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PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article 142 | POJ_0134 | 2018-2019)

Original Clinical Investigation

Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | Back to Total Name and Codes page2

Submitted: | Posted:

Authors:

Luisito O. Llido MD, FPCS, FPGS; Clinical Nutrition Specialist; St. Luke's Medical Center, Quezon City, Philippines (delivered during the 2018 PENSA congress at South Korea)

Institution where research was conducted

  • Philippine Society of General Surgeons, Head Office, Manila, Philippines
  • Phillippine Society of Parenteral and Enteral Nutrition, Philippines

Disclosures:

•Received educational grants from and involved in seminars and workshops with the following companies:
  • JW
  • BBraun
  • Fresenius-Kabi
  • Abbott
  • Marvex

ABSTRACT: | Back

Background:

To present the feature in the Philippines regarding ERAS and its subsequent topics especially on fluid dynamics and insulin changes.

Objective:

To be able to show the effects of ERAS on surgical management.

Methodology:

The following are featured regarding ERAS: nutritional secreening and assessment, fluid systems and dynamics, preoperative preparations and postoperative management, anesthesia modifications, NGT management (is it still needed?), feeding practices, early ambulations, saline treatment and progressive care.

Results:

These are the results of the assessments: passed the nutritional screening and assessment, fluid management, feeding route and adequate intake and monitoring and mobilization. There were still failures in the preoperative loading, nothing per orem in the pareparatory period, saline use, and diet progression attitudes. Regarding NGT placement - some are still applying it, some are not.

Conclusion:

There is a lot of things done with the ERAS regimen regarding preoperative and postoperative care. This has to be fully implemented in the future.

 

KEYWORDS: Early recovery after surgery practices

 

INTRODUCTION | Back

Background

•ERAS works and patients benefit from it. (1)
•ERAS principles and updates on fluid therapy have been taught globally with the goal of improving patient outcomes. (2)
•This includes the Philippines where Dr. Ljunqvist was invited to talk on ERAS in 2014* (3)
•It takes time for these principles to become practice > commitment to have these implemented becomes an issue with leadership.
•This presentation discusses the current status of implementation in the general surgery training and practice in the Philippines.(1)

Teaching the Way

•The surgical societies in the Philippines have not been remiss in educating and pushing for changes in surgical practice
•They were encouraged by the positive outcomes and updates reported in the literature regarding surgical metabolism, nutrition and techniques
•These updates were included in sessions in the congresses of the Philippine College of Surgeons and post-graduate courses of the different general surgery training hospitals in the country under the auspices of the Philippine Society of General Surgeons (3)


METHODOLOGY | Back

Statistics

•Philippine College of Surgeons and Philippine Society of General Surgeons yearly congresses from 2014 to 2017:
•Updates and discussions on ERAS: 100% (4)
•Fluid management updates: 100% (4)
•Critical care updates: 100% (5)
•Post-graduate courses in the different training hospitals in general surgery in the Philippines:
•ERAS related topics: 40-50%
•Fluid management sessions: 40-50%
Critical care sessions: 40-50% (6)

From theory to practice evalution points

•Nutritional screening and assessment > is it done?
•Pre-operative carbohydrate loading > is it practiced?
•Intraoperative fluid delivery > how is it done?
•Early feeding within 24 to 48 hours > is it practiced?
•Adequacy of intake monitoring > is it done?
•Early mobilization > how early?

The survey process

Phase 1 - Pilot project

  • Prepared questionnaire
  • To be implemented in 4 surgical centers in Metro-Manila
    • smdp (St. Martin de Porres Manila) - one consultant is a clinical nutrition specialist
    • tmc (The Medical City Manila) - has a nutrition team and is the ERAS center of excellence
    • qmmc (Quezon City Memorial Medical Center) - one consultant is an intensivist with clinical nutrition expertise
    • slmc (St. Luke's Medical Center) - has a clinical nutrition service (=nutrition team)
  • Major surgeries only
  • Data collection - random

Phase 2 - Main Project

  • The goal is to cover all 68 general surgery training centers in the country

Pilot project profile

  • Type of surgery
    • Elective - 64%
    • Emergency - 36%
  • Related to the gut
    • Gastrointestinal - 64%
    • Non-gastrointestinal - 36%

