Enhanced recovery nutrition -
In situations such as starvation, the drop of glucose level will cause a reduction in insulin levels and result in a condition known as glucose repression [6]. Glucose repression includes a cascade of genes and protein expression changes to switch to alternative fuels for different cells.
The result is Fatty acids FA oxidation of stored triglycerides and the formation of ketone bodies as the primary fuel. Please see Figure 1 for more details [].
However; in metabolic stress, as mentioned above, the insulin level is very high, and it will block the lipolysis and beta-oxidation, resulting in decreased usage of FA as the primary fuel the presence of insulin inhibits ketogenesis. Therefore the body will shift to gluconeogenesis and will use Amino Acids as the main fuel [7,10,11].
This shift to gluconeogenesis would initially affect the muscles by increasing the whole body and tissue-specific protein turnover which would consequently increase the free amino acid pool circulating in the body. Secondly, it would decrease the uptake of amino acids into the skeletal muscle as well [11].
Furthermore, metabolic stress also will cause a cascade of inflammatory responses. The liver would retain amino acids to synthesize acute phase proteins like Tumor necrosis factor TNF-alpha , C-Reactive Protein CRP , and Interleukins to send signals to the immune system, which will result in the sparing of body proteins as well [2,12].
The scientific outcomes of this negative protein balance can cause skeletal muscle wasting, respiratory impairment, fatigue, higher risk of malnutrition, and diminished mTOR signaling and muscle protein synthesis [1,2,12].
This condition would increase the risk of complications by six-folds and severe infection by ten folds especially in major surgeries and large burn wounds [13]. It also aims at decreasing postoperative deleterious consequences such as complications caused by metabolic stress and postoperative catabolism [15,11].
The use of prehabilitation is increasing in hospital settings for high-risk patients, since evidence has shown better postoperative outcomes, only minor infections, shorter length of stay, fewer readmissions, and a dramatic decrease in narcotic pain medication requirement.
Several smallrandomized trials have demonstrated that multimodal prehabilitation enhances pre- and postoperative functional capacity in elective surgical patients. One of the best practical methods of prehabilitation is Enhanced Recovery After Surgery ERAS [11,].
ERAS is designed to reduce complications, hospital length of stay LOS , and overall elective surgery setting costs. Since its introduction by Kehlet in the s, ERAS has shown several benefits in patients undergoing elective surgeries including colorectal, gynecological and urological surgery [].
ERAS protocol mainly focuses on the inflammatory responses and hormonal changes during metabolic stress. This effort includes medical optimization, psychological support, physical exercise, and nutritional support.
These interventions are provided by a multidisciplinary team consisting of physicians, nurses, geriatricians, physiotherapists, nutritionists, and psychologists [11,23,24].
Other than commercial recommendations, there is no globally accepted protocol for ERAS for oral nutrition supplements ONS.
The primary effect of ONS in ERAS is unclear, and some of the perioperative supplements might have limited efficiency on postoperative outcomes, if the preoperative risk factors are not addressed properly [3,]. As described by Gündoğdu, currently there are three main categories of ONS available for ERAS.
Oral carbohydrate supplementation: It is administered for metabolic preparation mainly via increasing insulin sensitivity. High protein supplementation: It is used for severely malnourished patients with or without metabolic stress risk to reduce the complications after surgery.
This group would benefit the ONS more than well-nourished patients. Immunonutrition supplementation: It is utilized to improve the immune system and gastrointestinal barrier.
In this review paper we sought to compare some of the most common nutritional supplements and their ingredients used for ERAS programs in the US by focusing on the cell signaling effect that they may have on metabolism, protein sparing, some elective amino acids, insulin resistance, and glycemic index.
Oral Carbohydrate: Clear Carbohydrate drink is one of the most commonly used ONS in ERAS protocols. This group of ONS contains Maltodextrin CF Preop ® or a mixture of Corn Maltodextrin, Fructose, Sucralose, Acesulfame Potassium Ensure® Pre-Surgery Clear Carbohydrate.
