The Practical Handbook of Perioperative Metabolic and Nutritional Care

By M. Isabel T.D Correia

Intended for any healthcare professional working with surgical patients, including medical students, residents, surgeons and internists, nurses, dieticians, pharmacists, and physical therapists, The Practical Handbook of Perioperative Metabolic and Nutritional Care focuses on topics from the history of surgery and metabolism, to organic response to stress. Based on clinical processes, the author explores screening, assessment, and the impact of nutritional status on outcomes, in addition to investigating nutritional requirements, including macronutrients and micronutrients. Chapters examine wound healing as well as metabolic and nutritional surgical preconditioning, including coverage of preoperative counseling, preoperative nutrition, and preoperative fasting. Physical exercise is addressed, as well as nutritional therapy in the form of oral supplements, and enteral and parenteral approaches. Additional topics explored include nutrition therapy complications and immunomodulatory nutrients, pro, pre and symbiotics, postoperative oral, enteral and parenteral nutrition, enteral access, vascular access, fluid therapy, and more. With up-to-date information, practical and cost-effective data, this resource is critical for translating theory to practice.

• Focuses on preoperative metabolic and nutritional preparation for surgery
• Explores processes for intra and postoperatively assessing metabolic and nutritional state to ensure patient progress
• Contains content based on clinical process

• Language: English
• Publisher: Academic Press
• Release date: Jun 25, 2019
• ISBN: 9780128175118

M. Isabel T.D Correia

Dr. Correia is a retired professor of surgery at Universidade Federal de Minas Gerais Medical School, and currently, she still acts as an invited professor of surgery at the same university. She has dedicated her time to clinical practice in surgery and nutrition, is the head of the nutrition therapy team at the Surgical Gastrointestinal Department at the University Hospital, and is a member of the nutrition team Eterna at Rede Mater Dei. She is the deputy editor-in-chief for Nutrition: The International Journal of Applied and Basic Nutritional Sciences and is also editor for the gastrointestinal issue of Current Opinion in Metabolic and Nutrition Care, as well as an editorial board member for several other nutrition journals.