RESULTS | Back

Survey (7): Perioperative Nutrition and Fluid Management in the Different Teaching Institutions in the Philippines

  1. Code ID of Hospital: ______________
  2. Patient Name Initials (e.g. FT for Felix Tan): _________________________
  3. Age: ______ years

PREOPERATIVE PERIOD:

  1. Sex Male [   ]  Female  [    ]
  2. Height: ___________ meter / cm (please encircle the unit used)
  3. Weight: ___________ kg / lbs (please encircle the unit used)
  4. BMI: ____________
  5. Weight Loss (%) in past 3 to 4 weeks: ___________
  6. Admission Date: ___________________
  7. Diagnosis:
  1. Nutrition screening done? Yes [  ] No [  ]
  2. Nutrition Assessment Done?  Yes  [  ]  No [  ]
  3. Pre-operative carbohydrate loading done? Yes  [  ]  No [  ]
  4. Date of Operation: ___________________________

INTRAOPERATIVE PERIOD       |      Type of Surgery:   Elective? [   ]     Emergency?  [   ]

  1. Surgery Done   
  1. Duration of NPO before surgery: 4 hrs [  ]  6 hrs [   ]  >6 hrs [   ] 
  2. Operation duration: _________ hours
  3. Intraop Fluids: Volume: _______ ml / Saline used: Yes [  ]  No [  ] / Colloids used: Yes [  ]  No [  ]

POST-OPERATIVE PERIOD

  1. NPO: 24-hr [   ] /  48-hr [   ] /  72-hr [   ] /  >3 days [   ]
  2. NGT: Yes  [  ]  No [  ] / Drain: Yes  [  ]  No [  ]
  3. Feeding started: [      ] post-op day (please write the number of post-op day)
  4. Type of feeding: oral [   ] /  enteral [   ] /  parenteral [   ] /  enteral/parenteral; [   ]
  5. Accumulated fluid balance monitored regularly? Yes [   ]   No [   ]
  6. Bowel movement on what post-operative day? [         ] (place the number)
  7. Progressive diet used (general liquid to full diet)? Yes  [  ]  No [  ]
  8. Full oral diet achieved? Yes  [  ]  No [  ] / On what postop day? [       ]
  9. Total Calorie Requirement/day: _______________ (25-30 kcal x actual weight in kg)
  10. Total Protein Requirement/day: _______________ (1g-1.5g x actual weight in kg)
  11. Adequate intake reached? On which Post-Op Day? Day 1-2 [   ] Day 3-4 [   ] >4 days [   ]  / Adequate intake not reached throughout post-operative period: Yes  [  ]  No [  ] / (Note: Adequate intake = 70% of computed calories and protein)
  12. Ambulation started: [       ] post-op day (please write the number)
  13. Discharge Date: __________________
  14. Total Post-operative Days: ___________ (please write the number)
  15. Discharge status: Alive [    ] / Dead [    ]
  16. Accomplished By: _________________________________________

St. Luke's Medical Center, Philippines (where the main research paper was done)

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ERAS Nutrition Update year 2018

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Where the first ERAS in the Philippines was conducted.

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My personal assessment with the following preoperative and postoperative nutrition section - 2018: (8)

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Was nutrition screening done? (9) - 61% was positive in terms of compliance.

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Was nutrition assessment done (10) - there was 59% in terms of compliance.

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Was pre-operative loading done? (11) - there was only a 20% compliance.

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Was there NPO before surgery?(12) - more than 3/4 had their NPO more than 6 hours.

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Pre-operative Fasting Updates (13)

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Fluid Balance 1 (14) - what should be followed, which is less than 500 ml/hr.

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Fluid Balance 2 (15) - very good intrafluid status before surgery (98%) thus preoperative deficits are not present.

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Use of Saline (16) - up to today there is still that thinking that saline is the best pre and postoperative fluid (76%)

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NGT (Nasogastric Tube Placement) (17) - there is still that pre and postoperative NGT placement (63%) meaning patients are still on NGT especially on the 3rd to 4th day and only 37% had no NGT. Although our lectures are having an impact it will be some time before this practice will take effect.

 

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Was there feeding and when was the feeding started? (18) - within 2 days almost full feeding was given (66%)

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Was there an order for diet progression? (19) - there is still that practice of giving liquid then eventually general liquid within 3-4 days; a lot of work is still to be done regarding this type since most patients are able to tolerate full feeding within 2 days.

