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251]

Review article 469

Perioperative nutrition to enhance recovery after surgery

Dina Salah
Department of Anesthesia, Intensive Care, and Preoperative malnutrition is a major risk factor for increased postoperative
Pain Management, Ain Shams University,
morbidity and mortality. Patients at risk for malnutrition should be identified
Cairo, Egypt
early. The Nutritional Risk Score is a validated tool to identify patients who
Correspondence to Dina Salah, MD, 8595, should benefit from nutritional support. The adoption of total parenteral nutrition
El Reda and Nour Street, Mokattam, Cairo,
followed by the extraordinary progress in parenteral and enteral feedings, in
11571, Egypt, Tel: 01223606450;
e-mail: dinabadre2013@gmail.com addition to the increased knowledge of cellular biology and biochemistry, has
allowed clinicians to treat malnutrition and improve surgical patient’s outcomes.
Received 2 October 2016
Accepted 5 October 2016
Periods of prolonged fasting should be minimized and nutrition should be
commenced as early as possible after surgery, preferably through the enteral
Ain-Shams Journal of Anaesthesiology route. The surgical patient with established malnutrition should begin aggressive
2016, 9:469–477
nutrition at least 7–10 days before surgery. Those patients in whom eating is not
anticipated beyond the first 5 days following surgery should receive the benefits of
early enteral or parenteral feeding depending on whether the gut can be used. Many
patients may benefit from newer enteral formulations, such as those designed to
enhance immune function (immunonutrition).

Keywords:
enteral nutrition, immunonutrition, total parenteral nutrition
Ain-Shams J Anaesthesiol 9:469–477
© 2016 Ain-Shams Journal of Anaesthesiology
1687-7934

phase proteins is also observed [9]. The body scavenges

Introduction
for the required nutrients during times of stress, which
Ever since 1936 when Studley [1] demonstrated a
if continues undetected for prolonged periods of time
direct relationship between preoperative weight loss
could lead to adverse consequences. Perioperative
and operative mortality, nutritional support of surgical
nutritional supplementation, therefore, should blunt
and critically ill patients has undergone significant
the catabolic effects of such a high-energy state [10].
advances. The WHO cites malnutrition as the
Interestingly, there is an increase in intestinal
greatest single threat to the world’s public health as
permeability during periods of surgical stress, which
the reported in-hospital prevalence of malnourished
can be as greater as four-fold in some patients, usually
patients on admission ranges up to 50% [2,3].
normalizing around fifth postoperative day [10–12].
Malnutrition is considered a risk factor for impaired
Associated with this increase in permeability is a
systemic and intestinal immune function, as well as
decrease in villous height, leading to malabsorption
decreased digestive and absorptive capacity due to the
and an impaired ability of the gut to act as a barrier
altered architecture of the gut barrier [4]. Perioperative
against endogenous bacteria and toxins [10,13].
nutrition has been convincingly shown to improve
clinical outcome in patients undergoing major
Malnutrition and surgery can also both present a stress on
gastrointestinal surgery, to reduce costs, and to
the heart. Patients undergoing cardiac surgery are
decrease length of hospital stay [5]. The mechanism
frequently found to be malnourished, resulting in
of action seems to be not only an improved nutritional
alteration in the structure of myocytes and depleting
status by providing a higher caloric intake, but
the substrates utilized by the heart for mechanical
primarily a re-enforced immune response; nutritional
work. It is therefore hypothesized that, by addressing
formulas containing immunomodulating agents
the undernourished state of the patient before surgical
(glutamine, arginine, n-3 fatty acids, and RNAs) are
intervention, we can improve cardiovascular performance
particularly beneficial modulators of the acute stress
and decrease the incidence of cardiac complications after
response [6,7].
surgery as well as lower perioperative mortality [14].
Major stress, such as surgery, can subject a patient to a
whole host of metabolic and physiologic changes. The
body responds to such stress by increasing its basal This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which
metabolic rate, using up its nitrogen stores, and allows others to remix, tweak, and build upon the work
creating a negative nitrogen balance [8]. An increase noncommercially, as long as the author is credited and the new
in gluconeogenesis as well as the synthesis of acute creations are licensed under the identical terms.