Previous studies also have shown consumption of these carbohydrate rich drinks could improve enterocytes function after surgery. In addition, preoperative carbohydrate loading was an independent predictor of positive clinical outcomes in patients undergoing colorectal surgery [29].
Maltodextrin is a small polysaccharide and a by-product of hydrolyzing starches. According to the FDA, maltodextrin is a GRAS Generally Recognized as Safe food additive. From a Glycemic Index GI standpoint, maltodextrin is categorized as high GI, even higher than sucrose. Therefore, maltodextrin consumption could result in a significant increase in blood sugar levels [30].
Furthermore, all of the mentioned sugar substitutes, including maltodextrin, fructose, sucralose, and acesulfame potassium can alter the gut microbiome and affect the balance of gut bacteria and cause insulin resistance in the long term [31,32]. However, since the usage of these supplements is limited to the day of surgery, the probability of that aforementioned problem, in the long run, is low.
Likewise, Chromium Cr is a trace mineral that can improve insulin sensitivity 7 and exists in Impact Advanced Recovery® Nestlé 33mcg and Ensure® Surgery Abbott 12mcg.
Zinc: Zinc is the essential element for the function of more than metalloenzymes, including those used for protein synthesis. It is mainly stored in muscles and bones [7].
There are several established functions for zinc, including improving the healing process for wounds, tissue repair and regeneration, and production of DNA and RNA. It is also part of the enzymes and proteins that repair skin cells and enhance their proliferation [33,34].
Metabolic stress may cause a reduction in the serum zinc concentration, which negatively affects its anti-inflammatory and wound-healing properties [35]. The two examples of main ERAS ONS used in the US are Impact Advanced Recovery® Nestlé and Ensure® Surgery Abbott.
Omega -3 Fatty Acids Supplementation: As mentioned above Ensure® Surgery Abbott and Impact Advanced Recovery® Nestlé are two main ONS used in pre-surgery settings, marketed as Immunonutrition supplements.
Fish oils mainly contain Eicosatetraenoic acid or EPA 20 C, and five double bonds and Docosahexaenoic acid or DHA 22 C, and six double bonds. Since the main omega-3 fatty acids in these products are provided by fish oil, none of them are appropriate for vegans.
Oppositely, Ensure® Enlive Abbott contains Canola oil which is rich in Alpha-linolenic acid or ALA 18C and three double bonds [7]. Unlike plants, vertebrates lack the enzymes needed to incorporate a double bond beyond C 9 in the chain.
However, given a delta 9,12 fatty acid ALA from the diet, additional double bonds can be incorporated, and carbon chains can be elongated to make more complex fatty acids, including the anti-inflammatory markers like cyclooxygenase, lipoxygenase, prostaglandins, leukotrienes [7].
Also, as shown by Hassman et al, Omega-3 fatty acids can diminish inflammation by providing specialized proresolving mediators SPMs , which can decrease the production of pro-inflammatory cytokines [38]. These improvements were independent of the omega-3 fatty acids type ALA vs. Nucleotides: Purine, pyrimidine bases, ribose, and phosphoric acid are needed to synthesize deoxynucleic acid DNA , ribonucleic acid RNA , and ATP.
They are required for cell growth, proliferation, and differentiation. Therefore, they play a vital role in rapidly dividing cells, including lymphocytes and enterocytes, and the maintenance and restoration of the immune response [42].
Akyuz emphasizes supplementation with nucleotide as part of an immune nutrition supplement including omega-3 fatty acids, arginine, and nucleotides that can protect the enterocytes against chemotherapy damage [43].
Although the body can synthesize these nucleotides during metabolic stress, their formation would be altered because of the hormonal and metabolic changes [44]. The only commercially available ONS in the US with nucleotides is Impact Advanced Recovery® Nestlé , with mg dietary nucleotides.
