Review Article| Volume 37, ISSUE 4, P683-696, April 1955

The role of protein metabolism in surgery

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      Much improvement has been made in mortality rate following major operations during the past two or three decades, but malnutrition remains a difficult problem to correct, and deserves much more attention on the part of the surgeon. For years, we have been aware of the increased nitrogen excretion after operation. This negative nitrogen balance appears to be closely related to the alarm reaction of Selye. Experiments show that with early feeding after operation, the negative nitrogen balance can be diminished but not completely obliterated.
      The deleterious effects of bed rest on nitrogen balance are not fully appreciated by the surgical profession. We must make sure that no elective surgery is performed on a patient who has been immobilized in bed for a few days prior to the date of operation.
      Proteins will be used as fuel unless carbohydrates or fat is available for use by the body. Plasma protein levels are very important in determining the state of protein metabolism, but, unfortunately, may be very misleading. In dehydration they will be abnormally high. On other occasions, they may be normal, whereas insufficient food intake may be known to exist for several weeks preceding examination. It is rather obvious that the blood stream draws upon protein deposits in an effort to keep the plasma level as nearly normal as possible. The causes of protein deficiency are innumerable. The important ones are inadequate intake, trauma, hepatic insufficiency, ulcer (external or in intestinal tract), diarrhea, fistulas, infection, intestinal distention, transudates, and exudates.
      If a patient requiring a major operation has a history of inadequate food intake for a period shortly before operation, all possible effort must be made to correct this malnutrition. Obviously, forced feedings by mouth are desirable. Occasionally, feedings by nasal tube are more effective than oral intake. Intravenous therapy including glucose and amino acids must be utilized wherever possible. If a patient has lost 10 or 15 pounds in fifteen or twenty days preceding operation, intense effort must be made to gain part of that back. Blood transfusions are very effective in improving hypoproteinemia. Intravenous plasma is likewise very effective, but expensive.
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