Book preview

The Practical Handbook of Perioperative Metabolic and Nutritional Care

M. Isabel T.D Correia

Table of Contents

Cover image

Title page

Copyright

Dedication

Biography

Foreword

Preface

Introduction

1. History of surgery, metabolism, and nutrition therapy

Common questions routinely asked in everyday practice

Response/Introduction

The history of surgery

The history of metabolism and nutrition

Conclusions

Recommended material

2. Organic response to stress

Common questions routinely asked in everyday practice

Response/Introduction

Principles

Stress definition

The ebb and flow phases

Glucose, lactate, protein, and lipid metabolism

Fluid and electrolyte response

The endocrine response

The inflammatory response

The immunologic response

Conclusions

Recommended material

3. Nutritional status and requirements

Common questions routinely asked in everyday practice

Response/Introduction

Nutritional status

Nutritional screening

Nutritional assessment

Impact on outcomes

Nutritional requirements

Conclusions

Recommended reading

4. Wound healing

Common questions routinely asked in everyday practice

Response/Introduction

Wound types

Tissue organization, disease states, and the wound

Wound healing phases

Wound contraction

Special wound healing characteristics in different tissues

Factors impacting wound healing

Conclusions

Recommended material

5. Metabolic and nutritional surgical preconditioning

Common questions routinely asked in everyday practice

Response/Introduction

Metabolic and surgical preconditioning

Preoperative parenteral nutrition therapy

Preoperative enteral nutrition

Preoperative fasting

Conclusions

Recommended reading

6. Bowel preparation

Common questions routinely asked in everyday practice

Response/Introduction

Principles behind bowel preparation and its evolution in clinical practice

Antibiotic use

Advantages and disadvantages

Conclusions

Recommended material

7. Rational for the use of antibiotics

Objectives

Common questions routinely asked in everyday practice

Response/Introduction

The human microbiota

Surgical site infections

Rational for antibiotic use

Conclusions

Recommended material

8. Postoperative nutrition therapy

Common questions routinely asked in everyday practice

Response/Introduction

Oral diet

Enteral nutrition

Parenteral nutrition

Nutrition care after hospital discharge

Conclusions

Recommended reading

9. Nutrition therapy complications

Common questions routinely asked in everyday practice

Response/Introduction

Metabolic complications related to all the nutrition therapy regimens

Oral nutrition complications

Enteral nutrition complications

Parenteral nutrition complications

Conclusions

Recommended reading

10. Immunonutrition

Common questions routinely asked in everyday practice

Response/Introduction

Definition

Rationale

Immunonutrients

Clinical use

Conclusions

11. Pro-, pre-, and symbiotics

Common questions routinely asked in everyday practice

Response/Introduction

Probiotics, prebiotics, and symbiotics

The operation and the disrupted microbiota

Probiotics and surgical complications

Conclusions

12. Exercise therapy

Common questions routinely asked in everyday practice

Response/Introduction

Preoperative interventions

Postoperative interventions

Conclusions

Recommended reading

13. Catheters

Common questions routinely asked in everyday practice

Introduction

Vascular catheters

Enteral catheters

Conclusions

Recommended material

14. Fluid and electrolyte therapy

Common questions routinely asked in everyday practice

Response/Introduction

Normal fluid and electrolyte physiology

Adverse events related to fluid and electrolyte imbalances

Goals of fluid replacement

Postoperative fluid, glucose, and electrolyte prescription

Daily fluid balance

Conclusions

Recommended reading

15. Acute pain management

Common questions routinely asked in everyday practice

Response/Introduction

Definition

Pain anatomy and physiology

Pain assessment

Pain control and effectivity

Implementation of pain strategies

Conclusions

Recommended reading

16. Antiemetic agents and motility stimulant medications

Common questions routinely asked in everyday practice

Response/Introduction

Definition of postoperative dysmotility and its consequences

The patient at high risk of postoperative dysmotility

Strategies to prevent postoperative dysmotility

The antiemetic and motility stimulant medications

Motility stimulant medications (prokinetics)

Conclusions

17. Other multimodal strategies

Common questions routinely asked in everyday practice

Response/Introduction

Preoperative counseling

Tubes, drains, and catheters

Premedication, short-acting anesthetics, and epidural analgesia

Normothermia

Thromboembolism prophylaxis

Minimal incisions and video procedures

Conclusions

Recommended reading

18. Music in the perioperative period

Common questions routinely asked in everyday practice

Response/Introduction

Concept of music

The difference of music therapy and music in the perioperative period

The benefits of music

Music for the surgical team

Conclusions

Recommended reading

19. The special patient

Common questions routinely asked in everyday practice

Response/Introduction

Children

Elderly

Pregnant

Obese

Diabetic

Disabled

Polypharmacy

Conclusions

Recommended reading

20. Interdisciplinary teams

Common questions routinely asked in everyday practice

Response/Introduction

Rationale

How to start

Challenges to face

Cost-effectiveness

Conclusions

Recommended reading

21. Quality, safety, and performance improvement

Common questions routinely asked in everyday practice

Response/Introduction

Quality, safety, and performance

The evolution of quality

How to improve quality in surgery

Conclusions

Recommended reading

22. Clinical and economic impact of protocols

Common questions routinely asked in everyday practice

Response/Introduction

Definition

Rationale

Clinical impact

Cost-effectiveness

Conclusions

Recommended reading

23. Knowledge translation

Common questions routinely asked in everyday practice

Response/Introduction

Knowledge translation concept

Knowledge translation in surgery

To implement knowledge translation

Conclusions

Recommended reading

24. Patient empowerment

Common questions routinely asked in everyday practice

Response/Introduction

Patient empowerment

Importance of empowering the surgical patient

Methods to help patient empowering

Conclusions

Recommended reading

25. Ethical considerations

Common questions routinely asked in everyday practice

Response/Introduction

Historical perspective

Principles

Current challenges

Conclusions

Recommended reading

26. Evidence-based Medicine in surgery

Common questions routinely asked in everyday practice

Response/Introduction

The concept

Critical appraisal

Evidence-based Medicine

Conclusions

Recommended reading

Index

Copyright

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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

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British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

ISBN: 978-0-12-816438-9

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Cover Designer: Christian J. Bilbow

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Dedication

We would like you to propose a book on the nutrition care of the surgical patient!

What for? There are already some very good ones written by excellent professionals!

To provide your input on the topic.

Nah…. not worth it, mine will be no different!

Give it a thought!

Some weeks later….

Ok, I will do it! But, under the condition that it will cover beyond technical aspects of nutrition care, and solely with my ‘bias’ perception of the ideal track patients undergoing operations should face with the support of various other ‘actors’. After all, in surgery, best practice is beyond the surgeon’s own technical expertise and background. The practice of Medicine, and thus Surgery, is a set of words, diseases, and people. So….

