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Journal ArticleDOI

Perioperative nutrition : what do we know?

01 Jan 2011-The South African journal of clinical nutrition (Health and Medical Publishing Group)-Vol. 24, Iss: 3, pp 19-22
TL;DR: Data suggests that all surgical patients should receive early postoperative nutrition support and all patients undergoing elective surgery with substantial risk of infectious complications should be prescribed arginine-supplemented diets along with omega-3 fatty acids, preferably pre- and postoperatively.
Abstract: Surgery patients are at risk for iatrogenic malnutrition and subsequent deleterious effects. The benefits of nutrition support on patient outcomes have been demonstrated and the possible benefit of perioperative nutrition support thus implied. Enhanced recovery after surgery (ERAS) protocols, including perioperative nutrition support as a component thereof, is indicated in the management of patients. In contrast to this, it seems the current trend is to follow the traditional perioperative management even when existing data demonstrate no merit in continuing with these practices. Data suggests that all surgical patients should receive early postoperative nutrition support. Immunonutrition, as part of ERAS has also been reported to derive beneficial effects in surgery patient outcomes but current clinical practice guidelines are inconsistent with regards to the administration of specific immunonutrients. Arginine is an immunonutrient that is of specific interest in surgical patients due to an assumed deficiency thereof. Insufficient arginine levels can lead to immunosuppression with an increased risk for complications. Available evidence indicates that all patients undergoing elective surgery with substantial risk of infectious complications should be prescribed arginine-supplemented diets along with omega-3 fatty acids, preferably pre- and postoperatively. No recommendations can be made on the practice of combined glutamine and arginine supplementation.

Summary (1 min read)

Introduction

  • Disease-related malnutrition is often prevalent in hospitalized patients and results in increased morbidity, mortality and healthcare costs.
  • 1, 2 Historically there has been some confusion on the classification of disease-related malnutrition due to the variety of definitions that existed but recently an International Guideline Committee developed a consensus approach to defining adult malnutrition in clinical settings.
  • The prevalence varies depending on the type of disease ranging for instance from 25% in chronic obstructive pulmonary disease to 85% in pancreatic cancer and 88% in head and neck cancer patients.
  • 2, 4 Postoperative malnutrition or delayed / insufficient nutrition support has also been associated with higher risk for complication rates and mortality.
  • This review will focus on postoperative nutritional support and arginine supplementation in surgical patients.

Effect of nutrition on patient outcomes

  • Several studies and reviews have demonstrated the benefits of nutrition therapy, specifically enteral nutrition (EN) in critically ill patients including surgical patients.
  • These benefits included reduced prevalence of complications, reduced mortality rates, and/ or shorter length of stay.
  • The limited available data on the direct assessment of cost-savings arising from improved outcomes associated with EN therapy indicate that it is a cost effective treatment.
  • The reasons for this approach was related to the fear for anastamotic breakdown and prolonged feeding intolerance due to postoperative ileus (POI) which was seen as an inevitable consequence of surgery.
  • Traditionally also, a more conservative dietary progression was followed which consisted of a clear liquid diet, followed by a full liquid diet advancing to a soft or normal diet.

Current perioperative patient management recommendations

  • Currently an important focus of perioperative patient management is the enhanced recovery of patients after surgery (ERAS) or the so-called "fast track" protocols.
  • Components of enhanced recovery after surgery (ERAS) protocols, also known as Table I.

Nasogastric tube removed Avoidance of postoperative drains Immediate postoperative fluid and diet initiation Epidural analgesia Diet initiation on postoperative day 1 Aggressive mobilisation program

  • Findings from various studies on ERAS indicate possible benefits from these programs for both patient and institution, thus contradicting traditional management.
  • In cases where enteral nutrition is not feasible in undernourished patients, parenteral nutrition should be administered.
  • These studies do not support the traditional nutritional management of postoperative patients and clearly indicates the positive effects on outcomes in patients receiving early EN.
  • The patient populations included in this meta-analysis included patients with GI malignancies, general abdominal surgery, head and neck malignancy and cardiac surgery.
  • The authors proposed that arginine-supplemented diets can overcome the arginine deficiency observed in surgical patients by increasing systemic arginine availability through supraphysiological supplementation doses .

