Medical nutrition therapy in surgery: ERAS protocol ***

Question 1

Which concept refers to a patient-centered, evidence-based, multidisciplinary team developed pathways for a surgical specialty and facility culture to reduce the patient’s surgical stress response, optimize their physiologic function, and facilitate recovery?

Answer 1

Enhanced Recovery After Surgery (ERAS).

Question 2

What are the primary goals of the multimodal, multidisciplinary, and comprehensive ERAS pathways?

Answer 2

• Blunt the response to surgical stress through optimization of nutritional and functional status.
• Limitation of preoperative fasting.
• Individualized fluid management.
• Opioid-sparing analgesia.
• Minimally invasive surgery.
• Early postoperative ambulation and feeding.

Question 3

What are the key elements of an ERAS program?

Answer 3

• Patient/family education.
• Patient optimization prior to admission.
• Minimal fasting that includes a carbohydrate beverage 2 hours before anesthesia.
• Multimodal analgesia with appropriate use of opioids when indicated.
• Return to normal diet and activities the day of surgery, and return home.

Question 4

What are the key pre-operative elements of an ERAS program?

Answer 4

• Medical optimization.
• Exercise
• Nutrition: Minimize fasting, carbohydrate drink.

Question 5

What are the key intra-operative elements of an ERAS program?

Answer 5

• Local, regional anesthesia: Minimization of narcotics and intravenous fluids.
• Fluid management.
• Prevention of nausea and vomiting.
• Normothermia
• Laparoscopy

Question 6

What are the key post-operative elements of an ERAS program?

Answer 6

• Early mobilization.
• Pain management.
• Early feeding.
• Immunonutrition
• Avoid postoperative nausea and vomiting (PONV).
• Minimize drains and catheters.

Question 7

It’s the process of optimizing functional and nutritional capacity and preparing the patient to better cope with the stress of surgery:

Answer 7

Prehabilitation

Question 8

It’s an independent risk factor for length of hospital stay, mortality, infection, and increased cost:

Answer 8

Malnutrition

Question 9

It’s a commonly used test to identify patients who are at increased risk of malnutrition:

Answer 9

Nutrition Risk Screening Tool.

Question 10

It’s associated with postoperative morbidity and mortality:

Answer 10

Preoperative anemia.

Question 11

It’s another factor that has been found to have a negative impact on recovery, as it increases inflammation, oxidative stress, hypercoagulability, and endothelial damage, leading to the progression of vascular atherosclerosis and thrombosis:

Answer 11

Chronic smoking.

Question 12

What are the current American Society of Anesthesiology (ASA) recommendations regarding preoperative fasting and carbohydrate loading?

Answer 12

To refrain from solid foods for 6 hours and to continue the intake of clear liquids until 2 hours before surgery.

Question 13

What do the ERAS guidelines recommend regarding preoperative fasting and carbohydrate loading?

Answer 13

800 mL of a 12.5% carbohydrate-containing clear drink (50 grams of carbohydrates) with a proven safety profile the night before surgery and 400 mL 2 hours before surgery.

Question 14

What are the five independent predictors by which high-risk of PONV patients are identified?

Answer 14

• Female gender.
• Age < 50 years.
• Opioid use in the PACU.
• History of PONV.
• Nausea in the PACU.
  *PACU = Postoperative anesthesia care unit.

Question 15

Which elements of the multimodal analgesia clearly improve analgesia and decrease postoperative systemic opioid consumption?

Answer 15

• Scheduled nonsteroidal anti-inflammatory drugs.
• Acetaminophen
• Gabapentinoids
• Ketamine
• Alpha-2 agonists.
• Neuraxial and/or peripheral neural blockade techniques.

Question 16

It’s associated with a host of complications including thromboembolic disease, skeletal muscle loss and weakness, atelectasis, and insulin resistance:

Answer 16

Prolonged immobility.

Question 17

What is the preferred mode of nutrition for surgical patients?

Answer 17

Early oral feeding.

Question 18

When should postoperative oral intake be initiated according to ESPEN guidelines for clinical nutrition in surgery?

Answer 18

Oral intake, including clear liquids, shall be initiated within hours after surgery in most patients.

Question 19

In which px is perioperative nutritional therapy indicated according to ESPEN guidelines for clinical nutrition in surgery?

Answer 19

• In patients with malnutrition and those at nutritional risk.
• If it is anticipated that the patient will be unable to eat for more than five days perioperatively.
• In patients expected to have low oral intake and who cannot maintain above 50% of recommended intake for more than seven days.

Question 20

What measure is recommended if the energy and nutrient requirements cannot be met by oral and enteral intake alone (< 50% of caloric requirement) for more than seven days according to ESPEN guidelines for clinical nutrition in surgery?

Answer 20

A combination of enteral and parenteral nutrition (GPP).

Question 21

Which nutrition therapy shall be administered as soon as possible if nutrition therapy is indicated and there is a contraindication for EN, such as in intestinal obstruction according to ESPEN guidelines for clinical nutrition in surgery?

Answer 21

Parenteral nutrition.

Question 22

Which nutrition therapy 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 7 days according to ESPEN guidelines for clinical nutrition in surgery?

Answer 22

Early tube feeding (within 24 h).

Question 23

What are some special risk groups for which early tube feeding shall be initiated?

Answer 23

• Patients undergoing major head and neck or GIl surgery for cancer.
• Patients with severe trauma, including brain injury.
• Patients with obvious malnutrition at the time of surgery.

Question 24

What are the additional pharmaconutrients included with the protein formula in immunonutrition?

Answer 24

• Arginine
• Omega-3-fatty acids.
• Glutamine
• Ribonucleic acid.
• Selenium and other antioxidants.

Question 25

The observed biological results of which pharmaconutrient included in immunonutrition are as follows?
- ↑ Activated and fuel T lymphocytes interferon gamma, and natural killer cells
- ↑ Immunoglobulin M and G levels.
- ↑ Phagocytosis and respiratory burst.
- ↑ Lymphocytes and percentage of T-helper cells.
- ↑ Postoperative IL-6 and TNF-a.
- ↑ Tissue perfusion due to ↑ NO levels.
- ↑ Proline, polyamines, collagen productions.

Answer 25

Arginine

Question 26

What is the other key ingredient of immunonutrition that minimizes loss of lean body tissue?

Answer 26

Fish oil.

Question 27

The characteristics of which component of immunonutrition are as follows?
- EPA and DHA omega 3 fatty acids.
- Minimizes loss of lean body tissue.
- Prevent oxidative injury in a variety of tissues.
- Changes in cell membrane phospholipids.
- Alterations in gene expression.
- Modifications to endothelial expression of ICAM-1, E-selectin.
- Generates resolvins and other novel modulations.
- Inhibits activation and migration of inflammatory cells in response to arachidonic acid.
- Suppresses T-cell activation and natural killer cells.

Answer 27

Fish oil.