Nutrition Assessment
and Post-Surgical
Advancement
Rebecca Cohen, MS, RD, LDN
Transplant Dietitian
Tulane Transplant Institute
Nutrition and Surgery
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Reported 40% incidence of malnutrition in
acute hospital setting
Malnutrition may compound the severity of
complications related to a surgical procedure
A well-nourished patient usually tolerates
major surgery better than a severely
malnourished patient
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Malnutrition is associated with a high incidence of
operative complications and death.
Normal Nutrition
(EatRight.org)
The Newest Food Guide
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Teaches ● Balancing Calories ● Enjoy your food, but eat less ● Avoid oversized
portions
Foods to Increase ● Make half your plate fruits and vegetables ● Make at least
half your grains whole grains ● Switch to fat-free or low-fat (1%) milk
Foods to Reduce ● Compare sodium in foods like soup, bread, and frozen meals
and choose the foods with lower numbers ● Drink water instead of sugary drinks
Website: http://www.choosemyplate.gov/
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Includes interactive tools including a personalized daily food plan and food tracker
Carbohydrates
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Limited storage capacity, needed for CNS (glucose) function
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Yields 3.4 kcal/gm
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Recommended 45-65% of total caloric intake
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Simple vs Complex
Fats
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Major endogenous fuel source in healthy adults
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Yields 9 kcal/gm
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Too little can lead to essential fatty acid (linoleic acid) deficiency and
increased risk of infections
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Recommended 20-30% of total caloric intake
Protein
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Needed to maintain anabolic state (match catabolism)
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Yields 4 kcal/gm
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Must adjust in patients with renal and hepatic failure
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Recommended 10-35% of total caloric intake
Normal Nutrition Requirements
HEALTHLY male/female
• Caloric intake= 25-30 kcal/kg/day
• Protein intake= 0.8-1gm/kg/day
(max=150gm/day)
• Fluid intake= ~30 ml/kg/day*
*Unless medical state warrants fluid restriction
Reasons for Malnutrition
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Inadequate nutritional intake
Metabolic response
Nutrient losses
Protein/energy store depletion
Prevalence of ileus, anorexia, malabsorption
Extraordinary stressors (surgical stress, hypovolemia,
bacteremia, medications)
Wound healing
 Anabolic state
 May require appropriate vitamins
Nutrition Comparison
HEALTHLY 70 kg MALE
Caloric intake
25-30 kcal/kg/day
Protein intake
0.8-1gm/kg/day
Fluid intake
30 ml/kg/day
SURGERY PATIENT
Caloric intake
*Mild stress
25-30 kcal/kg/day
*Moderate stress
30-35 kcal/kg/day
*Severe stress
30-40 kcal/kg/day
Protein intake
1-2 gm/kg/day
Fluid intake
INDIVIDUALIZED
Albumin
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Synthesized in and catabolized by the liver
Normal range: 3.5-5 g/dL
Half-life: 20 days
Pros
Cons
Ranked as the strongest predictor of
surgical outcomes
Lack of specificity due to long half-life
Inverse relationship between
postoperative morbidity and mortality
compared with preoperative serum
albumin levels
Not accurate in pt’s with liver disease
(elevated Tbili) or during inflammatory
response (elevated WBC or CRP)
Prealbumin
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Synthesized by the liver and partly catabolized by
the kidneys
Normal range:16-40 mg/dL
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Values of <16 mg/dL are associated with malnutrition
Half-life: 2-3 days
Pros
Cons
Shorter half life than albumin
More expensive than albumin
More favorable marker of acute change
in nutritional status (compared to
albumin)
Levels may be increased in the setting of
renal dysfunction, corticosteroid therapy,
or dehydration
*A baseline prealbumin is useful as part
of the initial nutritional assessment if
routine monitoring is planned
Over-hydration can decrease prealbumin
levels; result in false negative
