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UPDATE ON PERIOPERATIVE FLUID THERAPY

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In line with the latest advances in surgical and an esthetic techniques, new discoveries in perioperative fluid management are also introduced in recent years and al so contribute to the success of the surgery and the prognosis of patients. Various protocols and guidelines on per ioperative fluid and nutrition therapy have been developed and published by world leading associations, such as BAPEN (British Society of Parenteral and E nteral Nutrition), ESPEN (European Society of Parenteral and Enteral Nutrition) and ASPEN (American Society of Parenteral and Enteral Nutrition). This was revealed in a symposium on 15 April 2012 at Hotel JW Marriott, Jakarta with the theme "Update on perioperative Fluid and Nutrition Therapy". Scientific meeting that was attended by 85 surgeon featured three speakers and chaired by Dr Yarman Masni,SpB-KBD

As the first speaker, Dr. Iyan Darmawan, Medical Director of PT Otsuka Indonesia shared that it has become a t radition that many patients with gastrointestinal resection received massive crystalloid fluids during and after surgery. Apparently excessive fluids and electrolytes, results in significant weight gain and edema. Also concluded that excess weight is a major cause of postoperative ileus, and delayed gastric emptying. When the amount of water is restricted merely to maintain water and sodium balance, gastric emptying occurred more quickly and patients can tolerate a normal diet and bowel movements a few days earlier than patients with a positive water balance.

Rationale of provision of moderate water and sodium administration during postoperative period

It has long been known that the stress of surgery, as well as other trauma, may induce water retention and lead to positive sodium and water balance during the early phase of injury. Therefore, the amount of urine in the early postoperative

phase do not necessarily reflect hydration status. Moreover, water and sodium excretion tended to be slower after infusion containing high sodium. These findings have spurred recommendations of a m aximum of 2 l iters of water, and sodium of less than 60 to 100 mmol/day postoperatively.

Low sodium does not aggravate interstitial expansion in patients with hypoalbuminemia that could delay the healing of surgical wound. This concept is in line with the ERAS concept pioneered by Fearon et al.

Fearon KCH, Ljungqvist O, Von Meyenteldt M; Revhavy A, Dejong CHC, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet ; Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clinical Nutrition 2005; 24: 466-477

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Rationale of low glucose administration has long been known. Blood sugar levels increased after the operation began. Cortisol and catecholamines facilitate the production of glucose as a r esult of increased glycogenolysis and gluconeogenesis in the liver. In addition, glucose utilization is reduced due to these hormones.

Although the usual formula 25 kcal / kg BW is used to meet daily needs, and on the conditions of severe stress can approach 30 kcal / kg BW, rational approach for early-flow phase is providing 10-20 kcal / kg actual body weight or adjusted weight if actual BW > 120% ideal weight.

Further dr Iyan suggested that the effect of body protein catabolism saving (Protein-Sparing effect) which is known by providing 100-150 g of glucose per day is by 50% only, so administration of amino acids is also required to minimize the negative nitrogen balance. It is known from the calculation, that obligatory nitrogen excretion via urine, feces and skin is about 54 m g / kg / day. This is equivalent to 30 g rams of amino acids in adults. This is represented by one litre of Aminofuid® as a new generation maintenance solution. There are compelling reasons for giving Aminofluid® to surgical patients to speed recovery.

• 10-20 kcal/kg BW is ideal during flow phase, moderate supply of glucose prevents worsening of s tress-induced hyperglyc emia and insulin resistance

• Patients with mild to mederate stress and anticipated to lack of oral intake for 7 day , require only 500-600 kcal/day

• Simultaneous administration of BCAA enriched amino acids and glucose in dual-chamber soft bag will improve nirogen balance and combat postoperative fatigue

• Zinc promotes wound healing, support immune function and cellular growth, and improtant as body antioxidant system

• Na+ in moderate concentration prevents water retention and iatrogenic fluid overload; the content of K+ prevents further depletion of potassium

The second speaker of this symposium was Dr Toar Lalisang,PhD, SpB-KBD, Head of Department of Digestive Surgery, FKUI/RSCM. At the beginning of his presentation Dr Toar mentioned that the recovery of nutritional status to the pre-illness level in patients with major surgery, especially with resection of the colon, stomach or esophagus may take up to weeks.

