Cath Lab Digest

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  An abundance of research supports nutrition guidelines for treating pressure ulcers, but published guidelines on medical nutrition therapy for postsurgical wounds do not exist. Surgical wounds are distinctly different from chronic types of wounds; key factors in nonhealing surgical wounds are ischemia and bacterial colonization, which stall healing in the inflammatory stage.¹ Primary wound healing typically begins within hours of closing a surgical incision.² Nevertheless, the principle goals of wound healing are to eliminate factors that may complicate or delay wound healing, and then optimize the wound healing environment^3,4 (see Table 1). Some factors that may complicate or delay wound healing can be addressed (at least partially) through nutrition.

  Malnutrition puts stress on the immune system and is a risk factor for poor wound healing and other postoperative morbidities and mortality⁵ (see Table 2 and Table 3). Postoperative malnutrition is associated with higher complication rates.6 Deficiencies in a variety of nutrients can impair wound healing; severe protein deprivation is associated with an increased rate of wound infection. Superficial surgical site infection (SSI) is one of the most frequent hospital-acquired infections on surgical floors.⁷ One study found that the best predictor of SSI was the preoperative serum albumin level.⁸ Addressing malnutrition preoperatively may promote faster wound healing after surgery.⁵

Fast-Track Protocols

  According to the European Society for Clinical Nutrition and Metabolism (ESPEN),⁹ the main goals of perioperative nutrition support are to minimize negative protein balance in order to maintain muscle, immunity, and cognition and promote postoperative recovery. Guidelines from ESPEN on parenteral nutrition (PN) following surgery indicate that only a small number of patients should benefit from this type of therapy due to the introduction of modern surgical practices that use “enhanced recovery after surgery (ERAS) protocols” that lead to most patients eating regular food within 1 to 3 days. ERAS, also known as “fast-track” protocols, are multidisciplinary perioperative pathways designed to speed surgical recovery. Thus, patients identified preoperatively as severely malnourished who cannot obtain sufficient calories orally or enterally may benefit from 7 to 10 days of PN, but oral and enteral routes of nutrition should be given preference in postoperative patients.⁹

  Melnyk¹⁰ notes that adoption of ERAS protocols has been slow despite the strong evidence in their favor. Traditional feeding practices of surgical patients frequently contribute to malnutrition; such practices include nil per os (NPO) status preoperatively, delayed feeding while awaiting signs of the return of bowel function, and a slow advancement of the diet from clear liquids.