Safety: Nutrition Counseling Improves Outcomes

There’s a great deal of attention paid to the importance of optimizing the nutritional status of patients before surgery and doing away with NPO requirements to prepare them for the stress of invasive procedures — and rightfully so. Surgery stimulates a cascade of inflammatory metabolic responses that can cause the patient to be in a catabolic state, which can lead to insulin resistance and abdominal discomfort. Patients who fast leading up to surgery are often not prepared for the physical trauma they’re about to endure. But you might not know that even with pre-op nutritional interventions, patients do better after surgery when they eat right during their recoveries. They are what they eat, and their diet affects surgical outcomes.

As a clinical nutritionist, I see a host of different patients after surgery, and many have vastly different nutritional needs, in some cases because of the procedure they’ve undergone. Following neck procedures, for example, I make sure patients are on a diet of the correct food consistency, such as purees. Patients who suffer from digestive complications, such as not being able to eat anything for a prolonged period, might require total parenteral nutrition (TPN), which is a method of vein-feeding that bypasses the gastrointestinal tract.

Patients who have diabetes need to keep their glucose levels in check by measuring their A1C, which is a measure of the average blood glucose levels over the past three months. Typically, these patients should have an A1C of less than 8% prior to surgery and might need to be educated on making healthy and appropriate food choices if their blood glucose continues to be elevated after surgery. For example, they might be instructed to follow a consistent carbohydrate diet with no added sugars. This means they’d consume only four servings of carbohydrates per meal and would not be allowed juices and desserts.

Diabetes can also reduce blood flow to the surgical area, leading to an increased risk of SSIs. If a patient has a large surgical wound that’s not healing or perhaps a pressure injury, I might suggest high-protein nutrition supplements, amino acid supplementation such as glutamine and arginine, a multivitamin and perhaps some vitamin C or zinc. Amino acids are the building blocks of proteins, which are necessary for wound healing. Glutamine and arginine specifically have been shown to promote blood flow, stimulate collagen formation and support immune responses. Vitamin C and zinc act as antioxidants, which also aid in collagen formation.

Keep a close eye on patients who are malnourished or are at risk for malnutrition, which is diagnosed using specific, standardized criteria, including clinically significant weight loss, muscle and fat wasting and inadequate oral intake for a certain period. These patients might require oral nutrition supplementation and possibly tube feeding. Keep in mind that malnourished patients can be overweight or underweight. It’s easy to spot a patient who is carrying extra weight, but underweight patients are high-risk and may suffer post-op complications that increase their length of stay. 

You can always expect some resistance from patients when it comes to regulating their diet. Every patient has the right to refuse care, but patients are more cooperative if the advice and recommendations come from their primary care physician or surgeon. 

There are numerous surgical nutrition guidelines that provide helpful information on selecting screening tools, malnutrition assessments as well as treatment for malnourished and at-risk patients. Become familiar with guidance from the European Society for Clinical Nutrition and Metabolism, the American Society of Parenteral Enteral Nutrition and the American Society for Enhanced Recovery with Perioperative Quality Initiative. 

The nutritional management of patients should continue postoperatively to maintain a health status for supporting wound healing, improving the immune response and facilitating functional recovery. A healthy post-op diet can mean the difference between a speedy rehab with no complications and a lengthy recovery. OSM