Nitrogen Balance
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Measures net changes in body protein mass
Nitrogen Balance = protein intake (gm) - (UUN +4)
6.25
Healthy individuals= nitrogen balance (-1 to +1)
Positive Value
Negative Value
Found during periods of growth,
tissue repair, or pregnancy
Associated with burns, fevers,
wasting diseases and other serious
injuries, & during periods of fasting
Intake of nitrogen into the body is
greater than the loss of nitrogen
from the body
Amount of nitrogen excreted from
the body is greater than nitrogen
intake
Increase in the total body pool of
protein
Often seen following major surgery
*Patient will likely require extra
protein for tissue building
Postoperative Diet Advancement
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Delay feeds for 24-48 hours until bowel
sounds & function return
Begin with clear liquids
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Supply fluids and electrolytes
Require minimal digestion and stimulation of GI
tract
Intended for short-term use due to inadequacy of
nutritional needs
Clear Liquid Diet
Acceptable food items
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Water (plain, carbonated or flavored)
Fruit juices without pulp, such as apple or white grape
Fruit-flavored beverages, such as fruit punch or lemonade
Plain gelatin
Tea or coffee without milk or cream
Strained tomato or vegetable juice
Sports drinks
Clear, fat-free broth
Hard candy, such as lemon drops or peppermint rounds
Ice pops without milk, bits of fruit, seeds or nuts (except red)
http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/clear-liquid-diet/art-20048505
Diet Advancement cont.
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Advance diet to full liquids
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Middle step
Meet daily calorie and protein needs
Acceptable food items
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Coffee, tea, cream, carbonated beverages
Fruit and vegetable juices
Milk & Milkshakes
Nutritional supplements
Custard-style yogurt, pudding, custard
Plain ice cream, sherbet, sorbet
Jell-o (any flavor)
Cream soups, strained, cream of wheat, cream of rice, grits
Pureed soups & Tomato puree
Gravy, margarine
Sugar, syrup, jelly, honey
http://www.upmc.com/patients-visitors/education/nutrition/pages/full-liquid-diet-facts.aspx
Diet Advancement cont.
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Advance diet to solid foods
Appropriate to introduce solids as soon as the
GI tract is functioning & liquids are tolerated
Diets available:
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Regular
Pediatric
Heart healthy
ADA/Diabetic
Renal
Low sodium (2 gm)
Bland/Soft/Low residue
Key considerations
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Condition of the GI tract
Disease state
Complications that may have resulted from surgery
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For liquid diets, patients must have adequate
swallowing functions, as determined by SLP
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Ex: diabetes in a post-kidney transplant patient. Why?
Mechanical soft
Pureed
Thicken liquids
Must be specific in writing liquid diet orders for
patients with dysphagia
Nutrition Support Options
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Length of time a patient can remain NPO
without complications is unknown
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Tulane Protocol: NPO > 4 days
Two types of nutritional support
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Enteral
Parenteral
Enteral Nutrition
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Liquid mixture designed to meet nutrient needs
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Given through a tube in the stomach or small intestine
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Goal rates are individidualized
Nasogastric tube
Nasoduodenal tube
Nasojejunal tube
Gastrostomy/Jejunostomy
Continuous or Bolus feeds
Specialized formulas for select disease states
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Glucerna
Suplena
Nepro
Elemental formulas
Indications
Contraindications
Functioning GI tract
Severe acute pancreatitis
Adaptive phase of short bowel
syndrome
High output enteric fistula distal
to feeding tube
Following severe trauma or
burns
Inability to gain access
Intractable vomiting or diarrhea
Aggressive therapy not
warranted
Gastric vs. Small Bowel
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“If you don’t use it, you lose it.”
