake
• Anorexia
• Altered nutrient use
• Prevalence of GI obstruction,, malabsorption
• Increased metabolic expenditure
• Metabolic response (hypermetabolism from long term inflammation or infectious conditions)
• Extraordinary stressors (surgical stress, hypovolemia, sepsis, bacteremia, medications)
• Wound healing
• Anabolic state, higher demand for nutrients (amino acids, zinc, vitamin A & C, arginine)

Nutrient depletion in the surgical patient

Increased risk of malnutrition
Weight Mortalit
loss y
< 20% 3,5%

> 20% 33%

Studley HO. JAMA. 1936;106:458–460

 RECOVERY

SU AN D
TIB
R R
IO
GE TIC U
RY S GS

NUTRITION
ILLNESS

25 – 55% MALNOURISHED
HOSPITAL ADMISSION
Nutrition and Surgery
• Malnutrition may compound the severity of complications related to a
surgical procedure
• A well-nourished patient usually tolerates major surgery better than a
severely malnourished patient
• Malnutrition is associated with a high incidence of operative
complications and death

Poor nutrition = Poor outcomes

Consequences of Undernutrition
Poor nutritional status leads to an increase in therate of:
• In-hospital complications
• Length of hospital stay
• Mortality
• Costs
• Re-admissions
• Reduction QoL
Definition of Malnutrition

• Malnutrition is condition resulting from a combination of

varying degrees of under- or overnutrition and inflammatory
activity, leading to abnormal body composition and
diminished function

Soeters et al. Clin Nutrition 2008

 Nutrition Care Process
Inpatient
Evaluation of Care No Discharge
Acute Care Setting Longer Planning
Inpatient Required
Admission Screening and Nutritional Assessment Objectives
Care
Identify at-risk patients to reduce
Required Patient : Goals
Nutritional • Complications Monitoring achieved
Screening Not at•risk
Treatment failures Change in Termination
At risk • Physiological problems Status of Therapy
Development Implementation Patient Reassessment
Nutritional • Health care costs
of Nutrition & Updating of
of Nutrition
Assessment
Care Plan Care Plan Nutrition Care Plan

Taken from the ASPEN Standards for Nutrition Support: Hospitalized Patients
Nutritional screening / Malnutrition risk screening
• A rapid process to identify subjects at nutritional risk
• Using an appropriate validated tool
• Nutrition Risk Screening-2002 (NRS2002)
• Malnutrition Universal Screening Tool (MUST)
• Mini Nutritional Assessment (MNA) for older persons
• Malnutrition Screening Tool (MST)
• Short Nutritional Assessment Questionnaire (SNAQ)
• In all subjects that come in contact with healthcare services
• Should be performed within the first 24-48 h after first contact and thereafter
at regular intervals
• Subjects identified as at risk need to undergo nutritional assessment
Nutritional Risk Screening (NRS)

Answer
Is BMI < 20,5? Yes / No
Has the patient lost weight during the Yes / No
last 3 months
Is the dietary intake reduced in last Yes / No
week?
• If “No” to all question: re-screened at weekly intervals
Is the
• If “YES” patient
to any question: severely
the final screening is performed ill? (e.g. ICU) Yes / No
Kondrup et al, Clin Nutr 2003
Clinical Nutrition 36 (2017) 623-650
Malnutrition Screening Tool
• STEP 1: Screen with the MST
• Have you recently lost weight without trying?
• If yes, how much weight have you lost?
• Have you been eating poorly because of a decreased
appetite?
• STEP 2: Score to determine risk
• MST = 0 OR 1: NOT AT RISK : Eating well with little or no
weight loss
• If length of stay exceeds 7 days, then rescreen, repeating
weekly as needed.
• MST = 2 OR MORE: AT RISK : Eating poorly and/or recent
weight loss
• Rapidly implement nutrition interventions.
• Perform nutrition consult within 24-72 hrs, depending on risk.
• STEP 3: Intervene with nutritional support for your
patients at risk of malnutrition.
Short Nutritional Assessment Questionnaire
(SNAQ) screening tools
• SNAQ: for hospitalized patients
• SNAQRC: for the elderly in care homes
or residential care
• SNAQ65+: for patients in the
community who are aged 65 and over
 Nutrition Screening Tools, Outcome Measures, and Nutrition Risk Criteria

