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Nutrition. . . . and the surgical patient Carli Schwartz, RD,LDN. Nutrition and Surgery . 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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. . . and the surgical patient

Carli Schwartz, RD,LDN

nutrition and surgery
Nutrition and Surgery
  • 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
    • Malnutrition is associated with a high incidence of operative complications and death.
the newest food guide pyramid
The Newest Food Guide Pyramid
  • 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:
    • Includes interactive tools including a personalized daily food plan and food tracker
  • Carbohydrates
    • Main sources include grains, fruits and beans
    • Limited storage capacity, needed for CNS (glucose) function
    • Yields 3.4 kcal/gm
    • Recommended 45-65% total daily calories.
  • Fats
    • Main sources include oil, nuts, butter, milk and cheese
    • Major endogenous fuel source in healthy adults
    • Yields 9 kcal/gm
    • Too little can lead to essential fatty acid (linoleic acid) deficiency and increased risk of infections
    • Recommended 20-30% of total caloric intake
  • Protein
    • Main sources include fish, beef, poultry and dairy products
    • Needed to maintain anabolic state (match catabolism)
    • Yields 4 kcal/gm
    • Must adjust in patients with renal and hepatic failure
    • Recommended 10-35% of total caloric intake.
normal nutrition
Normal Nutrition
  • Requirements
  • HEALTHLY male/female
  • (weight maintenance)
  • Caloric intake=25-30 kcal/kg/day
  • Protein intake=0.8-1gm/kg/day (max=150gm/day)
  • Fluid intake=~ 30 ml/kg/day
comparison of protein energy demands
Comparison of Protein/Energy Demands


Caloric intake

25-30 kcal/kg/day

Protein intake

0.8-1gm/kg/day (max=150gm/day)