© 2016 Ain-Shams Journal of Anaesthesiology | Published by Wolters Kluwer - Medknow DOI: 10.4103/1687-7934.198247
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470 Ain-Shams Journal of Anaesthesiology, Vol. 9 No. 4, October-December 2016

The aim of this review was to focus on the advantages, Numerous laboratory indices have been proposed as
limitations, and comparisons of both parenteral markers of nutritional status. For example, low
and enteral nutrition (EN) in the malnourished preoperative serum albumin concentrations are
perioperative patient. associated with delayed wound healing [18] and can
be used to predict morbidity in patients undergoing
Preoperative elective operations [19–21]. However, as albumin
Nutritional assessment and population at risk for concentration is suppressed by surgery and illness, its
perioperative malnutrition postoperative measurement is of limited value [19].
Nutritional status is difficult to quantify accurately. A The perioperative measurements of serum transferrin
history of chronic disease, cancer, infection, surgery, and prealbumin have more potential, along with serum
recent reduced dietary intake, and weight loss help cholesterol and lymphocyte count, as their half-lives are
identify patients at risk for malnutrition. Assessment shorter than that of albumin [22]. However, the clinical
may include a calculation of BMI, an estimate of recent value of these markers is indicative rather than
loss of subcutaneous fat and muscle mass, and signs of diagnostic, as they are not specific for malnutrition.
specific nutritional deficiencies [15]. Interestingly,
malnutrition can occur in obese patients who have The European Society of Parenteral and Enteral
low muscle mass. This form of obesity, termed Nutrition guidelines recommend the use of the
sarcopenic obesity, may be less recognizable in many Nutrition Risk Screening 2002 tool, along with
cases [16]. In many patients, fat-free mass index may be subjective global assessment, and serum albumin
a better predictor for mortality compared with BMI. less than 30 g/l in their evaluation of under-
Van Venrooij et al. [17] found that low fat-free mass nutrition [23,24]. Table 1 illustrates the compo-
index was associated with an increased occurrence of nents of the tool. In one study by Jie et al. [24],
adverse outcomes after cardiac surgery. They advocate those patients scoring 5 or higher on the Nutrition
fat-free mass index as the leading parameter in Risk Screening 2002 malnutrition scale received
classifying and treating malnourished cardiac surgical the most benefit from perioperative nutritional
patients [17]. support.

Table 1 Nutrition Risk Screening 2002 [23]

Nutritional Risk Scoring Yes No
Initial screening
Is BMI<20.5?
Has the patient lost weight within the last 3 months?
Has the patient reduced dietary intake in the last week?
Is the patient severely ill (e.g. in intensive therapy)?
Yes: If the answer is ‘Yes’ to any question, the final screening is performed
No: If the answer is ‘No’ to all questions, the patient is rescreened at weekly intervals. If the patient, for example, is scheduled for
a major operation, a preventative nutritional care plan is considered to avoid the associated risk status
Final screening
Impaired nutritional status [severity of disease (≈increase in requirement)]
Absent score 0 Normal nutritional status Normal nutritional requirements
Mild score 1 Weight loss>5% in 3 months or Hip fracturea, chronic patients,
food intake below 50–75% of in particular with acute
normal requirement in preceding complications: cirrhosisa,
week chronic obstructive pulmonary
diseasea, chronic hemodialysis,
diabetes, oncology
Moderate score 2 Weight loss>5% in 2 months or Major abdominal surgerya,
BMI 18.5–20.5+ impaired general strokea, severe pneumonia,
condition or food intake 25–60% hematologic malignancy
of normal requirement in
preceding week
Severe score 3 Weight loss>5% in 1 month Head injurya, bone marrow
(>15% in 3 months) or BMI >18.5 transplantationa, intensive care
+impaired general condition or patients
food intake 0–25% of normal
requirement in preceding week
Score≥3: The patient is nutritionally at-risk and a nutritional care plan is initiated. Score<3: Weekly rescreening of the patient. If the
patient, for example, is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk
status. aA trial directly supports the categorization of patients with that diagnosis.
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Perioperative nutrition Salah 471