To people, in particular, those who rely on us physicians, to help them endure the hardness and the mysterious unknown of any surgical procedure, I dedicate this book. It was only made possible, however, because of the very strong backup of my men (Mário, Marco Túlio, and Gustavo) as well as my parents João and Margarida, who, out of life endurances, especially when we left Angola, made the impossible possible by providing me and my brother António Pedro with an education and sense of determination. Education, this simple powerful word that makes people stronger and better! Samuel, Heloísa, and baby ? have brought more color to my life and the certainty that I should strive for a better world. Undoubtedly, Pedro Henrique and Ana Luíza as well as Sara and Marcela, together with many others have also always been there, especially when things were gray and the prevailing feelings were despair and mediocrity. Thank you for all.

Biography

Dr. Correia is a retired professor of surgery at Universidade Federal de Minas Gerais Medical School, and currently, she still acts as an invited professor of surgery at the same university. She has dedicated her time to clinical practice in surgery and nutrition, is the head of the nutrition therapy team at the Surgical Gastrointestinal Department at the University Hospital, and is a member of the nutrition team Eterna at Rede Mater Dei. She is the deputy editor-in-chief for Nutrition: The International Journal of Applied and Basic Nutritional Sciences and is also editor for the gastrointestinal issue of Current Opinion in Metabolic and Nutrition Care, as well as an editorial board member for several other nutrition journals.

Foreword

My bias is that all surgeons share a fundamental aim: to serve our patients with skill and fidelity. There are many avenues to which surgeons serve this goal; each surgeon has a different path, with different level of experience and backgrounds, and settings. The words that describe this fundamental aim are expressed on the seal of the American College of Surgeons (ACS), which then lead to the mission of the ACS, which is to improve the care for surgical patients and to safeguard standards of care in an optimal and ethical practice environment. Although this mission was written to represent the surgeons of the ACS, I am most certain they represent the beliefs of surgeons far beyond—and includes all surgeons—who strive every single day to make the lives of their patients better, to continually seek improvement of their skill and craft, and to continually learn by gaining more knowledge and more experience, insight, and expertise.

Collections of knowledge, experience, and expertise are fundamentally needed and meaningful. The Practical Handbook of Perioperative Metabolic and Nutritional Care is an excellent example of such a collection. Authored by M. Isabel T.D. Correia, an internationally recognized surgeon who has been continuously awarded for her work on the metabolic and nutritional impact on surgery and other relevant topics, this book is evidence-based, relevant, and will no doubt be helpful for surgeons, trainees, and all who make up the team who cares for the surgical patient.

Through my years of work in the area of quality, performance, and value improvement in surgery, time and again research has shown us that coordinated multidisciplinary team-based care has a direct and positive impact on quality and outcomes. This is evident in not only in the operating room but also across the multiple phases of care from the preoperative phase to intraoperative, postoperative, and postdischarge phases as well. These concepts are clearly mirrored in this body of work, and the content is appropriately detailed in its directives to deliver optimal care. The Handbook addresses preoperative readiness and optimization, as well as how to comprehensively care for patients in the postoperative period, and beyond.

An important aspect to note is that the cycle of quality, safety, and performance improvement is continuous. True improvement stems from the idea of innovating and standardizing on a consistent basis. Isabel has provided her readers with fundamental and contextual evidence for the incorporation of metabolic and nutritional therapeutic practices for surgical care on-a-day to day and patient-by-patient basis. She has also provided evidence for more broad concepts toward improvement such as leadership, teamwork, safety culture, and evidence-based medicine, which all come together and contribute to achieving ethical and safe patient care. The distinction that Isabel has made is clear and important, that there are multiple elements that contribute toward success, and as surgeons, we must continually strive to incorporate these things to all facets of the surgical care we are providing.

I trust you will find great understanding and valuable lessons from Isabel’s wisdom and comprehensive text. The aim is for us to use these ideas, concepts, and knowledge in our daily practices, share these ideas with our fellow colleagues, and to serve and heal our patients with skill and fidelity. This Handbook was no small feat, especially with the extent to which the author has gone to incorporate a multimodal approach to surgical care, which encompasses many different disciplines and elements of care, to ultimately improve surgical quality and outcomes in surgery in a safe environment.

