Overview of perioperative nutritional support
- Kathleen M Fairfield, MD, DrPH
Kathleen M Fairfield, MD, DrPH
- Associate Chief of Medicine
- Maine Medical Center
- Reza Askari, MD, FACS
Reza Askari, MD, FACS
- Instructor in Surgery
- Harvard Medical School
- Associate Trauma Director
- Brigham and Women’s Hospital
- Section Editors
- Timothy O Lipman, MD
Timothy O Lipman, MD
- Section Editor — Nutrition
- GI-Hepatology-Nutrition Section
- Washington DC Veterans Affairs Medical Center
- Hilary Sanfey, MD
Hilary Sanfey, MD
- Section Editor — General Surgical Principles
- Professor of Surgery
- SIU School of Medicine
Malnutrition in hospitalized patients is well documented, with rates up to 50 percent in certain populations . Nutritional support may be indicated for malnourished individuals requiring surgical intervention, or for healthy individuals undergoing major surgery with an anticipated lengthy recovery time to return of normal gastrointestinal function; however, it can be unclear when it is appropriate to intervene. The notion that malnutrition can affect outcomes in surgical patients was first reported in 1936 in a study showing that malnourished patients undergoing ulcer surgery had a 33 percent mortality rate compared with 3.5 percent in well-nourished individuals . A prospective study of 500 patients, including 200 surgical patients, admitted to a teaching hospital in England found that 40 percent of patients were undernourished on presentation, and patients lost an average of 5.4 percent of their body weight during their hospital stay .
The nutritional assessment of surgical patients, options for, and potential benefits of nutritional support are reviewed here. An overview of parenteral and enteral nutrition and issues related to nutritional support in critically ill patients, and other specific populations (eg, cancer, burns, lung disease) are discussed in separate topic reviews.
CONSEQUENCES OF MALNUTRITION IN SURGICAL PATIENTS
Reduced food intake results in loss of fat, muscle, skin, and ultimately bone and viscera, with subsequent weight loss, and expansion of the extracellular fluid compartment . Nutritional requirements fall as an individual's body mass decreases, probably reflecting more efficient utilization of ingested food and a reduction in work capacity at the cellular level. However, the combination of decreased tissue mass and reduced work capacity impedes normal homeostatic responses to stressors such as surgery or critical illness .
The stress of surgery or trauma creates a hypermetabolic state, increasing protein and energy requirements. Macronutrients (fat, protein, and glycogen) from the labile reserves of fat tissue and skeletal muscle are redistributed to more metabolically active tissues such as the liver and visceral organs. This response can lead to the onset of protein calorie malnutrition (defined as a negative balance of 100 g of nitrogen and 10,000 kcal) within a few days . The rate of development of postoperative malnutrition in a given individual depends upon their preexisting nutritional status, nature and complexity of the surgical procedure, and the degree of hypermetabolism.
Malnutrition causes a number of negative consequences, including [4,5,7,8]:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- CONSEQUENCES OF MALNUTRITION IN SURGICAL PATIENTS
- NUTRITIONAL ASSESSMENT IN THE SURGICAL PATIENT
- History and physical
- Assessing protein status
- Other laboratory studies
- NUTRITIONAL INTERVENTIONS
- Enteral nutrition
- Parenteral nutrition
- OUTCOMES FOR NUTRITIONAL INTERVENTION
- Preoperative nutritional support
- - Oral supplementation
- - Parenteral feeding
- Postoperative nutritional support
- - Early enteral feeding
- - Total parenteral nutrition
- Immune-enhancing nutritional supplements
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS