New ESPEN guideline on nutritional needs of patients undergoing surgery

Necessity of preoperative fasting

• Preoperative fasting from midnight is unnecessary in most patients. Patients undergoing surgery, who are considered to have no specific risk of aspiration, shall drink clear fluids until 2 h before anesthesia. Solids shall be allowed until 6 h before anesthesia.
• In order to reduce perioperative discomfort including anxiety oral preoperative carbohydrate treatment (instead of overnight fasting, the night before and 2 h before surgery) should be administered. To impact postoperative insulin resistance and LOS, preoperative carbohydrates can be considered in patients undergoing major surgery.
• In most instances, oral nutritional intake shall be continued after surgery without interruption.
• It is recommended to adapt oral intake according to individual tolerance and to the type of surgery carried out with special caution to elderly patients.
• Oral intake, including clear liquids, shall be initiated within hours after surgery in most patients.

Indication for nutritional therapy

• It is recommended to assess the nutritional status before and after major surgery.
• Perioperative nutritional support therapy is indicated in patients with malnutrition and those at nutritional risk. Perioperative nutritional therapy should also be initiated if it is anticipated that the patient will be unable to eat for more than five days perioperatively. It is also indicated in patients expected to have low oral intake and who cannot maintain above 50% of the recommended intake for more than seven days. In these situations, it is recommended to initiate nutritional support therapy (preferably by the enteral route – oral nutritional supplements – tube feeding) without delay.
• If the energy and nutrient requirements cannot be met by oral and enteral intake alone (<50% of caloric requirement) for more than seven days, a combination of enteral and parenteral nutrition (PN) is recommended (GPP). PN shall be administered as soon as possible if nutrition therapy is indicated and there is a contraindication for enteral nutrition (EN), such as in intestinal obstruction.
• For the administration of PN, an all-in-one (three-chamber bag or pharmacy prepared) should be preferred instead of a multibottle system.
• SOPs for nutritional support are recommended to secure effective nutritional support therapy.
• Parenteral glutamine supplementation may be considered in patients who cannot be fed adequately enterally and, therefore, require exclusive PN.
• Postoperative PN including omega-3-fatty acids should be considered only in patients who cannot be adequately fed enterally and, therefore, require PN.
• Peri- or at least postoperative administration of specific formula enriched with (arginine, omega-3-fatty acids, ribonucleotides) should be given in malnourished patients undergoing major cancer surgery. There is currently no clear evidence for the sole use of these formulas enriched with immunonutrients vs. standard oral nutritional supplements (ONS) in the preoperative period.

Nutritional therapy in the preoperative period

• Patients with severe nutritional risk shall receive nutritional therapy prior to major surgery (A) even if operations including those for cancer have to be delayed (BM). A period of seven to 14 days may be appropriate.
• Whenever feasible, the oral/enteral route shall be preferred.
• When patients do not meet their energy needs from normal food it is recommended to encourage these patients to take ONS during the preoperative period unrelated to their nutritional status.
• Preoperatively, ONS shall be given to all malnourished cancer and high-risk patients undergoing major abdominal surgery. A special group of high-risk patients are the elderly people with sarcopenia.
• Immune modulating ONS including (arginine, omega-3 fatty acids, and nucleotides) can be preferred (0) and administered for five to seven days preoperatively (GPP).
• Preoperative EN/ONS should preferably be administered prior to hospital admission to avoid unnecessary hospitalization and to lower the risk of nosocomial infections.
• Preoperative PN shall be administered only in patients with malnutrition or severe nutritional risk where energy requirement cannot be adequately met by EN (A). A period of 7–14 days is recommended.

Postoperative nutrition

• Early EN (within 24 h) shall be initiated in patients in whom early oral nutrition cannot be started, and in whom oral intake will be inadequate (<50%) for more than seven days.
• In most patients, a standard whole protein formula is appropriate. For technical reasons with tube clotting and the risk of infection, the use of home-made diets for EN is not recommended in general.
• With special regard to malnourished patients, placement of a nasojejunal tube or NCJ should be considered for all candidates for EN undergoing major upper gastrointestinal and pancreatic surgery.
• EN shall be initiated within 24 h after surgery.
• It is recommended to start EN with a low flow rate (e.g. 10 – max. 20 ml/h) and to increase the feeding rate carefully and individually due to limited intestinal tolerance. The time to reach the target intake can be very different and may take five to seven days.
• If long-term EN (>4 weeks) is necessary, e.g. in severe head injury, placement of a percutaneous tube (e.g. percutaneous endoscopic gastrostomy - PEG) is recommended.
• Regular reassessment of nutritional status during the stay in hospital and, if necessary, a continuation of nutritional support therapy including qualified dietary counseling after discharge, is advised for patients who have received nutritional support therapy perioperatively and still do not cover appropriately their energy requirements via the oral route.

Organ transplantation

• Malnutrition is a major factor influencing outcome after transplantation, so monitoring of the nutritional status is recommended. In malnutrition, additional ONS or even EN is advised.
• Regular assessment of nutritional status and qualified dietary counselling shall be required while monitoring patients on the waiting list before transplantation.
• Recommendations for the living donor and recipient are no different from those for patients undergoing major abdominal surgery.
• After heart, lung, liver, pancreas, and kidney transplantation, early intake of normal food or EN is recommended within 24h.
• Even after transplantation of the small intestine, EN can be initiated early but should be increased very carefully within the first week.
• If necessary EN and PN should be combined. Long-term nutritional monitoring and qualified dietary counseling are recommended for all transplants. 

Bariatric surgery

• Early oral intake can be recommended after bariatric surgery.
• PN is not required in uncomplicated bariatric surgery.
• In case of a major complication with relaparotomy, the use of a nasojejunal tube/NCJ may be considered.
• Further recommendations are not different from those for patients undergoing major abdominal surgery.

Reference:

"ESPEN practical guideline: Clinical nutrition in surgery," is published in the journal Clinical Nutrition.

DOI: https://www.clinicalnutritionjournal.com/article/S0261-5614(21)00178-3/fulltext