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Indications to consider small bowel access:
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Gastroparesis
Recent abdominal surgery
Sepsis
Significant gastroesophageal reflux (GERD)
Aspiration risk
Mild ileus
Proximal enteric fistula or obstruction
Short-term vs Long-term
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No standard of care for cut-off time between short-term
and long-term access
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Long-term access should be considered if the patient is
expected to require nutrition support longer than 6-8
weeks
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NG tubes can be used for long term enteral nutrition
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However, complications can include:
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Non-elective extubation
Tube misplacement
Occasional need to check position of the tube
Choosing Appropriate Formulas
Polymeric
Monomeric/elemen Disease specific
tal
Basic Info:
Uses whole proteins
as nitrogen source
Predigested
nutrients; most have
a low fat content or
high % of MCT
Consider for
patients with:
Impaired GI function Specific disease
Normal or near
normal GI function
states
Specific
formulas for
• Respiratory
disease
• Diabetes
• Renal failure
• Hepatic
failure
• Immune
compromise
Tulane Enteral Nutrition
Product Formulary
Enteral Nutrition Guidelines
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Gastric feeding
Continuous feeding
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Start at rate 30 mL/hour
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Advance in increments of 20 mL •
q 8 hours to goal
Check gastric residuals q 4 hour •
Bolus feeding
Start with 120 mL bolus
Increase by 60 mL q bolus to
goal volume
Every 3-8 hours
Small bowel feeding
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Continuous feeding only; do not bolus due to risk of
dumping syndrome
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Start slowly @ 20 mL/hour
Advance in increments of 20 mL q 8 hours to goal
Do not check gastric residuals
Complications of Enteral
Nutrition Support
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Access
Administration
GI complications
Metabolic complications
Enteral Nutrition Case Study
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78-year-old woman admitted with new CVA
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Significant aspiration detected on bedside
swallow evaluation
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SLP recommends strict NPO with alternate means of
nutrition
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PEG placed for long-term feeding access
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Plan: stabilize the patient and transfer her to a
long-term care facility for rehabilitation
Enteral Nutrition Case Study
(continued)
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Height: 5’4”
Weight: 130# / 59kg BMI: 22
IBW: 120# +/- 10%
Usual weight: 130#
Estimated needs:
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Calories?
Protein?
Fluid?
Enteral Nutrition Prescription
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Jevity 1.2 (via PEG)
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Initiate at 30 mL/hour, advance by 20 mL q 8
hours to goal
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Goal rate = 55 mL/hour
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Check residuals q 4 hours
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1584 kcal
73g protein
1069 mL free H2O, additional ~515mL needed
hold feeds for residual > 200 mL
Aspiration precautions
What is parenteral nutrition?
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It is a special liquid mixture given into the blood
via a catheter in a vein
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Contains all the, carbohydrates, protein, fat,
vitamins, minerals, and other nutrients needed
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Light sensitive, always covered in a light resistant
bag
Indications for TPN
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Two criteria, need both
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Malnourished patient expected to be unable to eat
> 5-7 days
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Failed enteral nutrition trial per SLP
Appropriate tube placement
EN is contraindicated or severe GI dysfunction is
present
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Ex: paralytic ileus, mesenteric ischemia, small bowel
obstruction, enteric fistula distal to enteral access sites
TPN
(total parenteral nutrition)
PPN
(peripheral parenteral nutrition)
High glucose concentration
(15-25% final dextrose
concentration)
Similar nutrient components as
TPN, but lower concentration
(5%-10% final dextrose
concentration)
Provides a hyperosmolar
formulation (1300-1800 mOsm/L)
Osmolarity < 900 mOsm/L
(maximum tolerated by a
peripheral vein)
Must be delivered into a largediameter vein
May be delivered into a peripheral
vein
Large fluid volumes needed to
meet same calorie and protein
dose as TPN (because lower in
concentration)
Often used with other MNT and for
a short period of time
Parenteral Access Devices
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Peripheral venous access
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Catheter placed percutaneouly into a peripheral
vessel
Central venous access (catheter tip in SVC)
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Percutaneous jugular, femoral, or subclavian
catheter
Implanted ports (surgically placed)
PICC (peripherally inserted central catheter)
Writing TPN prescriptions
1.
Determine total volume of formulation based on
individual patient fluid needs
1.
Determine amino acid content
2.
Determine dextrose content
3.
Determine lipid content
4.