In summary, the significance of this work is simple—surgery encompasses more than surgical skills and technique; it relies on many aspects outside the operating room and a comprehensive multidisciplinary approach. Care of the surgical patient is dependent on a multitude of various fields of knowledge and expertise—and in this regard, this work offers us a solid and meaningful foundation. I wholeheartedly appreciate and commend this work by Dr. Isabel Correia—it will undoubtedly help those who provide surgical care, and I fully believe it will serve to ultimately help our patients.

Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS,     Director, Division of Research and Optimal Patient Care, American College of Surgeons, Professor of Surgery and Health Services, David Geffen School of Medicine, University of California, Los Angeles (UCLA)

Preface

At a time when it is easy to seek answers to questions via Google, Professor Maria Isabel Correia has written a well-researched single author book encompassing her lifetime experience with nutrition and surgical metabolism as applied to surgical patients.

The Practical Handbook of Perioperative Metabolic and Nutritional Care provides, at your fingertips, a comprehensive text summarizing critical information concerning best practice data to support the care of a sick patient with more complete information than a search engine. Search engines display bits of information, while solutions offered in this manual are comprehensive. The explanations are integrated with vital physiological information giving the full clinical picture required for the safe and efficient management of a patient.

As a practicing surgeon, the training I received puts the emphasis on autonomous decisions made in the surgical management of patients. This included making the correct diagnosis and performing the right surgical procedure to address the patient’s ailments. With the closing of the wound, the surgeon’s prerogative of care diminished.

Today, as acknowledged by the author, in surgery, best practice is beyond the surgeon’s own technical expertise and background. It demands a whole complex and intertwined environment with the surgeon as the leader working with an interdisciplinary team. No advice surpasses this culture of concern for the patient.

At the start of my first appointment as a staff surgeon at busy Boston City Hospital, I was thrust beyond my operative comfort zone by an eighteen-year-old healthy and muscular trauma patient named LeRoy. He had fallen off a fourth-floor ledge, fractured his femur, and, on examination in the emergency room, was found to be hemodynamically unstable and had intraabdominal free blood. I performed an emergency laparotomy in an attempt to save his life, fully expecting to find a ruptured liver or spleen and, perhaps, other internal injuries responsible for his life-threatening condition. To my chagrin, I found no internal injuries. The internal bleeding was minimal and was accounted for by his thigh fracture bleeding extensively into the surrounding tissues and tracking up into his abdomen. The orthopedic team fixed his femoral fracture and assumed his care in the ICU. As detailed in a subsequent account [1], after 30 days I heard that he had died. I was shocked.

How could an eighteen-year-old muscular man—one in his prime—simply die? Examination of the records showed that during his hospital stay he had remained on bed rest. The fracture was cared for, but no one seemed responsible for LeRoy’s other needs. LeRoy weighed about 150 pounds on admission. He lost 34 pounds during his 30-day hospital stay. Although the order was written for an oral diet, no calorie counts had been done to assess how much he consumed. He had been maintained on an intravenous drip of 5% glucose-saline. One liter provides 50 grams of glucose or about two tablespoons of sugar—the equivalent of 170 calories. He had received 3  liters a day, getting in total 510 calories or about two candy bars a day for 30 days.

To survive his massive leg injury, the stress of the shock from the bleeding, the physiological stress of two major operations, the laparotomy, and the femoral fracture, he would have needed at least 3000 calories. Not just as glucose, but protein, fat, vitamins, trace elements, and minerals to permit healing of his injured tissues plus he should have received active physical therapy to assist healing and strengthening of his muscles. In the absence of intense nutrition support, his limbs, diaphragm, intercostal, and cardia muscles had broken down to provide his daily nutrient needs. When he ran out of critical muscle mass, LeRoy died. He had perished of malnutrition in a primary hospital in affluent America. The date was August 1976.

At about the same time, two young physicians who were also practicing at Harvard hospital, an internist collaborating with a surgeon, published the results of their study about the nutritional status of general surgical patients in the prestigious peer-reviewed Journal of the American Medical Association [2]. It revealed that 15% of surgical patients were already malnourished on hospital admission and that malnutrition increased hospital-related infections from 15% to 70%. It also increased the death rate threefold. Even worse, the frequency of malnutrition in patient rose to 60% after 14 days in the hospital.

The headline in a leading Boston newspaper was Patients in a Harvard Hospital Become Malnourished. The gross neglect implied by the article led to formation of the American Society of Parenteral and Enteral Nutrition, an educational society that created training programs for medical professionals and encouraged the formation of hospital nutrition teams.

