Perioperative Nutrition: What Is the Current Landscape?

Editor(s): Conference Proceedings & Specific Issues Vol.37 / 1,  2013

Summary

Poor nutrition status has long been linked to increases in postoperative complications and adverse outcomes for the patient undergoing elective surgery. While optimal planning for nutrition therapy should be comprehensive spanning throughout the perioperative period, recent advances have focused on the concept of “prehabilitation” to best prepare the patient prior to the insult of surgery. Adding immune/ metabolic modulating formulas the week of surgery with carbohydrate drinks to optimize glycogen deposition immediately prior to surgery, enhances patient recovery and return to baseline function. Such nutrition strategies should now be combined with a host of other practices (such as smoking cessation, weight loss, glucose control, and specialized exercise program) as part of a structured protocol to maximize patients’ chances for a full and rapid recovery from their elective surgical procedure.

The optimal plan for perioperative nutrition in this setting would be a full evaluation several weeks prior to surgery, instituting a high protein formulation for nutrition and an exercise program which increases protein uptake into muscle. Unfortunately, this is not possible in most cases. Even procedures for non-malignant processes usually happen within 1-2 weeks of surgical consultation. Currently, no prospective randomized trials are available showing improved outcome with several weeks or a month of “prehabilitation,” but there are several trials now showing that the use of early exercise with good perioperative nutrition has been shown to increase blood flow to the musculature, enhance protein uptake, as well as decrease total body inflammation. In the immediate preoperative period, 5-7 days prior to surgery, metabolic modulating formulations have been evaluated in >40 prospective randomized clinical studies with >35 articles reporting benefit in decreasing infection and length of hospital stay. Unfortunately these have yet to report a mortality benefit. In the immediate preoperative period, carbohydrate loading should be considered within the 24 hours immediately following the procedure using a nutrient balance of relatively high protein, moderate fat content with some MCT and fish oils would be beneficial. Vitamins and antioxidants are still controversial, but data lean toward modest supplementation, primarily with antioxidants for major procedures. Prior to deciding who needs the intensive perioperative nutrition attention in this period, the patients need to be screened for nutrition risk. Patients who are well nourished and undergoing minor surgery, who are expected to be eating voluntarily within 2-3 days, would demonstrate minimal benefit from such an intervention and are not candidates for intensive perioperative nutrition therapy. When patients are malnourished preoperatively or are undergoing major procedures and expected to be NPO for >4 days, they should be offered perioperative nutrition therapy. Postoperatively, early enteral feeding within 6-12 hours should be encouraged after adequate resuscitation. Waiting for bowel sounds or flatus to begin feeding is clearly not required. Although the use of preoperative PN remains controversial, it is clear that enteral support in both the preoperative and postoperative period is the best option.