Check to make sure desired formulation will fit in the
total volume indicated
Tulane TPN Order Form
Parenteral Nutrition Monitoring
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Check electrolytes daily and adjust TPN/PPN
additives accordingly
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Check accu-check glucose q 6 hours
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Check triglyceride level within 24 hours of
starting TPN/PPN and weekly while patient
remains on it
Parenteral Nutrition Monitoring
(continued)
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Check LFT’s weekly
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Check pre-albumin weekly
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Acid/base balance
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Increase/decrease chloride as needed
Bicarbonate is unstable in TPN/PPN prep
Precursor—acetate—is used
Complications of TPN/PPN
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Hepatic steatosis
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Usually benign in patients on short-term PN
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Resolves in 10-15 days
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Limiting fat content of PN to control steatosis
in long-term use
Complications of TPN/PPN
(continued)
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Cholestasis
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Due to no intestinal nutrients to stimulate
hepatic bile flow
Gastrointestinal atrophy
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Trophic enteral feeding to minimize/prevent GI
atrophy
TPN/PPN Case Study
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55-year-old male admitted with small bowel
obstruction
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Complicated cholecystecomy 1 month ago.
Since, poor po intake and 20 # weight loss
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NPO for 3 days since admitright subclavian
central line was placed
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Plan: start TPN since patient is expected to be
NPO for at least 1-2 weeks
TPN/PPN Case Study
(continued)
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Height: 6’0”
Weight: 155# / 70kg
IBW: 178# +/- 10%
Usual wt: 175#
Estimated needs:
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Calories?
Protein?
Fluid?
BMI: 21
TPN/PPN Prescription
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Amino acid 4.5% (or 45 g/liter)
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Dextrose 17.5% (or 175 g/liter)
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Lipid 20% 285 mL over 24 hours
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2120 kcal, 90g protein (2 liters/24 hrs)
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GIR: 3.5 mg/kg/minute
Enteral Nutrition > Parenteral Nutrition
Enteral
Parenteral
Cost
$10-20 per day
$100 or more per day
Gut
Preserves intestinal
function
May be associated
with gut atrophy
Infection
Very small risk of
infection
High risk/incidence of
infection and sepsis
Miscellaneous Thoughts
• Transitional feeds
• PNEN
• PN/EN oral feeds
• Refeeding syndrome
• Caused by intracellular movement when energy is
provided after a period of starvation (usually > 7-10 days)
• Hypomagnesaemia, hypokalemia, hypophosphatemia
• Close monitoring of electrolytes
• Initiate feeds slowly, work towards goal rate
Miscellaneous Thoughts
Under-feeding
Over-feeding
Depressed ventilatory drive
Hyperglycemia
Decreased respiratory muscle
function
Hepatic dysfunction from fatty
infiltration
Impaired immune function
Respiratory acidosis from
increased CO2 production
Increased infection
Difficulty weaning from the
ventilator
Questions
Contact Information:
Rebecca Cohen, MS, RD, LDN
Transplant Dietitian, Tulane Transplant Institute
(504) 988-1176
Rebecca.Cohen@hcahealthcare.com
References
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American Society for Parenteral and Enteral Nutrition. The Science and
Practice of Nutrition Support. 2001.
Han-Geurts, I.J, Jeekel,J.,Tilanus H.W, Brouwer,K.J., Randomized
clinical trial of patient-controlled versus fixed regimen feeding after
elective abdominal surgery. British Journal of Surgery. 2001,
Dec;88(12):1578-82
Jeffery K.M., Harkins B., Cresci, G.A., Marindale, R.G., The clear liquid
diet is no longer a necessity in the routine postoperative management of
surgical patients. American Journal of Surgery.1996 Mar; 62(3):167-70
Reissman.P., Teoh, T.A., Cohen S.M., Weiss, E.G., Nogueras, J.J.,
Wexner, S.D. Is early oral feeding safe after elective colorectal surgery?
A prospective randomized trial. Annals of Surgery. 1995 July;222(1):73-7.
Ross, R. Micronutrient recommendations for wound healing. Support
Line. 2004(4): 4.
Krause’s Food, Nutrition & Diet Therapy, 11th Ed. Mahan, K., Stump, S.
Saunders, 2004.
American Society for Parenteral and Enteral Nutrition. The Science and
Practice of Nutrition Support. 2001.