Perioperative Ernährung

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2 Perioperative Ernährung Postaggressions- stoffwechsel SIRS ERAS Enhanced Recovery After Surgery Energiebedarf Gut - Injury - Hypothese integrierter Support Parenterale Ernährung hyper-, hypokalorisch enterale Ernährung Immunonutrition Zusammenwirkung künstl. Ernährung mit Analgesie, Pflege u. physikal.. Therapie Ziel: Reduktion der Krankenhausverweildauer

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4 = ERAS? Yehuda Elkana, Die Zeit, Geschichte: Nr.2, 2005

5 Prinzip: konventionell: Stressadaptation ERAS: Stressreduktion

6 Übelkeit / Erbrechen Ileus Nahrungskarenz Naso-gastrale Sonden Appetitsminderung multimodal: Antiemetika Opiat sparende Analgesie periphere Opiatantagonisierung thorakale epidurale Anästhesie frühzeitiger oraler Kostaufbau Limitierende Faktoren Fördernde Faktoren Bisgaard T, Kehlet H. Nutrition 2002; 18:

7 ESPEN-Guideline Proposal Enteral Nutrition 2005 Surgery and Organ Transplantation From a metabolic and nutritional point of view the key factors for the perioperative care include: avoidance of longer periods of starving reestablishing of oral feeding as early as possible after surgery integrate nutrition into the overall management of the patient

8 Metabolisches Konzept: konventionell: 1. Adaptation an Insulinresistenz 2. Vermeidung Hyperglykämie 3. hypokalorische Ernährung ERAS: 1. Vermeidung der Insulinresistenz 2. rascher oraler Kostaufbau

9 Soop et al, Br J Surg 2004; 91:

10 Soop et al, Br J Surg 2004; 91:

11 Prinzip: integrierter Support Clinical Pathway präoperative metabolische Konditionierung Flüssigkeitszufuhr Anästhesie Analgesie frühe enterale Ernährung Mobilisierung

12 ESPEN-Guideline Proposal Enteral Nutrition 2005 Surgery and Organ Transplantation Preoperative fasting from midnight is not necessary in most patients. Patients considered to have no specific risk for aspiration undergoing elective surgery may drink clear fluids until 2 hours before anaesthesia. Solids are allowed until 6 hours before anaesthesia (A).

13 Nygren et al, Ann Surg 1995; 222:

14 Nygren et al, Ann Surg 1995; 222:

15 Metabolische Konditionierung: Glukosedrink: 12.5% 800 ml am Abend und 400 ml 2-3h vor Narkoseeinleitung

16 Bisgaard et al, Br J Surg 2004; 91:

17 Hausel et al, Br J Surg 2005; 92:

18 Präoperativer Glukosedrink CHOD - carbohydrate drink Yuill et al, Clin Nutr 2005; 24: 32-37

19 Präoperativer Glukosedrink Yuill et al, Clin Nutr 2005; 24: 32-37

20 Prinzip: integrierter Support Clinical Pathway präoperative metabolische Konditionierung Flüssigkeitszufuhr Anästhesie Analgesie frühe enterale Ernährung Mobilisierung

21 Fast Track Surgery Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection Lobo et al, Lancet 2002; 359: Design: n = 20 pts. with colonic resection for cancer randomised for postop. Intravenous fluids n = 10 standard - > or = 3 l water and 154 mmol sodium / d n = 10 test: restricted - < or = 2 l water and 77 mmol sodium / d Primary endpoint: Secundary endpoints: Solid and liquid phase gastric emptying time, measured by dual isotope radionuclide scintigraphy on the pod 4 time to first bowel movement length of postoperative stay complications

22 Fast Track Surgery Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection Lobo et al, Lancet 2002; 359: Results: test vs standard 3 kg less weight gain median solid and liquid igastric emptying (T50) on pod 4 significantly shorter (p = 0,017) median passage of flatus 1 day earlier (p = 0,001) median passage of stool 2,5 days earlier (p = 0,001) median postop. hospital stay 3 days shorter (p = 0,001) no complications in the test group Conclusions: : : Positive salt and water balance after surgery delays return of gastrointestinal function and prolongs hospital stay in patients undergoing elective colonic resection

23 Lobo et al, Lancet 2002; 359:

24 Holte et al, Ann Surg 2004; 240:

25 Holte et al, Ann Surg 2004; 240:

26 Prinzip: integrierter Support Clinical Pathway präoperative metabolische Konditionierung Flüssigkeitszufuhr Anästhesie Analgesie frühe enterale Ernährung Mobilisierung

27 ESPEN-Guideline Proposal Enteral Nutrition 2005 (DGEM Guideline 2003) Surgery and Organ Transplantation Oral intake including clear liquids can be initiated within hours after surgery to most patients undergoing colon resection. (A)

28 Enterale Ernährung Lewis et al, BMJ 2001; 323: 1-5

29 Perioperative Nutrition prep. no Malnutrition slight, moderate severe enteral nutrition for d.. scheduled: esophageal resection gastrectomy pancreatoduodenectomy Immuneenhancing drink solution for 5-7 d. postop. OP early oral feeding within 7 d. yes within 4 d. no esophageal resection gastrectomy pancreatoduodenectomyy enteral access (NCJ early dag 1-14 late day 14 - yes Fast Track oral feeding covers caloric need yes no parenteral hypocaloric no enteral nutrition yes imunonutrition for 5 7d. oral feeding covers caloric need yes no combined enteral / parenteral oral feeding covers caloric need no enteral supplementation sip feeding

30 Oraler Kostaufbau innerhalb von 7 T ja nein innerhalb von 4 T ja nein Fast Track parenteral hypokalorisch Glukose/AS

31 Fast Track Surgery... In future, a combination of the physiological advantages of minimally invasive laparoscopic operation with the principles of fast-track multi-modal rehabilitation may provide significantly better outcome results than have been achieved so far with either method alone.... Schwenk and Kehlet, Br J Surg 2004; 91:

32 Basse et al, Ann Surg 2005; 241:

33 Basse et al, Ann Surg 2005; 241:

34 Verbesserung der Kolonchirurgie: laparoskopisch > konventionell - offen laparoskopisch = Fast Track - offen laparoskopisch + Fast Track >>> konventionell???

35 Fast Track Surgery... It may even be the most major operations, even in high-risk patients, will prove possible in an ambulatory or semiambulatory setting. For now, there is no need to slowdown, but careful progress in an orderly and prudent fashion should allow the goal of a pain and risk-free operation to be reached.... Kehlet and Wilmore,, Br J Surg 2005; 92: 3-4

36 Fast Track Surgery ERAS Consensus - Core protocol elements no routine oral preoperative bowel preparation clear fluids up to 2 h prior to anesthesia, preop carbohydrate loading no nasogastric decompression avoid excessive intravenous fluids, vasopressors for epidural-related hypotension, discontinuation of IV fluids on pod 1 continue thoracic epidural analgesia for 2 days, use of magnesium oxide twice daily postoperative nutrition includes ONS from the day of operation, in case of malnutrition continue ONS at home Fearon et al, Clin Nutr 2005; 24:

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39 Alles ist relativ