High Protein Supplementation: As mentioned before, the metabolic stress of major surgeries stimulates a catabolic state which increases gluconeogenesis and causes a higher need for proteins in general. Although required protein intakes for patients undergoing major surgeries are not very well-identified, the American Society of Parenteral and Enteral Nutrition ASPEN and the European Society of Clinical Nutrition and Metabolism ESPEN guidelines recommend at least 1.
Another study conducted by Yeung compared ERAS protocols with conventional care regarding protein intake and showed that even though ERAS patients consume more protein mainly via ONS , neither ERAS nor conventional care patients meet the required protein intake [47].
Well-nourished patients with a functional digestive system can initiate their oral intake 24 hours after surgery to achieve most of their dietary needs. However, any delay to restarting oral intake is connected to the higher rate of infections and lower survival rate [29,51]. Several meta-analyses emphasize an increased risk of vomiting and postoperative aspiration related to early oral intake as well [29].
There are many different ONS in several forms liquid, powder to provide different amino acids for gluconeogenesis caused by metabolic stress and prevent the body from going through muscle wasting and malnutrition due to metabolic stress.
Several studies have shown the effectiveness of different amino acids and high protein supplements. However, these types of supplementations seem to be more effective in malnourished patients undergoing major surgeries or critically ill patients [25,47,52,53].
Arginine: Arginine ARG is commonly categorized as a nonessential amino acid, but it becomes conditionally essential in situations like metabolic stress [54]. The main site for arginine metabolism is the liver and kidney.
The kidney can convert citrulline to arginine, then some of this endogenous arginine would be transported into the blood to be used by other organs. Please see Figure 2 for more details [55]. There are several known functions for ARG, but the most important one is the production of Nitric Oxide NO.
Since its discovery in , many biological roles have been established for NO. It is a critical molecule in vascular dilation, neurotransmission, acute and chronic inflammation, and the immune system [56].
Different cells, including macrophages and neutrophils, use ARG to make NO [57]. It also has been suggested that the presence of NO generated from the ARG-NO pathway facilitates the shift of a wound from the acute inflammatory phase to the proliferative phase of wound healing [35,38].
ARG supplementation may increase NO production in different cells, including immune cells and endothelial cells. Ornithine can be converted to L-proline, a substrate for collagen synthesis, and polyamines, stimulating cellular proliferation [58].
Interestingly, supplementation with L-citrulline increases levels of circulating L-arginine more than supplementing with ARG itself [59,60] In a normal situation, around half of the consumed ARG would be entered into the portal vein and the other half will be directly used by enterocytes or will be degraded [35].
ARG supplementation is generally safe when the consumed amount is 20 grams or less per day, but it could trigger gastrointestinal symptoms at quantities as low as 5 grams per day [61]. L-citrulline is claimed to be one of the ingredients in CF Preop ® but there is no information about the quantity in the nutrition facts about this ingredient.
Studies have shown that major surgical procedures can diminish circulating ARG due to more ARG breakdown for NO synthases and less endogenous ARG production [62].
The two main ERAS ONS used in the US are Impact Advanced Recovery® Nestlé and Ensure®® Surgery Abbott. Both of these supplements contain 4. The other ONS Ensure® Enlive, which is mainly recommended for postoperative care, does not have any additional ARG. Glutamine: Glutamine GLN is another nonessential amino acid.
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Copyright ©The Author s Published by Baishideng Publishing Group Inc. All rights reserved. World J Gastrointest Surg. Sep 27, ; 15 9 : Published online Sep 27, doi: Yan-Ru Shao , Xia Ke , Li-Hua Luo , Jin-Dong Xu , Li-Qian Xu.
ORCID number: Li-Qian Xu Author contributions : Shao YR, Ke X and Xu JD designed the research study; Luo LH, Xu JD and Xu LQ performed the research; Xue JZ, Luo LH and Ke X contributed new reagents and analytic tools; Shao YR and Xu LQ analyzed the data and wrote the manuscript; and all authors have read and approve the final manuscript.