Features of NRS- MUST MST SNAQ

Nutrition Risk 2002
BMI X X
Weight loss X X X X
Food/energy intake X X X
Nutrition X
supplements
Severity of disease X
Acute disease X
effect
Age X
Nutrition risk classification, points
• Conclusion: The MUST, MST, and SNAQ share similar accuracy to the
NRS-2002 in identifying risk of malnutrition, and all instruments were
positively associated with very long hospital stay. In clinical practice,
the 4 tools could be applied, and the choice for one of them should be
made per the particularities of the service.
 PONS score
Peri Operative Nutrition Screen
Not at Risk: Normal Nutrition
USDA 1992 – 2005 – 2011
Is preoperative fasting necessary?
• Preoperative fasting from midnight is unnecessary in most patients.
• Clear fluids until 2 hours before anaesthesia.
• Solids until 6 hours before anaesthesia
Grade of recommendation A - strong consensus (97% agreement)

ESPEN guideline: Clinical nutrition in surgery

Is preoperative metabolic preparation of the
elective patient using carbohydrate treatment
useful?
• Oral preoperative carbohydrate treatment (instead of overnight
fasting) the night before and 2 hours before surgery should be
administered to reduce perioperative discomfort
• Preoperative carbohydrates can be considered in patients undergoing
major surgery to impact postoperative insulin resistance and hospital
LOS
Grade of recommendation A/B - strong consensus (100% agreement)

ESPEN guideline: Clinical nutrition in surgery

Is postoperative interruption of oral nutritional
intake generally necessary after surgery?
• Oral nutritional intake shall be continued after surgery without interruption
Grade of recommendation A - strong consensus (90% agreement)

• It is recommended to adapt oral intake according to individual tolerance and

to the type of surgery carried out with special caution to elderly patients.
Grade of recommendation GPP - strong consensus (100% agreement)

• Oral intake, including clear liquids, shall be initiated within hours after surgery
in most patients.
Grade of recommendation A - strong consensus (100% agreement)

ESPEN guideline: Clinical nutrition in surgery

Nutritional Assessment

• Give the basis for the diagnosis decision and for further actions
including Nutritional Treatment
• Should be performed in all subjects identified as being at risk by
nutritional risk screening
When is nutritional assessment indicated in the
surgical patient?
• It is recommended to assess the nutritional status before and after
major surgery.
Grade of recommendation GPP e strong consensus (100% agreement)

ESPEN guideline: Clinical nutrition in surgery

Nutritional Assessment
• Anthropometric Measurement
• BW
• BMI (WHO1997)
• TSF
• MAC
• Biochemical data
• Subjective Global Assessment
• Clinical Assessment
Nutritional assessment
• Assessment tools:
• Subjective Global Assessment (SGA)
• PatientGenerated (PG)SGA
• Mini Nutritional Assessment (MNA)
SGA
Mini
Nutritional
Assessment
• For older person
Classification of Nutrition Disorders
• Malnutrition; Synonym: Undernutrition
• Disease-related malnutrition (DRM) with inflammation
• Chronic DRM with inflammation; Synonym: Cachexia (Cancer cachexia and other disease-specific forms of cachexia)
• Acute disease- or injury-related malnutrition
• DRM without inflammation. Synonym: Non-cachectic DRM
• Malnutrition/undernutrition without disease. Synonym: Non-DRM
• Hunger-related malnutrition
• Socioeconomic or psychologic related malnutrition
• Sarcopenia
• Frailty
• Over-nutrition
• Overweight
• Obesity
• Sarcopenic obesity
• Central obesity
• Micronutrient abnormalities (Deficiency/Excess)
• Refeeding syndrome
T. Cederholm et al. / Clinical Nutrition 36 (2017) 49-64
ESPEN Diagnostic Criteria for Malnutrition
Two options:
• Option 1: BMI <18.5 kg/m2
• Younger <20 kg/m2
• Older>70y <22 kg/m2
• Option 2: combined:
• Weight loss >10% or >5% over 3 months and
• Reduced BMI or a low Fat Free Mass Index
• (FFMI: female <15kg/m2, male<17kg/m2)

Clinical Nutrition 36 (2017) 623-650

Surgical patients at severe nutritional risk
• The presence of at least one of the following criteria:
• Weight loss >10-15% within 6 months
• BMI <18.5 kg/m2
• Subjective Global Assessment (SGA) Grade C or NRS >5
• Preoperative serum albumin <30 g/l (with no evidence of hepatic
or renal dysfunction).

• Need preoperative optimalization of the patient's condition before

major elective surgery.

Clinical Nutrition 36 (2017) 623-650

• ESPEN
• In case of severe metabolic risk 10-14 days of nutritional therapy may be
beneficial, but without measurable change in body composition or serum
albumin concentration.
• ERAS
• For significantly malnourished patients, nutritional supplementation (oral
and/or parenteral) has the greatest effect if started 7-10 days preoperatively,
and is associated with a reduction in the prevalence of infectious complications
and anastomotic leaks.

