Nutritional Considerations in Adult Cardiothoracic Surgical Patients

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Nutritional status of patients undergoing cardiac surgery

Assessing nutritional status in patients prior to cardiac surgery can be quite challenging. Often, these patients come under consideration for treatment by a surgeon during urgent or emergency conditions, mostly after having undergone an extensive series of diagnostic procedures to identify, triage, and stratify their heart disease. Unfortunately, valuable nutrition and metabolic information, which can be of immense importance in the perioperative period, is not always obtained during this

Heart failure and cardiac cachexia

Much of the cardiovascular disease burden in the United States and, increasingly, throughout the developed world is not associated with malnutrition, but rather is a product, directly or indirectly, of hypernutrition, a fact corroborated by the obesity epidemic.21 Through a complex and, as yet, incompletely understood series of biophysical processes and mechanisms involving the body’s capacity to handle lipids and carbohydrates, considerable genetic influences, as well as other contributions

Nutritional support of cardiac cachexia

When cardiac cachexia is detected in patients with chronic heart failure, 18-month survival is only approximately 50%, primarily because no specific therapy for patients who are cachectic with chronic heart failure exists.21 Theoretically, it appears clear that the nutritional status must be improved to regain energy reserves (fat tissue), the muscle tissue must be increased to improve exercise capacity, and anticytokine therapy might be feasible and useful.21 At the present time, except for

Chronic heart failure

Chronic heart failure is a significant problem that affects more than 2% of the United States population (about 5 million people), and 30% to 40% of patients die of heart failure within 1 year after diagnosis.41, 42 Moreover, heart failure can be disabling and severely compromise patients’ quality of life. On the other hand, in the past 2 decades, considerable progress has been made in the treatment of chronic heart failure with ACE inhibitors,43, 44 aldosterone antagonists,45 beta-receptor

Nutritional support of the failing heart

Neubauer summarized the complex subject of cardiac energy metabolism thusly:

The metabolic machinery has three main components. The first is substrate utilization – the use of fuel that comes from food. This process entails the cellular uptake of mainly three fatty acids and glucose, the breakdown of these components by beta-oxidation and glycolysis, and the entry of the resulting intermediary metabolites into the Krebs cycle. The second component is oxidative phosphorylation – the production of

Nutritional support of cardiothoracic surgical patients

Randomized, controlled clinical studies have been reported in patients undergoing cardiac surgery in whom arginine,17, 81, 82, 83 aspartate,84 or glutamate85 was administered, and have shown improved cardiac flow,82, 83 cardiac function measured as plasma troponin T, creatine kinase (CK), and CK-MB,81, 84, 85 or cardiac metabolism measured as myocardial acidosis, ATP, and lactate in myocardial biopsies.17, 84, 85 Amino acid supplementation minimized apoptosis in cardiomyocytes by increasing ATP

Rationale for nutrient administration in cardiac surgery patients

Both enteral and parenteral nutrition formulations contain amino acids, glucose, vitamins, and minerals, which function together as precursors for protein synthesis. Additionally, amino acids are available to replenish components of the tricarboxylic acid cycle, which can increase ATP production in heart cells, with resultant positive effects on cardiomyocyte metabolism.17, 21 Many of the amino acids are essential amino acids, such as histidine, isoleucine, leucine, lysine, methionine,

Current and future challenges for cardiac nutritional and metabolic support

A promising strategy for metabolic intervention in chronic heart failure is to modulate substrate utilization, which is feasible, for example, with the use of partial inhibitors of fatty acid oxidation or carnitine palmitoyl transferase 1 inhibitors. These compounds have complex actions, but they all partially inhibit fatty acid utilization and promote glucose utilization.41, 58, 60, 62 Whether the suppression of fatty acid oxidation is beneficial or detrimental in heart disease is highly

Infectious complications and hyperglycemia

Open heart operations are associated with several infrequent, but life-threatening complications. Sepsis (particularly in the setting of myocardial infarction), heart failure, and emergency bypass surgery are accompanied by increases in the incidence of postoperative infections and are independent risk factors for deep sternal wound infection along with diabetes, obesity, and other comorbid factors. The magnitude of these complications imposes enormous caloric requirements on patients and

Ventricular assistance and nutrition

Although transplantation of the heart and lungs carries considerable nutritional and metabolic consequences, these transplants are not dissimilar from other solid organ procedures and are not discussed directly in this article. However, the enhanced metabolic demands following the institution of long-term mechanical circulatory support, whether as a bridge to transplantation, to myocardial recovery, or as destination therapy, are underappreciated. It is well-known that, despite the usual

Nutritional status of patients undergoing pulmonary surgery

Cancer involving major organs and systems is closely associated with nutritional deficiencies, and patients with malignant neoplasms are often thought of as being malnourished virtually by definition. Moreover, nutritional status is often correlated not only with operative survival but also with long-term prognosis. Pulmonary complications following lung surgery are also associated with poor nutritional status.

Several studies have examined the effects of age on postoperative complications

Chylothorax

Chylous pleural effusions are found in a wide variety of disease states, and surgical procedures involving the mediastinal structures can infrequently result in chyle leakage. Chyle, or intestinal lymphatic fluid, is unique in that it is enriched with fat, in the form of triglycerides and chylomicrons, along with fat-soluble vitamins, lymphocytes, and albumin.109, 110 Disruption of the main thoracic duct or its tributaries can result in persistent leakage with significant consequences related

Summary

Cardiothoracic surgical patients are often critically ill, and the magnitude of cardiothoracic procedures often results in a severe assault on normal physiology with increased catabolism and augmented nutritional requirements. These adverse effects are compounded by the fact that, increasingly, these patients are older and present the surgeon with a panoply of comorbid conditions, including malnutrition, which increases the risk of postoperative complications. Accordingly, it is incumbent upon

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      Between 3% and 35% of patients require prolonged mechanical ventilation (eg, >24 h) or circulatory support (eg, vasoactive drugs [vasopressors or inotropes] or mechanical circulatory support [arteriovenous extracorporeal membrane oxygenation or intra-aortic balloon]) because the magnitude of the surgical procedures often results in severe damage to normal physiology and increases catabolism and nutritional requirements.13,14 These complications are negatively influenced by the recent trends toward more advanced patient age and poor preoperative nutritional status.41 A postoperative nutritional risk assessment should be performed to stratify patients who will benefit the most from nutritional support.

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