Informed consent statement : The informed consent statement was waived by the Ethics Committee. Data sharing statement : The labeled dataset used to support the findings of this study are available from the corresponding author upon request.
Open-Access : This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial CC BY-NC 4.
Received: May 9, Peer-review started : May 9, First decision : May 25, Revised: June 25, Accepted: August 2, Article in press : August 2, Published online: September 27, Key Words: Enhanced recovery after surgery , Extremely early postoperative enteral nutrition nursing , Gastrointestinal surgery , Tracheal intubation under general anesthesia , Agitation during recovery , Recovery of gastrointestinal function.
Citation: Shao YR, Ke X, Luo LH, Xu JD, Xu LQ. Table 1 Comparison of clinical data between the two groups.
BMI: Body mass index; ASA: American Society of Anesthesiologists. Comparison of related indexes of recovery period between the two groups. Open in New Tab Full Size Figure Download Figure. Figure 1 Comparison of relevant recovery duration indices for the two groups. A: Awakening time; B: Spontaneous breathing recovery time; C: Extubation time; D: Postoperative eye-opening time; E: Recovery time of directional force time.
Comparing the two groups' recovery agitation. Figure 2 Incidence of agitation among these two groups throughout the recovery period.
SAS: Riker's Sedation-Agitation Scale. Comparison of gastrointestinal function recovery across groups. Figure 3 Comparison of the two groups' recovery of gastrointestinal function. A: Intestinal sound recovery time; B: First postoperative exhaust time; C: Postoperative first defecation time; D: Time of first half-fluid feeding after operation.
Postoperative nutritional status comparison between groups. Figure 4 Comparison of postoperative nutritional condition observed among the two groups. A: Albumin; B: Hemoglobin; C: Fasting blood glucose.
Comparison of Anesthesia-related adverse responses in both groups. Group n Hypoxemia Chills Nausea and vomiting Total incidence Observation group 63 0 4 1 7. Provenance and peer review: Unsolicited article; Externally peer reviewed. Burcharth J , Falkenberg A, Schack A, Ekeloef S, Gögenur I.
The effects of early enteral nutrition on mortality after major emergency abdominal surgery: A systematic review and meta-analysis with Trial Sequential Analysis. Clin Nutr. Chen R , Yin W, Gao H, Zhang H, Huang Y.
The effects of early enteral nutrition on the nutritional statuses, gastrointestinal functions, and inflammatory responses of gastrointestinal tumor patients.
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J Laparoendosc Adv Surg Tech A. Jiang ZW , Li N. Zhonghua Weichang Waike Zazhi. Xiang Q , Yuan H, Cai W, Qie S. Effect of early enteral nutrition on laparoscopic common bile duct exploration with enhanced recovery after surgery protocols.
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Chongqing Yixue. Ohbe H , Jo T, Matsui H, Fushimi K, Yasunaga H. Differences in effect of early enteral nutrition on mortality among ventilated adults with shock requiring low-, medium-, and high-dose noradrenaline: A propensity-matched analysis.
Iranmanesh P , Delaune V, Meyer J, Liot E, Konrad B, Ris F, Toso C, Buchs NC. Comparison of Outcomes between Obese and Non-Obese Patients in a Colorectal Enhanced Recovery After Surgery ERAS Program: A Single-Center Cohort Study.
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A single blinded randomized pilot study. Cheng KW , Wang GH, Shu KS, Zheng M, Liu HX, Tang AP, Zuo BH, Wang ZX, Wang YJ, Hu WJ, Ma DH. Zhongguo Putong Waike Zazhi.
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Enhanced recovery after surgery ERAS protocol reduces perioperative narcotic requirement and length of stay in patients undergoing mastectomy with implant-based reconstruction.