Fluid intake

30 ml/kg/day


Caloric intake

*Mild stress, inpatient

25-30 kcal/kg/day

*Moderate stress, ICU patient

30-35 kcal/kg/day

*Severe stress, burn patient

30-40 kcal/kg/day

Protein intake

1-2 gm/kg/day

Fluid intake


The surgical patient . . . .
    • Nutrient depletion occurs in the surgical patient due to decreased intake, increased metabolic expenditure and altered nutrient use.
    • Increased risk of malnutrition due to:
      • Inadequate nutritional intake
      • Metabolic response (hypermetabolism from long term inflammation or infectious conditions)
      • Nutrient losses without proper replenishment
      • Protein /energy store depletion
      • Diminished nutrient intake (pre/post operative)
      • Prevalence of GI obstruction, anorexia, malabsorption
      • Extraordinary stressors (surgical stress, hypovolemia, sepsis, bacteremia, medications)
      • Wound healing
        • Anabolic state, higher demand for nutrients (amino acids, zinc, vitamin A & C, arginine)
perioperative nutritional assessment
Perioperative Nutritional Assessment
  • Individuals are generally classified as well nourished or mildly, moderately, or severely malnourished
  • 1: well nourished: no significant weight change; preoperative serum albumin > 3.5 g/dL
  • 2. Mildly malnourished: <10% wt loss; preoperative serum albumin 3.2-3.5 g/dL
  • 3. Moderately malnourished: 10-20% wt loss; preoperative serum albumin 2.5-32 g/dL
  • 4. Severely malnourished: >20% wt loss; preoperative serum albumin < 2.5 g/dL
  • Nutritional assessment parameters also include a complete medical history, surgical history, social history, diet history, physical exam, anthropometric and laboratory evaluations.
visceral proteins
Visceral Proteins
  • Albumin
    • Normal range: 3.5-5 g/dL.
    • Synthesized in and catabolized by the liver
    • Pro: often ranked as the strongest predictor of surgical outcomes- inverse relationship between postoperative morbidity and mortality compared with preoperative serum albumin levels
    • Con: lack of specificity due to long half-life (approximately 20 days). Not accurate in pt’s with liver disease or during inflammatory response
visceral proteins12
Visceral proteins
  • Prealbumin (transthyretin)- transport protein for thyroid hormone, synthesized by the liver and partly catabolized by the kidneys.
          • Normal range:16 to 40 mg/dL; values of <16 mg/dL are associated with malnutrition.
      • Pro: Shorter half life (two to three days) making it a more favorable marker of acute change in nutritional status. A baseline prealbumin is useful as part of the initial nutritional assessment if routine monitoring is planned.
      • Cons: More expensive than albumin. Levels may be increased in the setting of renal dysfunction, corticosteroid therapy, or dehydration, whereas physiological stress, infection, liver dysfunction, and over-hydration can decrease prealbumin levels.
visceral proteins13
Visceral proteins
  • Transferrin: acute-phase reactant and a transport protein for iron
      • normal range: 200 to 360 mg/dL.
      • Medium half-life (8-10 days)
      • Smaller body pool than albumin, reflects more acute changes.
      • influenced by several factors, including liver disease, fluid status, inflammation, iron status and illness.
      • Cons: not studied extensively as albumin and pre-albumin in relation to nutritional status, may indicator more about iron metabolism
      • Levels decrease in the setting of severe malnutrition, however unreliable in the assessment of mild malnutrition
other measures of nutrition status
Other measures of nutrition status
  • Nitrogen balance: the relationship between the amount of nitrogen taken into the body, usually as food, and that excreted from the body in urine and feces. Most of the body's nitrogen is incorporated into protein.
    • Protein ~ 16% nitrogen
    • Protein intake (gm)/6.25 - (UUN +4)= balance in grams
    • Positive value: found during periods of growth, tissue repair or pregnancy. This means that the intake of nitrogen into the body is greater than the loss of nitrogen from the body, so there is an increase in the total body pool of protein.
    • Negative value: can be associated with burns, fevers, wasting diseases and other serious injuries and during periods of fasting. This means that the amount of nitrogen excreted from the body is greater than the amount of nitrogen ingested.
    • Healthy Humans= Nitrogen Equilibrium
    • Cons: Complex determination of balance, measures of losses difficult and limited utility in clinical setting
traditional method diet advancement
Traditional Method: Diet advancement
  • Introduction of solid food depends on the condition of the GI tract.
  • Oral feeding delayed for 24-48 hours after surgery
    • Wait for return of bowel sounds or passage of flatus.
  • Start clear liquids when signs of bowel function returns
  • Rationale
    • Clear liquid diets supply fluid and electrolytes that require minimal digestion and little stimulation of the GI tract
  • Clear liquids are intended for short-term use due to inadequacy
things to consider
Things to Consider…
  • For liquid diets, patients must have adequate swallowing functions
    • Even patients with mild dysphagia often require thickened liquids.
    • Must be specific in writing liquid diet orders for patients with dysphagia
      • There is no physiological reason for solid foods not to be introduced as soon as the GI tract is functioning and a few liquids are being tolerated. Multiple studies show patients can be fed a regular solid-food diet after surgery without initiation of liquid diets.
diet advancement
Diet Advancement
  • Advance diet to full liquids followed by solid foods, depending on patient’s tolerance.
    • Consider the patient’s disease state and any complications that may have come about since surgery.
      • Ex: steroid-induced diabetes in a post-kidney transplant patient.
patients who cannot eat
Patients who cannot eat . . . ?

Consider Nutrition Support!

