Plastic Surgery and Modern Techniques Communication Advancing Outcomes in Plastic Surgery with Immunonutrition and Standardized Pre-Operative Wellness Education

Surgery is not without risks, as anywhere between 20-50% [1] of patients experience post-operative complications, including; prolonged Lengths of Stay (LOS) [2], increased morbidity and mortality [3], decreased quality of life [4] and infections the most common complication [5]. In addition, 40% of patients experience a loss in function [6] and these post-operative complications cost an estimated $10 billion per year to the healthcare industry. As plastic surgeons, we have become keenly aware of the need for opportunity to improve outcomes and reduce cost to the patients and health care system at large. This endeavor is widely considered a multi-factorial process with prevention techniques centered around nutrition (preventing pre-operative malnutrition [7], decreasing post-operative insulin resistance [8], early post-operative feeds [8]), pre-operative conditioning or pre-habilitation, as well as established standards of post-operative care including encouraging incentive spirometry [9] and physical activity [10]. These interventions are aimed at creating an evidence-based model to aid post-operative recovery. They are based on our enhanced understanding of the pathophysiology of surgery and built upon a new protocol of Enhanced Recovery after Surgery (ERAS), with origins in European protocols from the 1990’s. Major changes to alreadyexisting protocols included emphasis on nutrition with fluid and carbohydrate loading without a prolonged fast in the pre-operative phase, and initiating early oral nutrition while encouraging mobilization in the early post-operative period. While ERAS had been shown to decrease morbidity and length of stay when compared to conventional peri-operative management at the time [11], it did not include new research on the role played by immunotherapy and exercise in decreasing complications.


Communication
Surgery is not without risks, as anywhere between 20-50% [1] of patients experience post-operative complications, including; prolonged Lengths of Stay (LOS) [2], increased morbidity and mortality [3], decreased quality of life [4] and infections -the most common complication [5]. In addition, 40% of patients experience a loss in function [6] and these post-operative complications cost an estimated $10 billion per year to the healthcare industry. As plastic surgeons, we have become keenly aware of the need for opportunity to improve outcomes and reduce cost to the patients and health care system at large. This endeavor is widely considered a multi-factorial process with prevention techniques centered around nutrition (preventing pre-operative malnutrition [7], decreasing post-operative insulin resistance [8], early post-operative feeds [8]), pre-operative conditioning or pre-habilitation, as well as established standards of post-operative care including encouraging incentive spirometry [9] and physical activity [10]. These interventions are aimed at creating an evidence-based model to aid post-operative recovery. They are based on our enhanced understanding of the pathophysiology of surgery and built upon a new protocol of Enhanced Recovery after Surgery (ERAS), with origins in European protocols from the 1990's. Major changes to alreadyexisting protocols included emphasis on nutrition with fluid and carbohydrate loading without a prolonged fast in the pre-operative phase, and initiating early oral nutrition while encouraging mobilization in the early post-operative period. While ERAS had been shown to decrease morbidity and length of stay when compared to conventional peri-operative management at the time [11], it did not include new research on the role played by immunotherapy and exercise in decreasing complications.
Carbohydrate loading was added to the other ERAS elements in 2014, further expanding the program. Prior to adoption of ERAS protocols, it was routine to have patients fast 12 hours before a surgical procedure, due to a perceived risk of aspiration events, however a Cochrane review found no difference in aspiration events when comparing patients who fasted and patients who had liquids up to two hours before [12]. Therefore in 1999 the American Society of Anesthesiologists changed guidelines, recommending that patients can eat 6 hours prior to surgery as well as drink clear fluids 2 hours prior to surgery, except for patients with delayed gastric emptying [13]. This is beneficial not only for patient comfort and psychological health, but it has also been thoroughly documented that there is insulin resistance post-surgery resulting in hyperglycemia and creating an anabolic state that slows repair and recovery. Preexisting malnutrition in fact exacerbates this effect. It has also been previously suggested that immuno nutrition can be helpful with mitigating the anabolic state associated with surgical stress [14,15]. When comparing giving only carbohydrate drinks preoperatively and carbohydrate with glutamine and antioxidants, one study found lower levels of both glucose and insulin [16] in patients who received the latter [17]. When patients were given a more comprehensive nutrition supplement, IMPACT (nucleotides in RNA, arginine, and omega 3 fatty acids) for 5-7 days pre-operatively, reduced wound infections, abdominal abscesses, anastomotic leaks, pneumonias, and UTIs were observed [18].