Dietitian Team building exercisesMNT Guidelines Jun 15 recoverg One nutritikn component of Enhanced Recovery After Surgery ERAS protocol is Enhancwd provision of pre- Enhanced recovery nutrition post-op nutrition in patients undergoing elective surgery. ERAS focuses on the reduction of physiological stress to promote faster recovery. And in fact, many of the aspects of ERAS protocols, including IV fluid provision, analgesia selection, and anesthetic technique, are designed to support early post-op feeding. Read on to find out how nutrition earned a starring role in the world of fast-track surgery.
Enhanced recovery nutrition -
A shift in clinical care usually takes several years to develop. Many units all across the world have made tremendous changes in just a few days for COVID This would not have been feasible without a shared desire to address a major problem by combining the knowledge of everyone involved, from the operating room to hospital administration.
The goal was achieved thanks to the collaboration of all these entities 2. This is where the future of surgery and anesthesia will be decided. Surgery and anesthesia must take the opportunity to revolutionize perioperative care by building on the momentum of change established during the COVID epidemic.
Telemedicine, for example, has been utilized to eliminate needless in-person visits. A major obstacle is to close knowledge gaps through high-quality research. As part of its mission to advance clinical research, the Enhanced Recovery After Surgery ERAS Society has produced suggestions for writing about ERAS 3.
ERAS integrates modern monitoring and auditing to gain control of the entire perioperative process, resulting in much-needed surgical and nutritional outcomes improvement 4.
Part of the ERAS protocol includes perioperative nutrition support. They minimize several of the detrimental consequences of overnight fasting when taken before surgery. Carbohydrates consumed before surgery result in decreased post-operative insulin resistance, decreased hyperglycemia, and decreased insulin treatment requirements while preserving skeletal muscle and, in patients having heart surgery, cardiac muscle function.
Carbohydrate beverages vary significantly in composition, and their content has a direct impact on their physiological function and safety.
Numerous carbohydrate-containing products have been recommended for pre-operative usage, but only a few have been adequately studied. As a result, customers should require manufacturers to give data on their specific recipe demonstrating that their product has been studied for safety and efficacy before usage 5.
Delivering care through the ERAS system is proving to be highly beneficial. Surgery, nutrition, and anesthesia will be elevated to new heights with the help of low-cost, high-quality research in the next phase of ERAS. Patients and health systems will benefit from the efforts of perioperative care professionals during this time of global crisis.
COVIDSurg Collaborative. Elective surgery cancellations due to the COVID pandemic:global predictive modelling to inform surgical recovery plans. Br J Surg. Global guidance for surgical care during the COVID pandemic. Elias KM, Stone AB, McGinigle K, Stone AB, McGinigle K, Tankou JI, et al.
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Gianotti L, Biffi R, Sandini M, Marrelli D, Vignali A, Caccialanza R, et al. Preoperative oral carbohydrate load versus placebo in major elective abdominal surgery PROCY :a randomized, placebo-controlled, multicenter, phase III trial.
Ann Surg. Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this study. Confidentiality of data. The authors declare that no patient data appear in this article. Right to privacy and informed consent.
cervantes academico. According to the personalized evaluation of patients, the satisfaction of the ERAS group was also much higher than that of the control group.
Indeed, the patients in the ERAS group had better clinical compliance of postoperative follow-up. In recent years, it has been recognized that the gastrointestinal tract is not only an organ of digestion and absorption, but an important immune organ 21 , Based on this, the advantages of EN are not only reflected in the direct absorption and utilization of nutrients through the intestine, more physiological, convenient administration and low cost, but helped to maintain the integrity of intestinal mucosal structure and barrier function 23 , The ESPEN guidelines propose that normal food intake or EN should start early after surgery An analysis was conducted to investigate the relationship between perioperative nutritional intervention, especially preoperative intervention and surgical effect in the ERAS group.
Patients receiving the perioperative nutrition regimen had a shorter hospital stay, faster recovery of intestinal function, and greater patient satisfaction compared with patients in the control group.
