parenteral nutrition in oncology in oncology.pdf · parenteral nutrition oral < 75% intake tube...

Parenteral nutrition in surgery/oncology

Dr. Luisito O. Llido, FPCS, DPBCN

Head, Clinical Nutrition Services

St. Luke’s Medical Center

Objectives

• To present and discuss updates on parenteral nutrition in oncology

Hospital malnutrition prevalence

Malnutrition syndrome

• Wasting / marasmus

• Cachexia

• Protein-energy malnutrition

• Sarcopenia

• Failure to thrive

• Obesity

Gordon Jensen. International Guidelines: malnutrition syndrome;

ASPEN Congress 2008, Chicago.

The patient’s onco/surgical journey

1. Powell-Tuck J. Pennington Lecture Teams, strategies and networks: developments in nutritional support; a personal perspective. Proc Nutr Soc. 2009 Apr 29:1-7

2. Weimann A, Braga M, Harsanyi L, et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 2006; 25: 224-244.

Pre-operative status Surgery Post-operative status

Goals: 1. Optimize nutritional status 2. Improve wound healing / faster recovery 3. Reduce infectious complications

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DIAGNOSIS THERAPY PHASE OUTCOME

NON-OPERATIVE / PRE-OPERATIVE PERIOD

ESPEN Guidelines 2009: non-surgical

• Nutritional assessment of all cancer patients should begin with tumor diagnosis and be repeated at every visit in order to initiate nutritional intervention early, before the general status is severely compromised and chances to restore to normal condition is few (Grade C)

ESPEN: European Society of Parenteral and Enteral Nutrition

Weight loss in cancer

, 2003-4

Nutritional assessment predicts complications

Nutrition risk assessment predicts morbidity and mortality in surgical patients while in the hospital

Predicting post-operative complications based on surgical nutritional risk level using the SNRAF in colon cancer patients - a Chinese General Hospital & Medical Center experience. Ocampo R B et al. Phil J Surg Spec 2007;

63(4): 147-53. (Accessible http://www.philspenonline.com.ph/POJ_1.html)

Nutrition assessment, risk level

• Simplified form • Uses validated tool:

Subjective Global Assessment

• Incorporates Body Mass Index, serum albumin, Total Lymphocyte Count

• Scoring system

http://www.philspenonline.com.ph/nst_dev.html

Approaches to management

Surgery required

Severely malnourished

Build up first • Oral

• EN

• Combined EN / PN

• PN

Post operative

• Chemotherapy

• Radiotherapy

• Combination

• Others

No surgery

Indications Can the GIT be used?

Yes No

Parenteral nutrition Oral

< 75% intake

Tube feed

Short term Long term

Peripheral PN Central PN

More than 3-4 weeks

No Yes

NGT

Nasoduodenal

or nasojejunal

Gastrostomy

Jejunostomy

“inadequate intake”

“Inability to use the GIT”

A.S.P.E.N. Board of Directors. Guidelines

for the use of parenteral and enteral

nutrition in adult and pediatric patients,

III: nutritional assessment – adults. J

Parenter Enteral Nutr 2002; 26 (1 suppl):

9SA-12SA.

ESPEN 2009 Guidelines

• Total daily energy expenditure in cancer patients may be assumed to be similar in healthy subjects, or 20-25 kcal/kg/day for bedridden and 25-30 kcal/kg/day for ambulatory subjects (Grade C)

• The majority of cancer patients requiring PN for only a short period of time do not need a special formulation (Grade C)

ESPEN Guidelines 2009: surgery

• INDICATION(S):

– Preoperative parenteral nutrition is indicated in severely undernourished patients who cannot be adequately orally or enterally fed (Grade A)

ESPEN: European Society of Parenteral and Enteral Nutrition

Parenteral nutrition

Intravenous: • macronutrients • micronutrients • nutraceuticals

Safe delivery: • aseptic technique • dedicated line • infusion pump

NUTRIFLEX series

“All in One” PN bags

• 1250 ml/bag

• Protein: 0.032g/ml or 40g

• Carbo: 0.064g/ml or 80g

• Fat: 0.04g/ml or 50g

• Total calories: 0.764 kcal/ml or 955kcal/bag

• Osmolality: 920 mOsm/kg

Peripheral access


• 1250 ml/bag

• Protein: 0.057g/ml or 71.8g



• Total calories= 1.18 kcal/ml or 1475 kcal/bag


Central access


• 1875 ml/bag




• Total calories: 0.765 kcal/ml or 1435 kcal


Peripheral access


• 2500 ml/bag



• Fat: 0.04g/ml or 100g

• Total calories: 0.764 kcal/ml or 1910 kcal

• Osmolality: 920 mOsm/kg Peripheral access

Parenteral nutrition?