DR Toar further explained that the definition of perioperative nutritional support included following:

1. Provide nutritional support in the period before and after surgery: enteral or parenteral.

2. Surgical trauma has impact on changes in metabolism: From Anabolisme to metabolism

3. Recovery from surgery needs healing from trauma 4. Nutritional support can minimize the catabolism 5. Nutritional support promotes anabolism. 6. Decrease morbidity and mortality

Metabolism during fasting period is characterized by the following:

• TEE (totalEnergy expenditure) ± 1500 kcal/day

• Catabolism of muscle/protein ± 75 g/ day Gluconeogenesis to yield glucose from alanine.

• Fat deposit ± 120 g/day will be metabolized

Surgical intervention/trauma increased catabolism and has the features of:

• TEE (total Energy expenditure) ± 3000 kcal/day

• Catabolism of muscle protein ; ± 180 g /day

Patient with good nutritional status can withstand up to 3-4 days. But if it continues can slow wound healing, reduce protein synthesis and lower immune system function

Changes of nutritional status after elective surgery have been investigated by Dr Toar Lalisang as follows:

• Weight loss occurred in 76% of patients (mean weight loss was 4%)

• Decreased serum albumin concentration occurred in 88% of patients(mean derease was 15%)

Dr Toar further stated that from the existing publications found to date, ther were no benef its of giving albumin solution to cases of early postoperative hypoalbuminemia.

Dosages of macronutrients required during acute surgical stress can be summarized below (Barton RG. Nutr. Cln. Pract. 1994.8.127-139 ASPEN Board of D irectors. JPRN 2002;26 S uppl 1:22SA):

Carbohydrate

• At least 100 g of glucose/day is needed to prevent ketosis and as fuel to the brain

• Carbohydrate intake during stress should range from 50%-60% of total caloriesi

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• Glucose infusion rate should not exceed 5mg/kg/min

Fat

• Provides 20%-35% of total calories

• Recommended maximum administration rate of lipid 1.0 – 1.5 g/kg/day

• Monitor triglyceride levels to ensure adequate lipid clearance

• Sources of fatty acids should be considered

Amino acids

• Requirement range from 1.2 – 2.0 g/kg/day in stress

• Constitutes 20% - 30% of total calories during stress

As additional information, branched-chain amino acids aka BCAA (Leucine, isoleucine, valine) have special advantage in surgical patients as precursors glutamine and alanine in skeletal muscle. Healthy person needs daily BCAA estimated at 144 m g/kg/day. In certain circumstances of metabolic stress more exogenous BCAA might be required.

The third speaker of this symposium was Dr. Benny Philippi, SpB-KBD with the topic of “Parenteral Nutrition in Critically Surgical Patients”. At the beginning of his presentation, Dr. Benny emphasized that malnutrition is common in critically ill patients, where 20-40% of them showed evidence of protein-energy malnutrition. Therefore, serial assessment of nutritional status should be a routine component of care in the ICU, and adequate nutrient intake is critical for cell and organ function and wound healing

Many critical surgical patients released chemical mediators, including hormones and c ytokines. Counter-regulatory hormones (catecholamines, cortisol, glucagon) tends to increase blood sugar and insulin resistance, while ADH and aldosterone lead to Na+ and water retention. Pro-inflammatory cytokines such as TNF-α, IL-1β and IL-6 are responsible for the excessive catabolism in surgical patients, major trauma and sepsis through activation of the neuroendocrine axis.

Assessment of nutritional status in critically ill patients needs to be done if the following is found:

1. Too thin (< 80% ideal BW) 2. Too fat (>120% ideal BW) 3. Recent weight loss(>10% within 3 months) 4. Alcohol/drug dependence 5. NPO (nothing per oral) > 5 days

6. Excessive nutrient loss a. Malabsorption b. Short bowel syndrome c. Fistula d. Draining abscess or wound (burn) e. Dialysis

7. Increased nutrient requirements a. Trauma b. Burn c. Sepsis d. Medications with anti-nutrient property

Most critically ill patients who require nutritional support (85 to 90%) can be administered by enteral tube feeding through the stomach or intestines, and t hen switch to oral food with supplements..