Fasting (6) In addition, composition of meal ingested, high

The most common surgical practice of making patients caloric load, large lipid component, pregnancy or
nil per os after midnight of the day of any planned postpartum state, and advanced age [34].
surgical procedure has been recently questioned. Brady
et al. [25] reviewed 38 randomized controlled trials on Carbohydrate loading
perioperative fasting and concluded that there was no Surgical stress causes postoperative insulin resistance,
evidence to suggest that overnight fasting for fluids immunosuppression, and increased patient discomfort
results in a decrease in perioperative aspiration risk or [35,36]. Patient outcomes may be improved by a shorter
related morbidities [25]. Evidence is emerging that fasting period preceded by prescribed carbohydrate
overnight fasting is not only unnecessary but may also intake [37]. Studies have reported that postoperative
be harmful. insulin sensitivity is preserved by carbohydrate drinks
(100 g the night before surgery and 50 g 2 h before
Gastric emptying is controlled by neural and hormonal surgery) [38] or intravenous glucose (5 mg/kg/min)
pathways and is determined by a number of intraluminal [39], possibly through suppression of fat and glucose
and extraluminal factors. Intraluminal factors include oxidation and attenuation of pyruvate dehydrogenase
meal composition (caloric load, volume, temperature, kinase [40].
and nutrient type), the osmolality of small intestinal
contents, and the length and the region of small Preoperative nutritional support and immunonutrition
intestine exposed to nutrient [26]. Extraluminal International guidelines recommend nutritional
factors include glycemia, posture, pain, sex, and age support for severely malnourished patients 7–14
[27,28]. The optimal duration of fasting for a days before elective major surgery. Severely
particular patient depends on numerous factors. The malnourished patients have at least one of the
rate of emptying of nutrient from the stomach is linear, following: weight loss more than 10–15% within 6
with emptying occurring more rapidly for liquids than for months; BMI less than 18.5 kg/m2; or serum albumin
solids. In contrast, water is emptied from the stomach below 30 g/l without hepatic or renal dysfunction
exponentially, with an approximate half-life of 10 min [41].
[29–31].
The optimal timing of nutritional intervention remains
Gastroesophageal regurgitation and pulmonary a controversial topic. Preoperative preparation of the
aspiration is thought to be more likely in critically ill patient gained support following several landmark
patients, due to disturbed gastric and esophageal studies by Gianotti et al. [42] and Braga et al. [43]
motility [27]. Preoperative fasting, particularly demonstrating that major morbidity could be reduced
when 6 or more hours in duration, will starve by ∼50% in patients undergoing resection for
critically ill patients who require frequent operations malignancy of the esophagus, stomach, or pancreas.
[32,33]. This benefit was noted in both the well-nourished and
malnourished patient populations. They provided
Factors associated with slower gastric emptying are as an immunomodulating formula given 5 days
follows. preoperatively, which included arginine, omega-3 (ω)
fatty acids, and nucleic acids, and resulted in significant
(1) Diseases affecting autonomic dysfunction, such as decreases in infectious morbidity, length of hospital
diabetes mellitus, amyloidosis, Parkinson’s disease, stay, and hospital-related expenses.
multiple sclerosis, HIV, and spinal injury.
(2) Other diseases such as hyperglycemia, alcoholism, In terms of nutritional support, it is generally
hypothyroidism, malignancy, and critical illness. accepted that earlier is better than later, that
(3) Gastrointestinal diseases such as gastric dysmotility, enteral is superior to parenteral, that the quality of
gastric outlet, or bowel obstruction. nutrient appears more important than the quantity,
(4) Surgical causes such as vagotomy, fundoplication, and that select populations will show additional
and Roux-en-Y anastomosis. benefit from specific nutrient supplementation.
(5) Drugs such as opiates, tricyclic antidepressants, Goals of nutritional support have changed in the
calcium channel blockers, dopamine agonists, past few years from attempts to preserve lean body
α-2-adrenergic agonists, glucagon-like peptide-1 mass following a surgical or traumatic stress to
receptor agonists, muscarinic cholinergic receptor efforts to attenuate the hypermetabolic response,
antagonists, catecholamines, cyclosporine, and reverse loss of lean body mass, prevent oxidant
somatostatin analogs (e.g. octreotide). stress, favorably modulate the immune response
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472 Ain-Shams Journal of Anaesthesiology, Vol. 9 No. 4, October-December 2016

