Impact of nutritional support on the clinical outcome of the surgical patient

[Weaning from invasive ventilation : Challenges in the clinical routine]

Modern intensive care medicine is caught between the conflicting demands of an efficient but also increasingly more technical intensive care treatment with numerous therapeutic options and, at the same time, an ageing society with increasing morbidity. This is reflected, among other things, in an increasing number of ventilated patients in intensive care units and an increasing proportion of patients for whom ventilation cannot easily be discontinued. Weaning from a ventilator, which can account for more than 50% of the total ventilation time, therefore plays a central role in this process. This main topic article presents the need for strategically wise and holistic actions to minimize the consequences of invasive mechanical ventilation for patients. An attempt is made to shed more light on individual aspects of the ventilation weaning process with high relevance for clinical practice. Especially for prolonged weaning from ventilation, many more concepts are needed than simply ending ventilation.

ESPEN practical guideline: Clinical nutrition in surgery

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.

The Role of Preoperative Parenteral Nutrition

Malnutrition is associated with poor surgical outcomes, and therefore optimizing nutritional status preoperatively is very important. The purpose of this paper is to review the literature related to preoperative parenteral nutrition (PN) and to provide current evidence based guidance. A systemic online search of PubMed, Medline, and Cochrane Databases from January 1990 to February 2020 was done. Sixteen studies were included in this narrative review, including four meta-analyses and twelve clinical trials. The majority of studies have demonstrated benefits of preoperative PN on postoperative outcomes, including reduced postoperative complications (8/10 studies) and postoperative length of stay (3/4 studies). Preoperative PN is indicated in malnourished surgical patients who cannot achieve adequate nutrient intake by oral or enteral nutrition. It can be seen that most studies showing benefits of preoperative PN often included patients with upper gastrointestinal cancer and inflammatory bowel disease (10/12 studies), which gastrointestinal problems are commonly seen and enteral nutrition may be not feasible. When preoperative PN is indicated, adequate energy and protein should be provided, and patients should receive at least seven days of PN prior to surgery. The goal of preoperative PN is not weight regain, but rather repletion of energy, protein, micronutrients, and glycogen stores. Complications associated with preoperative PN are rarely seen in previous studies. In order to prevent and mitigate the potential complications such as refeeding syndrome, optimal monitoring and early management of micronutrient deficiencies is required.

Influence of nutritional status on postoperative outcome in patients with colorectal cancer - the emerging role of the microbiome

Many patients with colorectal cancer are overweight. Even then, nutritional status is a frequently underestimated risk factor for perioperative complications. Enhanced Recovery after Surgery is the goal for perioperative management, and preoperative nutritional risk screening should be a standard. In case of nutritional risk, perioperative nutrition therapy should be started without delay and should follow recent guideline recommendations. The preservation of the microbiome has an emerging role in preventing postoperative anastomotic leakage and septic complications. The time window for recovery after neoadjuvant treatment for rectal cancer may be used for conditioning appropriate-risk patients in a “prehabilitation” program. In order to assess metabolic recovery and the prognosis for long-term survival, C-reactive protein/albumin ratio may be a promising parameter, which has to be validated in the future. This narrative review summarizes recent strategies and guideline recommendations.

Enhanced Recovery Pathways in Gynecology and Gynecologic Oncology

IMPORTANCE

Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology.

OBJECTIVE

The aim of this study was to describe ERP principles and the role of ERPs in gynecology and gynecologic oncology.

EVIDENCE ACQUISITION

Comprehensive literature search was performed using MEDLINE, the Cochrane Collaboration Database, and PubMed.

RESULTS

Meta-analyses of a substantial number of randomized controlled trials have shown that implementation of ERP protocols is associated with decreased length of hospital stay, a decrease in rates of postoperative complication, decreased morbidity, and cost savings while preserving patient satisfaction and quality of life.

CONCLUSIONS AND RELEVANCE

High-quality evidence exists for improved outcomes among patients in ERPs. Enhanced recovery programs save resources and costs across the health care system. As quality metrics and bundled payments increase in health care, ERPs will have increasing prominence.

One-year postoperative resource utilization in sarcopenic patients

BACKGROUND

It is well established that sarcopenic patients are at higher risk of postoperative complications and short-term health care utilization. Less well understood is how these patients fare over the long term after surviving the immediate postoperative period. We explored costs over the first postoperative year among sarcopenic patients.