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S19
Review Article: Perioperative nutrition: what do we know?
2011;24(3) SupplementS Afr J Clin Nutr
Kotze V, BSc Human Genetics, BDietetics
Lecturer, Department of Human Nutrition, University of Pretoria
Correspondence to: Vanessa Kotze, e-mail: vanessa.kotze@up.ac.za
Perioperative nutrition: what do we know?
Introduction
Disease-related malnutrition is often prevalent in hospitalized
patients and results in increased morbidity, mortality and
healthcare costs.
1,2
Historically there has been some confusion on
the classification of disease-related malnutrition due to the variety
of definitions that existed but recently an International Guideline
Committee developed a consensus approach to defining adult
malnutrition in clinical settings.
3
Due to the past lack in clear
classification of malnutrition, the actual prevalence of malnutrition,
using defined criteria, is unknown. The prevalence varies depending
on the type of disease ranging for instance from 25% in chronic
obstructive pulmonary disease to 85% in pancreatic cancer and
88% in head and neck cancer patients.
1
Furthermore, patients
with preoperative malnutrition have a significantly higher risk of
postoperative complications and death along with increased hospital
length of stay (LOS) and overall costs.
2,4
Postoperative malnutrition
or delayed / insufficient nutrition support has also been associated
with higher risk for complication rates and mortality.
4
This suggests
that perioperative nutrition support may positively affect outcomes.
4
This review will focus on postoperative nutritional support and
arginine supplementation in surgical patients.
Effect of nutrition on patient outcomes
Several studies and reviews have demonstrated the benefits of
nutrition therapy, specifically enteral nutrition (EN) in critically ill
patients including surgical patients.
4
A meta-analysis by Stratton
et al identified functional benefits of enteral nutrition support
administered to hospitalized patients in varied clinical settings as
well as in postoperative surgical patients. These benefits included
reduced prevalence of complications, reduced mortality rates, and/
or shorter length of stay.
1
The limited available data on the direct
assessment of cost-savings arising from improved outcomes
associated with EN therapy indicate that it is a cost effective
treatment.
1
Similarly, there are also limited data in this regard which
compare EN to parenteral nutrition (PN) as well as preoperative to
postoperative nutrition with regards to treatment effect and the cost
to benefit ratio.
1
Traditional management of surgical patients
Traditional perioperative management of patients entailed keeping a
patient nil per os (NPO) from the previous evening (six to 12 hours
preoperatively) and postoperatively for several days. Only IV fluids
were administered until bowel function returned, this being perceived
Abstract
Surgery patients are at risk for iatrogenic malnutrition and subsequent deleterious effects. The benefits of nutrition support on patient
outcomes have been demonstrated and the possible benefit of perioperative nutrition support thus implied.
Enhanced recovery after surgery (ERAS) protocols, including perioperative nutrition support as a component thereof, is indicated in the
management of patients. In contrast to this, it seems the current trend is to follow the traditional perioperative management even when existing
data demonstrate no merit in continuing with these practices. Data suggests that all surgical patients should receive early postoperative
nutrition support.
Immunonutrition, as part of ERAS has also been reported to derive beneficial effects in surgery patient outcomes but current clinical practice
guidelines are inconsistent with regards to the administration of specific immunonutrients. Arginine is an immunonutrient that is of specific
interest in surgical patients due to an assumed deficiency thereof. Insufficient arginine levels can lead to immunosuppression with an
increased risk for complications. Available evidence indicates that all patients undergoing elective surgery with substantial risk of infectious
complications should be prescribed arginine-supplemented diets along with omega-3 fatty acids, preferably pre- and postoperatively. No
recommendations can be made on the practice of combined glutamine and arginine supplementation.
© SAJCN S Afr J Clin Nutr 2011;24(3): S19-S22

