Using nutrition counseling to help prep surgery patients for better outcomes

Marathon runners know to carbo-load the night before a big run and the importance of replenishing electrolytes as they tick off miles.

Being attuned to their bodies, exercise enthusiasts do what they can to minimize the physical stress they'll undergo during an event.

Preparing for surgery should be no different, argues Dr. Paul Wischmeyer, an anesthesiologist at Duke University Hospital in Durham, N.C.

Yet, patients are told to essentially starve themselves beforehand.

"Why are we doing this?" he asked.

For starters, habit. Telling patients to forgo eating or drinking before surgery has become commonplace and it is a hard pattern to break. The other issue is that nutrition just isn't top of mind for doctors when their patients go into surgery. Most physicians only took one class during medical school on the importance of nutrition. But it's closely related to how a patient will recover after a procedure, according to Wischmeyer.

Studies show that a well-nourished individual is more likely to survive and is quicker to recover from many kinds of surgery, especially abdominal and vascular procedures. Despite this, an estimated 30% of patients are malnourished before surgery.

Duke University Hospital is part of a growing movement tackling malnutrition for surgical patients. Called Enhanced Recovery After Surgery, it mimics common practices in Europe that encourage food before and after procedures to improve outcomes.

Some studies have shown that these interventions can reduce infection rates by 40% and shorten length of stay by two days, Wischmeyer said.

Duke recently established a clinic focused on helping patients improve their nutritional health before they undergo procedures. Patients are referred to the Perioperative Screening Clinic if they are found to be malnourished right before a non-emergency surgery.FB01

A clinical decision-support function was added to the electronic health record to help physicians identify malnourished surgical patients. The EHR prompts physicians to complete three steps to determine if their patient is undernourished before a scheduled procedure.

• Weigh the patient to know if his or her body mass index is too low for their height and age.
• Ask the patient if he or she has lost more than 10% of their weight in the past six months.
• Ask if the patient has been eating less than 50% of their normal diet in the past week.

Patients with an abnormally low BMI score or who respond affirmatively to either question are referred to the nutrition clinic and their surgery is postponed.

"We know that if you have low muscle mass in your body, and you undergo chemotherapy or surgery, your chances of dying are much, much higher," Wischmeyer said.

Duke also plans on screening patients for vitamin D deficiency soon since it's an effective way to know if patients suffer from weak bone mass, which also can impact healthy surgical outcomes.

At the clinic, the patient typically meets with a dietitian for about a month to get healthy. A big part of the meetings are focused on nutritional education. The dietitian will recommend high-protein foods to eat before and after their surgery. Protein supplements are also administered. Once it has been determined the patient is healthy enough to undergo surgery, the procedure is rescheduled.

All surgical patients at Duke are told to have a liquid supplement loaded with carbohydrates two hours before their surgery. This goes against common practice at most hospitals around the country which usually inform patients not to eat or drink anything 8 hours before a procedure.

After they awake from surgery, they are again given another protein supplement. A patient usually isn't hungry shortly after surgery, but it's important to encourage patients to have nutrients in their body to improve their likelihood of a speedy recovery, Wischmeyer said. A dietitian will also call the patient about a month after their surgery to ask about their eating habits and if they have lost or gained weight since the procedure.

So far, physicians at Duke have been receptive to the program, Wischmeyer said. "They want to better serve their patients," he said.