• After earlier surgery with infectious complications, at least 6 weeks

and sometimes longer may be required to restore a metabolic and
nutritional state allowing a successful reoperation
Nutritional Care Plan
• a scheme for nutrition therapy based on the results of the assessment
• developed by a multi/interdisciplinary team together with the patient
and his/her carer

Clinical Nutrition 36 (2017) 49-64

The Nutritional Care Plan includes information on:
• Energy, nutrient and fluid requirements
• Measureable nutrition goals (immediate and long-term)
• Instructions for implementing the specified form of nutrition therapy
• The most appropriate route of administration and method of nutrition
access
• Anticipated duration of therapy
• Monitoring and assessment parameters
• Discharge planning and training at home (if appropriate)
Strong Consensus, 100% agreement

Clinical Nutrition 36 (2017) 49-64

Protein – Energy Demand
• HEALTHY PATIENT • SURGERY PATIENT
• Caloric intake • Caloric intake
• 25-30 kcal/kg/day • Mild stress, inpatient 25-30 kcal/kg/day
• Moderate stress, ICU patient 30-35 kcal/kg/day
• Severe stress, burn patient 30-40 kcal/kg/day
• Protein intake
• 0.8-1gm/kg/day
(max=150gm/day) • Protein intake 1-2 gm/kg/day

• Fluid intake • Fluid intake INDIVIDUALIZED

• 30 ml/kg/day
Patient who cannot eat any/enough food?

Consider NUTRITIONAL SUPPORT!

What is nutrition therapy/support
• Provision of nutrition or nutrients either orally or via enteral nutrition
(EN) or parenteral nutrition (PN) to prevent or treat malnutrition

Fundamental goals of nutritional support:

1. To meet the energy requirement for metabolic processes
2. To maintain a normal core body temperature
3. For tissue repair
Nutritional Support Therapy - Surgery
• Indications:
• prevention and treatment of catabolism and malnutrition perioperative to
prevent postoperative complications
i.e.
• correction of undernutrition before surgery
• maintenance of nutritional status after surgery, when periods of prolonged
fasting and/or severe catabolism are expected.
When is nutritional therapy indicated in the
surgical patient?
• Perioperative nutritional therapy is indicated in patients
• With malnutrition
• At nutritional risk
• Unable to eat >5 days perioperatively
• Have low oral intake and cannot maintain >50% of recommended intake for >7
days
•  initiate nutritional therapy (preferably by the enteral route–ONS–
TF) without delay.
Grade of recommendation GPP e strong consensus (92% agreement)

ESPEN guideline: Clinical nutrition in surgery

Question?
 TUTOSOL®
• Tutosol® merupakan cairan intravena yang mengandung
natrium, kalium, kalsium, magnesium, klorida, asetat, dan
sorbitol
• Sorbitol termasuk dalam kelompok polyols asiklik dengan enam
rantai karbon.
• Sorbitol memiliki aksi protein-sparring dan dan menunjukkan
efek ketolitik pada beberapa percobaan.

Soesilo D, Santoso RE, Diyatri I. The role of sorbitol in maintaining saliva’s pH to prevent caries process. Maj.Ked.Gigi (Dent.J).2005;38(1):25-28
12

Shuman CR, Kemp RL, Coyne R, Wohl MG. Clinical use of sorbitol as a sweetening agent in diabetes mellitus. The American Journal of Clinical Nutrition.
13

1956;4(1):61-67
TUTOFUSIN OPS®
 Tutosol® : cairan IV yg mengandung natrium,
kalium, kalsium, magnesium, klorida, asetat,
dan sorbitol.
 Sorbitol (C6H14O6) : gula alkohol (polyols),
termasuk kelompok polyols asiklik dgn 6
rantai karbon, memiliki aksi protein-sparring
& menunjukkan efek ketolitik.
TUTOFUSIN OPS®
ASETAT VS LAKTAT
1. Asetat dimetabolisme di otot sedangkan laktat dimetabolisme di hati menjadi
bikarbonat
oleh karena itu, pada pasien dangan gangguan fungsi hati
konversi menjadi bikarbonat tidak terganggu
2. Laju metabolisme asetat adalah 250-400 mEq/jam, sedangkan laktat 100
mEq/jam
Lebih cepat mengatasi asidosis yang menyertai syok.
3. Walaupun asetat dan laktat keduanya merupakan prekursor ion bikarbonat,
asetat juga merupakan dapar fisiologis untuk menetralkan metabolisme asam
yang berlebihan
Efisien untuk mengatasi syok yang disertai asidosis
• Tutosol merupakan cairan rumatan yang
mengandung elektrolit lengkap dan karbohidrat
parsial
• Sumber karbohidrat Tutosol menggunakan sorbitol,
yang dari penelitian di luar maupun dalam negeri
menunjukkan bahwa penggunaannya relatif aman
pada pasien dengan DM.
• Tutosol juga mempunyai uji kompatibilitas terhadap
beberapa obat injeksi.