Similar societies were created or incorporated into international umbrella societies, such as the European Society of Parenteral and Enteral Nutrition and the Latin American group FELANPE. Industry responded by producing nutrient formulas—intravenous and enteral—and catheters to deliver the amino acids, glucose, fat, minerals, vitamins, and trace elements mixture. Concomitantly, Nutrition Support Teams were formed to identify patients who could not eat, would not eat, or were unable to eat sufficiently to maintain their metabolic needs so that Total Parenteral Nutrition or Intravenous Alimentation was given. If the gastrointestinal tract functioned, then these nutrients could be given via a nasogastric tube into the stomach. To share study data with colleagues around the globe, The International Journal of Nutrition was founded.

As delineated by Professor Correia, the conventional nutrition support team consisted of dedicated professionals with specialized skills. The team leader is either a surgeon or other physician specialist. The dietitian is well versed in recognizing and diagnosing specific nutritional problems as they related to the patient’s disease or those induced by the stress of therapy during their hospital stay. The nurse is familiar with the various intravenous catheters and nasogastric tubes, their placement, and their daily care, for if infected these catheters could become a source of sepsis. The pharmacist is comfortable with the sterile mixing of the various nutrients, vitamins, minerals and trace elements, and their compatibility. In sum, these individuals reflected a highly knowledgeable group of health-care professionals to prevent and treat malnutrition. The tangible results of the teams, nationwide, showed that complications plummeted and survival rates rose in hospitalized patients who were sustained by nutrient support.

LeRoy would have benefitted from such care.

Nutritional data gained in the past have not always been passed on. Nutritional Support Teams have fallen into disuse due to lack of funding. Yet, 50 years later the practice of surgery has become even more complex, and the need to work closely with other specialties has greatly increased in this culture of concern. Best practice information may lead to avoidable complications, including death and potential liability. This easily readable book provides the required knowledge.

Michael M. Meguid, MD, Ph.D., MFA, FACS,     Professor Emeritus Surgery, Neuroscience and Nutrition, Emeritus Editor-in-Chief, Nutrition, Department of Surgery, Upstate Medical University, University Hospital, 750 E. Adams Street, Syracuse, NY 13210

E-mail: [e-mail]

Website: http://www.michaelmeguid.com

Wiki: https://en.wikipedia.org/wiki/Michael_M._Meguid

References

[1] Meguid M.M. The LeRoy catastrophe: a story of death, determination, and the importance of nutrition in medicine. Col Med Rev. 2015;1:5.

[2] Bistrian B.R, Blackburn G.L, Vitale J, Cochran D, Naylor J. Prevalence of malnutrition in general medical patients. J Am Med Assoc. 1976;235(15):1567–1570.

Introduction

The Practical Handbook of Perioperative Metabolic and Nutritional Care is specially targeted, but not only, to medical students, residents, and surgeons of any specialty who believe that surgery lies beyond the detailed art of surgical skills and techniques. Multimodal care and the participation of different discipline backgrounds are essential for the benefit of the patients. Therefore, distinct professionals who directly work with surgical patients may also find the book handy and helpful in their daily practice. The sequence of the book was thought to address a logic educational trajectory as similarly faced by the surgical patient who when first visits the surgeon’s office has his disease history that has tackled the need for the operation.

Surgery has evolved in the last decades at a great speed with new technologies and treatments made available everywhere, from First World countries to those underdevelopment. Understanding the history of surgery is a way of maturing and continuing the education of surgeons and those directly working with surgical patients. The heuristic value of history is essential to add adjunctive humanistic, literary, and philosophic tastes [1], and this is the principle behind the Chapter 1 of the handbook, that is followed (Chapter 2) by the conceptualization of the organic response to stress faced by all the individuals undergoing any operation from minor to major procedures. The traumatic event triggers a series of responses to stress, which are necessary to preserve vital functions such as oxygen delivery and an adequate circulatory balance, among others.

The organic response to stress is an important physiologic phenomenon that aims at protecting the body after injury. However, once it is perpetuated or not adequately addressed, it can be maximized and place the patient at a higher risk of complications and mortality. Therefore, the various pathways of the organic response, especially those that can be counterbalanced by adequate adjuvant interventions in the perioperative period should be regarded. Good nutrition care, proper choice of anesthetic agents, and pain control medication, as well as rigorous fluid balance, among many others are strategies that surgeons should adopt to decrease potential short-, medium-, and long-term negative consequences to patients. Despite currently decreased surgery-associated complication and mortality rates, specific groups of patients, like the malnourished, are still at higher risk of morbidity, mortality, length of hospital stay, and costs [2–8]. Unfortunately, malnutrition is highly prevalent in the hospitals worldwide, and surgical patients are at higher risk. Several studies have shown that malnutrition may vary from 30% to 70% of individuals undergoing major operations [3,9–20].