with early enteral feeding, attain meticulous [42,43,50], with the most common duration being 7
glycemic control, and administer appropriate days [6,51,52].
macronutrients and micronutrients [20].
Route of administration
Enteral nutrition
Intraoperative Specific benefits to perioperative EN include a
There are few randomized controlled trials assessing reduction in the incidence of postoperative
intraoperative enteral feeding. Studies are limited to infections and complications, and improved wound
surgery following burn injury and nongastrointestinal healing [8,10]. This would also include fewer
trauma [40]. Following burn injury, the small life-threatening surgical complications, such as
intestine can be fed during surgery, which reduces anastomotic stenosis or leak, delayed gastric
cumulative calorie deficits and does not appear to emptying, recurrent nerve palsy, and superficial or
increase the risk for aspiration of gastric contents deep fascial surgical site infections [12,53]. EN has
[44]. Intraoperative EN, except during surgery on the been shown to be cost-effective by reducing the length
airway or gastrointestinal tract, can shorten the of hospital stay [12]. These effects are thought to be
duration of fasting in mechanically ventilated due to EN capacity to maintain gastrointestinal
critically ill patients. integrity, thus preventing villous atrophy, to
attenuate the body’s response to stress and maintain
immunocompetency through IgA secretion [10,4,12].
Postoperative EN contraindications include the presence of
Optimal time to start nutrition intestinal obstruction, malabsorption, multiple
The optimal time to start postoperative nutritional fistulas with high output, intestinal ischemia, severe
intervention is significantly influenced by a host of shock with impaired splanchnic perfusion, and
factors such as age, premorbid conditions, route of fulminant sepsis [54,55].
delivery, metabolic state, organ involvement, etc.
The reported benefits of early enteral feeding are Strategies used to reduce postoperative gastrointestinal
prevention of adverse structural and functional dysmotility and increase success of postoperative
alterations in the mucosal barrier, augmentation of enteral feeding include the following [34]:
visceral blood flow, and enhancement of local and
systemic immune response [45]. (1) Correction of pH imbalance.
(2) Correction of electrolyte abnormalities (especially
Postoperatively, normal oral food intake or nutrition potassium and magnesium).
through feeding tube should start within the first (3) Limiting excessive fluid administration.
24 h. A meta-analysis evaluated early commen- (4) Minimization of exogenous opiates.
cement of postoperative EN (within 24 h) versus (5) Optimization of glycemic control to avoid
traditional management in patients undergoing hyperglycemia-induced slowing of gastric emptying.
gastrointestinal surgery. It was in favor of early (6) Early institution of enteral feeding.
enteral feeding following gastrointestinal surgery (7) Use of prokinetic medications to treat established
to reduce morbidity and mortality rates [46]. feed intolerance (Table 2).
The beneficial effect of early oral feeding was
also shown by El Nakeeb et al. [47]. There is Table 2 Complications associated with enteral nutrition [34]
strong evidence that oral nutritional supplements Mechanical complications
(200 ml twice daily) given from the day of Aspiration
surgery until normal food intake is achieved are Tube malposition
beneficial. Tube clogging
Gastrointestinal complications
Nausea and vomiting
The optimal duration of nutritional support in the
Diarrhea or constipation
postoperative period remains unclear. Although
Malabsorption/maldigestion
using postoperative oral nutritional supplements for Metabolic complications
8 weeks in malnourished patients enhances recovery of Hyperglycemia or hypoglycemia
nutritional status and quality of life [11], benefits for Electrolyte imbalance
well-nourished patients are less evident [48]. Early satiety
Concerning postoperative immunonutrition, duration Dehydration
of therapy varied from 3 [49] to more than 10 days Refeeding syndrome
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Perioperative nutrition Salah 473