METHODS

We identified 1279 patients in the Michigan Surgical Quality Collaborative database who underwent inpatient elective surgery at a single institution from 2006-2011. Sarcopenia, defined by gender-stratified tertiles of lean psoas area, was determined from preoperative computed tomography scans using validated analytic morphomics. Data were analyzed to assess sarcopenia's relationship to costs, readmissions, discharge location, intensive care unit admissions, hospital length of stay, and mortality. Multivariate models were adjusted for patient demographics and surgical risk factors.

RESULTS

Sarcopenia was independently associated with increased adjusted costs at 30, 90, and 180 but not 365 d. The difference in adjusted postsurgical costs between sarcopenic and nonsarcopenic patients was $16,455 at 30 d and $14,093 at 1 y. Sarcopenic patients were more likely to be discharged somewhere other than home (P < 0.001). Sarcopenia was not an independent predictor of increased readmission rates in the postsurgical year.

CONCLUSIONS

The effects of sarcopenia on health care costs are concentrated in the immediate postoperative period. It may be appropriate to allocate additional resources to sarcopenic patients in the perioperative setting to reduce the incidence of negative postoperative outcomes.

Current practices and challenges of adjuvant chemotherapy in patients with colorectal cancer

Colorectal cancer is one of the most commonly diagnosed cancers in men and women in the developed world. Although surgery is the foundation of curative treatment, adjuvant chemotherapy also improves overall and disease-free survival in high-risk stage II and all stage III patients. Research strongly suggests that the timing from surgery to adjuvant chemotherapy is critical, because delays to the start of treatment significantly affect patient outcomes. Both clinical and systemic barriers, such as postoperative complications and institutional wait times, challenge the timely administration of adjuvant chemotherapy. Further research investigating solutions to overcome these barriers is needed.

Enhanced recovery program following colorectal resection in the elderly patient

BACKGROUND

The enhanced recovery program (ERP) aims to reduce the metabolic response to surgery, hastening recovery and shortening hospital stay. Concerns exist regarding morbidity and hospital stay in elderly patients. The present study aimed to compare the outcomes and compliance of elderly patients managed by an ERP protocol with a younger group.

METHODS

A review was performed of a prospective database of patients undergoing colorectal resection managed under the ERP protocol between 2005 and 2010. Patients were grouped into <80 years and ≥ 80 years, and perioperative data were collated. The postoperative outcomes were compared with the goals set out by the ERP protocol.

RESULTS

A total of 688 patients were included, 558 were <80 years (median: 66 years; range: 17-79 years) and 130 were ≥ 80 years (median: 83 years; range: 80-95 years). Some 96% of operations were planned laparoscopically. Median total length of hospital stay was 6 days (range: 1-108 days) for the <80 year group and 8 days (range: 1-167 days; P 0.363) for the elderly group, with a 30 day readmission rate of 8.6% for the population and no significant differences between groups. The 30 day mortality was 5%, with a significant difference between the two groups (P < 0.0001). Differences in protocol adherence were identified in the discontinuation of intravenous fluids, catheter removal, and early mobilization.

CONCLUSIONS

An enhanced recovery program is feasible for colorectal surgery patients ≥ 80 years of age, with similar compliance as the younger group to some aspects of the protocol and an acceptable readmission rate. Attention to improving compliance in the postoperative phase is necessary, particularly in such high-risk patients, as such improvement may reduce the morbidity and mortality.

Early postoperative complications in patients with Crohn's disease given and not given preoperative total parenteral nutrition

OBJECTIVE

The effect of preoperative total parenteral nutrition (TPN) on the rate of early (within 30 days) postoperative complications in patients with moderate to severe Crohn's disease (CD) was examined.

MATERIAL AND METHODS

A series of 15 consecutive patients with CD (mean CD activity index score, 270) given preoperative TPN for 18-90 days (mean, 46 days) and undergoing bowel resection and primary anastomosis was compared with matching controls (105 patients) consecutively selected from all CD patients operated in Stockholm County during a preceding 20-year period without preoperative TPN.

