Perioperative nutrition in abdominal surgery: recommendations and reality.

Introduction. Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Definition and diagnosis of malnutrition and its treatment is still subject for controversy. Furthermore, practical implementation of nutrition-related guidelines is unknown. Methods. A review of the available literature and of current guidelines on perioperative nutrition was conducted. We focused on nutritional screening and perioperative nutrition in patients undergoing digestive surgery, and we assessed translation of recent guidelines in clinical practice. Results and Conclusions. Malnutrition is a well-recognized risk factor for poor postoperative outcome. The prevalence of malnutrition depends largely on its definition; about 40% of patients undergoing major surgery fulfil current diagnostic criteria of being at nutritional risk. The Nutritional Risk Score is a pragmatic and validated tool to identify patients who should benefit from nutritional support. Adequate nutritional intervention entails reduced (infectious) complications, hospital stay, and costs. Preoperative oral supplementation of a minimum of five days is preferable; depending on the patient and the type of surgery, immune-enhancing formulas are recommended. However, surgeons' compliance with evidence-based guidelines remains poor and efforts are necessary to implement routine nutritional screening and nutritional support.

Perioperative nutrition is still a surgical orphan

Objective: To assess if screening programs and treatment of preoperative malnutrition have been implemented into surgical practice to decrease morbidity. There is strong evidence that postoperative morbidity can be minimized by early identifying and treating patients at nutritional risk before major surgery.The validated nutritional risk score (NRS) is recommended by the European Society of Parenteral and Enteral Nutrition for nutritional screening. It remains unclear whether routine preoperative nutritional assessment and perioperative nutrition is widely implemented.Methods: A survey was conducted in 173 Swiss and Austrian surgical departments. Implementation of nutritional screening, perioperative nutrition, and estimated impact on clinical outcome were assessed. Non-responders were repeatedly contacted by the authors.Results: The overall response rate was 55%, whereby 69% (54/78) of Swiss and 44% (42/95) of Austrian centers responded. Despite 80% and 59% of the responding centers are aware of a reduced complication rate and shortened hospital stay, respectively, only 20% of them implemented routine nutritional screening. Financial (49%) and logistic restrictions (33%) are the predominant reasons against the routine clinical use. Screening is mainly performed either in the outpatient's clinic (52%) or during admission (54%). The NRS is only used by 14%. Instead, various clinical (78%), e.g. BMI and laboratory findings (56%), e.g. albumine, are used. Indication for perioperative nutrition is based on preoperative screening in 49%.While 23% use preoperative nutrition, 68% apply nutritional support pre- and postoperatively. Preoperative nutritional treatment ranged from three days (33%), to five days (31%) and even seven days (20%).Conclusion: Despite malnutrition is well recognized as major risk factor for increased postoperative morbidity, the majority of surgeons are reluctant to implement routine screening and nutritional support. If nutritional assessment is performed, local institutional screening parameters are still preferred. It remains difficult to overcome traditions, and to change surgeon's mind.

Parenteral nutrition in the intensive care unit: cautious use improves outcome.

Critical illness is characterised by nutritional and metabolic disorders, resulting in increased muscle catabolism, fat-free mass loss, and hyperglycaemia. The objective of the nutritional support is to limit fat-free mass loss, which has negative consequences on clinical outcome and recovery. Early enteral nutrition is recommended by current guidelines as the first choice feeding route in ICU patients. However, enteral nutrition alone is frequently associated with insufficient coverage of the energy requirements, and subsequently energy deficit is correlated to worsened clinical outcome. Controlled trials have demonstrated that, in case of failure or contraindications to full enteral nutrition, parenteral nutrition administration on top of insufficient enteral nutrition within the first four days after admission could improve the clinical outcome, and may attenuate fat-free mass loss. Parenteral nutrition is cautious if all-in-one solutions are used, glycaemia controlled, and overnutrition avoided. Conversely, the systematic use of parenteral nutrition in the ICU patients without clear indication is not recommended during the first 48 hours. Specific methods, such as thigh ultra-sound imaging, 3rd lumbar vertebra-targeted computerised tomography and bioimpedance electrical analysis, may be helpful in the future to monitor fat-free mass during the ICU stay. Clinical studies are warranted to demonstrate whether an optimal nutritional management during the ICU stay promotes muscle mass and function, the recovery after critical illness and reduces the overall costs.

Preoperative nutritional screening by the specialist instead of the nutritional risk score might prevent excess nutrition: a multivariate analysis of nutritional risk factors.

