Marathoners eat and drink before races to make sure they're well-nourished and hydrated, but even that amount of preparation can't prevent their muscle glycogen levels — stores of energy in muscle — ?from dropping from 90 (perfect) to 50 (average). That's nothing compared with what's endured by surgical patients, whose glycogen levels can drop to as low as zero after major procedures. If runners fuel their bodies to survive 26.2 grueling miles, why wouldn't you do the same for your patients, who leave the OR feeling like they've run multiple marathons? Efforts to optimize their pre-op nutrition should begin with putting one of surgery's sacred cows out to pasture.

NPO.

Asking your patients to go NPO after midnight is an antiquated approach. Patients who drink carbohydrate supplements 2 to 3 hours before surgery show up at your facility feeling less anxious and less irritable because they're hydrated and nourished. After surgery, they're less likely to be nauseated and vomiting. They experience less pain, recover faster and head home sooner. Their blood sugar levels are stabilized, so they don't become hyperglycemic or hypoglycemic, which decreases their risk of infection. Also consider that complication rates increase from 29% in well-nourished patients to 72% in malnourished patients, according to a study in Current Opinion in Anesthesiology osmag.net/ruFTZ3. The study also found that malnourished patients are 3 times more likely to suffer post-op complications and up to 5 times more likely to die after surgery.

Drink 2 hours before

Enhanced Recovery After Surgery (ERAS) protocols recommend having patients drink a carb-rich formula 2 hours before surgery. Guidelines issued by the American Society of Anesthesiology have stated for more than a decade that patients can drink clear liquids up to 2 hours before induction of anesthesia. Current guidelines don't need to be changed. We just need to communicate the benefit of drinking carb-loaded drinks to providers and patients.

The problem is surgeons and anesthesia providers are set in their ways and have often not told patients to forgo going NPO for the many hours that are common now. They also haven't had easy-to-use products available to keep patients hydrated and nourished on the day of surgery. That's changing because pre-op drinks that are clinically proven to improve outcomes and that are safe for patients to drink before surgery in Europe are now entering the U.S. market. The amount of a carb-rich drink patients should imbibe the night before and morning of surgery varies between 16 and 32 ounces, depending on the brand. Patients can order the drinks — which cost about $4 for an 8-ounce bottle — online or receive them during visits to surgeons' offices or pre-op clinics. Consider including the drinks in your case costs because the clinical payoff is well worth the relatively nominal expense. Encourage patients to drink the carb-load over 10 to 15 minutes or less to ensure it induces the most beneficial response.

Asking patients to go NPO is done in part to lower the risk of aspiration, but drinking a carb-rich solution the morning of surgery is thought to distend the stomach, which actually helps to empty its contents. In fact, the small amount of gastric secretion that collects overnight in the stomach of NPO patients might not be pushed out as quickly before surgery.

An important note: Gatorade does not appear to be a suitable substitute for the complex carb drinks specifically formulated and studied for pre-op consumption. The simple sugars in the energy drink don't always empty from the stomach as quickly, which could increase the risk of aspiration during surgery. Moreover, the simple sugar drinks have not been shown to improve surgical outcomes.

The malnourished patient

The average lead time for ambulatory surgery is 4 to 6 weeks, which is long enough to improve the nutritional status of malnourished patients. Assess the nutritional status of patients as soon as cases are scheduled (see sidebar). If a nutritional intervention is needed, begin it immediately.

Overall protein intake is more important than total caloric intake in malnourished patients, who should ingest more than 1.2 g/kg/d of protein. Patients who need nutritional help should therefore take high protein-based supplements as well as an immune nutrition supplement, which in many studies has been shown to reduce the risk of post-op infection.

Unrecognized malnutrition may be the most pressing silent epidemic facing the surgical patient today.

Patients can drink over-the-counter high-protein (>18 grams/protein per bottle) nutritional supplements like Boost or Ensure for 3 or 4 weeks before procedures to improve their nutritional status. The drinks cost $1 to $2 a piece, so a patient might spend $30 to $40 to take the nutritional supplements leading up to surgery. Consider writing prescriptions for the drinks so patients can submit the expenses for reimbursement to healthcare savings plans and insurers.

Vitamin D deficiency is rampant among surgical patients. Those who are deficient have been shown to be at 3 to 4 times the risk of post-op infection. That's inexcusable because Vitamin D supplements (50,000 units D3 x 1 dose) can often replenish deficient levels within a week

The duration of needed pre-op nutritional support varies in guidelines from 7 to 14 days, but even 5 to 7 days of therapy can reduce post-op morbidity in malnourished patients by 50%. No malnourished patient should have surgery without nutritional optimization, but 2 out of every 3 patients who undergo GI procedures are malnourished and 43% of malnourished patients are not identified. Malnutrition is the 4th leading association of death within 30 days of surgery, according to the National Surgical Quality Improvement Program. It's also the only one on the Top 10 list that you can address by telling patients to reach for a carb-rich drink. OSM