The reasons behind malnutrition and its negative impact on surgical patients, discussed in Chapter 3, are related to a series of severe derangements as diminished muscle mass and functionality, which, in the surgical patient, affect the capacity of early mobilization and adequate respiratory function. Also, malnourished individuals present with impaired immunological and inflammatory responses that affect wound healing (discussed in Chapter 4) and raise infection rates, increasing mortality, length of hospital stay, and costs [2,8,10,20–24]. Malnutrition can be prevented or treated, aiming to decrease the related adverse events. Therefore, the deranged metabolic and nutrition status of the surgical patient could be currently regarded as the fifth killer related to the operation. Surgeons must bear in mind their leading role when preparing patients to the surgical act by screening and assessing the need for nutrition therapy and when indicated prescribing preoperative oral, enteral, or parenteral nutrition according to the patient’s requirements (Chapter 5). Furthermore, current knowledge has indicated that even well-nourished patients when undergoing major procedures should be metabolic, immunologic, and physical exercise preconditioned to face the surgical trauma at the best metabolic and functional balance (Chapters 11–13). In this regard, some nutrients may play an important role in boosting the immunologic system and downregulating the hyper inflammatory response, such as arginine, glutamine and omega-3 fatty acids discussed in Chapter 11 [25–31]. Also, the future will indicate if the already shown benefits related to probiotics (living bacteria) in decreasing postoperative infections in liver transplant and colorectal cancer patients will be confirmed in other surgical populations, either alone or in combination with prebiotics (e.g., fibers) (Chapter 12) [32–36].

Preoperative physical exercise, when feasible (Chapter 13), will confer patients, in particularly, the elderly, an improved reserve that allows them to tolerate the surgical stress better and will enable these individuals to remain independent throughout the course of recovery. Bed rest further causes a marked and quick muscle loss, which predominates in the lower limbs, leading to decreased strength, impairing gait, and perpetuating a vicious cycle—bed rest–muscle loss–bed rest. Moreover, patients undergoing major operations with surgical manipulation of the upper abdomen or of the thorax will suffer from diaphragm muscle degradation, which is worsened by reflex inhibition of the phrenic nerve output and by mechanical ventilation. This will further compromise diaphragm function, placing the patients at increased risk of pulmonary complications [37]. A good functional status is part of person’s health, and a physically healthy individual will better tolerate a stressful event, also recovering from it faster. Therefore, surgeons should reckon that the detrimental impact of the operation will affect all, in particular, the nonfit, which should stimulate surgeons to screen for risk factors and refer patients to presurgical physical conditioning if possible. It has been shown that functional status can be improved by high-quality individualized exercises, even in the very elderly, and in a short period of time while waiting for the surgical procedure. This represents a paradigm shift not only to surgeons, but also to patients and families who think that sick people should not exercise.

Innovation in surgical care brings about another important discussion over the old concept related to the long preoperative fasting time, a routine practiced since the late 19th century and the advent of anesthesia, when women undergoing operative deliveries were reported to vomit and aspirate. The cruel nil per os prevailed for many decades until it started to be challenged about two decades ago, when the new recommendations indicated that children and adults could eat a light meal 6  h before anesthesia induction and drink clear fluids up to 2  h before the operation. However, clear liquids are not enough to contribute to a metabolic balance. Currently, clear liquids rich in carbohydrates have been advocated to replenish glycogen stores because the body runs out of them after about a 10-h fasting. Long fasting leads the body to rely on protein breakdown, especially after stress, to acquire glucose, an essential substrate for key tissues such as the brain and red blood cells, while at the same time leading to increased insulin resistance after trauma. Therefore, long preoperative fasting is contraindicated as it negatively interferes with the metabolic response to injury and negatively affects mitochondria function, while impacting on preoperative patients’ well-being and postoperative nausea and vomiting [38–40]. The use of complex carbohydrate drinks alone or in combination with peptides or amino acids have been safely administered to patients before the surgical procedure, and this is discussed in Chapter 5. Other controversial aspects as preoperative mechanical bowel preparation (Chapter 6) and the use of different types of catheters (Chapter 7) may also interfere with the metabolic balance of the surgical patients and deserve attention, in particular, when assessing risk factors for surgical site infections (SSI).

