Prise en charge nutritionnelle périopératoire du patient obèse

Recommendations for perioperative nutrition in obese subjects require considering the following evidences. Obesity has long been falsely considered a risk factor for poor outcomes from a variety of surgical procedures, yet recent studies of critically and chronically ill patients suggest that overweight and obese patients may paradoxically have better outcomes than normal weight patients. Preoperative weight loss should be considered as a risk factor of postoperative complications in obese subjects as in normal weight patients. Obese patients could be malnourished because of vitamin deficiencies and of sarcopenia. The prevalence of vitamin deficiencies in the morbidly obese population prior to surgery is high, especially for vitamins B1, B12, B9, A, C, D and E. Standard of care should include perioperative thiamine replacement, especially in case of prolonged vomiting. Vitamin B12 deficiency could appear fast after gastric or ileal surgery, and iron deficiency is more frequent. Low caloric diet is not recommended in obese subjects before surgery, especially for the elderly, because of the frequent sarcopenia in this population. Energy and protein recommendations are not easy to be determined in obese subjects. Recommended allowance for protein should be defined according of the fat free mass, which is not easy to evaluate in clinical practice. So it is recommended to use a normalized weigh for a theoretic BMI between 25 and 30 kg/m². The loss of muscle mass can be very fast in the postoperative period in these subjects. The nutritional objective of care is to preserve skeletal muscle mass and to enhance the protein balance.     

Place de la pharmaconutrition en périopératoire

Since 20 years, data from high quality studies have demonstrated that perioperative immunonutrition is able, even in well-nourished patients, to reduce septic complications, length of stay and costs, in elective digestive cancer surgery. Then update of recommendations for clinical practice has been proposed. As this treatment is effective, French system reimburses the cost of treatment since 2006. Educational programme is now necessary to diffuse state of art.     

Évaluation de l’état nutritionnel péri-opératoire

In surgical patients, malnutrition is associated with an increase in morbidity, mortality, length of stay and health care costs, and has an impact on quality of life. Before surgery, the risk of malnutrition is depending on patient-related factors (age, associated diseases, on-going symptoms, duration of pre-operative hospital stay), surgical procedure, and medical treatment (radiotherapy, chemotherapy, corticoid treatment). The early screening and management of malnutrition are mandatory during the peri-operative period, with the aim to improve post-operative prognosis and clinical outcome. The nutritional assessment is based on the research of weight loss, the calculation of body mass index and the research of an hypoalbuminemia, all of them having a negative impact on postoperative prognosis. The Nutritional Risk Index (NRI) is also of strong prognostic value. We propose a stratification of the nutritional risk indicating several levels of surgical risk. The organization, the planning and the traceability in the medical record of the nutritional assessment should allow optimizing the management and the clinical outcome of surgical patients. The pre-operative consultation of anaesthesia could be the privileged time to perform the screening of malnutrition and to plan its management, if they were not previously performed by the medico-surgical team.     

La nutrition artificielle en periopératoire chez le patient diabétique

The diabetic patients are at high risk of malnutrition. One recommends seeking specific deficiencies (zinc, selenium, vitamins C and E) for malnourished diabetic patients. For the perioperative cares, one recommends to cover their protein needs and their caloric needs and to accordingly optimize the antidiabetic treatment. One should probably use oral supplements or enteral nutrition products with a low glycemic index. The presence of diabetic gastroparesis can make it difficult or dissuade enteral nutrition. The incidence of gastroparesis justifies gastric residue control, the use of prokinetic, and nutrition in postpyloric site. An equivalent parenteral carbohydrate intake has a hyperglycaemic effect more important than with the oral or enteral way. It is recommended to use an infusion pump in diabetic patients to administer parenteral nutrition. Daily use of lipid emulsions is recommended in this context.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant en cancérologie

In children with cancer, malnutrition may antedate the diagnosis or be a result of aggressive chemotherapeutic regimens. The prevalence of malnutrition at diagnosis is related to the type of tumour and the extent of the disease, ranging from < 10% in patients with standard-risk acute lymphoblastic leukaemia to 50% in children with advanced neuroblastoma. The pathogenis of the energy imbalance that underlies the development of malnutrition is complex, including increased breakdown of fat and protein as well as energy-consumptive changes in carbohydrate metabolism (Cori cycle). Despite several confounding factors (different definitions of nutritional status and the wide variety of measures used for its assessment), studies have shown decreased tolerance of chemotherapy associated with altered metabolism of antineoplastic drugs, increased infection rates, altered quality of life and possibly poor clinical outcome in malnourished patients. In this article, we review guidelines for the nutritional management of a child with cancer and we purpose an algorithm for nutritional support.     