perioperative nutritional support
Perioperative Nutritional Support
  • Length of time a patient can remain NPO after surgery without complications is unknown, however depends on:
    • Severity of operative stress
    • Patient’s preexisting nutritional status
    • Nature and severity of illness
  • “In uncomplicated cases, well nourished patients tolerate up to 10 days of starvation with no medical complications. Moderately or severely malnourished patients usually require nutritional support earlier.” (A.S.P.E.N Nutrition Support Practice Manual 2nd Ed)
goals of perioperative nutrition support
Goals of perioperative Nutrition Support
  • Decrease surgical mortality
  • Decrease surgical complications and infection
  • Reduce the catabolic state and restore anabolism
  • Support the depleted patient throughout the catabolic phase of recovery
  • Decrease hospital LOS
  • Speed the healing/recovery process
  • Ensure the prompt return of GI function to resume standard oral intake as soon as possible
perioperative nutrition support guidelines
Perioperative Nutrition Support Guidelines
  • The American Society for Parenteral and Enteral Nutrition evidence-based practice guidelines
    • 1. preoperative specialized nutrition support should be administered for 7-14 days to moderately or severely malnourished pts undergoing major surgery
    • 2. PN should not be routinely given in the immediate post-op period to pts undergoing major GI procedures
    • 3. Postoperative nutrition support should be administered to patients who are expected to be unable to meet their nutrient needs orally for 7-10 days
nutrition support
Nutrition Support
  • Enteral Nutrition Support
  • Parenteral Nutrition support
what is enteral nutrition
What is enteral nutrition?
  • Enteral Nutrition
    • Also called "tube feeding," enteral nutrition is a liquid mixture of all the needed nutrients.
    • Consistency is sometimes similar to a milkshake.
    • It is given through a tube in the stomach or small intestine.
    • If oral feeding is not possible, or an extended NPO period is anticipated, an access devise for enteral feeding should be inserted at the time of surgery.
    • Feeds can meet 100% of patient’s needs or can be used to supplement poor po intake.
indications for enteral nutrition
Indications for Enteral Nutrition

When the GI tract is functional or partially functional and…..

  • Patient has inability to consume or absorb adequate nutrients.
  • Patient is not meeting > 75% of needs with po intake.
  • Malnourished patient expected to be unable to eat adequately for > 5-7 days
  • Adequately nourished patient expected to be unable to eat > 10 days
contraindications to enteral nutrition support
Contraindications to Enteral Nutrition Support
  • Expected need less than 5-7 days if malnourished or 7-9 days if normally nourished
  • Severe acute pancreatitis
  • Small bowel obstruction, ileus or high output enteric fistula distal to feeding tube
  • Inability to gain access
  • Hemodynamic instability
  • Need for high dose pressors/vasoactives
  • MAP consistently < 60 mmHg
  • Intractable vomiting or diarrhea
  • Those requiring massive fluid resuscitation
enteral access devices
Enteral Access Devices
  • Nasogastric
  • Nasoenteric
  • Gastrostomy
    • PEG (percutaneous endoscopic gastrostomy)
    • Surgical or open gastrostomy
  • Jejunostomy
    • PEJ (percutaneous endoscopic jejunostomy)
    • Surgical or open jejunostomy
  • Transgastric Jejunostomy
    • PEG-J (percutaneous endoscopic gastro-jejunostomy)
    • Surgical or open gastro-jejunostomy
feeding tube selection
Feeding Tube Selection
  • Can the patient be fed into the stomach, or is small bowel access required?

2) How long will the patient need tube feedings?

gastric vs small bowel access
Gastric vs. Small Bowel Access
  • Gastric access: “If the stomach empties, use it.”
  • Indications to consider small bowel access:
    • Gastroparesis / gastric ileus
    • Recent abdominal surgery
    • Sepsis
    • Significant gastroesophageal reflux
    • Pancreatitis
    • Aspiration
    • Ileus
    • Proximal enteric fistula or obstruction
short term vs long term tube feeding access
Short-Term vs. Long-Term Tube Feeding Access
  • No standard of care for cut-off time between short-term and long-term access
  • However, if patient is expected to require nutrition support longer than 6-8 weeks, long-term access should be considered
choosing appropriate formulas
Choosing Appropriate Formulas
  • Categories of enteral formulas:
    • Polymeric
      • Whole protein nitrogen source, for use in patients with normal or near normal GI function. Examples include Ensure and Jevity.
    • Monomeric or elemental
      • Predigested nutrients; most have a low fat content or high % of MCT; for use in patients with severely impaired GI function. Examples include Peptamen and Optimental
    • Disease specific
      • Formulas designed for feeding patients with specific disease states
      • Formulas are available for respiratory disease, diabetes, renal failure, hepatic failure, and immune compromise. Examples include Glucerna and Nepro