Macronutrients: • protein • fat • carbohydrate

Micronutrients: • vitamins

• water soluble • fat soluble

• trace elements • electrolytes

Complete Food

Nutraceuticals: • glutamine • fish oils • antioxidants • arginine

Special Diet / Specialized Nutrition Therapy

Why three in one? Cell membrane receptors and transporters

• lipid • carbohydrate • protein • electrolytes • trace elements • vitamins • glutamine • fish oils

Nuclear membrane • DNA • enzymes • complex bodies

• energy production systems • endoplasmic reticulum • Golgi aparatus • subcellular bodies

• tubules • vesicles • proteasomes • peroxisomes

• Mitochondrial • Transporters • membrane enzymes • energy production systems

The Cell

Why macro + micro? → optimize function / structure

ESPEN Guidelines 2009: PN

• “STANDARD PRACTICE”

– Preoperative fasting from midnight is unnecessary in most patients (Grade A)


• GLUCOSE

– Preoperative carbohydrate loading using the oral route is recommended in most patients. In the rare patients who cannot eat or are not allowed to drink preoperatively for whatever reasons the intravenous route can be used (Grade A)

Pre-operative phase

Normal to moderate malnutrition

SURGERY

Severe Malnutrition

Enteral nutrition 10-14 days

Condition: Patient can eat

• Esophageal resection • Gastrectomy • Pancreaticoduodenectomy

Immunonutrition 6-7 days

Nutritional Assessment

Pre-operative phase

Normal to moderate malnutrition

SURGERY

Severe Malnutrition

Condition: Patient CANNOT eat

• Esophageal resection • Gastrectomy • Pancreaticoduodenectomy

Parenteral nutrition + Omega-3-Fatty Acids + Antioxidants (+ glutamine); 6-7 days

Nutritional Assessment

Pharmaconutrition

Dose Content in preps

Glutamine 0.4 – 0.5 g/kg 12 – 15 g/L

Arginine ? 4 – 16 g/L

Omega-3-fatty acids (EPA)

2 – 6 g/day 1 – 2 g/L

Antioxidants

Carotenoids

Vitamin C,E

>100% daily requirement

Single or combinations

Formerly termed “IMMUNONUTRITION”

ESPEN 2009 Guidelines

• Therapeutic goals of PN in cancer patients are the improvement in function and outcome by:

– Preventing and treating undernutrition/cachexia

– Enhancing compliance with anti-tumor treatments

– Controlling some adverse effects of antitumor therapies

– Improving quality of life

• Grade level C

Cachexia

Cancer

cytokines

Loss of appetite

Proteolyis

Inducing Factor Lipid

Mobilizing Factor

Protein Loss Fat Loss

Physical obstruction

No Intake

Very thin; progressive weight loss not corrected by increased intake

Resources: Omega-3-FA (cachexia) W

eig

ht

loss

kg

Duration of treatment

Wigmore et al. Nutrition in cancer, 2000

Nutrient delivery approaches Can the GIT be used?

Yes No

Parenteral nutrition Oral

< 75% intake

Tube feed

Short term Long term

Peripheral PN Central PN

More than 3-4 weeks

No Yes

NGT

Nasoduodenal

or nasojejunal

Gastrostomy

Jejunostomy

CALORIE COUNT

The team performs the calorie count and fluid balance

The fluid, calorie, and protein intake are recorded and adequacy of intake

is recorded in the patient’s chart

The NST at work

Procedures: 1. Fluid intake is recorded 2. Fluid output is

recorded and the fluid balance determined (%)

3. Calorie balance is computed (actual and % of computed)

4. Protein balance is computed (actual and % of computed)

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Nutrient & fluid balance

The summary

Post-operative Period While in the OR ask yourself: “is oral feeding possible within 7 days?”

