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

Main Open Research Topics Concerning Nutrition in Patients After Cardiac Surgery

The few randomized trials of nutrition support in patients undergoing cardiac surgery are limited to small numbers of patients and demonstrate heterogeneous results, so the experts felt unable to give strong recommendations for clinical practice. Nevertheless, six key messages have been identified by the experts, which are thought to be of clinical relevance in the treatment of these patients:

  1. Whenever possible, preoperative optimization of the nutritional state should be targeted in the malnourished patient undergoing cardiac surgery. The increasing number of patients with advanced heart failure and planned VAD implant represent a subpopulation that may as well benefit from optimization of the nutritional state. Thus, determination of nutritional risk, preferably using a structured scoring tool, should be part of the patient's preoperative assessment.

  2. To reach maximum benefit, preoperative nutritional therapy should be initiated in malnourished patients after cardiac surgery at least 2–7 days before surgery (e.g., as part of a preoperative evaluation and optimization therapy).[46]

  3. Monitoring of nutrition intake should be routinely assessed daily in patients after cardiac surgery during the ICU stay. In particular, on day 3 all patients should be carefully evaluated as to their nutrition risk and effort should be made to achieve at least 80% of their prescribed protein/energy requirements, either by enteral or parental feeding, as soon as possible.

  4. Postoperative nutrition support should be initiated early (0–24 hours after surgery) in patients at high nutritional risk with an expected prolonged ICU stay.

  5. Attention to refeeding syndrome may be of importance for patients in whom nutrition support is started after a prolonged period of starvation or in patients with preexisting malnutrition, respectively. In those patients, advancement of feeding should be slower, taking 3–4 days to reach goal, and targeting to adapt to both macronutient and micronutrient special needs.[31]

  6. If initiated early postoperatively within <24 hours after ICU admission, an additional immune-modulating component (e.g., selenium, fish oil) to nutrition may be considered for patients with complex and prolonged surgical procedures, to counteract the overwhelming inflammatory response.

In extension to the need of reliable data, international standardized procedures such as the ESPEN and IASMEN endorsed strategy for Enhanced Recovery After Surgery (ERAS) are warranted to optimize nutrition support in cardiac surgery patients. In view of the heterogeneous standards of perioperative care in these patients and lack of evidence provided by large-scale RCTs, the multi-modal ERAS program for optimal perioperative care may help to reduce surgical stress, maintain physiological functional capacity, and facilitate postoperative recovery by providing the best available evidence.[47]

Furthermore the multidisciplinary group identified six important topics for future research:

  1. Targeting preoperative optimization of the nutritional state may result in improved postoperative outcome. Structured scoring tools should be validated and implemented as part of preoperative assessment and to monitor the efficacy of nutrition therapy.

  2. In identified patients, the feasibility and clinical significance of early-initiated postoperative nutrition support needs to be evaluated.

  3. Dose-finding studies for both macronutrients and micronutrients are needed to answer the questions of "how to supplement patients after cardiac surgery" and "with which combination of nutrients".

  4. To counteract the frequently occurring inflammatory response, the clinical significance of an immune-modulating component (e.g., selenium, fish oil) should be evaluated in patients with complex and prolonged surgical procedures.

  5. Validated and reliable assessment of energy requirement in patients after cardiac surgery need to be developed.

  6. The role trophic EN might play in the hemodynamically stable patient after initial stabilization needs further evaluation.

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