*well-designed clinical trials may or may not be available

complications of enteral nutrition support
Complications of Enteral Nutrition Support
  • Issues with access, administration, GI complications, metabolic complications. These include:
    • Nausea, vomitting, diarrhea, constipation, delayed gastric emptying, malabsorption, refeeding syndrome, hyponatremia, microbial contamination, tube obstruction, leakage from ostomy/stoma site, micronutrient deficiencies.
implementation of enteral nutrition
Implementation of Enteral Nutrition
  • Gastric feeding
    • Pump assisted: Continuous feeding and cyclic feeding
      • Allows for max nutrient absoroption and improved tolerance
      • best in sicker/hospitalized patients
      • Start at rate 30 mL/hour and advance in increments of 20 mL q 8 hours to goal. Check gastric residuals q 4 hours for tolerance
    • Gravity Controlled: Bolus feeding
      • Infusion of a predetermined volume of formula at specified intervals. Example: 1 can Glucerna (240 ml) via PEG tube q 4 hours.
      • Easiest, least expensive, more physiologic (mimic normal eating pattern)
  • Small bowel feeding
    • Continuous feeding only; do not bolus due to risk of dumping syndrome
      • Start at low volume to assess tolerance (20 mL/hour)
      • Advance in increments of 20 mL q 8 hours to goal
      • Do not check gastric residuals
determining your enteral nutrition prescription
Determining Your Enteral Nutrition Prescription
  • Estimate energy, protein, and fluid needs
  • Select most appropriate enteral formula
  • Determine continuous vs. bolus feeding
  • Determine goal rate to meet estimated needs
  • Write/recommend the enteral nutrition prescription
enteral nutrition case study
Enteral Nutrition Case Study
  • 78-year-old woman admitted with new CVA
  • Significant aspiration detected on bedside swallow evaluation and confirmed with modified barium swallow study; speech language pathologist recommended strict NPO with alternate means of nutrition
  • PEG placed for long-term feeding access
  • Plan of care is to stabilize the patient and transfer her to a long-term care facility for rehabilitation
enteral nutrition case study continued
Enteral Nutrition Case Study (continued)
  • Height: 5’4” IBW: 120# +/- 10%
  • Weight: 130# / 59kg 100% IBW
  • BMI: 22
  • Usual weight: ~130# no weight change
  • Estimated needs:
    • 1475-1770 kcal (25-30 kcal/kg)
    • 59-71g protein (1-1.2 g/kg)
    • 1770 mL fluid (30 mL/kg)
enteral nutrition prescription
Enteral Nutrition Prescription
  • Tube feeding via PEG with full strength