Review Article: Perioperative nutrition: what do we know?
S20
Review Article: Perioperative nutrition: what do we know?
2011;24(3) SupplementS Afr J Clin Nutr
as the passing of flatus, a bowel movement or the presence of bowel
sounds. Once bowel function returned, enteral nutrition or diet per
mouth was initiated. The reasons for this approach was related to the
fear for anastamotic breakdown and prolonged feeding intolerance
due to postoperative ileus (POI) which was seen as an inevitable
consequence of surgery. Traditionally also, a more conservative
dietary progression was followed which consisted of a clear liquid
diet, followed by a full liquid diet advancing to a soft or normal diet.
5
This slow commencement of dietary intake has limited nutritional
value and along with the delayed commencement of nutritional
support is known to contribute to the development of nutritional
deficits and accentuated postoperative weight loss.
2
Current perioperative patient management
recommendations
Currently an important focus of perioperative patient management
is the enhanced recovery of patients after surgery (ERAS) or the
so-called “fast track protocols.
4
The key aspects of ERAS from a
metabolic and nutritional point of view are avoidance of long periods
of preoperative fasting, re-establishment of oral feeding as soon
as possible after surgery, integration of nutrition support, including
administration of specialized nutrients into the overall management
of the patient, metabolic control, early mobilization and reduction
of factors known to exacerbate stress-related catabolism or impair
gastrointestinal function (Table I).
5-7
Table I: Components of enhanced recovery after surgery (ERAS)
protocols.
4,5,7
Preoperative period
Preoperative counselling
Prebiotics/probiotics administration
Oral carbohydrate load
Fasting limited to three hours
No bowel preparation
Omission of nasogastric tube
Perioperative period
Nasogastric tube removal
Transverse incision
Administration of specialized nutrients
Postoperative period
Nasogastric tube removed
Avoidance of postoperative drains
Immediate postoperative fluid and diet initiation
Epidural analgesia
Diet initiation on postoperative day 1
Aggressive mobilisation program
Findings from various studies on ERAS indicate possible benefits
from these programs for both patient and institution, thus
contradicting traditional management. Some of these benefits
include shorter length of stay (LOS) in hospital, earlier return of
bowel function, decreased length of time to mobilization, fewer
postoperative complications, ability to tolerate solid food sooner and
lower readmission rate 30 days postoperatively. In addition, there
was no difference in reported pain or fatigue in patients treated with
the ERAS protocols when compared with traditional management.
It should, however be borne in mind that the ERAS protocols
incorporate a number of components and as such it is difficult to
associate the claimed benefits with one specific component such
as nutritional support.
5
Regarding perioperative nutrition support, the ESPEN guidelines on
EN in surgery and organ transplantation recommend that patients
with severe nutritional risk should receive nutritional support 10–14
days prior to major surgery even if it means delaying surgery (Grade
A evidence). The enteral route is preferred except in patients with
intestinal obstruction, ileus, severe shock or intestinal ischaemia
(Grade C evidence).
6
Preoperative fasting from midnight is
unnecessary in most patients (Grade A evidence)
with solids allowed
up to six hours in patients with no specific risk for aspiration and clear
fluids up to two hours preoperatively.
6,8
Patients who do not meet
their requirements from a normal diet should be encouraged to take
oral supplements (Grade C evidence) or enteral nutrition should be
administered prior to hospital admission.
6
In severely undernourished
patients who cannot be fed adequately enterally, parenteral nutrition
is recommended but this route is costly and mostly administered
in hospital.
8
Early postoperative feeding, whether it is via normal
food intake or enteral feeding is recommended and, in the case
of colon resection, even within hours after surgery. Care should
be taken to adapt oral intake according to individual tolerance as
well as to the type of surgery. In cases where enteral nutrition is not
feasible in undernourished patients, parenteral nutrition should be
administered.
8
With regards to the early enteral nutrition component of ERAS, the
first study on this aspect was conducted in 1979. Currently there are
about 30 randomised control tials on early enteral nutrition, most of
them on surgical oncology patients. These studies do not support
the traditional nutritional management of postoperative patients
and clearly indicates the positive effects on outcomes in patients
receiving early EN. A recent meta-analysis confirmed the statistically
significant reduction in total postoperative complications following
surgery with the introduction of nutritionally significant nutrition,
early, postoperatively within 24 hours.
9
What is currently happening postoperatively?
A study comparing critically ill surgical and medical patients in
relation to the nutritional support they received during the course
of their illness reported that surgical patients had received less
nutrition support and were more at risk for iatrogenic malnutrition
than internal medicine patients.
4
More specifically, surgical patients were less likely to receive EN,
more likely to receive parenteral nutrition (PN), and when started
on EN it was found that they received EN, on average, 21 hours
later than medical patients. As a result, surgical patients received