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Monitoring and Adequacy of Intake (20) - this is now okay, but the concept of adequate protein and calorie delivery is still to be given fully applied.

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Mobilization Days / Total Post-Op Days (21) - still to be fully practiced

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DISCUSSION: | Back

My personal assessment - was I wrong? Yes, have a little faith man. (22)

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The followint data came out to be: very good increase in nutrition screening (61%) and a lower assessment (59%) in the nutritional assessment area but still quite good in this area. There was no change in the preoperative carbohydrate loading, however, there was non-compliance in the restrictive fluid care especially in the preoperative section (95%). Saline use was also non-compliant at 76%, but there was some response in giving preoperative feeding (66%). There was improvement in giving progressive diet (78%). adequate monitoring (83%) and early mobilizaton (85%).

Our report card:

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So our nutrition screening and pre and postoperative care showed: nutrition screening and assessment - passed. Preoperative carbon loading and preoperative NPO were failures; fluid management was a passing mark, but saline use was a failure mark. There was a questionable result in NGT placement, but the feeding route was a passing mark. Diet progression was a failure mark but both adequate monitoring and mobilization were passing.


CONCLUSION: | Back

•There is progress specially in the following areas:
•Nutrition screening and assessment
•Fluid management
•Use of oral route for feeding
•Monitoring adequacy of intake
•Mobilization
•Over-all, the implementation of updates on general surgery practice still needs a lot of work
•Our general surgery training institutions need to use more aggressive and inventive solutions to make these changes happen.

Planned next steps

•Updating guidelines and protocols
•Frequent evaluations of practice change by the national societies of surgery
•A strict credentialing system for training institutions – this includes these aforementioned monitoring variables, to be implemented for accreditation purposes
•There may be a need for penalties and sanctions for non-compliance
•The need for more outcome studies and surveys in the future

 

REFERENCES: | Back

  1. Ljungvist O. (2014). ERAS enhanced recovery after surgery: moving evidence based perioperative care to practice. JPEN - Journal of Parenteral and Enteral Nutrition, 38 (5), 559-566.
  2. Ljungvist O. Nutrition and recovery after surgery. PhilSPEN 2014 Convention lecture.
  3. Ljungvist O. Nutrition and recovery after surgery: After the PhilSPEN 2014 Convention.
  4. Updates and Discussions on ERAS (After ERAS) - 2018.
  5. Critical Nutrition Updates - 2014 -2018 lectures.
  6. Critical Care Sessions - 2018 lectures.
  7. Perioperative Nutrition Survey for PSGS - 2017.
  8. Personal Assessment of the following perioperative nutrition survey 2018.
  9. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: Why is nutrition screening done? PENSA lecture in South Korea.
  10. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: Why is nutrition assessment done? 2018 PENSA lecture in South Korea.
  11. Ljungvist, O. (2012). Jonathan E. Rhoads lecture 2011: insulin resistance and enhanced recovery after surgery. JPEN - Journal of Parenteral and Enteral Nutrition, 36 (4), 389-398.
  12. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: Was there NPO before surgery? 2018 PENSA lecture in South Korea.
  13. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: Preoperative fasting updates. 2018 PENSA lecture in South Korea.
  14. Brandstrup B et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two postoperative fluid regimens: a randomized assessor blinded multicenter trial. Annals of Surgery 2003; 238: 641-648.
  15. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: Fluid Balance 1. 2018 lecture in South Korea.
  16. Lobo D, Macafee D, Allison S. How perioperative fluid balance influences postoperative outcome. Best Pract Clin Anesthesiology 2006; 20(4): 439-55.
  17. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: Use of NGT. 2018 Lecture in South Korea.
  18. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: Was there tube feeding when feeding started? 2018 lecture in South Korea.
  19. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: Was there an order for diet progression? 2018 PENSA Lecture in South Korea.
  20. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: Was there monitoring of adequacy of intake? 2018 PENSA lecture in South Korea.
  21. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: Was there monitoring of mobilizing days. 2018 PENSA lecture in South Korea,
  22. Perioperative Surgical Management: Theory and Reality, the Philippine Experience 2016-2018: What was my personal assessment of the preoperative and postoperative data? 2018 PENSA lecture in South Korea.

 

 

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Total Name and Codes page2