Targeting the Use of Specialized Nutritional Formulas in Surgery and Critical CareFrom the Medical College of Georgia, Augusta, Georgia Correspondence: Gail Cresci, RD, CNSD, Medical College of Georgia, 1120 15th Street, Room 4072, Augusta, GA 30912. Electronic mail may be sent to gcresci{at}mail.mcg.edu.
It is agreed among most clinicians that patient morbidity, mortality, and hospital length of stay can be negatively affected by malnutrition. In fact, nutrition guidelines state that any patient unable to consume adequate nutrients orally (60% nutrition needs) for at least 5 days in the critically ill, or 7 to 14 days in the general population, should be a candidate for specialized nutrition support and that enteral feeding is preferred over parenteral nutrition.1 However, inadequate attention to nutrition intervention may occur for several reasons, including lack of recognition of need for various patient populations, low priority, and controversial clinical outcomes. Because of variance in research designs where nutrition intervention may be provided to well-nourished or mildly malnourished patients and lack of stratification for comorbidities or surgical pathology, thus resulting in little to no benefit with early nutrition intervention, many clinicians opt not to aggressively feed their patients until complications arise and forgo preoperative nutrition intervention altogether. Significantly increased postoperative complications, mortality rates, intensive care unit (ICU) and hospital length of stays were found to occur among general surgery patients that were capable of receiving preoperative nutrition but did not.2 Complications were correlated with operative site, magnitude and complexity of the procedures and preoperative albumin levels, with complications rising as albumin levels dropped (Table I). For patients with an albumin level <3.25 g/dL, pancreatic surgery resulted in higher major complication rates than those undergoing gastric (p = .03) or colonic surgery (p = .003); esophageal surgery resulted in significantly more major complications than patients undergoing colon surgery (p = .02). Complications were also different among hospital systems; there were significantly fewer serious complications in private hospitals than in the Veterans Affairs (VA) or public hospitals (p < .05). But when patients were stratified by preoperative albumin levels (<3.25 or >3.25 g/dL), all differences vanished, reflecting the high number of poorly nourished patients in the VA system and public hospitals.
Several researchers have investigated providing specialized oral enteral formulas to surgical patients in anticipation of reducing postoperative complications.3–6 In well-nourished surgical patients, an immune formula (Impact; Novartis Nutrition, Minneapolis, MN) provided just preoperatively rather than both pre- and postoperatively, may be just as beneficial.3 However, malnourished patients seem to benefit from a perioperative approach. Malnourished patients that received 1 L of an immune formulation (Impact) for at least 5 to 7 days preoperatively in addition to postoperative immune tube feedings had significantly decreased length of stay, significantly less postoperative complications, and a shorter duration of antibiotic therapy when compared with the control group that received standard formulas.4–6 Studies like these indicate that nutrition support of malnourished surgical patients is no longer about the quantity of nutrient provision but that the quality, type, and duration of the nutrients provided is important to aid the patient in defending themselves against potential postoperative infectious and noninfectious complications. Critically ill patients are also prone to contract infections because of their compromised immune status and the clinical conditions and therapies in which they are exposed. Once a patient remains in the ICU >5 days, bloodstream infections commonly result. For trauma ICU patients, risks for potential complications are quantified by indices such as the Abdominal Trauma Index or Injury Severity Score. Research studies often site the APACHE II scores as indicators of risk severity for medical ICU patients. However, few clinicians actually calculate these scores in daily practice as it can be quite cumbersome. Therefore, it would be beneficial to have other means of identifying ICU patients at risk for infections. Laupland et al identified several demographic and chronic conditions as risk factors for acquiring severe bloodstream infections (Table II).7 Patients had a higher risk and incidence of developing bloodstream infections if they had one of the following underlying conditions: age (>65 years), urban residence, male gender, hemodialysis, diabetes, cancer, lung disease, and alcoholism. The most common etiologies were Staphylococcus aureus, Escherichia coli, and streptococcus pneumonia. They concluded that identification of risk factors for severe bloodstream infections may allow targeting of preventive efforts such as specialized nutrition intervention to individuals at greatest potential benefit.
In multiple clinical research studies, provision of immune formulations has
resulted in decreased infectious complications and improved patient outcomes.
The immune formulation provided in the preoperative and perioperative research
studies and the majority of clinical trials evaluating immune formulations was
Impact Recover (Novartis Nutrition) preoperatively, and Impact (Novartis
Nutrition) postoperatively. To date, these are the only formulations
commercially available that, when provided in desired and tolerated volumes,
will deliver the appropriate amounts of studied immune nutrients (arginine,
Ideal candidates for these formulations are outlined in Table III and include the following: malnourished and nonmalnourished elective surgery patients that may also have comorbid conditions such as diabetes, heart disease, lung disease, and obesity; critically ill ICU patients that have several comorbid conditions placing them at higher risk of infections; and critically ill trauma and surgical patients that are anticipated to remain in the ICU for >3 to 5 days. In the elective surgery patient, these formulations should be provided as an oral supplement in addition to a regular oral diet for 5–7 days preoperatively. If the patient is malnourished preoperatively, then early enteral feeding with an immune formulation postoperatively is suggested. For the patient that is anticipated to remain in the ICU >5 days, these formulations should be provided as soon as the patient is adequately resuscitated and hemodynamically stable. Delivering these formulations post-pylorically is preferred, particularly in the surgical and trauma population. Feedings should be started at a low rate, 10–20 mL/h, and increased over the course of 72–96 hours toward the targeted goal rate as the patient demonstrates tolerance. Delivery of immune nutrients should be continued for at least 7 days, providing at minimum 50% of nutrient needs but attempting to achieve caloric goals, in order for the patient to receive the appropriate amounts of targeted nutrients. After this time, the patient should be reevaluated for continued need of product, or determination of whether a standard formulation may be indicated.
With the exponential rise of resistant bacteria invading hospital settings, and little hope for new antibiotics to fight them, it is exciting and encouraging to demonstrate the reduction of infections and infectious complications simply by modulating the patient's immune function through nutrition intervention. Clearly it is the role of the nutritionist and other key medical team members to advocate good nutritional health for patients to optimize patient outcomes. Early identification of patients at risk for poor outcomes and extended hospital stays and ultimately increased resource use should become part of outpatient and inpatient screening process and medical nutrition therapy. By decreasing the absorbent costs associated with infectious complications, the up-front cost of these specialized formulas becomes trivial, as shown in other articles in this supplement. Nutrition care providers should advocate to administration to support the costs of these formulations to achieve the ultimate nutritional goal of improving patient outcomes with cost-effective nutrition interventions.
Administration of specific immune formulations both preoperatively and postoperatively has resulted in decreased infectious complications and improved patient outcomes. Thus, the cost of these specialized formulas becomes insignificant as they decrease the overall cost associated with infectious complications. Received for publication September 20, 2004. Accepted for publication October 13, 2004.
Journal of Parenteral and Enteral Nutrition, Vol. 29, No. 1 suppl,
S92-S95 (2005) This article has been cited by other articles:
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-3 fatty acids, nucleotides, glutamine) that have been linked with
decreasing infectious risks and complications. Because these formulations
carry a higher cost with them, selective use is advocated. Despite the
increased cost of providing the formula Impact itself
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