RESULTS

During the preoperative TPN, all the patients studied displayed clinical remission of CD as reflected in improvement in their general well-being, relief of abdominal pain, and abatement of fever and diarrhea. There was no significant early postoperative complication in the TPN-treated group, whereas there were 29 patients with early postoperative complications in the control group, which means a significantly higher rate of postoperative complications when preoperative TPN was not provided. During the preoperative TPN, some crucial variables increased such as the body weight, the serum concentrations of albumin and triiodothyronine reflecting improved nutritional state, whereas the serum concentration of haptoglobin and the white cell count decreased reflecting decreased inflammatory activity.

CONCLUSIONS

This study shows that preoperative TPN for at least 18 days may be recommended to be given to patients with moderate to severe CD until clinical remission is achieved in order to minimize the risk of early postoperative complications.

Sham feed or sham? A meta-analysis of randomized clinical trials assessing the effect of gum chewing on gut function after elective colorectal surgery

PURPOSE

Enhanced recovery programs aim to expedite gut function after elective colorectal surgery. Early oral feeding simulates gut function but is not always feasible. Gum chewing, a form of sham feed, is an alternative. We assessed current evidence for gum chewing and gut function.

STUDY DESIGN

All randomized controlled trials (RCTs) between 1990 and 2008 comparing gum chewing with controls/placebo were analyzed irrespective of language, blinding, or publication bias. The Jadad scale was used to assess study quality. Endpoints were time to flatus/feces, postoperative complications, and hospital stay. Random and fixed models were employed to aggregate study endpoints and assess heterogeneity.

RESULTS

Six RCTs containing 256 patients were included. Significant heterogeneity was identified and random effects model was employed. Heterogeneity may be explained through variations in delivery of surgical care. Significant reductions in the time to flatus and time to feces were identified but no significant difference in hospital or in-hospital postoperative complications were found.

CONCLUSIONS

Gum chewing significantly reduced time to flatus and feces; however, hospital stay and postoperative complications were not reduced. Significant study heterogeneity means that these results should be interpreted with caution.

Determinants of outcome after colorectal resection within an enhanced recovery programme

BACKGROUND

Postoperative outcomes were studied in relation to adverse nutritional risk (body mass index (BMI) below 20 kg/m(2)), advanced age (80 years or more) and co-morbidity (American Society of Anesthesiologists (ASA) grade III-IV) in patients undergoing colorectal resection within an enhanced recovery after surgery programme.

METHODS

Outcomes were audited prospectively in 1035 patients. Morbidity and mortality were compared with those predicted using the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, and a multivariable model was used to determine independent predictors of outcome.

RESULTS

Postoperative morbidity was lower than predicted (observed to expected 0.68; P < 0.001). Independent predictors of delayed mobilization were ASA III-IV (P < 0.001) and advanced age (P = 0.025). Prolonged hospital stay was related to advanced age (P = 0.002), ASA III-IV (P < 0.001), male sex (P = 0.037) and rectal surgery (P < 0.001). Morbidity was related to ASA III-IV (P = 0.004), male sex (P = 0.023) and rectal surgery (P = 0.002). None of the factors predicted 30-day mortality.

CONCLUSION

Age and nutritional status were not independent determinants of morbidity or mortality. Pre-existing co-morbidity was an independent predictor of several outcomes.

PROUD: effects of preoperative long-term immunonutrition in patients listed for liver transplantation

Background

Patients with end stage liver disease are characteristically malnourished which is associated with poor outcome. Formulas enriched with arginine, ω-3 fatty acids, and nucleotides, "immunonutrients", potentially improve their nutritional status. This study is designed to evaluate the clinical outcome of long-term "immunonutrition" of patients with end-stage liver disease while on the waiting list for liver transplantation.

Methods/design

A randomized controlled double blind multi-center clinical trial with two parallel groups comprising a total of 142 newly registered patients for primary liver transplantation has been designed to assess the safety and efficacy of the long-term administration of ORAL IMPACT^®, an "immunonutrient" formula, while waiting for a graft. Patients will be enrolled the day of registration on the waiting list for liver transplantation. Study ends on the day of transplantation. Primary endpoints include improved patients' nutritional and physiological status, as measured by mid-arm muscle area, triceps skin fold thickness, grip strength, and fatigue score, as well as patients' health related quality of life. Furthermore, patients will be followed for 12 postoperative weeks to evaluate anabolic recovery after transplantation as shown by reduced post-transplant mechanical ventilation, hospital stay, wound healing, infectious morbidities (pneumonia, intraabdominal abscess, sepsis, line sepsis, wound infection, and urinary tract infection), acute and chronic rejection, and mortality.

