ESPEN Guidelines on Parenteral Nutrition: Surgery

SummaryIn modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1–3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery.Several studies have demonstrated that 7–10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity.Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7–10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice.The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights.In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.Summary of statements: SurgerySubjectRecommendationsGradeNumberIndicationsPreoperative fasting from midnight is unnecessary in most patientsAPreliminary remarksInterruption of nutritional intake is unnecessary after surgery in most patientsAPreliminary remarksApplicationPreoperative parenteral nutrition is indicated in severely undernourished patients who cannot be adequately orally or enterally fedA1Postoperative parenteral nutrition is beneficial in undernourished patients in whom enteral nutrition is not feasible or not toleratedA2Postoperative parenteral nutrition is beneficial in patients with postoperative complications impairing gastrointestinal function who are unable to receive and absorb adequate amounts of oral/enteral feeding for at least 7 daysA2In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choiceA2Combinations of enteral and parenteral nutrition should be considered in patients in whom there is an indication for nutritional support and in whom >60% of energy needs cannot be met via the enteral route, e.g. in high output enterocutaneous fistulae or in patients in whom partly obstructing benign or malignant gastro-intestinal lesions do not allow enteral refeeding. In completely obstructing lesions surgery should not be postponed because of the risk of aspiration or severe bowel distension leading to peritonitisC2In patients with prolonged gastrointestinal failure parenteral nutrition is life-savingC2Preoperative carbohydrate loading using the oral route is recommended in most patients. In the rare patients who cannot eat or are not allowed to drink preoperatively for whatever reasons the intravenous route can be usedA3Type of formulaThe commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weightB4In illness/stressed conditions a daily nitrogen delivery equivalent to a protein intake of 1.5 g/kg ideal body weight (or approximately 20% of total energy requirements) is generally effective to limit nitrogen lossesB4The Protein:Fat:Glucose caloric ratio should approximate to 20:30:50%C4At present, there is a tendency to increase the glucose:fat calorie ratio from 50:50 to 60:40 or even 70:30 of the non-protein calories, due to the problems encountered regarding hyperlipidemia and fatty liver, which is sometimes accompanied by cholestasis and in some patients may progress to non-alcoholic steatohepatitisC5Optimal nitrogen sparing has been shown to be achieved when all components of the parenteral nutrition mix are administered simultaneously over 24 hoursA6Individualized nutrition is often unnecessary in patients without serious co-morbidityC7The optimal parenteral nutrition regimen for critically ill surgical patients should probably include supplemental n-3 fatty acids. The evidence-base for such recommendations requires further input from prospective randomised trialsC8In well-nourished patients who recover oral or enteral nutrition by postoperative day 5 there is a little evidence that intravenous supplementation of vitamins and trace elements is requiredC9After surgery, in those patients who are unable to be fed via the enteral route, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basisC9Weaning from parenteral nutrition is not necessaryA10Full-size tableTable optionsView in workspaceDownload as CSV