Review Article: Perioperative nutrition: what do we know?
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Review Article: Perioperative nutrition: what do we know?
2011;24(3) SupplementS Afr J Clin Nutr
a lower proportion of their initial prescription from EN alone or even
from a combination of EN, propofol and appropriate PN.
4
Surgical
subgroup comparisons indicated that those patients undergoing
cardiovascular and gastrointestinal surgery were more likely to
receive PN, less likely to receive EN as well as delayed EN, and lower
total nutrition adequacy when compared with other surgical groups.
4
Among the reasons identified for the delay in initiating nutrition
support were anticipated return of the patient to surgery and
possible extubation with subsequent oral intake. Another reason
for the delay was hemodynamic instability, especially in the
cardiovascular surgical subgroup. This is in contrast to consistent
data indicating that early EN is associated with improved outcomes
in hemodynamically compromised critically ill patients. In the case
of distal gastrointestinal anastamoses, the delay centered on the
belief that EN might compromise the integrity of the anastomosis,
4
indicating that traditional beliefs still persist among surgeons,
despite the established ERAS protocols.
Proposed strategies to overcome these perceived barriers are trophic
feeding, administration of EN at reduced doses for the first day with
subsequent reassessment the following day, the implementation of
feeding protocols along with protocols for blood glucose control, the
utilization of motility agents and small bowel feeding tubes.
4
Immunonutrition: an integral element of ERAS
Immunonutrition therapy has also been demonstrated to result in
fewer infectious complications and reduced length of stay in hospital
in selected populations of surgical patients. However, the clinical
benefit of immunonutrition remains controversial with some studies
indicating potential harm, especially in patients with underlying sepsis.
In addition, the limited experience of immunonutrition in patients with
gastrointestinal intolerance has also been documented.
10
In order
to address these limitations, the approach to pharmaconutrition
therapy has evolved to administering immunonutrients on their
own, separate from other forms of nutrition.
11
In summary, current
clinical practice recommendations of the Canadian Clinical Practice
Guidelines (CCPG), European Society for Parenteral and Enteral
Nutrition (ESPEN) on both enteral and parenteral nutrition in surgery,
and the Society of Critical Care Medicine (SCCM) and American
Society for Parenteral and Enteral Nutrition (ASPEN) guidelines
on immunonutrients for elective surgery, specifically relating to
arginine, are inconsistent or absent.
6,8,11
There is also a paucity of
practice guidelines regarding the use of glutamine, omega-3-fatty
acids and antioxidant nutrients in such patients.
With regard to role of arginine in major surgery, a deficiency state is
thought to develop which results in an immunosuppression and an
increased risk for infectious complications. Patients with sepsis and
surgical trauma appear to regulate arginine metabolism differently,
with lower arginine circulating levels and increased arginase activity
having been observed in surgical trauma when compared with that
of sepsis.
12
An arginine deficiency appears most likely in the earlier
stages of sepsis and deteriorates progressively with the severity
of sepsis.
10
It would therefore appear that the effect of arginine
supplementation may differ in different patient populations.
A recent meta-analysis on the evidence for specifically
supplementing arginine in surgical patients, which included thirty
five studies, reported that arginine supplementation resulted in
a considerable reduction in infectious complications and shorter
length of hospital stay without having an overall significant effect
on mortality when compared with standard care. Limitations of
the meta-analysis include the time span over which the studies
included were conducted (two decades) and the small nature of the
studies. The heterogeneity of the populations studied and included
in the meta-analysis was also addressed. In subgroup analysis,
arginine supplementation seemed to have a consistent beneficial
effect across all types of patients with gastrointestinal (GI) and non-
GI surgery in term of duration of hospitalisation, with an average
reduction in LOS of 2 days in GI surgery and 3.7 days in non-GI
surgery. However, no substantial reduction in LOS was observed in
lower GI surgical patients as a subset.
13
A similar meta-analysis on the use of arginine in combination with
other immunonutrients, reported that immunonutrition formulas
containing both arginine and sh oil reduced the risk for acquired
infections, reduced wound complications, and shortened hospital
LOS in patients at high risk of postoperative complications.
12
The
patient populations included in this meta-analysis included patients
with GI malignancies, general abdominal surgery, head and neck
malignancy and cardiac surgery. The treatment benefit was noted
in all such groups of patients and did not depend on the timing
of initiation, thus suggesting that both peri- and postoperative
supplementation may be beneficial.
Another study
2
concluded that the largest treatment effect of argi-
nine supplementation was seen with perioperative administration
of arginine-supplemented diets and hypothesized that the use of
arginine-supplemented diets both pre-and postoperatively may be
beneficial. The authors proposed that arginine-supplemented diets
can overcome the arginine deficiency observed in surgical patients by
increasing systemic arginine availability through supraphysiological
supplementation doses (Figure 1). Furthermore, it was proposed
that the addition of omega 3 fatty acids along with arginine probably
blunted the upregulation of arginase 1, the enzyme responsible
for arginine degradation and for which elevated levels have been
reported in surgical patients, whereas the inclusion of vitamin
A supplementation could downregulate arginase 1 expression,
thus resulting in lower levels of the enzyme. It is currently not
clear though how elective surgery patients who develop systemic
infections should be treated and further studies are necessary
before an optimal nutrition support therapy regimen with regard to
immunonutrients in this specific population is established.
12
There are currently no recommendations regarding glutamine
supplementation in conjunction with arginine in surgical patients.