SSI, defined as infections of the incision or organ or space that occur after an operation [41], are the most common health care–associated infections and may vary from 1% to more than 50% of surgical patients [42,43], according to the type of wound [44]. SSI account for 31% of all hospital infections [42]. However, the number of SSI may be underestimated, given that about 50% becomes evident only after hospital discharge. The rationale for the use of antibiotics in surgery as a way to decrease SSI is addressed in Chapter 8. The correct prescription of antibiotics in surgery requires physicians to be acquainted with the human microbiota and the organ that will be operated on, as there are risk factors associated to its improper use. Decisions on the right moment and if to maintain antibiotic use postoperatively are related to some of peri- and postoperative care aspects.

The perioperative and postoperative phases are geared by different actors. For example, when should oral diets be allowed? When is there the need to provide artificial nutrition either enteral or parenteral (Chapter 9)? Are the nutrition therapy–associated complications surpassed by the benefits? The answer to this query and topics related with how to prevent or treat complications are discussed in Chapter 10. Rigorous protocols are deemed essential. Also, in the peri- and postoperative phases, fluid and pain control will directly affect the organic response to trauma and motility. Thus, tolerance to oral or enteral feeds is influenced, and as a consequence, the patients’ outcomes are also impacted. Fluid and electrolyte therapy (Chapter 15) of the surgical patient is an integral and vital step of the metabolic and nutrition perioperative care. Fluids and electrolytes play an important role in several metabolic pathways and cellular functioning, affecting organelles such as the mitochondria. Fluid balance in surgical patients is directly related to the organic response to trauma and associated factors such as the long preoperative fasting period, losses during the operation either due to long time of open cavities (in special, abdomen) or blood losses, and postoperative adverse events [45]. Furthermore, medication-related vasodilation (anesthetics) and inadequate perioperative fluid replacement must also be acknowledged as causes for fluid imbalances [45], which will adversely influence the gastrointestinal motility and the cardiorespiratory and renal systems.

Pain as discussed in Chapter 16 is inevitable after any type of lesion, in particular postoperatively due to local injured tissues/cells, and consequently, nociceptive stimulus triggers different phenomena that will be translated into a complex sensation experienced in various modes and intensities by patients. So, pain is linked to the surgical procedure, but this does not mandatorily mean that patients have to face pain as an integral and normal process after surgery. There are various multimodal attitudes that can prevent or decrease the intensity of pain that directly impacts patients’ morbidity. For example, patients with pain will not breathe adequately and are prone to higher risk of pulmonary complications. Also, a painful patient will tend to lie in bed longer, which per se increases the risk of thromboembolic events and loss of muscle mass. Concomitant to the use of adequate pain control, antiemetic medication (Chapter 17), and other multimodal options such as music (Chapter 18) may help the surgical patient face the postoperative period better.

Music was first described in surgical patients by Evan Kane, in 1914 [46], but despite the number of studies reporting its advantages in the hospital setting, in particular, for the surgical patient [46–50] as ways of decreasing pain, anxiety, and fear, music has not been implemented as a routine practice to help patients overcome the psychological distress of surgery. It is an inexpensive technique and easy to be implemented; however, few centers and health-care professionals have adopted it as an integral part of surgical care, something that should be stimulated, and in particularly assessed for patient satisfaction and improved quality of life while in the hospital.

Every patient should be regarded as a unique individual; however, there are special conditions such as the ones covered in Chapter 19 as the children, elderly, obese, diabetic, pregnant, disable, or those using polypharmacy that demand specific care. The special patient undergoes the same organic response to stress, but because of his/her condition, he/she demands accurate and specific approaches that will help minimize the higher risk imposed by such special situation. Interdisciplinary teamwork is fundamental and mandatory to improve results, considering that some specificities are essentially controlled by other nonsurgical-related professionals such as internists, psychiatrists, gynecologists, psychologists, and many others. In this regard, ideally, the surgical team should be interdisciplinary. From a practical point of view, this means combining individuals together in new ways and literally defines working between different academic disciplines (Chapter 20). There is growing recognition of interdisciplinary importance in the health-care business despite its low compliance in many centers. Globally, health-care accreditation agencies have required interdisciplinary teamwork as an element of quality assurance processes.