Along with nutrition management, ERAS included early mobilization of patient's post-operatively, but new studies have suggested that mobilization pre-operatively or pre-habilitation can provide benefits to patients. Pre-habilitation has been associated with faster recovery and decreased pain and length of stay after surgical procedures [19]. In cardiovascular surgery, patients see a reduction in pulmonary complications (atelectasis, pneumonia), especially if pre-habilitation therapy includes maximal inspiratory muscle strength training [20]. In non-cardiac thoracic and abdominal surgery, cardiovascular exercise preoperatively has demonstrated improved functional status post-operatively [21]. Based on our National Surgical Quality Improvement Program (NSQIP) DOI: 10.29011/2577DOI: 10.29011/ -1701 data at Indiana University (IU) Health, 75% of the surgical patients treated at the IU Health Adult Academic Health Center had three or more major risk factors for major complications. In 2011, to address the need to improve outcomes, IU Health initiated efforts to improve pre-surgical wellness with a Pre-Operative Wellness program that expanded our standard pre-surgical assessment and intervention protocols. The core element involved prescription of an immuno nutrition drink, containing arginine, omega-3 fatty acids, and nucleotides, which have been shown to reduce infectious complications by 41% [4], as well as mortality and LOS of patients [6]. The patients were originally required to purchase the immuno nutrition drink, as no insurance program would cover the cost of a short-term oral nutrition drink. The results of the initial program were consistent with the evidence-based literature and showed significant improvement in wound healing, LOS and infection rates.
Using the initial data, we obtained executive level support and an IU Health financial grant to refine a standard IU Health POWERR (Peri-Operative Wellness Enhanced Rapid Recovery) education process and a POWERR "Tool Kit", which included a 5 day supply of the immuno nutrition drink, incentive spirometer, chlorhexidine soap bath, mupirocin pre-treatment, incentive spirometry and a pedometer to encourage exercise. These were provided to the patients without charge along with Pre-Admission Testing (PAT) clinic education. Included in each kit was a patient education sheet itemizing the components of their pre-surgical regimen? Under each component, the sheets contained blank tables for the patients to track which scheduled doses or activities were performed to serve as a reminder as well as a method to track compliance. Compliance to the POWERR program was also monitored through a standard questionnaire completed during pre-operative nursing assessment on the day of surgery.
Our retrospective chart review was conducted on 6,834 elective adult surgical patients at two major university hospitals in the IU Health system, seen in PAT clinic in 2015 and 2016. The PAT clinic encouraged pre-operative exercise, smoking cessation, and provided patients with a pre-surgical education package containing the POWERR tool kit. Patients were queried about compliance with the POWERR tool kit components on the day of elective surgery during the nursing assessment. A review of Length of Stay (LOS), Surgical Site Infections (SSI), Catheter-Associated Urinary Tract Infections (CAUTI), Central Line-Associated Blood Stream Infections (CLABSI), Methicillin-Resistant Staphylococcus Aureus (MRSA), Vancomycin-Resistant Enterococcus (VRE) and Clostridium Difficile (CDIFF) infections among participating patients was done. Statistical analysis was conducted through Fisher's exact test with a two sided p-value <.05.The percentage of the patients receiving at least 1 component of the POWERR program is 91.1%. The patient overall compliance rate is 57% with 47.1% for immuno nutrition, 49.5% for IS, 52.8% for chlorhexidine bathing and 68% for Mupirocin. A global analysis of the data indicates a statistically significant decrease in the post-surgical complication rates for patients who were compliant with the presurgical components. The global harm event rate was reduced by 39% with POWERR compliance.
Plastic surgeons are faced routinely with reconstructive or cosmetic patients with underlying risk factors for surgical complications and surgery imparts major bodily stress. We should therefore ensure pre-operative patient optimization to achieve superior outcomes. At our institution, we have dramatically improved our outcomes with simple, direct immuno nutrition and wellness based (POWERR) program, which is easily reproducible with very tangible and durable outcomes. We have also been able to track patient compliance and relate this directly to these outcomes, noting that providing the tool kits to the patients at no cost further improves patient engagement and compliance. We conclude that all patients undergoing elective plastic surgery will benefit from immuno nutrition and pre-surgical education and that these interventions will significantly decrease their risk of post-operative complications, while providing major cost savings to the health system. As evidenced by our study, providing a pre-surgical wellness kit with the immuno nutrition, at no cost to the patient, will further improve the surgical outcomes and engagement with providers and patients.