Utilising ERAS to improve meal advancement post

operatively.

Nathan Billing-Surgical Dietitian

Acknowledgement

Some slides taken from others presentations found online. Emma Osland Carli Schwartz

Other slides from AERAS study group slides Mattias Soop

Overview

Overview of Enhanced recovery programs Increasing intake after surgery Key Nutritional components of ERAS

Early Oral Feeding – Identifying issues Traditional vs Early post operative diet

advancement Clear Oral fluids versus Free Oral Fluids

Providing guidance to surgical team Rationalisation of diets available ? Recommended for diet advancement

Enhanced Recovery Program Pioneered by Henrik Kehlet group in

Denmark Identified factors which delay postoperative

recovery Pain

Gut dysfunction

Immobilization

Combined a series of interventions to reduce perioperative stress and organ dysfunction1

1. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78:606–617.

Recovery After SurgeryWhat are we trying to achieve?

Reduce the surgical stress response and support basic body functions by 1, 2

– Use of optimised analgesia – Early mobilisation– Early return to normal diet

These interventions have been shown to improve postoperative outcomes 3,4

1. Fearon, et al, Clinical Nutrition 2005; 24: 466–477. 2. Kehlet, Lancet 2008; 371: 791–793. 3. Khoo, et al, Annals of Surgery 2007; 245: 867–872. 4. Wind, et al. British Journal of Surgery 2006; 93: 800–809.

Multimodal steps of ERAS protocol

• Optimised health / medical condition

• Informed decision and patient education

• Pre operative health & risk assessment

• Optimised hydration & nutrition

• Reduced starvation

• Patient information and expectation managed

• Discharge planning

• No / Reduced bowel prep (bowel surgery)

• Minimally invasive surgery

• Use of transverse incisions

• No nasogastric tubes (bowel surgery)

• Use of Local anaesthetic with sedation

• Epidural management (inc thoracic)

• Optimised fluid management

• Planned mobilisation

• Rapid hydration & nourishment

• Appropriate IV therapy

• No wound drains

• No NG ( bowel surgery)

• Catheters removed early

• Regular oral analgesia – paracetamol and NSAIDS

• Avoidance of opiate-based analgesia where possible or administered topically

• Estimated discharge date as planned

• Full information and ongoing support

• Allied Health professional follow up where required

• Personal follow up from clinical team (home calls)

Pre Operative

Intra Operative

Post Operative

Discharge

Increasing oral intake after surgery

Day 0 patients receive Sandwich for day of surgery 2 x supplements post operatively

Day 1 onwards patients receive progress to standard diet 3 x supplements post operatively

Use of nutritional supplements in malnourished patients post operatively

(600kcal/day)

Beattie A H et al. Gut 2000;46:813-818

©2000 by BMJ Publishing Group Ltd and British Society of Gastroenterology

Fluid input: ERAS vs Conventional Care

Teeuwen, et al, J Gastrointestinal Surgery 2010; 14:pp88–95.

61 ERAS patients vs 122 historical matched controlsERAS total IV fluid intake ≠ > 2 l/24 h

Effect of mobilization on oral intake

00.20.40.60.81

Intervention Control

Mean Protein intake

Patients in intervention group encouraged to active mobilization from day 1

Control mobilized in traditional manner without specific aims

Main part of meals was eaten while sitting at a table and not in a bed

0

20

40

60

80

Intervention Control

Mean Energy Intake

Henriksen, et al, Nutrition 2002; 18(3): pp:263–267.

Kj /

kg /

day

g /

kg /

day

Importance of team approach

Agreement between anaesthesia and surgical teams

FTE requirement importance of ERAS nurse

Need surgeon buy in

ERAS alone is not enough

Influence of compliance with the separate care elements on length of stay on various components on length of hospital stay

Hazzard ratio above 1 indicates a better chance of early discharge whereas a value below 1 indicates a lower chance.

Maessen, et al, British Journal of Surgery 2007; 94: pp224-231.

Oral feeding

Nutrition 2002; 18:944-948

Factors that limit or promote post operative feeding

Feeding the patient: Postoperative Nutrient

Provision

Traditional Postoperative Diet AdvancementTraditional practice NBM prior to surgery NBM and gastric

decompression until bowel function resumed post surgery

Diet progression once gut working Clear fluids free fluids soft/light diet full diet

Rationale Initially adopted to

combat post operative vomiting and subsequent concerns Aspiration pneumonia Increase abdominal

pressure anastomotic rupture

Also thought to “protect the anastomosis” by allowing gut rest and avoiding food passing the surgical site

Clear Oral Fluids vs Free Oral Fluids

Aim: To provide a diet of liquid foods that require no chewing.