Review Article: Perioperative nutrition: what do we know?
S22
Review Article: Perioperative nutrition: what do we know?
2011;24(3) SupplementS Afr J Clin Nutr
Glutamine is considered a conditionally essential amino acid in
catabolic states due to the muscle stores being rapidly depleted.
Glutamine supplementation, especially high dose parenteral
supplementation, in elective surgical patients is documented to
reduce infectious complications and LOS.
14
In addition to glutamine
supplementation itself, a recent study conducted found that that
an arginine-supplemented immune-enhancing diet increased
plasma glutamine levels.
15
The speculative effects (Table II) of the
potentially beneficial effects of combined glutamine and arginine
supplementation remain to be substantiated.
Table II: Speculative effects of combined arginine and glutamine
14
Glutamine Arginine Glutamine + arginine
Immune response
↑↑ ↑↑ ↑↑↑
Oxidative stress
↓↓ or ↓↓
Inflammatory response
↓↓ or ↓↓
Nitric oxide production
or ↑↑
Gut barrier
↑↑ ↑↑
Insulin resistance
↓↓
Wound healing
↑↑ ↑↑
Conclusion
Early postoperative nutrition is recommended in all surgery
patients. All patients undergoing elective surgery with substantial
risk of infectious complications should be prescribed arginine-
supplemented diets along with omega-3 fatty acids preferably
pre- and postoperatively. No recommendation can be made on the
combined supplementation of glutamine and arginine.
References
1. Directors, National Alliance for Infusion Therapy and the American Society for Parenteral and Enteral
Nutrition Public Policy Committee and Board of. Disease-related Malnutrition and Enteral Nutrition
Therapy: A Significant Problem with a cost-effective solution. Nutr Clin Prac 2010;25:548-554.
2. Garth AK, Newsome CM, Simmance N, Crowe TC. Nutritional status, nutrition practices and post-
operative complications in patients with gastrointestinal cancer. J Hum Nutr Diet 2010;23:393-401.
3. Jensen GL, Mirtallo J, Compher C et al. Adult starvation and disease-related malnutrition: a proposal for
etiology-based diagnosis in the clinical setting from the international consensus guideline committee.
JPEN.2010;34:156.
4. Drover JW, Cahill NE, Kutsogiannis J, Pagliarello G, Wischmeyer P, Wang M et al. Nutrition therapy for the
critically ill surgery patient: we need to do better! JPEN 2010;34:644-652.
5. Waters JM. Postoperative Nutrition: Past, Present, and future. Support line, 2011;32(5):2-7.
6. Weimann A, Braga M, Harsanyi L, Laviano A, Ljunqvist O and Soeters P. ESPEN guidelines on enteral
nutrition: Surgery including organ transplant. Clinical Nutrition, 2006(25): 224-244.
7. Bozetti F, Gianotti L, Braga M, Di Carlo V, Mariani L. Postoperative complications in gastrointestinal
cancer patients: the joint role of the nutritional status and the nutritional support. Clinical Nutrition
2007;26:698-709.
8. Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A and Bozetti F. “ESPEN guidelines on parenteral
nutrition: Surgery.” Clinical Nutrition, 2009(28): 378-386.
9. Osland E, Yunus RM, Khan S, Memon MA. Early versus traditional postoperative feeding in patients
undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN 2011;35(4):473-487.
10. Mizock BA. Immunonutrition and critical illness: An update. Nutrition 2010(26):701-707.
11. Heylandt DK, Dhaliwal R, Drover JW, Gramlich L and Dodek P. Canadian clinical practice guidelines for
nutrition support in mechanically ventilated, critically ill adult patients. JPEN 2003(27):355-373.
