Malnutrition in surgical patients

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Malnutrition in surgical patients

• Surgical Nutrition Training Module
• Level 1
• Philippine Society of General Surgeons
• Committee on Surgical Training

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Objectives

• To define malnutrition and discuss its impact on
  the surgical patient
• To identify malnutrition in hospitalized surgical
  patients

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Malnutrition is a syndrome
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Malnutrition syndrome features

• Wasting / marasmus
• Cachexia
• Protein-energy malnutrition
• Sarcopenia
• Failure to thrive
• Obesity

Gordon Jensen. International Guidelines
malnutrition syndrome ASPEN Congress 2008,
Chicago.
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Malnutrition syndrome features

• Wasting/marasmus
• Loss of body cell mass without underlying
  inflammatory condition Pure starvation
• Cachexia
• Loss of body cell mass with underlying
  inflammatory condition Cytokine mediated
• Cancer moderate to advanced stage

Gordon Jensen. International Guidelines
malnutrition syndrome ASPEN Congress 2008,
Chicago.
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Cancer Cachexia
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Inflammation in cachexia
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Malnutrition syndrome features

• Protein-energy malnutrition
• In modern healthcare this is often acute
  metabolic derangement driven by pro-inflammatory
  state not classic PEM with clinical and
  metabolic evidence for reduced intake of protein
  and energy

Gordon Jensen. International Guidelines
malnutrition syndrome ASPEN Congress 2008,
Chicago.
9
Malnutrition syndrome features

• Sarcopenia (mostly geriatric)
• Age related loss of muscle often with
  inflammation / cachexia overlap
• Failure to thrive
• Classic pediatric growth failure syndrome
• Now also applied in clinical practice to
  undernourished older persons in functional or
  cognitive decline (Alzheimers disease)

Gordon Jensen. International Guidelines
malnutrition syndrome ASPEN Congress 2008,
Chicago.
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Sarcopenia
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Malnutrition syndrome features

• Obesity WHO (World Health Organization) criteria
• BMI (Body Mass Index) Weight in kg / Height in
  meter / Height in meter
• 30 - 34.9 Obese class 1
• 35 - 39.9 Obese class 2
• 40 and above Obese class 3
• 40 - 50 Morbidly Obese
• gt 50 Super-Obese

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Malnutrition syndrome summary
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Malnutrition process

• It is a continuum
• Starts with poor intake
• Effect of initiation and progress of the disease
  process severity of disease and adequacy of
  intake
• Effect of efforts to correct both body
  composition and disease process

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Malnutrition concerns

• Lean body mass
• Structure and function
• Body composition capacity for healing and
  recovery
• Quality of life
• Energy reserves
• Function
• Optimal utilization of substrates and protein
  synthesis

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Malnutrition syndrome features and effects

• Wasting / marasmus
• Cachexia
• Protein-energy malnutrition
• Sarcopenia
• Failure to thrive
• Obesity

• Loss of lean body mass
• Structural and functional impairment
• Energy utilization problems
• Antioxidant capabilities
• Increased complications and mortality

Gordon Jensen. International Guidelines
malnutrition syndrome ASPEN Congress 2008,
Chicago.
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effect of surgery on the patient
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Surgery injury
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Surgery, wound healing, and nutritional status
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?Energy needs ? free radicals
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Role of nutrition in surgery
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Nutrition and wound healing
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Malnutrition in surgical patients

• Surgical patients
• 9 of moderately malnourished patients ? major
  complications
• 42 of severely malnourished patients ? major
  complications
• Severely malnourished patients are four times
  more likely to suffer postoperative complications
  than well-nourished patients

Detsky et al. JPEN 1987
Detsky et al. JAMA 1994
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Malnutrition and costs
Malnutrition is associated with increased cost
and the higher the risk the higher the number of
complications plus cost
Reilly JJ, Hull SF, Albert N, Waller A,
Bringardener S. Economic impact of malnutrition
a model system for hospitalized patients. JPEN
1988 12(4)371-6.
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Malnutrition effects on surgery

• Slow wound healing.
• Reduced muscle strength.
• Decrease in respiratory muscle strength
• Impaired cardiac function
• Immune hypofunction and dysfunction
• Higher morbidity and mortality
• Poor quality of life

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Prevalence of malnutrition
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Malnutrition detection tools

• Nutrition screening

• Nutritional assessment

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Nutritional Assessment and Risk Level Form
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Hospital malnutrition global
Year Author Location Prevalence
1974 Bistrian US 50
1977 Hill England 44
1979 Weinsier US 48
1984 Agradi Italy 34
1993 Larsson Sweden 27
1994 McWhirter Scotland 40
1995 Fernando Philippines 48
1997 Waitzberg Brazil 47
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Malnutrition in the Philippines
Hospital BMI lt18.5 BMI gt30 SGA C
1. Marikina, Rizal (Amang Rodriguez Medical Center) 38 15 -
2. Lipa City, Batangas (Mary Mediatrix Med Center) 18 5 -
3. Quezon City (St. Lukes Medical Center) 6 12 -
4. Manila (Philippine General Hospital) - - 42
5. Pasig (The Medical City) 4 14 -
6. Alabang (Asian Hospital Medical Center) 8 20 -
7. Cabanatuan City (Premiere Medical Center) 15 9 -
8. Mandaluyong (St. Martin De Porres Hospital 12 8 -
Mean 14.4 11.8
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Malnutrition in the units
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Nutritionally at risk patients
Llido L. The impact of computerization of the
nutrition support process in the nutrition
support program in a tertiary care hospital in
the Philippines report for the years 2000-2003.
Clin Nutr 2006 25(1)91-101 .
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What is the prevalence of malnutrition among
surgical patients in your center?
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conclusion
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Malnutrition

• Is a syndrome
• Its presence in surgical patients influences
  outcome
• Detection and management is a priority in
  surgical patients
• Is prevalent in the surgical patient population