that outdated practice. One of the fundamentals of ERAS is replacing
pre-op fasting with carbohydrate loading in the hours leading up to
surgery. A patient who isn't hungry or thirsty when presenting for sur-
gery is usually in a better state of being than one who has been fasting
for many hours. Removing NPO requirements will likely immediately
improve your patient experience scores.
Nutrition can help improve surgical outcomes. Immunonutrition —
oral supplements or tube feeding formulas that contain a blend of pro-
tein, arginine and fish oil, help address the metabolic and inflammato-
ry changes associated with surgery. These changes include arginine
deficiency and a pro-inflammatory state.
The use of high protein immunonutrition shakes five to seven days
before and after surgery support protein synthesis, tissue repair and
wound healing and are supported by society guidelines such as the
American Society for Enhanced Recovery (ASER)/Perioperative
Quality Initiative (POQI). Consuming a preoperative oral carbohy-
drate drink two to four hours before surgery has been shown to help
reduce postoperative insulin resistance compared to a placebo, water
or fasting.
• Physical optimization. Another key preoperative component of
enhanced recovery is to optimize the patient's underlying diseases to
better cope with the physical trauma of surgery.
Optimization takes roughly three weeks. You need to make sure
patients start a prehab routine, that their nutritional status is opti-
mized, that they stop smoking and perhaps lose weight. For example,
if a patient's diabetes is at an A1C greater than 7%, you need to work
with the patient to lower the number before surgery.
The focus on patient optimization might even be more important in
outpatient facilities than it is at hospitals, because this prescreening
and preplanning can make the difference in terms of whether or not a
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