12. Marik PE, Zaloga GP. Immunonutrition in High-Risk surgical patients: A systemic review and analysis of
the literature. JPEN 2010;34:378-386.
13. Drover JW, Dhaliwal R, Weitzel L, Wischmeyer PE, Ochoa JB, Heylandt DK. Perioperative use of arginine-
supplemented diets: a systemic review of the evidence. J Am Coll Surg 2011;212(3):385-399.
14. Novak F, Heylandt DK, Avenell A, Droger JW, Su X. Glutamine supplementation in serious illness: a
systemic review of the evidence. Crit Care Med 2002;30:2022-2029.
15. Loi C, Zazzo JF, Delpierre E, Niddam C, Neveux N, Curis E et al. Increasing plasma glutamine in
postoperative patients fed an arginine rich immune-enhancing diet a pharmacokinetic randomized
controlled study. Crit Care Med 2009;37:501-509.
Omega 3 fatty acids
Vitamin A
Arginine
Surgery Arginase levels Arginine levels
Figure 1: Proposed mechanism by which immunonutrients could possibly
increase circulating arginine levels in surgical patients
Citations
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Journal ArticleDOI
TL;DR: Poor implementation of evidence-based nutrition practices in GI and oncologic surgery programs is confirmed, confirming a significant opportunity to capitalize on current favorable surgeon beliefs regarding the benefit of perioperative nutrition to improve surgical nutrition practice and patient outcomes in the U.S.
Abstract: Background Implementation of evidence-based peri-operative nutrition in the U.S. is poorly described and hypothesized to be suboptimal. This study broadly describes practices and attitudes regarding nutrition screening/intervention in U.S. gastrointestinal and oncologic surgeons. Methods Nationwide nutritional practice survey of GI/Oncologic surgical faculty. Results Program response rates were 57% and 81% for colorectal and oncology fellowships, respectively. Only 38% had formal nutritional screening processes in place. Average estimated percent of patients malnourished, receiving nutritional screening, and receiving nutritional supplementation preoperatively were 28%, 43%, and 21%, respectively. University-affiliation ( p = 0.0371) and a formal screening process ( p = 0.0312) predicted higher preoperative nutritional screening rates. Controversy existed regarding routine use of perioperative immunonutrition, but strong consensus emerged that lack of awareness regarding positive data for immunonutrition impedes usage. Conclusion U.S. surgeons recognize importance of perioperative nutritional screening and benefits of basic nutrition therapy. However, limited formal nutrition screening programs currently exist indicating a significant need for implementation of nutrition screening and basic nutrition intervention. Further work on education, implementation and identifying clinical research needs for immunonutrition interventions is also vitally needed. Summary This study broadly describes nutritional practices and attitudes of gastrointestinal and oncologic surgeons across the U.S. Surgeons recognize both the importance of proper perioperative surgical nutritional support and the potential value to their practice in terms of outcomes, but this study confirms poor implementation of evidence-based nutrition practices in GI and oncologic surgery programs. This study describes a significant opportunity to capitalize on current favorable surgeon beliefs (and positive published data) regarding the benefit of perioperative nutrition to improve surgical nutrition practice and patient outcomes in the U.S.

