Peri-operative nutrition -

Table of Contents

Introduction

Malnutrition has a big effect on surgical outcomes, which means that patients who are malnourished are less likely to be good candidates for surgery. Surgery itself causes physiological stress, which puts the body in a hyper-metabolic state and a catabolic response. This might be bad for people who are already malnourished. The level of malnutrition differs across patients, frequently associated with underlying conditions that exacerbate their nutritional deficiencies during the postoperative phase. Patients like these are more likely to have problems, such as wounds that don’t heal well, greater rates of infection, and skin deterioration. Peri operative nutrition

Because of these dangers, it is very important that anyone who is going to have elective or semi-elective surgery be checked for malnutrition. When recognized, nutritional support should be given before and after surgery to improve results.

Evaluation

All hospitalized patients should be screened for malnutrition so that they can get help as soon as possible. The Malnutrition Universal Screening Tool (MUST) is a common tool for screening that makes it easy to find out how well a patient is eating. Calculating the MUST score is useful, but clinical evidence of cachexia, including muscle loss, loose skin, and changes in how clothes fit, are typically enough to show that someone is malnourished.

After the first screening, it is best to have a Registered Dietitian (RD) do a full nutritional assessment. Important steps are:

Body Mass Index (BMI): A standard metric that is found by dividing weight (kg) by height (m)². A healthy range is between 18.5 to 24.9 kg/m².
Grip Strength: A sign of how strong your muscles are and how healthy your diet is generally.
Triceps Skin Fold Thickness: This tells you how much body fat you have.
Mid Arm Circumference: Shows how much muscle and fat you have.

Along with these tests, indications like aphthous ulcers, angular cheilitis, and pressure sores can also help you figure out whether you are lacking in certain nutrients.

Nutritional Support Before Surgery

Nutritional support can be very important for improving surgical results after malnutrition is found. However, the time and type of this help should be based on the needs of each patient, and it would be best to talk to a trained dietician about it.

Enteral nutrition (oral intake) is the best way to give nutritional assistance before and after surgery, where possible. If patients can’t get enough calories by mouth, they may need to use oral nutritional supplements (ONS), nasogastric tube feeding (NGT), or possibly gastrostomy feeding (via a PEG/RIG tube).

Here’s a general order for giving nutritional support:

Oral Nutritional Supplements (ONS): Are for people who can eat but have trouble getting enough calories.
Nasogastric Tube Feeding (NGT): If you can’t eat enough or have trouble swallowing.
Gastrostomy Feeding (PEG/RIG): For people whose esophagus doesn’t work right.
Jejunal feeding (jejunostomy): Is when the stomach can’t be reached or is blocked.
Parenteral Nutrition: This is used when the intestines don’t work or when all other ways of getting food into the body don’t work.

It is necessary to address malnutrition, but surgery should not be postponed for an extended period purely for nutritional enhancement, particularly when underlying diseases such as active Crohn’s disease complicate preoperative nutritional optimization.

People with Intestinal Failure

Parenteral nutrition (PN) is often necessary for people with intestinal failure (IF), however it depends on the person’s unique situation. When thinking about surgery for these patients, keep the SNAP acronym in mind:

Sepsis: Treat any infections that are still going on.
Nutrition: Once the infection is under control, give the right nutritional support.
Anatomy: Figure out the anatomy of the GI system so you can design the surgery.
Procedure: Do the procedure for sure After the infection is gone, the patient is fed, and the anatomy is clear.

The Albumin Myth

A prevalent fallacy is that diminished serum albumin levels immediately indicate a patient’s nutritional condition. But low serum albumin is usually an indication of chronic inflammation, liver problems, or protein-losing enteropathy, not starvation. Even individuals with severe anorexia nervosa, characterized by starvation, frequently have normal serum albumin levels. So, trying to raise albumin levels by only feeding is pointless and wrong. Instead, the focus should be on treating the cause of the low albumin.

Nutrition During Surgery

The advent of Enhanced Recovery After Surgery (ERAS) guidelines represented a major change in how nutrition is handled before, during, and after surgery. In the past, patients were not allowed to eat or drink anything for a long time after surgery, which slowed down their recuperation. ERAS has questioned this method, stressing:

Less “Nil By Mouth” Times: You can drink clear liquids up to two hours before surgery.
Carbohydrate loading before surgery: Helps keep muscles from losing too much and speeds up recovery.
Minimally invasive surgery cuts down on recuperation time and problems.
Quick Reintroduction of Feeding: Feeding starts as soon as possible after surgery.
Early Mobilization: Helps you heal faster and lowers the risk of problems.

Nutrition After Surgery

It is now generally known that feeding patients soon after surgery might help them recover faster and lower the risk of problems. Most surgical patients may handle an enteral meal within 24 hours of uncomplicated gastrointestinal surgery without raising the risk of complications, according to ERAS recommendations. Early food and early movement together help keep muscles from losing strength and speed up recovery.

In Certain Cases

Entero-Cutaneous Fistulae (ECF): These fistulas usually don’t need parenteral nourishment right away. Instead, dietary support should be given to be ready for the surgery. How to feed someone depends on where the fistula is. High fistulas (in the jejunum) may necessitate enteral or parenteral nourishment, while low fistulas (in the ileum or colon) may usually be handled with a low-fiber diet.

High Output Stoma (HOS): The nutritional support for patients with HOS is contingent upon the length of bowel that remains to the stoma. Parenteral feeding may be necessary for jejunostomies with limited remaining bowel (<100cm). For bigger parts of the colon, enteral feeding is usually enough, but intravenous fluids may be needed in some cases.

Medical Management of High Output Stoma

To take care of high-output stomas, think about:

Limiting Hypotonic Fluid Intake: 500ml/day is the most you can have.
Changing how the gut moves: Taking a lot of loperamide or codeine phosphate.
To lower secretion, give proton pump inhibitors.
Low-Fiber Diet: To help the intestines hold on to less water.

Main Points

Patients who are malnourished are more likely to have problems during surgery.
Early nutritional support can help with surgery, and a registered dietitian should be involved from the start.
The hierarchy of feeding systems should be used correctly for each patient based on their demands.
Surgery shouldn’t be put off because of malnutrition, but getting the right nourishment at the right time is vitally important for recovery.

In conclusion, the nutritional state of surgical patients is essential for both pre-operative and post-operative recovery. Early management, proper nutritional support, and prompt surgical intervention are essential for enhancing surgical results and reducing complications.

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Peri-operative nutrition