Yes No

Can I feed within 4 days? Needle catheter jejunostomy

• Enteral nutrition (12 hrs) • Better: immunonutrition

If enteral nutrition is inadequate

Supplemental PN

Yes No

“Fast Track” PN

Transition

Indications for parenteral nutrition

• Unable to use the GIT

• Inadequate intake through oral and enteral route

• Enterocutaneous fistula

• Short bowel syndrome (< 60 cm, TPN)

Surgery & immunosuppression Cell destruction

↑ Inflammatory mediators Glutamine depletion from muscle

↑ inflammatory cell activity Low plasma glutamine

↑ glutamine utilization

HLA-DR surface antigen on monocytes are down-regulated

↓ Monocyte cell surface marker expression

↓ capacity to present antigen & phagocytize

monocytes

immunosuppression

Surgery

1. Lennard TW et al. The influence of surgical operations on components of human immune system. Br J Surg 1985;72:771–6

2. Exner R et al. Perioperative GLY-GLN infusion diminishes the surgery-induced period of immunosuppression: accelerated restoration of the lipopolysaccharide-stimulated tumor necrosis factor-alpha response. Ann Surg 2003;237:110–5.

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Glutamine

• Lessens immunosuppressive status

• Reduces infectious complications and mortality

• Lessens mucositis induced by chemo and radiotherapy


• INADEQUATE ORAL/ENTERAL NUTRITION:

– Postoperative parenteral nutrition is beneficial in patients with postoperative complications impairing gastrointestinal function who are unable to receive and absorb adequate amounts of oral/enteral feeding for at least 7 days (Grade A)


• “STANDARD PRACTICE”

– Interruption of nutritional intake is unnecessary after surgery in most patients (Grade A)

Malnutrition, infection, antibiotics

Commensal

/ pathogenic

bacteria

↑Pathogenic

bacteria

antibiotics

• No feeding / NPO

• Malnutrition

• Stress

• Acute injury

Gastro-Intestinal Tract

• Bacteremia

• Toxins, by-products

Local infection → Sepsis / SIRS

Gastrointestinal Tract


• LIPIDS

– The optimal parenteral nutrition regimen for critically ill surgical patients should probably include supplemental n-3 fatty acids. (Grade C)

MCT/LCT

Lipid emulsions

• 250 ml, 20%

• MCT: 0.1g/ml or 25g

• LCT: 0.1g/ml or 25g

• MCT:LCT ratio = 50% to 50%

• Lipid subcomponents: – Linoleic acid (ω6): 0.048g/ml to

0.058g/ml or 12g to 14.5g

– Linolenic acid (ω3): 0.005g/ml to 0.011g/ml or 1.25g to 2.75g


• Total calories: 450 kcal

Omega-3-Fatty Acid solution

• 250 ml bottle • MCT: (0.1 g/ml) or 25g • LCT: (0.08 g/ml) or 20g • Omega-3-FA: (0.02 g/ml) or 5g • Lipid Subcomponents:

– EPA/DHA (ω3): 0.0086g/ml to 0.0172g/ml or 2.15g to 4.3g

– α-linolenic acid (ω3): 0.005g/ml to 0.011g/ml or 1.25g to 2.75g

– Linoleic acid (ω6): 0.048g/ml to 0.058g/ml or 12g to 14.5g

• Osmolality: 410 mOsm/kg • Total kcal: 450 kcal


• VITAMINS & TRACE ELEMENTS

– After surgery in those patients who are unable to be fed via the enteral route, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis

Antioxidants

Randomized prospective trial of antioxidant supplementation in critically ill surgical patients


• MIXTURE

– Optimal nitrogen sparing has been shown to be achieved when all components of the parenteral nutrition mix are administered simultaneously over 24 hours (Grade A)


• WEANING

– Weaning from parenteral nutrition is not necessary (Grade A)

ERAS: Enhanced Recovery After Surgery (colon surgery)

• Pre-operative bowel preparation: not required for all patients

• Pre-anesthetic medication: not indicated • Pre-operative fasting and fluids:

– Can drink fluids 2 hrs before anesthesia – Should receive preoperative carbohydrate loading

• Standard anesthetic protocol: epidural or intravenous

• Prevention of intraoperative hypothermia • Thromboembolic prophylaxis • Nasogastric decompression – not recommended

ERAS: Enhanced Recovery After Surgery (colon surgery)

• Prophylactic antibiotics – recommended • Drainage should not be routinely used • Urinary bladder drainage – 24 to 48 hours after

surgery • Fluid therapy – avoid excessive fluids • Ileus prophylaxis and promotion of GI motility • Post-operative analgesia: continuous thoracic

epidural • Nutrition: oral nutrition on first day in addition to

normal food • Early mobilization: out of bed on the 6th hour post

parenteral nutrition in oncology in oncology.pdf · parenteral nutrition oral < 75% intake tube...

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