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Nutrition Strategies to Optimize Surgical Outcomes

Nutrition risk should consider the patients pre-existing nutrition status, the severity of the planned
surgery, and postoperative anatomical alteration. There has been a paradigm in preoperative nutrition;
it is not to replete nutrition stores, but to pre-habilitate the patient by modulating the metabolic
response to the insult of the planned surgical stress (1).

When undergoing major surgery, both malnourished and well-nourished patients benefit from
a preoperative nutrition regimen. Patients who are well nourished undergoing a minor surgery
who are expected to eat PO within two to three days postoperation do not require preoperative
nutrition treatment.

Preoperative assessment should include recent oral intake, percent of recent unintended weight
loss (high risk: >5% over 1 month, >7.5% over 3 months or 10% in 6 months), BMI (high risk
<18.5 or >40), comorbidities, and objective lab markers (1).

Nutrition risk should be evaluated with the Nutrition Risk Screen (NRS) 2002, which is the only
nutrition screening tool validated for surgical patients by a large randomized trial (1-3). A high
risk NRS 2002 nutrition score-greater than or equal to 5-will have improved outcomes with
receiving 5-7 days of a pre- operative and 5-7 days postoperative nutrition regimen (1, 2).


C-Reactive Protein: assess inflammatory status

HbA1c <7.5%: An analysis of Veterans Administration hospitals found surgical site infections
were reduced when the preoperative HbA1c was less than 7% (2). Thus, ASPEN recommends a
preoperative HbA1c target of less than 7.5% (1).

CBGs and Glycemic Control: 140-160mg/dl

Glycemic control 30-60 days prior to surgery decreases surgical complications.

Albumin-Target Preoperative Goal: >3.0 g/dl: While serum albumin is not a good marker of
nutritional status, it is a good surrogate marker for poor surgical outcomes, making it important
to note in preoperative patients. A large prospective study by the US Department of Veterans
Affairs investigated preoperative risk and found a serum albumin of less than 3.0 g/dL to be the
most valuable predictor of poor outcomes (4). Other studies have since confirmed this finding,
showing serum albumin to be inversely correlated with complications, length of stay,
postoperative stay, intensive care unit (ICU) stay, mortality, and resumption of oral intake (2, 46).The degree of the correlation does seem to be dependent on the surgical site.

For example, patients undergoing esophageal or pancreatic procedures sustained a

significantly higher complication rate at most albumin levels (6). Thus, elective, nonemergent esophageal and pancreatic procedures performed and not delayed for
preoperative nutrition are at a higher risk at any level of serum albumin below 3.25

Albumin should be used as a marker to determine need for preoperative nutrition, but should
not be used for monitoring. Serum albumin may not change through the course of
intervention/management due to it being an acute phase response protein (1).


Immunization through Pharmoconutrition Formulary- Arginine, Omega-3fatty acids, and nucleotide Oral Nutrition Supplement (ONS)
All major surgical patients should receive IMPACT ADVANCED RECOVERY TID (500-1000mL) 5-7 days
preoperatively. Perioperative complications have been shown to be reduced as much as 50% with the
use of the amino acid arginine, omega-3-fatty acid, and nucleotide containing ONS, such as Nestle
IMPACT ADVANCED RECOVERY (2). Multiple clinical trials have shown that these specific metabolic
immune active nutrients support the immune system and help reduce the rate of infection, ventilator
days, and length of stay in surgical patients when used as part of an early nutrition regimen of 500-1000
mL/day for 5-7 days preoperatively (1, 2). Preoperative immunonutrients metabolically prepare the
patients cells for surgical stress since the defense system is compromised directly after surgery.