In surgery, best practice is beyond the surgeon’s own technical expertise and background. It demands a whole complex and intertwined environment with the surgeon as the leader working with an interdisciplinary team, in an adequate controlled geographical area, with the availability of good materials and resources. Furthermore, adequate quality attitudes/practices, auditing/control, and result sharing are fundamental aspects to ensure the best practice and foster a culture of safety and performance improvement. However, the traditional health-care culture has been sustained around a hierarchy with the surgeon at the top with the greatest autonomy and with the other team members (anesthesiologists, assistants, residents, interns, other junior members, nurses, technicians) at the bottom. As a consequence of this status quo, some caregivers hesitate to speak up when the leader issues an inaccurate order or is about to perform an unsafe procedure. Moreover, it’s also known that in most institutions, the various departments and divisions frequently act independently with each specialty locked in its own cocoon, not sharing/discussing experiences and practices of either success or failure. These myopic behaviors negatively impact toward performance improvement and, in the end, the patients and their safety.

Safety is the pivotal aspect for the patients and such a safety culture must be implemented in modern institutions because aside from guaranteeing the patients’ needs and quality of life, it ensures best practices resulting in decreased health-care costs (Chapter 21). To achieve a successful culture of safety, it is mandatory to change the paradigm culture of blame and shame and assume a proactive behavior of leadership. This is undoubtedly not an easy task as people, in general, are resistant to changes because it is comfortable to remain in the so called comfort zone. Against the comfort zone culture, the advances of the big data era have provided the health-care systems with abundance of statistics supporting the need to change and further challenge the old surgical hierarchies, placing the safety of the patient upfront and leading to the need of quality initiatives.

Quality and performance improvement used in other life scenarios have been adopted by the health-care industry, and, in surgery, a unique and intricate field of Medicine, similarly to the complex aviation industry, its adequate implementation will lead to the best practice and patient safety and it is cost saving (Chapter 22). It is, nonetheless, an audacious task, but surgeons must take the reins and assume the leadership. To follow-up with the vast information regarding the surgical process, its metabolic, nutritional, functional, economic, quality, and safety implications, it is of utmost importance for the surgeon to be fully updated. However, the galloping technology developments have placed a dramatic challenge to the medical professionals, and the surgeon is no exception, on how to be updated. Above all, long-term achievements and improvements rely on the adequate translation of knowledge, discussed in Chapter 23, for which education plays a key supporting role, particularly when data indicate that it may take as much as 20  years to apply into practice what has been supported by research [51].

Education is key to improve quality, safety, and results to all the individuals, including the patient and his/her relatives. Patient empowerment, as discussed in Chapter 24, is a rather novel concept in health care and in surgery particularly. It is another paradigm shift, moving from a doctor-centered medical practice into a patient-sharing concept. Essentially, the idea of empowerment implies that any patient has the potential to make choices and gain control of his/her life. To achieve this status, though, he/she must acquire abilities through education and social processes of behavior change in which he/she will not any longer see the physician as the sole authority for treatment. It is the abandonment of the paternalistic approach of health care. According to the World Health Organization patient empowerment is a process through which people gain greater control over decisions and actions affecting their health [52,53]. Several authors have shown that patient empowerment improves surgical patients’ outcomes [54–58]. Nonetheless, all these attitudes must be guided by good ethical principles.

The basis for human ethics (Chapter 25) is that all human beings are born free and equal in dignity and rights [59]. In the surgical field, sometimes, they are not strictly applied and followed, which will eventually impact the patients’ homeostasis and the physician–patient relationship. Surgeons are very pragmatic and busy doctors who, in general, seldom dedicate time to read and discuss philosophy-based sciences, such as ethics, and not to mention that they often consider it unnecessary for their clinical routine practice. On the other hand, surgeons are increasingly facing ethical issues brought about by the common practice, innovative techniques, economical aspects, teaching scenarios, and personal/family situations. Thus, ethics should permeate the holistic formation of a surgeon for him/her to face such complex and challenging competence [60,61]. Surgeons must also face a code of trust with colleagues (physicians and other professionals), trainees, administrators, insurance companies, patients, and families, which encompasses ethical considerations. Medicine has become business guided, with financial aspects and innovations that certainly interfere a surgeon’s perception of his/her role in the practice toward the sick and vulnerable patient.

Lastly, but not least, in Chapter 26, the topic of evidence-based medicine is debated. This is an extremely compelling subject that raises discussions with distinct, and sometimes, opposing, opinions. The concept is rather new because it emerged from the seventies into the nineties of the last century, which represents a short time for the translation of many ideas [62]. However as striking as it may seem, the concept has been rapidly diffused. Several theories can justify the speed with which the principles behind evidence-based medicine have