Jevity 1.2

  • Initiate at 30 mL/hour, advance by 20 mL q 8 hours to goal
  • Goal rate = 55 mL/hour continuous infusion
    • Above goal will provide 1584 kcal, 73g protein, 1069 mL free H2O
  • Give additional free H2O 175 mL QID to meet hydration needs and keep tube patent
  • Check gastric residuals q 4 hours; hold feeds for residual > 200 mL
  • Keep HOB > 30° at all times
what is parenteral nutrition
What is parenteral nutrition?
  • Parenteral Nutrition
    • also called "total parenteral nutrition," "TPN," or "hyperalimentation."
    • Defined as nutrients provided intravenously.
    • Components of a PN mixture include:
      • Protein (Amino Acids) , carboydrates (dextrose) , Fats (Long-chain fatty acids), sterile water, electrolytes, vitamins and trace minerals
    • For use in nutritionally compromised patients when enteral nutrition is contra-indicated.
indications for parenteral nutrition support
Indications for Parenteral Nutrition Support
  • Malnourished patient expected to be unable to eat > 5-7 days AND enteral nutrition is contraindicated
  • Patient failed enteral nutrition trial with appropriate tube placement (post-pyloric)
  • Enteral nutrition is contraindicated or severe GI dysfunction is present
    • Paralytic ileus, mesenteric ischemia, small bowel obstruction, enteric fistula distal to enteral access sites
ppn vs tpn
  • TPN (total parenteral nutrition)
    • High glucose concentration (15%-25% final dextrose concentration)
    • Provides a hyperosmolar formulation (1300-1800 mOsm/L)
    • Must be delivered into a large-diameter vein
  • PPN (peripheral parenteral nutrition)
    • Similar nutrient components as TPN, but lower glucose concentration (5%-10% final dextrose concentration)
    • Osmolarity < 900 mOsm/L (maximum tolerated by a peripheral vein)
    • May be delivered into a peripheral vein
    • Because of lower concentration, large fluid volumes are needed to provide a comparable calorie and protein dose as TPN
parenteral access devices
Parenteral Access Devices
  • Peripheral venous access
    • Catheter placed percutaneously into a peripheral vessel
  • Central venous access (catheter tip in SVC)
    • Percutaneous jugular, femoral, or subclavian catheter
    • Implanted ports (surgically placed)
    • PICC (peripherally inserted central catheter)
writing tpn prescriptions
Writing TPN prescriptions
  • Determine total volume of formulation based on individual patient fluid needs
  • Determine amino acid (protein) content
    • Adequate to meet patient’s estimated needs
  • Determine dextrose (carbohydrate) content
    • ~70-80% of non-protein calories or ~50% calorie needs
  • Determine lipid (fat) content
    • ~20-30% non-protein calories
  • Determine electrolyte needs
  • Determine acid/base status based on chloride and co2 levels
  • Check to make sure desired formulation will fit in the total volume indicated
parenteral nutrition prescription
Parenteral Nutrition Prescription
  • Important items to consider:
    • Glucose infusion rate should be < 5 mg/kg/minute (maximum tolerated by the liver) to prevent hepatic steatosis
    • Lipid infusion should be < 0.1 g/kg/hour (ideally < 0.4 g/kg/day to minimize/prevent TPN-induced liver dysfunction)
    • Initiate TPN at ~½ of goal rate/concentration and gradually increase to goal over 2-3 days to optimize serum glucose control
parenteral nutrition monitoring
Parenteral Nutrition Monitoring
  • Electrolytes -adjust TPN/PPN electrolyte additives daily according to labs
  • Check accu-check glucose q 6 hours
    • Regular insulin may be added to TPN/PPN bag for glucose control as needed
  • Check triglyceride level within 24 hours of starting TPN/PPN
    • If TG >250-400 mg/dL, lipid infusion should be significantly reduced or discontinued
    • Daily addition of Carnitine to TPN/PPN may improve lipid metabolism
    • ~100 grams fat per week is needed to prevent essential fatty acid deficiency
  • Check LFT’s weekly
    • If LFT’s significantly elevated as a result of TPN, then minimize lipids to < 1 g/kd/day and cycle TPN/PPN over 12 hours to rest the liver
    • If Bilirubin > 5-10 mg/dL due to hepatic dysfunction, then discontinue trace elements due to potential for toxicity of manganese and copper
  • Check pre-albumin weekly
    • Adjust amino acid content of TPN/PPN to reach normal pre-albumin 18-35 mg/dL
    • Adequate amino acids provided when there is an increase in pre-albumin of ~1 mg/dL per day
  • Acid/base balance
    • Adjust TPN/PPN anion concentration to maintain proper acid/base balance
    • Increase/decrease chloride content as needed
    • Since bicarbonate is unstable in TPN/PPN preparations, the precursor—acetate—is used; adjust acetate content as needed
complications of parenteral nutrition
Complications of Parenteral Nutrition
  • Hepatic steatosis
    • May occur within 1-2 weeks after starting PN
    • May be associated with fatty liver infiltration
    • Usually is benign, transient, and reversible in patients on short-term PN and typically resolves in 10-15 days
