Role of Nutrition Support in Adult Cardiac Surgery

A Consensus Statement From an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery

Christian Stoppe; Andreas Goetzenich; Glenn Whitman; Rika Ohkuma; Trish Brown; Roupen Hatzakorzian; Arnold Kristof; Patrick Meybohm; Jefferey Mechanick; Adam Evans; Daniel Yeh; Bernard McDonald; Michael Chourdakis; Philip Jones; Richard Barton; Ravi Tripathi; Gunnar Elke; Oliver Liakopoulos; Ravi Agarwala; Vladimir Lomivorotov; Ekaterina Nesterova; Gernot Marx; Carina Benstoem; Margot Lemieux; Daren K. Heyland

Disclosures

Crit Care. 2017;21(131) 

In This Article

Nutrition in Cardiac Surgery Patients

Preoperative fasting sets the stage for catabolic stress,[7] insulin resistance,[8] nutrient deficiencies, and adverse immune function.[9] During cardiac surgery, patients commonly receive only intravenous crystalloid solutions, which are continued for several days postoperatively.[9]

Considering the postoperative course, in a retrospective analysis of about 5400 mechanically ventilated patients, cardiac surgery was most associated with iatrogenic malnutrition.[5] This alarming finding is compounded by observations that nutrition support was implemented later and with the lowest nutritional adequacy in the cardiac surgery population compared to all other surgical or medical ICU patients.[5] Recently, Rahman et al.[6] evaluated nutrition practices in cardiac surgery patients and demonstrated that nutrition support was insufficient with respect to energy and protein needs. Patients only received approximately 50% of what was prescribed. Importantly, an improvement in 60-day mortality with greater nutrition intake could not be demonstrated. This observation raises the question whether all cardiac surgery patients benefit the same from artificial nutrition therapy or whether there are specific subgroups of cardiac surgery patients that will benefit more.

As society ages, older patients are presenting for cardiac surgery with an increased prevalence of comorbidities. In addition, the number of patients with advanced heart failure has increased and the implantation of pulsatile-flow ventricular assist devices (VAD) has become an established therapeutic strategy to improve survival rates and quality of life.[10] Malnutrition may be a significant comorbidity and driver for dysfunction of many organ systems. This can exacerbate an already impaired organ reserve, increasing susceptibility to operative trauma, ischemia/reperfusion injury, anesthesia-related complications, and inflammation. Cardiac patients who are well-nourished prior to surgery experience less morbidity and mortality than those who are malnourished.[11,12] Several observational studies have noted the importance of energy and protein metabolism in the early recovery period after cardiac surgery, documenting significant postoperative depletion of macronutrients and micronutrients.[11–14] Adequate nutritional therapy was suggested to improve patients' outcomes through maintenance of energy metabolism, gut integrity, microbial diversity and improved wound healing.[15] In summary, preoperative nutritional status and postoperative nutritional management may represent important drivers for clinical outcomes in patients undergoing cardiac surgery, who are at high nutritional risk, which will be discussed in the following section.

Figure 1 demonstrates selected key factors, which are considered to crucially influence the nutritional state and potential need for intense nutrition therapy in cardiac surgery patients.

Figure 1.

Organizing framework malnutrition and undernutrition and impact on outcomes in cardiac surgery patients. The patients' preoperative, intraoperative and postoperative time windows comprise specific variables, which may be of particular relevance for potential nutrition support and patients' outcomes after surgery. Notably, additional studies are encouraged to identify further relevant factors and to validate its clinical significance. STS Society of Thoracic Surgeons, BMI body mass index, ICU intensive care unit, APACHE II Acute Physiology And Chronic Health Evaluation II, SOFA sequential organ failure assessment, Nutric Nutrition Risk in the Critically ill, CRP C reactive protein, IL interleukin, PCT procalcitonin, PUFA polyunsaturated fatty acids, SYNTAX scoring system to guide decision between coronary artery bypass graft (CABG) surgery or percutaneous intervention (PCI), NRS nutritional risk score

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