Dénutrition périnatale : prise en charge nutritionnelle spécifique du nouveau-né

Malnutrition is quite rare in neonates. However perinatal malnutrition occurs in two situations. Fetal malnutrition leading to intra-uterine growth retardation with a birth weight below the lower limit for gestational age. On the other hand a postnatal relative malnutrition ("extra-uterine" growth retardation) which occurs mainly in preterm neonates. Both these situations need specific nutritional care after birth but also during the first years of life as there is probably a relationship between post-natal nutrition and health in adults (Barker hypothesis).     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant et l'adulte jeune atteints d'un handicap

Handicapped children are at high risk for malnutrition. In this situation nutritional assessment becomes difficult to perform due to musculo-skeletal deformities, patient's collaboration. In any case nutritional indices require simple measures: weight and height. Nutritional care must be presented early to parents in order to start as soon as possible when oral intake does not meet nutritional needs. For the handicapped child, surgery is often a major stress that requires nutritional care before, during and after. Obesity often aggravates the burden of the handicap and does not provide protection against malnutrition. Like in non-handicapped persons nutritional care can improve the outcome and well being of handicapped children.     

Prise en charge nutritionnelle des troubles du comportement alimentaire chez l'adolescent

This review underlines the importance of a structured nutritional treatment in eating disorders particularly in anorexia nervosa, its physiopathological bases and influence on short and long term prognosis of the disease. Somatic and neuropsychological effects of undernutrition, their consequences in terms of morbidity, mortality and sequelae are underlined. The modalities of refeeding at home and during hospitalisation, the necessity of renutrition to a right target weight, and, after that, the importance to work for maintaining a good nutritional state are indicated. The frequency of relapses (around 50%) is underlined, as well as the importance of "therapeutic alliance" between physicians and families (and, as soon as possible, with anorectic adolescent) and the advantage of a good collaboration between psychiatric and pediatric teams. They discuss more briefly about nutritional aspects of bulimia management. Finally the authors state on their own results about 161 patients followed for more than 4 years of which 144 participate in an evaluation (68% of good, 23.3% of intermediary and 8.7% of bad results) attesting of progress versus an anterior evaluation and best results than 2 other studies, published in 1991 and 2001, with the same tests for evaluation.     

Nutrition dans la période postopératoire (dont urgence)

Policies which tend to reduce surgical stress and therefore decrease catabolism and to improve anabolism could allow patients to recover more quickly and efficiently even after major surgery. In most instances, interruption of nutritional intake is not necessary after surgery. Oral intake can be started as soon as possible within the first 24 hours unless surgical contra-indication. Oral intake should be adjusted according to patient's tolerance. In patients without overt under-nutrition, postoperative nutritional support for periods of less than 7 days is not indicated. However, nutritional support is recommended when postoperative food intakes reach less than 60% of daily needs for 7 days. Moreover, early nutritional support should probably be administered if expected postoperative food intake will be less than 60% of daily needs for more than 7 days. In malnourished patients, nutritional support (using enteral rather than parenteral route) is strongly recommended within the first postoperative 24 hours regardless of preoperative nutritional support.     

Nutrition périopératoire : protocoles de soins

Based on texts written by experts, the objective of this paper is to propose a practical approach to nutrition for clinicians, according to the nutritional status of patients and the evaluation of surgical risk. Any patient with a nutritional grade greater than or equal to 2 should benefit from nutritional support. Indeed, current data confirm that preoperative and early nutritional support in surgery at risk can reduce significantly postoperative morbidity for patients with non-malnourished (immunonutrition in cancer surgery GI), and the morbidity and mortality in malnourished patients (enteral nutrition when possible). A preoperative oral intake is recommended 2 to 3 hours before elective surgery for clear fluids and 6 hours for a light meal. Moreover, a preoperative oral intake of carbohydrates (maltodextrin 12.5%) is recommended (except in diabetic patients). Postoperatively, early oral feeding (within 24 hours) is recommended in the absence of cons to surgery. Glutamine is recommended in case of postoperative complications.     