    • Limiting fat content of PN and cycling PN over 12 hours is needed to control steatosis in long-term PN patients
  • Cholestasis
    • Occurs because there are no intestinal nutrients to stimulate hepatic bile flow
    • May occur 2-6 weeks after starting PN
    • Indicated by progressive increase in TBili and an elevated serum alkaline phosphatase
    • *Trophic enteral feeding to stimulate the gallbladder can be helpful in reducing/preventing cholestasis
  • Gastrointestinal atrophy
    • Lack of enteral stimulation is associated with villus hypoplasia, colonic mucosal atrophy, decreased gastric function, impaired GI immunity, bacterial overgrowth, and bacterial translocation
    • *Trophic enteral feeding to minimize/prevent GI atrophy
parenteral nutrition case study
Parenteral Nutrition Case Study
  • 55-year-old male admitted with small bowel obstruction
  • History of complicated cholecystecomy 1 month ago. Since then patient has had poor appetite and 20-pound weight loss
  • Patient has been NPO for 3 days since admit
  • Right subclavian central line was placed and plan noted to start TPN since patient is expected to be NPO for at least 1-2 weeks
parenteral nutrition case study continued
Parenteral Nutrition Case Study(continued)
  • Height: 6’0” IBW: 178# +/- 10%
  • Weight: 155# / 70kg 87% IBW
  • BMI: 21
  • Usual wt: 175# 11% wt loss x 1 mo.
  • Estimated needs:
    • 2100-2450 kcal (30-35 kcal/kg)
    • 84-98g protein (1.2-1.4 g/kg)
    • 2100-2450 mL fluid (30-35 mL/kg)
parenteral nutrition prescription51
Parenteral Nutrition Prescription
  • TPN via right-SC line
  • 2 L total volume x 24 hours
  • Amino acid 4.5% (or 45 g/liter)
  • Dextrose 17.5% (or 175 g/liter)
  • Lipid 20% 285 mL over 24 hours
  • Above will provide 2120 kcal, 90g protein, glucose infusion rate 3.5 mg/kg/minute, lipid 0.9 g/kg/day
benefits of enteral nutrition over parenteral nutrition
Benefits of Enteral Nutritionover parenteral nutrition
  • Cost
    • Tube feeding cost ~ $10-20 per day
    • TPN cost ~ $100 or more per day!
  • Maintains integrity of the gut
    • Tube feeding preserves intestinal function; it is more physiologic
    • TPN may be associated with gut atrophy
  • Less infection
    • Tube feeding—very small risk of infection and may prevent bacterial translocation across the gut wall
    • TPN—high risk/incidence of infection and sepsis
transitional feedings
Transitional Feedings
  • Parenteral to enteral feedings
    • Introduce a minimal amount of enteral feeding at a low rate (30-40 ml/hr) to establish tolerance.
    • Decrease PN level slowly to keep nutrient levels at same prescribed amount
    • As enteral rate is increased by 25-30 ml/hr increments every 8-24 hrs, parenteral can be reduced
    • Discontinue PN solution if 75% of nutrient needs met by enteral route.
  • Parenteral/Enteral to oral feedings
    • Ideally accomplished by monitoring oral intake and concomitantly decreasing rate of nutrition support until 75% of needs are met.
    • Oral supplements are useful if needs not met 100% by diet. Ex (Nepro, Glucerna, Boost, Ensure).
dangers of over and under feeding
Dangers of Over and Under Feeding
  • Risks associated with over-feeding:
    • Hyperglycemia
    • Hepatic dysfunction from fatty infiltration
    • Respiratory acidosis from increased CO2 production
    • Difficulty weaning from the ventilator
    • Refeeding syndrome
  • Risks associated with under-feeding:
    • Depressed ventilatory drive
    • Decreased respiratory muscle function
    • Impaired immune function
    • Increased infection
    • Weight loss and malnutrition
refeeding syndrome
Refeeding Syndrome
  • “the metabolic and physiologic consequences of depletion, repletion, compartmental shifts, and interrelationships of phosphorus, potassium, and magnesium…”
  • Severe drop in serum electrolyte levels resulting from intracellular electrolyte movement when energy is provided after a period of starvation (usually > 7-10 days)
  • Physiologic and metabolic sequelae may include:
    • EKG changes, hypotension, arrhythmia, cardiac arrest
    • Weakness, paralysis
    • Respiratory depression
    • Ketoacidosis / metabolic acidosis
refeeding syndrome continued
Refeeding Syndrome(continued)
  • Prevention and Therapy
    • Correct electrolyte abnormalities before starting nutrition support
    • Continue to monitor serum electrolytes after nutrition support begins and replete aggressively
    • Initiate nutrition support at low rate/concentration (~ 50% of estimated needs) and advance to goal slowly in patients who are at high risk

Contact Information:

Carli Schwartz, RD,LDN

Clinical Dietitian, Tulane Abdominal Transplant Institute

(504) 988-1176

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  • 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
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  • 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.
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