Nutrition Before and After Surgery

After a major trauma or accident, surgery is often necessary to repair some of the damage and improve functionality and quality of life.  Sometimes this surgery is done immediately as an emergency case, and other times, elective surgery is conducted months or even years later.  Adequate nutrition before and after ALL types of surgery is absolutely essential to minimise complications and speed recovery time.   The European Society for Enteral and Parenteral Nutrition have developed extensive guidelines on “Clinical Nutrition in Surgery.”  Nutrition is also a key element in the Department of Health’s 2010 Enhanced Recovery Partnership Program aimed at speeding recovery times.  Here are the highlights from both of these documents:

 1.  Screen all patients for malnutrition.

Malnutrition and/or underfeeding puts patients at risk of postoperative complications, yet 42% of patients hospitalised for orthopaedic trauma (for example) exhibit at least one sign of malnutrition.1 I had previously assumed that hospital dietitians were addressing and correcting these issues, but recent discussions with case managers have indicated that this is not always the case, particularly if the surgery is elective.

So how exactly is malnutrition identified?  That is where discrepancies exist.  Some studies use the Malnutrition Universal Screening Tool (MUST) which focuses on weight and percent weight loss in the last 3-6 months.1. Other studies use blood test results measuring albumin levels, lymphocyte count and/or transferrin levels.2

The European Society for Enteral and Parenteral Nutrition defines malnutrition as:

• BMI <18.5 kg/m2

OR

• Combined: weight loss >10% OR >5% over 3 months + a reduced BMI or a low fat free mass index.

Malnutrition has been independently associated with chronic septic failure, acute postoperative infection, neuromuscular complications, renal complications, postoperative hematoma, overall complication rate, longer length of stay, slower wound healing and readmission to hospital.1, 2  The more malnourished the person is, the higher the risk of complications — in fact, each additional point on the client’s nutrition score increases the odds of developing a complication by 49.5%.1  The Malnutrition Universal Screening Tool is a quick and inexpensive way that case managers (or other professionals) in the community can determine whether input from a dietitian is required.  Clients who are identified as being malnourished would benefit from at least 7-14 days of nutritional therapy prior to surgery.3

2.  Make sure the GP performs the “fit for list” health screening prior to elective surgery.

The goal is to “optimise the patient’s condition” before surgery by checking: iron levels, blood sugar levels, blood pressure, kidney function, weight, smoking and physical activity level.4  This allows time for corrective action to be taken thus reducing the risk of surgical delays and complications.

3.  Support clients to lose weight if they are obese.

Morbid obesity (defined as a BMI >40 kg/m2) has been linked to higher rates of 30 day postoperative complications.2  It has also been linked to higher rates of surgical site infections and poor wound healing.5  Obese clients can also be malnourished, so be sure to screen all clients for malnutrition, regardless of weight and ensure that any weight loss program they engage in does not compromise their nutritional status.

4.  Make sure clients with diabetes have good control of their blood sugar levels.

Blood sugar levels are influenced by diet, physical activity levels, medication, stress and illness.  Keeping blood sugar levels within a healthy range supports faster wound healing, fewer infections and a shorter hospital stay.4  Seek advice from a GP, practice nurse or dietitian if required.

5.  Minimise ‘Nil by Mouth’ prior to surgery.  

The Enhanced Recovery Partnership Program advises that people should be allowed to eat normally up to 6 hours prior to surgery and take clear fluids up until 2 hours before (unless the client is at risk of aspiration).  A special carbohydrate supplement may be given the night before plus two hours before major surgery to improve insulin resistance, reduce anxiety, improve hydration levels and shorten hospital stay (unless of course the patient has severe diabetes or anticipated gastroparesis).4

6.  After surgery, initiate oral intake (as tolerated) as soon as possible.

Early refeeding can reduce complications. 3,4  Clear fluids can generally be initiated within hours of the surgery.  Oral nutrition supplements can be used to help patients meet their requirements if they they are struggling to eat enough.

7.   Support wound healing and prevent pressure sores with adequate nutrition after discharge.

Wound healing requires extra calories and protein along with sufficient amounts of fluid, vitamins and minerals.6  Clients who are not eating well will require nutrition supplements in order to meet their requirements.  A dietitian can advised on when nutrition supplements are necessary and which ones would be most suitable.

If you have clients in the community who need support with nutrition before or after surgery, please get in touch at info@specialistnutritionrehab.co.uk, 07787 603863 or by using the contact form below.  Also, if you would like monthly articles (such as this one) sent straight to your inbox, please sign up for my newsletter below.