68 citations

Journal ArticleDOI
TL;DR: This review focuses on new developments in peri‐operative nutrition, including: patient preparation and pre‐operative fasting; the role of nutritional supplementation; the optimal route and timing of nutrient delivery; and the nutritional management of specific groups including critically ill, obese and elderly patients.
Abstract: Patients are frequently malnourished or are at risk of malnutrition before surgery. Peri-operative nutritional support can improve their outcomes. This review focuses on new developments in peri-operative nutrition, including: patient preparation and pre-operative fasting; the role of nutritional supplementation; the optimal route and timing of nutrient delivery; and the nutritional management of specific groups including critically ill, obese and elderly patients.

35 citations

Journal ArticleDOI
TL;DR: Early feeding has been shown to resolve postoperative ileus earlier, decrease infection rates, promote wound healing, and reduce length of hospital stay, and postoperatively, earlyFeeding should be limited to restricting solid foods and non-human milk 6 hours prior to the procedure and allowing clear liquids until 2 hours before the procedure.
Abstract: Nutrition status prior to surgery and nutrition rehabilitation after surgery can affect the morbidity and mortality of pediatric patients. A comprehensive approach to nutrition in pediatric surgical patients is important and includes preoperative assessment, perioperative nutrition considerations, and postoperative recovery. A thorough nutrition assessment to identify patients who are at nutrition risk prior to surgery is important so that the nutrition status can be optimized prior to the procedure to minimize suboptimal outcomes. Preoperative malnutrition is associated with increased complications and mean hospital days following surgery. Enteral and parenteral nutrition can be used in cases where food intake is inadequate to maintain and possibly improve nutrition status, especially in the 7-10 days prior to surgery. In the perioperative period, fasting should be limited to restricting solid foods and non-human milk 6 hours prior to the procedure and allowing clear liquids until 2 hours prior to the procedure. Postoperatively, early feeding has been shown to resolve postoperative ileus earlier, decrease infection rates, promote wound healing, and reduce length of hospital stay. If nutrition cannot be provided orally, then nutrition through either enteral or parenteral means should be initiated within 24-48 hours of surgery. Practitioners should identify those patients who are at the highest nutrition risk for postsurgical complications and provide guidance for optimal nutrition during the perioperative and postoperative period.

28 citations

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TL;DR: Review of the Australian recommended daily allowance for vitamin C is suggested, not only in clinically well patients but particularly in ICU and hospital inpatients.

21 citations

Journal ArticleDOI
TL;DR: Failure to have protocols in place for delivery of enteral nutrition through the perioperative period should not lead to inappropriate use of parenteral nutrition (PN) as a default therapy, because in many circumstances, standard therapy with no specialized nutrition support may be associated with better outcome.
Abstract: Recent advances in nutrition therapy of the patient undergoing elective surgery have focused on greater utilization of the gut, feeding closer to the time of surgery, avoiding extensive bowel preparations or use of nasogastric tubes and drains, and measures to promote and maintain intestinal motility. Failure to have protocols in place for delivery of enteral nutrition (EN) through the perioperative period should not lead to inappropriate use of parenteral nutrition (PN) as a default therapy, because in many circumstances, standard therapy with no specialized nutrition support may be associated with better outcome. In cases where EN is not feasible and the patient shows evidence of malnutrition, surgery should be delayed 7-10 days to provide perioperative PN. For patients requiring urgent surgery where EN is not feasible, the initiation of PN postoperatively should be delayed 5-7 days. Whether alternative sources for lipid emulsion and availability of parenteral immune-modulating agents in the future can improve the risk/benefit ratio of PN and expand its use through the perioperative period awaits further study.

15 citations


Cites background from "Perioperative nutrition : what do w..."

  • ...A trend was seen toward increased mortality with supplemental PN, but the difference did not reach statistical significance.15 The results from the Casaer et al3 EPaNIC study, done primarily in elective surgery patients, provided evidence supporting an adverse effect from supplemental PN added the first week of hospitalization to hypocaloric EN....

    [...]

  • ...Inadvertent reasons leading to use of PN, however, may result because of the delays in initiation of EN.(8) In situations in which patients are anticipated to return to surgery soon or undergo possible extubation and return to an oral diet, have hemodynamic instability following cardiovascular surgery, or have distal gut anastomoses, doctors are reluctant to initiate enteral feeding, postoperative ileus is perpetuated, and initiation of PN results as a default therapy....

    [...]

