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8. Perioperative nutrition: Recommendations from the ESPEN expert group

Author

Lobo, D, Gianotti, L, Adiamah, A, Barazzoni, R, Deutz, N, Dhatariya, K, Greenhaff, P, Hiesmayr, M, Hjort Jakobsen, D, Klek, S, Krznaric, Z, Ljungqvist, O, Mcmillan, D, Rollins, K, Panisic Sekeljic, M, Skipworth, R, Stanga, Z, Stockley, A, Stockley, R, Weimann, A, Lobo D. N., Gianotti L., Adiamah A., Barazzoni R., Deutz N. E. P., Dhatariya K., Greenhaff P. L., Hiesmayr M., Hjort Jakobsen D., Klek S., Krznaric Z., Ljungqvist O., McMillan D. C., Rollins K. E., Panisic Sekeljic M., Skipworth R. J. E., Stanga Z., Stockley A., Stockley R., Weimann A., Lobo, D, Gianotti, L, Adiamah, A, Barazzoni, R, Deutz, N, Dhatariya, K, Greenhaff, P, Hiesmayr, M, Hjort Jakobsen, D, Klek, S, Krznaric, Z, Ljungqvist, O, Mcmillan, D, Rollins, K, Panisic Sekeljic, M, Skipworth, R, Stanga, Z, Stockley, A, Stockley, R, Weimann, A, Lobo D. N., Gianotti L., Adiamah A., Barazzoni R., Deutz N. E. P., Dhatariya K., Greenhaff P. L., Hiesmayr M., Hjort Jakobsen D., Klek S., Krznaric Z., Ljungqvist O., McMillan D. C., Rollins K. E., Panisic Sekeljic M., Skipworth R. J. E., Stanga Z., Stockley A., Stockley R., and Weimann A.

Abstract

Background & aims: Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14–15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. Methods: This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. Results: Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. Conclusions: Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.

Published
2020

11. Hypoxia increases the potential for neutrophil-mediated endothelial damage in COPD

Author

Lodge, K, Vassallo, A, Liu, B, Long, M, Tong, Z, Newby, P, Agha-Jaffar, D, Paschalaki, K, Green, C, Belchamber, K, Ridger, V, Stockley, R, Sapey, E, Summers, C, Cowburn, A, Chilvers, E, Li, W, Condliffe, A, National Heart and Lung Foundation, The Academy of Medical Sciences, and British Heart Foundation

Subjects
Neutrophils, Respiratory System, DEGRANULATION, EMPHYSEMA, Pulmonary Disease, Chronic Obstructive, Critical Care Medicine, GELATINASE-ASSOCIATED LIPOCALIN, cardiovascular disease, General & Internal Medicine, SPUTUM, Humans, Hypoxia, 11 Medical and Health Sciences, AIRWAYS, Science & Technology, CYCLOPHILIN, Endothelial Cells, cell degranulation, Vascular System Injuries, respiratory tract diseases, PLATELET-ACTIVATING-FACTOR, SECRETION, Leukocyte Elastase, Life Sciences & Biomedicine, neutrophil elastase, vascular endothelium, ELASTASE, SMOKERS
Abstract

Rationale: Chronic obstructive pulmonary disease (COPD) patients experience excess cardiovascular morbidity and mortality, and exacerbations further increase the risk of such events. COPD is associated with persistent blood and airway neutrophilia, and systemic and tissue hypoxia. Hypoxia augments neutrophil elastase release, enhancing capacity for tissue injury. Objective: To determine whether hypoxia-driven neutrophil protein secretion contributes to endothelial damage in COPD. Methods: The healthy human neutrophil secretome generated under normoxic or hypoxic conditions was characterised by quantitative mass spectrometry, and the capacity for neutrophil-mediated endothelial damage assessed. Histotoxic protein levels were measured in normoxic versus hypoxic neutrophil supernatants and plasma from exacerbating COPD patients and healthy controls. Main results: Hypoxia promoted PI3Kγ-dependent neutrophil elastase secretion, with greater release seen in neutrophils from COPD patients. Supernatants from neutrophils incubated under hypoxia caused pulmonary endothelial cell damage and identical supernatants from COPD neutrophils increased neutrophil adherence to endothelial cells. Proteomics revealed differential neutrophil protein secretion under hypoxia and normoxia; hypoxia augmented secretion of a subset of histotoxic granule and cytosolic proteins, with significantly greater release seen in COPD neutrophils. The plasma of COPD patients had higher content of hypoxia-upregulated neutrophil-derived proteins and protease activity, and vascular injury markers. Conclusions: Hypoxia drives a destructive ‘hyper-secretory’ neutrophil phenotype conferring enhanced capacity for endothelial injury, with a corresponding signature of neutrophil degranulation and vascular injury identified in COPD patient plasma. Thus, hypoxic enhancement of neutrophil degranulation may contribute to increased cardiovascular risk in COPD. These insights may identify new therapeutic opportunities for endothelial damage in COPD.

Published
2021

17. Perioperative nutrition : Recommendations from the ESPEN expert group

Author

Lobo, D. N., Gianotti, L., Adiamah, A., Barazzoni, R., Deutz, N. E. P., Dhatariya, K., Greenhaff, P. L., Hiesmayr, M., Hjort Jakobsen, D., Klek, S., Krznaric, Z., Ljungqvist, Olle, McMillan, D. C., Rollins, K. E., Panisic Sekeljic, M., Skipworth, R. J. E., Stanga, Z., Stockley, A., Stockley, R., Weimann, A., Lobo, D. N., Gianotti, L., Adiamah, A., Barazzoni, R., Deutz, N. E. P., Dhatariya, K., Greenhaff, P. L., Hiesmayr, M., Hjort Jakobsen, D., Klek, S., Krznaric, Z., Ljungqvist, Olle, McMillan, D. C., Rollins, K. E., Panisic Sekeljic, M., Skipworth, R. J. E., Stanga, Z., Stockley, A., Stockley, R., and Weimann, A.

Abstract

Background & aims: Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14–15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. Methods: This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. Results: Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. Conclusions: Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient., Funding Agency:European Society for Clinical Nutrition and Metabolism (ESPEN), Luxemborg

Published
2020
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