Includes more protein high in saturated fat and low in fibre, and may require vitamin and mineral supplementation.

Clear Oral Fluids Free Oral fluids

Aim: To replace or maintain the body’s water balance and leave minimum residue in the intestinal tract

Meets anaesthesia fasting guidelines

Inadequate in all nutrients

Early Postoperative Feeding

Early post-op feeding Clear fluids to 3-4hrs

pre-anaesthetic Fluids or diet from first

postoperative day irrespective of resumption of bowel function

No NGT post op Often in the context of

multimodal approach including earlier mobilisation, non-opioid

analgesia, key-hole surgery

Rationale Gut secretes and reabsorbs

~7L fluid/d irrespective of oral intake, so “protecting the anastomosis” is based on a false premise

Many patients already malnourished more postoperative complications

Nausea/vomiting is much less of a problem with new anaesthetic agents

Some evidence that early feeding reduces the body’s stress response to surgery/trauma

The research …

Increasing numbers of studies investigating this topic dating from 1978 Tube feeding early liquids early solids

Individual studies do not demonstrate major adverse outcomes with early feeding

Some suggestion of organisational benefits May decrease length of hospital stay and cost

of treatment

Reported adverse outcomes Nausea, vomiting, NG reinsertion (common)

Previously conducted meta-analyses

Nutritional issues• Inclusion of immune-modulating EN products• Inclusion of studies feeding both proximal and distal to

anastomoses• Nutrition provided at 24hrs post op may have included

clear fluids little nutritional valueGeneral issues

Appears to contain inconsistencies in inclusion criteria of studies included

Criteria for this meta-analysis Early feeding provision of diet (excluding COFS) and

enteral feeding given within 24 hours postoperatively. Traditional postoperative management = withholding

nutrition provision until bowel function had resumed, as evidenced by either passage of flatus or bowel motion

Early vs Traditional PostOp feeding

• Fifteen studies involving a total of 1240 patients were analysed in meta-analysis.

• To investigate impact of early feeding vs traditional postoperative feeding and

• Mortality • Anastamotic Leaks• Days to passing Flatus• Length of stay• Postoperative Complications

Results - Mortality

Osland et al, JPEN J Parenter Enteral Nutr 2011 35(4):p 481

Results – Anastamotic Leaks

Osland et al, JPEN J Parenter Enteral Nutr 2011 35(4):p 481

Results – Days to passing flatus

Osland et al, JPEN J Parenter Enteral Nutr 2011 35(4):p 482

Results – Length of Stay

Osland et al, JPEN J Parenter Enteral Nutr 2011 35(4):p 483

Results – Postoperative Complications (Nausea and Vomiting

excluded)Study pre 2000SagarRyanSchroederBinderowBeier-HolgersenCarrOrtizHartsellNessimStewartsubtotal

post 2000Han-GeurtsDelaneyLuchaZhouHan-Geurtssubtotal

POOLED

Early

3 of 152 of 7

4 of 160 of 328 of 300 of 14

17 of 931 of 293 of 27

10 of 4048 of 303

12 of 567 of 311 of 26

23 of 16122 of 46

65 of 320

113 of 623

Traditional

5 of 157 of 7

7 of 160 of 32

19 of 304 of 14

18 of 951 of 294 of 27

12 of 4077 of 305

13 of 4910 of 33

1 of 2570 of 155

20 of 50114 of 312

191 of 617

OR

0.530.030.46

10.220.080.96

10.750.780.55

0.760.690.960.211.370.62

0.55

L

0.080

0.070.020.05

00.240.070.110.170.34

0.180.140.070.060.330.26

0.35

U

3.780.942.91

61.411.082.063.77

13.425.013.56

0.9

3.273.38

12.990.745.611.51

0.87

0.1 2.0 4.0 6.0

favour Early favour Traditional

Osland et al, JPEN J Parenter Enteral Nutr 2011 35(4):p 479

Conclusions of Meta-analyisis No merit in withholding nutrition

provided proximal to the anastomosis until bowel function is resumed.

Statistically significant reductions in total complications in the postoperative course with early feeding.

No negative effect of early feeding was demonstrated with regard to in hospital mortality, anastomotic dehiscence, LOS, and time to recovery of bowel function

Recommending Diet Advancement

Advance diet to full liquids followed by solid foods, depending on patient’s tolerance. Consider the patient’s disease state and any

complications that may have come about since surgery.

