Nutrition in the Surgical Patient
Nutrition in the surgical patient is a multifactorial, complex subject. Beyond the decision to feed enterally or parenterally, a surgeon must consider specific patient characteristics that interfere with the delivery of nutrients for useful and purposeful
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Rosemary Kozar, Anthony Tannous, and Diane A. Schwartz
Nutrition in the surgical patient is a multifactorial, complex subject. Beyond the decision to feed enterally or parenterally, a surgeon must consider specific patient characteristics that interfere with the delivery of nutrients for useful and purposeful digestion and metabolism. The patient with postoperative ileus, a previous bowel obstruction, short gut, an open abdomen after damage control, or discontinuous bowel, to mention only a few special circumstances, has energy requirements beyond what is provided by maintenance or resuscitative fluids. These examples comprise situations in which early feeding would inherently be of benefit. Certainly the patient with an enteric fistula deserves focused discussion as this patient population, more than the standard surgical patient or even the patient with an open abdomen after damage control, has the additional complexity of nutrient and digestive component loss. Attention should also be given to the consideration of nutritional access as many patients with these special circumstances do not have the ability to take food orally. Surgeons must decide how they will provide nutrition to their patients and many times this requires surgical or endoscopic placement of lines and tubes that can be used to administer nutrients into the body. Timing of feeding and location of feed entry into the body are further decisions that the surgeon faces. This chapter serves to discuss and present data regarding the differences in parenteral, enteral, gastric, and post-pyloric feeding, and includes algorithms for instituting early nutritional support in the acute and traumatic patient populations.
ationale for and Types of Nutritional R Support The rationale for providing nutritional support is to prevent acute protein malnutrition, to modulate the immune response, and to promote normal gut function [1].
Enteral Versus Parenteral Nutrition In the 1970s total parenteral nutrition (TPN) was introduced, but despite its availability, enteral nutrition (EN) was still more economical and convenient to provide. However, the practice at that time was to hold EN until the gut proved to be completely functional, which could take days or even weeks, for surgical and trauma patients. By the 1980s enough data had been collected to support the use of EN in these surgical populations. Enteral nutrient provisions were functional and processed effectively in the critically ill patient with mal- adapted gut mucosa [2, 3]. In fact it was shown in multiple studies that introducing enteral feeds into the gut stimulated immunologic response and competence [4–7]. The 1990s introduced data that TPN may be harmful in patients who could otherwise tolerate enteral feeds. There were more infections, including catheter-related sepsis, seen in the parenteral group [8, 9]. Meta-analyses confirmed that early enteral feeding, compared to parenteral nutrition, reduced postoperative infections and complications [10, 11].
Enteral Nutrition R. Kozar (*) • A. T
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