  • ...In situations in which patients are anticipated to return to surgery soon or undergo possible extubation and return to an oral diet, have hemodynamic instability following cardiovascular surgery, or have distal gut anastomoses, doctors are reluctant to initiate enteral feeding, postoperative ileus is perpetuated, and initiation of PN results as a default therapy.(8) It is this last category of patients in whom changing institutional strategies, implementing nurse-driven protocols, and challenging traditional practices will result in more successful delivery of EN (Table 1)....

    [...]

  • ...Inadvertent reasons leading to use of PN, however, may result because of the delays in initiation of EN.8 In situations in which patients are anticipated to return to surgery soon or undergo possible extubation and return to an oral diet, have hemodynamic instability following cardiovascular surgery, or have distal gut anastomoses, doctors are reluctant to initiate enteral feeding, postoperative ileus is perpetuated, and initiation of PN results as a default therapy.8 It is this last category of patients in whom changing institutional strategies, implementing nurse-driven protocols, and challenging traditional practices will result in more successful delivery of EN (Table 1)....

    [...]

  • ...Similar to the EPaNIC study, all patients were placed on EN....

    [...]

References
More filters
Journal ArticleDOI
TL;DR: Significant potential benefit from implementing evidence-based clinical practice guidelines for nutrition support in critically ill adults is improved clinical outcomes of critically ill patients (reduced mortality and ICU stay) and potential harms of implementing these guidelines include increased complications and costs related to the suggested interventions.
Abstract: OBJECTIVE: This study was conducted to develop evidence-based clinical practice guidelines for nutrition support (ie, enteral and parenteral nutrition) in mechanically ventilated critically ill adults. OPTIONS: The following interventions were systematically reviewed for inclusion in the guidelines: enteral nutrition (EN) versus parenteral nutrition (PN), early versus late EN, dose of EN, composition of EN (protein, carbohydrates, lipids, immune-enhancing additives), strategies to optimize delivery of EN and minimize risks (ie, rate of advancement, checking residuals, use of bedside algorithms, motility agents, small bowel versus gastric feedings, elevation of the head of the bed, closed delivery systems, probiotics, bolus administration), enteral nutrition in combination with supplemental PN, use of PN versus standard care in patients with an intact gastrointestinal tract, dose of PN and composition of PN (protein, carbohydrates, IV lipids, additives, vitamins, trace elements, immune enhancing substances...

1,414 citations

Journal ArticleDOI
TL;DR: These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients and it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

1,008 citations

Journal ArticleDOI
TL;DR: In surgical patients, glutamine supplementation may be associated with a reduction in infectious complication rates and shorter hospital stay without any adverse effect on mortality, and in critically ill patients, the greatest benefit was observed in patients receiving high-dose, parenteral glutamine.
Abstract: ObjectiveTo examine the relationship between glutamine supplementation and hospital length of stay, complication rates, and mortality in patients undergoing surgery and experiencing critical illness.Data SourcesComputerized search of electronic databases and search of personal files, abstract procee

684 citations

Journal ArticleDOI
TL;DR: In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days and in patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice.

576 citations

Journal ArticleDOI
TL;DR: This commentary is intended to present a simple etiology-based construct for the diagnosis of adult malnutrition in the clinical setting and development of associated laboratory, functional, food intake, and body weight criteria and their application to routine clinical practice will require validation.
Abstract: Background & Aims:Multiple definitions for malnutrition syndromes are found in the literature resulting in confusion. Recent evidence suggests that varying degrees of acute or chronic inflammation are key contributing factors in the pathophysiology of malnutrition that is associated with disease or injury.Methods:An International Guideline Committee was constituted to develop a consensus approach to defining malnutrition syndromes for adults in the clinical setting. Consensus was achieved through a series of meetings held at the A.S.P.E.N. and ESPEN Congresses.Results:It was agreed that an etiology-based approach that incorporates a current understanding of inflammatory response would be most appropriate. The Committee proposes the following nomenclature for nutrition diagnosis in adults in the clinical practice setting. “Starvation-related malnutrition”, when there is chronic starvation without inflammation, “chronic disease-related malnutrition”, when inflammation is chronic and of mild to moderate degr...

426 citations

Frequently Asked Questions (1)
Q1. What are the contributions mentioned in the paper "Perioperative nutrition: what do we know?" ?

This review will focus on postoperative nutritional support and arginine supplementation in surgical patients.