Prise en charge nutritionnelle à domicile des malades cancéreuxHome artificial nutrition in cancer patients

Cancer is the first indication for home artificial nutrition in France, with rising figures. Survival of cancer patients on home parenteral nutrition is lower than that of other patients on home parenteral nutrition, due to the evolution of the underlying disease, and cancer is also associated with lower survival figures in home enteral nutrition patients. More than half of cancer patients die within the first year of home artificial nutrition. Home artificial nutrition seems to improve health-related quality of life, and may improve life expectancy in some patients. It is prescribed in patients during treatment (supportive care) or with therapeutic sequels, the indications being comparable to those in the hospital setting. Home artificial nutrition as a palliative care is much more debated, as it has not proved to increase quality of life or survival. It should be banned for patients with a life expectancy lower than three months and a Karnofsky index lower than 50. There is no specific nutrition technique for cancer patients.     

Stratégie de prise en charge nutritionnelle de l'enfant et de l'adolescent (Nutrition orale, entérale, parentérale)

Children are especially threatened by malnutrition, because of the high protein-energy cost of growth. Any nutritional deficiency is the source of protein energy malnutrition, which compounds the problems of underlying disease. The protein-energy cost of catch-up growth is particularly high, and should lead to a rigorous adjustment of nutritional supply to prevent metabolic disorders associated with refeeding syndrome (directly related to the homeostatic change secondary to severe protein energy malnutrition). If the gastrointestinal tract can be used for refeeding, it should be used (oral or enteral nutrition). When the gastrointestinal tract is unable to meet the protein and energy requirements, parenteral nutrition is required. Catch-up growth may be achieved by using appropriate nutritional support.     

Nutrition artificielle : utilité ou futilité chez l'enfant en situation palliative

Palliative care are intended to children with life limiting conditions. In France, for the majority of pediatric team, the idea of continuity of cares is essential for the announcement of the diagnosis to the final state. The author describes here different situations according to the initial disease of these children. In all cases, the choices of artificial feeding depend of pluridisciplinary medical teams and their experience, and of family opinion. Ethical consideration must be present in this decision.     

La consultation pré-anesthésique comme outil de dépistage nutritionnel préopératoire

Objective

In severely malnourished patients, preoperative nutritional support helps lessen the adverse impact of malnourishment on postoperative progress. An essential prerequisite is to identify this malnourishment. We wanted to find out whether pre-anaesthetic consultation (which is not compulsory in Belgium) was a tool that could be used to achieve these objectives of preoperative nutritional screening in patients undergoing abdominal surgery.

Method

Our working method comprised of three phases. Having conducted a study to determine our situation, we integrated the NRS 2002 into our computerised consultation protocol and created a procedure used to link our consultation with the dietetics consultation on the same day. We then analysed the effectiveness of our actions.

Results

We received 87.8% of patients undergoing elective abdominal surgery at the pre-anaesthetic consultation. Thanks to the computerisation of the NRS 2002, our nutritional screening rose from 60.8% to 86.1%. All patients at risk of malnutrition were referred to the dietetics service on the same day for a nutritional assessment and nutritional support if necessary. This procedure reduced the hospital re-admittance rate as much as possible. The average period of 13 to 15 days between the pre-anaesthetic consultation and the surgery was sufficient to put in place preoperative nutritional support.

Conclusion

Pre-anaesthetic consultation has therefore become a tool used for preoperative nutritional screening and care.     

Conséquences de la dénutrition chez l'enfant et l'adolescent. Mortalité, morbidité, conséquences médicoéconomiques

In the developed countries, the sick children are at risk of protein-energy malnutrition (PEM). Marasmus is the most common form of severe PEM in such children. Its major characteristics are low muscle and fat masses with the presence of marked facial, axillary and inguinal skinfolds. Furthermore the marastic children are irritable and depressed. When the PEM is moderate, which is more frequent, the affected children present a failure to thrive. Severe and moderate PEM have multiple functional consequences on different systems and organs with an impact on mortality, morbidity and costs. In this paper, the functional consequences on the immune system, digestive tract, liver, lung, heart, kidney, skin, bone and brain are passed in review. To end, some comments are done about the particularities of PEM in mental anorexia and obesity.