However, in approximately 10 to 15% of such patients, enteral nutrition is contraindicated. This is where the role of parenteral nutrition is very helpful

TPN (total parenteral nutrition) supplies water, dextrose, amino acids, lipid emulsion, electrolytes, vitamins and microminerals.

The indications of PN in critically-ill patients(ESPEN Guideline on PN : Intensive Care. Clinical Nutrition 2009; 28:387–400) can be summarized as follows:

• All patients anticipated to be NPO within 3 day s should be given a PN within 24 to 48 ho urs if EN is contraindicated or if the patient does not tolerate EN

• All patients who received less EN after 2 day s according to the target should be considered to supplementation with the PN

• Ideally the total caloric needs are measured by indirect calorimetry. But if there is no indirect calorimetry, ICU patients should receive 25 k cal / kg / day which is increased gradually to reach the target in the next 2-3 days.

To conclude the presentation of Dr. Benny Philippi, when enteral nutrition is impossible, parenteral nutrition should be started

'Do not rush in approach to parenteral nutrition "should be adopted

If you need t o give a high caloric parenteral nutrition and osmolarity of more than 900-1000 mOsmol / L and t he necessary monitoring of central venous pressure, central

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venous access with the preparation of "all-in-one bag" is the preferred route for parenteral nutrition

DISCUSSION

Q What is the background of intraoperative administration of amino acids?

A In some experimental studies with intraoperative administration 200 ml of 10% amino acids, thermogenic effect was obtained to maintain core temperature, instead of nutritional effect of protein synthesis.

Q Do you recommend albumin administration to correct early postoperative hypoalbuminemia?

A Although pre-operative hypoalbuminemia is an independent risk factor for postoperative complications after colorectal surgery(World J Gastroenterol. 2008 February 28; 14(8): 1248–1251)( Asia Pac J Clin Nutr. 2007;16(2):213-7., and preoperative values should be >3 g/dl (Ann Surg. 2003 March; 237(3): 319–334.), kcorrection of potoperative hypoalbuminemia is controversial, and many studies did not confirm the benefits.

Q Is administration of Aminofluid® adequate for complicated surgical patients and severe metabolic stress?

A The rationale of Aminofluid® administration in surgical patients with complications and severe stress is as follows: 1. In acute phase of severe surgical stress, insulin

resistance occurs so the calorie provision must be start low go slow

2. 10-20 kcal/ kg BW is ideal during flow phase; Moderate content of glucose in Aminofluid® has protein-sparing effect and avoids worsening of stress-induced hyperglycemia. Therefore Aminofluid® can be given as starting solution.

3. BCAA-enriched amino acids combined with glucose are required to minimize negative nitrogen balance and combat postoperative fatigue

4. Na+ in moderate amount prevents iatrogenic fluid overload and K+ prevents potassium depletion

Q Is it reasonable to administer Aminofluid® to

patients with straightforward surgery where as they can be discharged early?

A In patients with straightforward surgery, Aminofluid® can be given straight after the patient is transferred from OT to the ward,as complete maintenance solution and

transition before patients can eat and drink enough, because of protein-sparing effect and prevention of ketosis. BCAA and microminerals contained in Aminofluid® make patients feel more fresh and recover faster.

Q Do you recommend fat emulsion premixed to Aminofluid®?

A Preferably Aminofluid® and fat emulsion given by 3-way, although empiric experience of many clinicians suggests that premixture is not problematic and with good results.

Q With pre-operative oral carbohydrate loading, what is the concentration and can iv glucose yield the same result in reducing postoperative insulin resistance?

A 800 ml midnight and 200 ml 2 hour before induction of anesthesia, clear liquid containing 12.5% of carbohydrate or equivalent. Parenteral glucose gives the same results to minimize postoperative insulin resistance.

CONCLUSION

Surgical patients have a wide spectrum in terms of nutritional status and metabolic stress experienced and the complexity of surgery and anes thesia techniques. Therefore, individualization in the management of perioperative fluid and nutrition needs serious attention.

In modern surgical practice, various protocols have been developed where patients can recover quickly and return to normal food intake after a few days. This applies especially for surgical patients who are not malnourished or without complications of infection / sepsis. Therefore, there are scanty of indications for routine provision of nutritional support, in which patients were given nutritional support "full dose". In this case, patients in the early postoperative phase needs only a complete maintenance fluid therapy to improve outcomes and speed up recovery.