BACKGROUND: The aim of the current study was to assess whether widely used nutritional parameters are correlated with the nutritional risk score (NRS-2002) to identify postoperative morbidity and to evaluate the role of nutritionists in nutritional assessment. METHODS: A randomized trial on preoperative nutritional interventions (NCT00512213) provided the study cohort of 152 patients at nutritional risk (NRS-2002 ≥3) with a comprehensive phenotyping including diverse nutritional parameters (n=17), elaborated by nutritional specialists, and potential demographic and surgical (n=5) confounders. Risk factors for overall, severe (Dindo-Clavien 3-5) and infectious complications were identified by univariate analysis; parameters with P<0.20 were then entered in a multiple logistic regression model. RESULTS: Final analysis included 140 patients with complete datasets. Of these, 61 patients (43.6%) were overweight, and 72 patients (51.4%) experienced at least one complication of any degree of severity. Univariate analysis identified a correlation between few (≤3) active co-morbidities (OR=4.94; 95% CI: 1.47-16.56, p=0.01) and overall complications. Patients screened as being malnourished by nutritional specialists presented less overall complications compared to the not malnourished (OR=0.47; 95% CI: 0.22-0.97, p=0.043). Severe postoperative complications occurred more often in patients with low lean body mass (OR=1.06; 95% CI: 1-1.12, p=0.028). Few (≤3) active co-morbidities (OR=8.8; 95% CI: 1.12-68.99, p=0.008) were related with postoperative infections. Patients screened as being malnourished by nutritional specialists presented less infectious complications (OR=0.28; 95% CI: 0.1-0.78), p=0.014) as compared to the not malnourished. Multivariate analysis identified few co-morbidities (OR=6.33; 95% CI: 1.75-22.84, p=0.005), low weight loss (OR=1.08; 95% CI: 1.02-1.14, p=0.006) and low hemoglobin concentration (OR=2.84; 95% CI: 1.22-6.59, p=0.021) as independent risk factors for overall postoperative complications. Compliance with nutritional supplements (OR=0.37; 95% CI: 0.14-0.97, p=0.041) and supplementation of malnourished patients as assessed by nutritional specialists (OR=0.24; 95% CI: 0.08-0.69, p=0.009) were independently associated with decreased infectious complications. CONCLUSIONS: Nutritional support based upon NRS-2002 screening might result in overnutrition, with potentially deleterious clinical consequences. We emphasize the importance of detailed assessment of the nutritional status by a dedicated specialist before deciding on early nutritional intervention for patients with an initial NRS-2002 score of ≥3.

Nutrition Campaign

McDonald's wished to promote the nutritional value of its menu items.

The role of vermiculite in the fixation of potassium in soils and the availability of potassium for vine nutrition in some Niagara vineyards

The Niagara P e n i n s u l a Supports a f l o u r i s h i n g grape and wine i n d u s t r y , where much of the potassium f e r t i l i z e r a p p l i e d to the vineyard s o i l s may not show up in the f r u i t or vines but is fixed by the clay m i n e r a l s in the s o i l . Soil samples were c o l l e c t e d on a n o r t h - s o u t h l i ne through a high d e n s i t y of v i n e y a r d s and examined by x - r a y d i f f r a c t i o n to determine the r e l a t i o n s h i p of potassium with r e s p e c t to c l a y minerals p r e s e n t . The i n v e s t i g a t i o n shows the p h y l l o s i l i c a t e m i n e r a l s present t o be i l l i t e , c h l o r i t e and v e r m i c u l i t e . The v e r m i c u l i t e p r e s e n t is not t h e usual M g - v e r m i c u l i t e , but a K - v e r m i c u l i t e which can be c o n s i d e r e d as a degraded i l l i t e - - t h a t i s , an i l l i t e which has l o s t potassium i o n s . The r e s u l t i n g K - d e f i c i e n t mineral possesses a very l i m i t e d expansion l a t t i ce and is capable of c a p t u r i n g potassium ions and c o n v e r t i n g back t o the i l l i t e form. A g r i c u l t u r a l l y , t h i s causes potassium d e f i c i e n c y in p l a n t s.

Soil-Transmitted Helminth Infections, Nutrition and Growth in School-age Children from Rural Communities in Honduras

Background: Soil-transmitted helminth (STH) infections are endemic in Honduras but their impact on children’s health is not well studied. Objectives: To evaluate the prevalence and intensity of STH infections and their association with nutrition and growth in a sample of Honduran children. Methodology: A cross-sectional study was done among Honduran rural school-age children in 2011. Blood and stool samples and anthropometric measurements were obtained to determine nutritional status, STH infection and growth status, respectively. Results: The STH prevalence among 320 studied children was 72.5%. Prevalence by species was 30%, 67% and 16% for Ascaris, Trichuris and 16% hookworms, respectively. High intensity infections were associated with decreased growth scores but regardless of intensity, co-infections negatively affected growth indicators. Conclusions: The health burden of STH infections is related to high parasitic load but also to the presence of low-intensity concurrent infections. The synergistic effects of polyparasitism in underprivileged children warrants more attention.