Surprisingly, this benefit was noted in both well-nourished and malnourished patients undergoing
surgeries of various disciplines. Thus, a preopertative nutrition regimen should be considered for all
patients undergoing major surgeries where there is an expected stay in the hospital, especially those
involving major gastrointestinal cancer, head and neck, cardiac, and trauma surgeries. This becomes
especially important in the malnourished population who are at higher risk for complications (1). For
emergent surgeries were a preopertative nutrition regimen cannot be established, an ONS can be
provided post operatively to optimize wound healing, but may not be sufficient in reaching necessary
tissue and plasma concentrations (1).
The mechanism of the active ingredients in these ONSs is not fully understood. The omega-3-fatty acids
have multiple systemic reactions including modulation of the metabolic and inflammatory response to
stress and promotion of the vagal efferent regulation of bowel motility (1, 2). Arginine has been
reported to optimize wound healing and increase blood flow through vasodilation (2). It is expected that
there is a synergetic effect between arginine and fish oils (1). Single substrate use has not shown to be
clinically significant.

An antibiotic (abx) regimen is often given to patients preoperatively to allow for a minimum inhibitory
concentration to be reached within the tissues to inhibit bacteria postoperatively. Along with the
initiation of preoperative abx regimen, Nancys kefir 80 ml TID (+ benefiber 4 pkts/d) should be given
to prevent abx associated diarrhea. Preoperative abx is responsible for an estimated 20% of abx
associated diarrhea and Clostridium difficile diarrhea (2). Caution with use in severe acute pancreatitis,
immune compromised, hemodynamically unstable patients. (per ASPEN, no recommendations can be
made for routine use in the ICU due to lack of consistent outcomes because of differences in bacterial

For elective surgical procedures that can be delayed, obese patients should be counseled on weight loss
strategies and lose weight before the procedure. Obesity is correlated with a high incidence of
postoperative incisional hernia (2, 7). Surgical patients should be encouraged to exercise as medically
warranted and approved by their physician. Immunonutrition therapy seems to be the most effective
when incorporated with physical activity. Preoperative exercise and nutrition increases the blood flow to
skeletal muscles, enhances protein uptake, and decreases inflammation resulting in better surgical
outcomes (1)

The order NPO after midnight is steeped in surgical tradition with little data to support any real
benefit (2, 8). The intention is to avoid oral intake of any kind to prevent aspiration. There has been
growing concern of continuing the NPO tradition due to more recent data showing prolonged fasting
periods prior to operative insult may have poor outcomes and increased risk of complications (1, 2, 8).
Prior to procedural sedation, according to the newest recommendations from the American Society of
Anesthesiologists (ASA) guidelines, the patient should cease intake of: fried/fatty foods for at least 8
hours, a light meal for at least 6 hours, and clear liquids for at least 2 hours before surgery(8).

The night prior to a major elective operation, the patient should drink two containers of Boost Breeze
diluted to 800 mL or 800 mL of a 12% isotonic glucose solution (see Table 1 & 2 for formularies). On
the morning of the surgery, 2-3 hours prior to the induction of anesthesia the patient should drink one
Boost Breeze diluted to 400mL or one BevMD Clearfast (1).
One of the most intriguing reasons to revisit the protocols for perioperative fasting relates to the
depletion of glycogen stores. NPO status essentially depletes the patients glycogen stores prior to the
surgical insult, which contributes to the loss of lean body mass (1, 2, 8). This metabolic strategy
maximally loads muscle tissues with glycogen prior to surgical stress and becomes the main body fuel at
the start of surgery (2, 8). Theoretically, the patient would use these stored carbohydrates rather than
converting lean body tissue to support the increased need for gluconeogenic substrates. Surgical
carbohydrate loading studies consistently show beneficial results to the metabolic response to stress
postoperatively by enhancing: lean tissue mass, retention of muscle function, and insulin sensitivity (1,
2, 7, 8). Yet, these studies need to be evaluated with caution as the experimental groups are usually
receiving multimodality treatment. It is important to note however, that these benefits are seen
without increased risk of aspiration or other anesthetic complications (8).


Use of Glutamine, leucine, selenium, zinc, vitamin E and vitamin C show promising metabolic benefits,
but they need more research for recommended use in the perioperative period (2).

CALORIES, PROTEIN, and FLUIDS: refer to OHSU Medical/Surgery Nutrition Guidelines
LABS TO MONITOR: All especially: Na, BUN/Cr, K, Phos, Mg, CBGs

Potassium: Correct as needed.

Phosphorus: Replete prior to initiation of nutrition support if <2.