Parenteral nutrition Table 3 Complications associated with total parenteral

Total parenteral nutrition (TPN) has been shown to nutrition [15]

significantly affect postoperative outcomes in the Catheter insertion complications

severely malnourished patient group [10,56]. Because Arterial puncture
Pneumothorax
of its direct central venous administration, parenteral
Hemothorax
nutrition can rapidly improve nitrogen balance, which Catheter and wire tip embolization
allows for quicker lymphocyte recovery and improved Air embolism
wound healing [8,10]. Although TPN has many Thoracic duct injury
benefits, there are considerable risks to its use. Volume Catheter malposition
overload can cause respiratory compromise, particularly in Cardiac arrhythmias
individuals with marginal cardiopulmonary reserve [45]. Mediastinal air/hematoma
Hyperglycemia, along with its metabolic consequences, Cardiac perforation
Brachial plexus injury
can result in adverse outcomes if allowed to remain
Catheter-related complications
uncorrected. Subcalvian vein, internal jogular vein or superior vena cava
thrombosis
Hyperglycemia is also associated with the dysfunction of Catheter site infection
the immune response. Abnormalities include affecting Septic phlebitis
the granulocyte adhesion, chemotaxis, phagocytosis, Catheter associated blood stream infection
Metabolic complications
complement function, and intracellular killing [53,57].
Hyperglycemia or hypoglycemia
Compher et al. [56] were able to demonstrate that tight
Ketoacidosis
glycemic control in ICU patients receiving TPN resulted Azotemia and hyperosmolar state
in fewer infectious complications and a decrease in Electrolyte imbalance
mortality. Overfeeding is another concern with TPN, Hypertriglyceridemia
especially in patients at extreme ages. Overfeeding Metabolic acidosis
can lead to azotemia, hypertonic dehydration, and Hepatic dysfunction
metabolic acidosis. Excessive carbohydrate infusion Fluid overload
Coagulopathy
results in hyperglycemia, hypertriglyceridemia, and
hepatic steatosis. High lipid infusions can cause
hypertriglyceridemia and fat-overload. Hypercapnia with no change in overall mortality [60,61]. Some
and refeeding syndrome may also result from aggressive editorials continue to support the use of immune
feeding [58] (Table 3). formulas [62], whereas others report them as poison
[63].

Optimum nutrition The greatest debate revolves around the pros and cons of
As regards specific macronutrients, the requirement additional arginine in the ICU setting. One school
for carbohydrates is estimated at 3–6 mg/kg/ considers that arginine is potentially toxic [63],
min (roughly 200–300 g/day), for protein it is whereas another argument is that arginine is deficient
1.25–2.0 g/kg/day, and for lipids it is 10–25% of in critical illness and should be supplemented. No
total calories, depending on the route and lipid prospective clinical data are currently available proving
composition [59]. These figures vary depending on that arginine is harmful, whereas numerous prospective
the specific patient condition. Ideally, one would like articles have demonstrated arginine to be beneficial,
to provide sufficient nutrients to minimize the especially in the surgical and trauma population.
catabolic loss associated with stress, injury, and
surgery while avoiding the problems associated with Glutamine is the other conditionally essential amino
overfeeding, such as hyperglycemia, azotemia, excess acid that has recently gained even greater support in
CO2 production, etc. the critical care setting. Glutamine has been reported
to offer a myriad of benefits, including maintenance of
Several trials suggest additional benefits with acid/base balance, provision of primary fuel for rapidly
immunomodulation compared with the standard proliferating cells (i.e. enterocytes and lymphocytes),
formulas when the appropriate population is chosen. synthesis of glutathione and arginine, and lowering
More than 27 prospective randomized trials using of insulin resistance, and functions as a key substrate
immunomodulation formulas have resulted in very for gluconeogeneis [64]. Evidence that glutamine
similar conclusions, demonstrating a decrease in can induce heat-shock protein is yet another
infectious complications and shortened hospital stays beneficial molecular effect of this amino acid [65].
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474 Ain-Shams Journal of Anaesthesiology, Vol. 9 No. 4, October-December 2016

