Energy and protein deficits in postoperative catabolic states
Energy and protein deficits are common in patients hospitalized for surgery and put patients at risk of poor clinical outcomes.
Patients suffering from malnutrition upon hospitalization and those with energy and protein deficits during their hospitalization carry an increased risk of infections and other complications, of prolonged stay in the intensive care unit (ICU), the hospital, and are at a higher risk of death.[i][ii][iii]
Those admitted for upper gastrointestinal surgery and cancer patients have been repeatedly identified as populations at risk:
- A survey of 943 patients in Hong Kong undergoing major abdominal surgery revealed that 33% of patients were moderately or severely malnourished, with negative effects on outcomes and treatment costs.[iv]
- More than 50% of postsurgical cancer patients are affected by energy and protein deficits. Underlying reasons include inflammation, side effects of aggressive anti-cancer therapies, and altered metabolism. Untreated weight loss may progress into cancer anorexia-cachexia syndrome (CACS), a syndrome characterized by metabolic abnormalities and loss of skeletal muscle and adipose tissues.[v]
- Observational studies confirm the notion that patients with energy and protein deficits before hospitalization will suffer stronger from unmet needs during their ICU stay: Increased amounts of calories were associated with reduced mortality for patients with a low body mass index (BMI <25).
Major surgery triggers a catabolic state that depletes the body’s energy stores and skeletal muscles
Energy and protein deficits impair the body’s immune response and the capacity to handle surgical stress. Surgical procedures result in hemodynamic, metabolic, neurohormonal, and immune responses. The metabolic state is characterized by catabolism, the breakdown of energy stores (glycogen and fat) and protein for the release of glucose, free fatty acids and amino acids. These substrates, normally dedicated to maintaining peripheral musculature, are rededicated for healing and immune response. The resulting loss of muscle mass is a significant long-term burden for the recovery of functional status. [vi]
The energy and protein deficits are often aggravated by prolonged perioperative fasting. Therefore, nutritional intake or therapy is pivotal in providing the necessary nutrients for rebuilding the body cell mass and peripheral muscles.
Nutritional support is key in the prevention of complications and adverse functional outcomes
Among all the multiple demands of perioperative care, nutrition may be overlooked as a key factor for patient recovery. Experts call for integration of nutritional care into the overall management of the patient. Guidelines recommend measures to counteract energy and protein deficit as perioperative risk factors [vii]
- Assessment of nutritional status before and after major surgery
- Avoidance of prolonged perioperative fasting
- Reestablishment of oral feeding as soon as possible after surgery
- Initiation of nutritional therapy as soon as nutritional risk is detected, preferably via the enteral route. This risk includes the anticipated inability to eat sufficiently for several days.
- Initiation of parenteral nutrition if oral and enteral nutrition is contraindicated or cannot meet the energy and protein requirements
- Early mobilization to promote protein synthesis and muscle function
Improved nutrition practice may pay off: Patients who receive nutritional support not only suffer from less infectious and non-infectious complications, they also leave the hospital earlier7 and have a good chance of leaving the hospital in better shape. It was observed that patients who accumulated a lower energy and protein deficiency during their stay at a surgical ICU were more likely to be discharged home versus being discharged to a nursery facility due to their poor functional status. [viii]
- iShpata V, Prendushi X, Kreka M, et al. (2014) Malnutrition at the time of surgery affects negatively the clinical outcome of critically ill patients with gastrointestinal cancer. Med Arch 68:263-267
- iiKang MC, Kim JH, Ryu SW, et al. (2018) Prevalence of Malnutrition in Hospitalized Patients: a Multicenter Cross-sectional Study. Journal of Korean medical science 33:e10
- iiiSorensen J, Kondrup J, Prokopowicz J et al. (2008) EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr. 27:340-9
- ivHo JW, Wu AH, Lee MW, et al. (2015) Malnutrition risk predicts surgical outcomes in patients undergoing gastrointestinal operations: Results of a prospective study. Clin Nutr. 34:679-84.
- vGangadharan A, Choi SE, Hassan A et al. (2017) Protein calorie malnutrition, nutritional intervention and personalized cancer care. Oncotarget. 8:24009-24030.
- viZhong JX, Kang K, Shu XL (2015) Effect of nutritional support on clinical outcomes in perioperative malnourished patients: a meta-analysis. Asia Pacific journal of clinical nutrition 24:367-378
- viiWeimann A, Braga M, Carli F, et al. (2017) ESPEN guideline: Clinical nutrition in surgery. Clinical nutrition (Edinburgh, Scotland) 36:623-650
- viiiYeh DD, Fuentes E, Quraishi SA, et al. (2016) Adequate Nutrition May Get You Home: Effect of Caloric/Protein Deficits on the Discharge Destination of Critically Ill Surgical Patients. JPEN Journal of parenteral and enteral nutrition 40:37-44