Preoperative Nutrition Protocols

“Traditional beliefs still persist among surgeons to delay initiating nutrition support, despite recommendations to the contrary” said David Evans, MD at last year’s Food & Nutrition Conference and Expo in October 2014. David Evans is an Assistant Professor of Surgery, Medical Director, and Director of Nutrition Support Service at The Ohio State University. And the recommendations in question, a collection of strategies to improve surgical outcomes before, during, and after surgery, are garnering some press. The Sweden-based society, known as Enhanced Recovery After Surgery (ERAS) have considered the application of pre- and postsurgical nutrition interventions to surgical patients. Some of the interventions selected include “nutrition assessments and counseling; prebiotic/probiotics administration; limiting preoperative fasting to two to three hours, rather than the traditional six to 12 hours; and immediate postoperative fluid and diet initiation” (Webb, 2015), carbohydrate loading presurgery and increasing protein intake. Such interventions have shown to benefit postoperative mobilization, reduce post-op complications, prevent nutritional deficiencies, reduce aspiration risk, minimize incidence of post-op insulin resistance, promote healing and preservation of lean tissue, and improve recovery time, to a few (Hegazi et al., 2014; Hayhurst, et al., 2014; Webb, 2015).
Not all patients benefit from preoperative nutritional assessment equally. Two basic rules for nutritional assessment presurgery: 1. Determine nutritional status and nutrition risk in patients and 2. Identify high- vs low-risk surgeries. Practical guidelines for dietitians to be mindful of in a surgical patient’s initial nutritional assessment are listed below:

·       Degree of weight loss/trends in recent month(s)

·       BMI

·       Current dietary intake  

·       Supplementation and medication use

·       Clinical status – current diagnosis, type, severity of the disease, etc.

·       Nitrogen balance

·       Hydration status
 

Given the above guidelines, characteristics that predominate among high-risk patients include weight loss >5% over the past 1-3 months, BMI <18.5, food intake ≤75% of requirements, take steroids and have immunosuppression or cancer (Webb, 2015). Parenteral nutrition (PN) administration would be beneficial in this case, however, do bear in mind the solution’s composition and rate. (To those interested, I included a review article written by Evans and colleagues that further discusses the nutrition screening protocols). Doing so can help avoid complications and infections. Esophageal, gastric, colorectal surgeries, major orthopedic and neurological surgeries are cited as surgeries with high nutrition risk.

The Ohio State University surgeon, David Evans, MD, has this to say about delivering convincing evidence to surgeons and anesthesiologists of routine preoperative nutrition screening and support: “Bring evidence that will encourage them to buy into these nutrition protocols."

References
Evans, D., Martindale, R., Kiraly, L., & Jones, C. Nutrition optimization prior to surgery. Nutr Clin Pract. 2014;29(1):10-21. doi: 10.1177/0884533613517006

Hayhurst C, Durieux ME. Enteral hydration prior to surgery: the benefits are clear. Anesth Analg. 2014;118(6):1163-1164.

Hegazi RA, Hustead DS, Evans DC. Preoperative standard oral nutrition supplements vs immunonutrition: results of systematic review and meta-analysis. J Am Coll Surg. 2014;219(5):1078-1087.

Webb, D. Optimizing nutrition before surgery. Today’s Dietitian. 2015;17(1):19. http://www.todaysdietitian.com/newarchives/011315p10.shtml. Accessed January 19, 2015.

CP