The heat-shock proteins are a class of cellular evaluating TPN and caloric delivery, McCowan
chaperone proteins that support appropriate protein et al. [70] demonstrated an interesting but not
folding [66]. With glutamine enhancing heat-shock statistically significant trend in decreasing infectious
protein, the cell protects itself from subsequent complications. Several studies in critically ill obese
stress. patients use a hypocaloric high-protein regimen with
excellent metabolic results [71,72]. Although the
The ω-3 fats in fish oil have multiple beneficial effects optimal caloric load for the hypermetabolic
in the perioperative period, including modulation of (nonobese) patient remains in transition, the caloric
leukcocyte function and regulation of cytokine release delivery currently considered safe for the perioperative
through nuclear signaling and gene expression [67]. period is in the range of 20–30 kcal/kg/day (excluding
The ω-3 lipids have recently been reported to enhance the morbidly obese).
the production of a new group of prostaglandin
derivatives called resolvins and neuroprotectins,
which play a role in accelerating their solution of the Special patient groups
proinflammatory state [68] (Table 4). Obese patients
Despite a considerable fat store, obese patients are at
risk of loss of lean body mass through gluconeogenesis
How much to feed? and micronutrient deficiency during times of acute
The caloric requirement for the perioperative and ICU stress. Fasting insulin concentrations are increased,
patient is evolving as the concept of hypocaloric which suppress lipid mobilization from stores and
feeding, or so-called permissive underfeeding, in the result in accelerated protein breakdown to fuel
early ICU and postoperative period. There is a relative gluconeogenesis [73]. These risks may be increased
anorexia that occurs from significant illness and the because of an incorrect assumption that obese patients
supply of nutrients during this period induces a have a greater ‘nutritional reserve’ compared with
proinflammatory state, which then exacerbates the nonobese patients [74].
condition. This concept has led several investigators
to encourage hypocaloric feeding in the early phases of Screening and supplementation for micronutrient
critical illness. Krishnan et al. [69] reported that deficiency may be of benefit. For example, patients
underfeeding the septic medical ICU patient resulted undergoing laparoscopic sleeve gastrectomy can be
in a small improvement in survival. In a study deficient in vitamin D, iron, thiamine, and vitamin
B12 [75]. Postoperative nutrition should contain
Table 4 The daily vitamins and trace element requirements enough protein to minimize muscle loss and aid
for an adult receiving artificial nutrition [54] wound healing and should contain enough calories
Vitamin/trace element Requirement to prevent severe ketoacidosis [74]. High-protein
Thiamine (B1) (mg) 6 hypocaloric feeding of critically ill obese patients has
Riboflavin (B2) (mg) 3.6 been evaluated with the aim of allowing fat stores to
Niacin (B3) (mg) 40 be utilized for energy and sparing muscle protein
Folic acid (μg) 600 from excessive catabolism [76–78]. Suggested caloric
Pantothenic acid (mg) 15 requirements for this group of patients are 22–25 kcal/
Pyridoxine (mg) 6
kg ideal body weight/day (or 11–14 kcal/kg actual body
Cyanocobolamin (B12) (μg) 5
Biotin (μg) 60
weight/day) with 2 g/kg/day of protein, but the
Ascorbic acid (C) (mg) 200 evidence upon which the recommendation is based
Vitamin A (IU) 3300 is weak [76].
Vitamin D (IU) 200
Vitamin E (IU) 10 The elderly
Vitamin K (μg) 150 Aging is associated with a reduction in lean body mass,
Chromium (μg) 10–15
increase in body fat, decrease in total body water, and a
Copper (mg) 0.3–0.5
Iron (mg) 1.0–1.2
reduction in bone density [73]. Advanced age is
Manganese (mg) 0.2–0.3 independently associated with poor nutritional status
Selenium (μg) 20–60 in hospitalized patients [77]. Deficiencies of vitamins
Zinc (mg) 2.5–5 B6, B12, C, D, folate, and calcium are prevalent in this
Molybdenum (μg) 20 group [73,78]. Elderly patients who have experienced
Iodine (μg) 100 10% or more weight loss in the previous 6 months, or
Fluoride (mg) 1 who are hypoalbuminemic, experience more adverse
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