Liaise closely with surgical teams Provide guidance of meal choices available in your

kitchen. Define meal advancement. Standardize practices.

Liasing with Surgical teams

What does “E & D as tolerated” mean? Review of diet codes available for use

i.e. Light diet vs Low Residue Diet vs Post Op Diet When to use Modified consistency diets

e.g. Upper GI surgery vs Lower GI surgeryUpper GI surgery could have impact on peristalsis

so may require liquid or pureed meals

?Sham feeding (i.e. Chewing gum)

Type of Surgery / Underlying Condition

Recommended diet post op

Rationale

Recurrent Small bowel obstruction

Low residue diet A diet low in fibre to minimise chance of further obstructions occurring

Upper GI surgery:Nissens FundoplicationOesophagectomyIvor Lewis Gastrectomy

Liquid Diet or

Pureed Dietor

Low residue diet

As this surgery would have an impact on the mechanical ability to swallow feed and lead to a degree of dysphagia. A liquid or pureed diet is recommended initially to help minimise difficulties in swallowing

Small bowel resections  Liquid Diet or

Low residue dietor

Standard diet

As this surgery may result in anastamotic joins in small intestine low residue foods are recommended to minimise pressure on these joins initially.

Colorectal surgery Standard diet or

High Energy protein diet

As this surgery involves the lower GI tract, most food is well digested by the time it reaches the colon and regardless of the type of food should be pretty well digested

Cholecystectomy Standard diet  

As gut motility or function has not been altered by surgery no special requirements or surgery

Non Gut surgery 

Standard diet As gut motility or function has not been altered by surgery no special requirements or surgery

Alternative to E+D as tolerated?

Tailor made protocols

Specific surgeries / conditions that will have own specialist diet progression pathway and dietetic input

Bariatric SurgeryGastric Bypass (Roux en Y)Gastric SleeveDuodenal Switch

Water only Optifast Fluid diet Pureed diet

Patients need to adjust to smaller stomach volume and advance their diet slowly after surgery. There is close working with surgeons and set plans for these patients in place.

Chylous ascites and Chyle leaks

Specialist diet with reduced fat and

high MCT content

Dietary chylomicrons are absorbed in the small intestines and gradually pass along larger omental lymphatics. Reducing the intake of fat has been shown to be beneficial at minimising

Pancreatic surgery or other fistulas

Potential enteral NJ feeding and or

IVN/TPN

Stimulation of pancreatic or other GI secretions may be an issue and may need to be minimised. Dietitian input is recommended.

As per Surgeon

Questions References: Anderson et al. Early enteral nutrition within 24h of colorectal surgery versus later

commencement of feeding for postoperative complications. Cochrane Database Syst Rev, 2006 (4): CD002080.

Franklin, G.A., McClave, S.A., Hurt, R.T., Lowen, C.C., Stout, A.E, et al., 2011. Physician- Delivered Malnutrition: Why do patients receive nothing by mouth or a clear liquid diet in a university hospital setting? Journal of Parental and Enteral Nutrition. 35(3):pp337-342.

Hancock, S., Cresci, G., Martindale, R., 2002. The clear Liquid Diet: When is it appropriate? Current Gastroenterology reports. 4: pp324-331.

Jeffery, K.M., Harkins, B., Cresci, G.A., Martindale, R.G., 1996. The clear liquid diet is no longer a necessity in the routine postoperative management of surgical patients. The American Surgeon 62(3):167-70.

Kawamura, Y.J., Kuwahara Y., Mizokami K., et al., 2010. Patient’s appetite is a good indicator for postoperative feeding: a proposal for individualized postoperative feeding after surgery for colon cancer. Int J Colorectal Dis.;25:pp239-243.

Lewis et al. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: a systematic review and meta-analysis of controlled trials. BMJ, 2001, 323 (7316) 773-776

Lewis et al. Early enteral nutrition within 24h of intestinal surgery versus later commencement of feeding: A systematic review and meta-analysis. J Gastrointest Surg, July 16 2008

Story, S.K., Chamberlain, R.S,. 2009 A Comprehensive Review of Evidence-Based Strategies to Prevent and Treat Postoperative Ileus. Digestive Surgery 2009; 26:265–275.

Warren, J., Bhalla, V., Cresci, G., 2011. Postoperative Diet Advancement: Surgical Dogma vs Evidence based Medicine. Nutrition in Clinical Practice. 26(2): pp115-125.