Furthermore, immunity was enhanced and there were less postoperative complications compared with the control group. Early preoperative nutrition status was associated with a significant reduction in postoperative overall complications. According to the experimental results, the extremely low incidence of postoperative complications may be related to long-term preoperative training.
This effect was more pronounced in patients who received longer periods of preoperative nutrition. In addition, their physical condition and mental outlook were better in the early postoperative period than those in the control group.
This was mainly reflected in their significantly better physical condition and earlier participation in postoperative exercise recovery, and their compliance and overall satisfaction were better than those in the control group. In conclusion, we have shown that preoperative nutritional intervention played a key role in the prognosis of patients undergoing surgery.
The analysis of the satisfaction test results showed that patients found value in using personalized clinical nursing measures. Furthermore, important results were through data collation: clinical compliance of the patients such as quitting smoking and drinking, taking medication regularly, and exercising regularly was significantly associated with patient satisfaction.
Compared with the control group, no significant difference in the ERAS group was found in regard to satisfaction with clinical nursing. However, in terms of self-subjective feelings, the survey results showed that the ERAS group had more positive emotions and better expectations for both the near and distant future.
This is obviously of great value to the clinical rehabilitation and follow-up treatment of patients. These predictors could be interpreted as the determinants of patient satisfaction in each group when other factors do not change greatly within the group. The current study had some limitations.
The main weakness of this study was the absence of important nutritional indices, such as calorie needs, energetic needs, protein needs etc. Advantages were that we used NRS score and preoperative EN before surgery, and we followed the patients nutritional support suggestions after discharge.
Furthermore, while our data supported the efficacy and safety of our perioperative nutrition support program, larger multicenter studies are needed to assess its applicability in patients undergoing CEA surgery. According to our study, perioperative nutrition in ERAS program had a positive effect on postoperative rehabilitation and improved postoperative complications in CEA patients.
The LOS and the cost of hospitalization were, in turn, significantly reduced. Finally, under dedicated nursing care, the mental state and subjective feelings of patients were greatly improved. Further research is needed to demonstrate the effect of clinical nutrition support in a pragmatic manner.
The studies involving human participants were reviewed and approved by the Institutional Human Research and Ethics Committee of Tangdu Hospital. BL and YQ conducted the study design.
Y-QL, X-PQ, and L-WP completed the writing of the manuscript. Later revisions were done by BL, YQ, J-YA, X-WL, and YZ. Y-QL, X-PQ, L-WP, J-YA, X-WL, YZ, CW, XJ, LG, GL, D-LW, and D-CZ participated in the data collection, while data analysis is done by CW, XJ, LG, GL, D-LW, and D-CZ.
All authors contributed to the article and approved the submitted version. This work was supported by the National Natural Science Foundation of China nos. This research received no specific grant from any funding agency in the public, commercial, or non-profit sectors.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.
Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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Patient satisfaction with nursing care in the context of health care: a literature study. Scand J Caring Sci. Keywords: carotid endarterectomy, enhanced recovery after surgery, nutrition, rehabilitation, ischemic stroke. Citation: Li Y-Q, Qu X-P, Peng L-W, An J-Y, Liu X-W, Zhang Y, Wang C, Jiang X, Gao L, Li G, Wang D-L, Zhao D-C, Qu Y and Liu B Targeted nutritional intervention with enhanced recovery after surgery for carotid endarterectomy: A prospective clinical trial.
Received: 23 May ; Accepted: 22 March ; Published: 13 April Copyright © Li, Qu, Peng, An, Liu, Zhang, Wang, Jiang, Gao, Li, Wang, Zhao, Qu and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY.
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Nurtition recovery after surgery ERAS nutrition protocol during Enhanced recovery nutrition pandemic. Protocolo Enhanced recovery nutrition de Enanced acelerada después de cirugía durante la pandemia por covid Gabino Cervantes-Guevara 1 2. Alejandro González-Ojeda 3. Clotilde Fuentes-Orozco 3. Sol Ramírez-Ochoa 4 5. Lorena A.
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