Magnesium: Replete prior to initiation of nutrition support <1.5.

CBGs and Glycemic Control: 140-160mg/dl

Hyperglycemia is especially important in the first 24 hours post-surgery. 140-160mg/dl is the
optimal blood glucose range during the immediate perioperative period to reduce surgical site
infections and post-surgery insulin resistance

Serum albumin, prealbumin, and C-reactive protein- reflect metabolic response to surgery and
not post-surgery nutrition status (1).

PROBIOTICS: should continue above preoperative regiment if continued on a postoperative abx


IMMUNONUTRITION ONS: A patient who scored as a high nutrition risk (a NRS 2002 greater than
or equal to five) during preoperative nutrition screening should receive IMPACT AR 500-1000mL 5-7
days postoperatively. Emergent surgical cases should be considered for pharmaconutrition

MVI REQUIREMENTS: Daily MVI w/mineral supplementation may be needed for pts with poor PO
intake or inadequate TF volume to meet RDA. Consider ETOH history: MVI w/ repletion of thiamine and

WOUND HEALING: Vitamin C 500 mg BID x 10 days (100 mg/day with renal impairment) & ZnSo4
220 mg x 10d = 50 mg elemental Zn to optimize nutrition for wound healing.

Table 1 Carbohydrate Rich Recipes/Beverage Options



Gatorade G Series Sports

Drink + Gatorade Prime

180 ml Gatorade G Series Sports Drink (3/4 cup)

60 ml Gatorade Prime (1 sachet)
1 tbsp sugar
180 ml water (3/4 cup)
180 ml Gatorade G Series Sports Drink (3/4 cup)
4 tbsp sugar
240 ml water (1 cup)
360 ml Vitamin Water (1 cups)
60 ml Gatorade Prime (1 sachet)
Dilute with Boost Breeze with 160 ml water (~2/3 cup
*Available at select grocery stores and pharmacies
Dilute Ensure Clear with 200 ml water(~3/4 cup water)
*Available at select grocery stores and pharmacies
BevMD - Special order

Gatorade G Series Sports

Drink + Sugar
Vitamin Water +
Gatorade Prime Sachet
Boost Breeze *

Ensure Clear *

TABLE 2: Composition and Price Carbohydrate Loading Beverages


TABLE 3: Osmolality and Nutritional Comparison of Beverages

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Herndon DN, et al. Summary points and consensus recommendations from the North American Surgical
Nutrition Summit. JPEN J Parenter Enteral Nutr 2013;37:99S-105S.
2. Martindale RG, Deveney CW. Preoperative risk reduction: strategies to optimize outcomes. Surg Clin
North Am 2013;93:1041-55.
3. KONDRUP J, RASMUSSEN HH, HAMBERG O, STANGA Z. Nutritional risk screening (NRS 2002): a new
method based on an analysis of controlled clinical trials. Clinical Nutrition 2003;22:321-36.
4. Daley J, Khuri SF, Henderson W, Hur K, Gibbs JO, Barbour G, Demakis J, Irvin III G, Stremple JF, Grover
F, et al. Risk adjustment of the postoperative morbidity rate for the comparative assessment of the
quality of surgical care: Results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg
5. Goh SL, De Silva RP, Dhital K, Gett RM. Is low serum albumin associated with postoperative
complications in patients undergoing oesophagectomy for oesophageal malignancies? Interactive
Cardiovascular and Thoracic Surgery 2015;20:107-13.
6. Kudsk KA, Tolley EA, Chance DeWitt R, Janu PG, Blackwell AP, Yeary S, King BK. Preoperative albumin
and surgical site identify surgical risk for major postoperative complications. J Parenter Enteral Nutr
7. Martindale RG, McClave SA, Taylor B, Lawson CM. Perioperative nutrition: what is the current
landscape? JPEN J Parenter Enteral Nutr 2013;37:5S-20S.
8. Miller KR, Wischmeyer PE, Taylor B, McClave SA. An evidence-based approach to perioperative
nutrition support in the elective surgery patient. JPEN J Parenter Enteral Nutr 2013;37:39S-50S.