An Evidence-Based Approach to Perioperative Nutrition Support in the Elective Surgery Patient
In surgical practice, great attention is given to the perioperative management of the elective surgical patient with regard to surgical planning, stratification of cardiopulmonary risk, and postoperative assessment for complication. However, growing evidence supports the beneficial role for implementation of a consistent and literature-based approach to perioperative nutrition therapy. Determining nutrition risk should be a routine component of the preoperative evaluation. As with the above issues, this concept begins with the clinician’s first visit with the patient as risk is assessed and the severity of the surgical insult considered. If the patient is an appropriate candidate for benefit from preoperative nutrition support, a plan for initiation and reassessment should be implemented. Once appropriate perioperative nutrition end points have been achieved, special consideration should be given to beneficial practices the immediate day preceding surgery that may better prepare the patient for the intervention from a metabolic standpoint. In the operating room, consideration should be given to the potential placement of enteral access during the index operation as well as judicious and targeted intraoperative resuscitation. Immediately following the intervention, adequate resuscitation and glycaemic control are key concepts, as is an evidence-based approach to the early advancement of an enteral/oral diet in the postoperative patient. Through the implementation of perioperative nutrition therapy plans in the elective surgery setting, outcomes can be improved. Just as patients are appropriately subjected to preoperative cardiac risk stratification and intervention when indicated, so too should patients be evaluated for nutrition-related risk and intervened upon when deemed appropriate. Perioperative nutrition management in elective surgery begins with the preoperative risk assessment followed by the development and implementation of the nutrition intervention plan in appropriate candidates. Screening tools, such as the NRS-2000, are invaluable and readily applied in the outpatient setting to assist the clinician for perioperative nutrition support. Elective surgery should be delayed when significant nutrition risk is identified if urgent or emergent surgery is not required. In the case of malignant disease, sufficient literature suggests that as little as 7 days of preoperative nutrition support can affect outcome. Preoperative carbohydrate drinks the night before and up to 2 hours prior to operative intervention are safe, may be beneficial, and fit within the constraints of current preoperative fasting guidelines. Intraoperative consideration for the placement of enteral feeding access by the operating surgeon and judicious but adequate resuscitation by the anesthesiologist are the goals of care during the operation and can greatly affect the delivery and tolerance of postoperative nutrition support. Glycaemic control and ongoing resuscitation are the cornerstones of immediate postoperative care. Finally, the early initiation of enteral or oral nutrition postoperatively should be dictated by clinical examination rather than surgical dogma. Results of a number of rigorous meta-analyses demonstrate that early nutrition initiation can improve clinical outcomes and in fact reduce mortality following major surgery. Based on these data, this practice of early perioperative nutrition delivery should be standard of care following operative procedures, such as elective lower GI operations. Through the application of these principles, the clinician can be confident that appropriate nutrition support has been delivered throughout the perioperative period and that improved clinical outcomes will follow.