Perioperative Nutritional Support: Nestle

Speaker: Dr. B. Ravinder Reddy, Consultant Gastrointestinal & General Surgeon, CARE Hospitals, Hyderabad Presented at: CRITICARE 2011 New Delhi, Workshop on Nutrition in Critical Care


In an average healthy individual there exists an equal amount of anabolism and catabolism. However, once a person is operated, the breakdown increases and becomes more than the synthesis. Perioperative nutrition revolves around determining the nutritional status of all patients undergoing elective and/or emergency surgery. Glutamine acts as an anti-catabolic, that helps reduce translocations and infections. It also aids in preservation of muscle mass and cell function and also functions as an antioxidant. Arginine plays a vital role in wound healing. Omega-3 Fatty Acids reduces inflammatory response and increases graft function. All patients who are malnourished should undergo nutritional assessment.

Nutrition support should commence within 12 to 24 hours of an acute event (operation, trauma) or after stabilisation of vital functions (hemodynamics, volume status, respiration, etc). Nutrition support should be given after resuscitation, assessment, planning (EN/PN/Combined) and after confirming the position of appropriate tubes and cannulas. It should be started ASAP to avoid development of deficiencies and to avoid nutrition-related complications. Disease severity is proportional to the extent of catabolism. Higher severity patients need earlier initiation of artificial nutritional support.

The common micronutrients are glutamine, arginine, omega 3 fatty acids and nucleotides. Glutamine leads to significant increase in serum HSP-70 with 7 days of treatment. This increase in HSP-70 correlates with decreased ICU stay and time on ventilator. Arginine helps in synthesis of proteins, creatine, agmantine, proline, ornithine and polyamines. It also increases T cells, monocytes, macrophages, natural killer cells, and cytokines while reducing wound infections. Arginine also preserves normal mitogen response following surgical stress, plays a significant role in wound healing reduces clinical infections and postop length of stay. Omega-3 Fatty Acids are of 3 types Aipha-linolenic acid (ALA), Eicosapentaenoic acid (EPA) and Docosahexaenoic acid (DHA). Omega 3 fatty acids reduce inflammatory response while increasing tissue microperfusion and graft function.

Determine nutritional status of all patients undergoing elective surgery Determine nutritional status of all patients undergoing emergency surgery. Commence artificial nutritional support as soon as the patient is hemodynamically stable. Bowel sounds and passage of flatus is necessary to start EN. Monitor for refeeding syndrome, glucose and electrolytes. Initiate trophic feeds in ileus, and in presence of anastomosis. Consider PN in all patients in whom calorie requirements are not achieved. Commence PN in all cases of malnutrition. Consider immunonutrition in all cases of major elective and trauma cases. Practice safe nutritional intervention.

Periop. Nutritional Support is for all patients who are malnourished and unable to eat for more than 3 to 5 days. All patients should undergo nutritional assessment. Nutritional intervention is a multi-stage process and should be part of the overall integrated protocol which also includes non-nutritional practices. Nutritional interventions can be enteral and parenteral. Both can be combined. The art and science of providing perioperative nutrition should be evidence-based.