Discussion

Formulas enriched with arginine, ω-3 fatty acids, and nucleotides have been proven to be beneficial in reducing postoperative infectious complications and length of hospital stay among the patients undergoing elective gastrointestinal surgery. Possible mechanisms include downregulation of the inflammatory responses to surgery and immune modulation rather than a sole nutritional effect.

Trial registration

ClinicalTrials.gov NCT00495859

The nutritional management of surgical patients: enhanced recovery after surgery

Malnutrition has long been recognised as a risk factor for post-operative morbidity and mortality. Traditional metabolic and nutritional care of patients undergoing major elective surgery has emphasised pre-operative fasting and re-introduction of oral nutrition 3-5 d after surgery. Attempts to attenuate the consequent nutritional deficit and to influence post-operative morbidity and mortality have included parenteral, enteral and oral sip feeding. Recent studies have emphasised that an enhanced rate of recovery can be achieved by a multi-modal approach focused on modulating the metabolic status of the patient before (e.g. carbohydrate and fluid loading), during (e.g. epidural anaesthesia) and after (e.g. early oral feeding) surgery. Using such an approach preliminary results on patients undergoing elective colo-rectal surgery indicate a significant reduction in hospital stay (traditional care, n 48, median stay 10 d v. enhanced recovery programme, n 33, median stay 7d; P<0.01) can be achieved. Such findings emphasise the potential role of multi-modal care programmes in the promotion of early recovery from major surgical trauma.

Nutritional support

Despite the increasing obesity of the American population, many chronically ill patients are malnourished. When this malnutrition is combined with the hypermetabolic response and protein catabolism of an acute event, such as an operation, nutritional support becomes an important facet for optimal critical care. This chapter reviews the basic tenants of nutritional support with special emphasis on patients with pulmonary compromise. Important aspects of caloric and protein support are discussed and enteral nutrition is emphasized because of its numerous advantages and documented improvement in outcome.

In vivo inter-organ protein metabolism of the splanchnic region and muscle during trauma, cancer and enteral nutrition

The study of protein kinetics has entered a new era by the recognition that whole body protein turnover only poorly reflects the true events occurring in several organs and with regard to the multitude of proteins present in the body. It is also increasingly recognized that the simultaneous synthesis and degradation of proteins is important in regulation and adaptation during several metabolic conditions like starvation, feeding, after trauma, and during exercise. Especially important is the recognition that the kinetics of individual proteins may change in opposite directions, thereby leading to fluxes of alpha-amino-nitrogen that serve to adapt to and survive a changing environment. At present, much emphasis is put upon molecular biological regulation. However, it is important that the metabolic processes that occur in the intact organism are still poorly defined. New technology allows the exploration of these processes, which should therefore prompt the initiation of further research in this area.

Long-term outcome and cost-effectiveness of parenteral nutrition for acute gastrointestinal failure

Although there are several published audits of long-term home parenteral nutrition for chronic gastrointestinal failure, there is little data concerning the long-term outcome following prolonged in-patient parenteral nutrition for an episode of acute gastrointestinal failure. Between 1983 and 1 July 1993, 162 patients received total parenteral nutrition (TPN) in our unit for acute gastrointestinal failure for a total of 4997 patient days and using 192 central venous catheters. Over the 10 years there were 11 mechanical complications resulting in one death. Although the overall catheter infection rate was 5.7%, in the last 4 years it was 0%, associated with a reduction in the frequency of site dressing and change of giving set from three times to once weekly. All patients had lost more than 10% of their body weight before TPN. In the non-malignant group, fed for more than 21 days (mean 50 days), the 10-year survival was 74% at a cost of 4723 pounds sterling per year of life saved. In the malignant group, the 5-year survival was 27% at a cost of 8351 pounds sterling per year of life saved. These costs compare favourably with other technologies, such as dialysis for acute renal failure. Better patient selection, fewer complications and lower costs are obtained when this treatment is carried out by an expert team.