The malnourished surgery patient: a silent epidemic in perioperative outcomes?

Abstract

Purpose of review: As many as two of every three major surgery patients are malnourished preoperatively - a diagnosis rarely made and treated even less frequently. Unfortunately, perioperative malnutrition is perhaps the least often identified surgical risk factor and is among the most treatable to improve outcomes.

Recent findings: Two important perioperative nutrition guidelines were published recently. Both emphasize nutrition assessment as an essential component of preoperative screening. The recently published perioperative nutrition screen (PONS) readily identifies patients at malnutrition risk, allowing for preoperative nutritional optimization. The use of computerized tomography scan and ultrasound lean body mass (LBM) evaluation to identify sarcopenia associated with surgical risk and guide nutrition intervention is garnering further support. Preoperative nutrition optimization in malnourished patients, use of immunonutrition in all major surgery, avoidance of preoperative fasting, inclusion of postoperative high-protein nutritional supplements, and early postoperative oral intake have all recently been shown to improve outcomes and should be utilized.

Summary: The recent publication of new surgical nutrition guidelines, the PONS score, and use of LBM assessments will allow better identification and earlier intervention on perioperative malnutrition. It is essential that in the future no patient undergoes elective surgery without nutrition screening and nutrition intervention when malnutrition risk is identified.

Figure 1.

Pre-Operative Nutrition Score (PONS) Assessment Tool (PONS; adapted from reference [6]). PONS utilizes questions from the validated Malnutrition Universal Screening Tool to assess for malnutrition risk in perioperative patients. A PONS score ≥ 1 and/or an albumin <3.0 or vitamin D < 20 signifies malnutrition risk, and the patient should receive preoperative nutrition therapy before undergoing surgery.

Figure 2.

Example of MuscleSound® Lean Body Mass Loss Over Hospital Stay is ICU Patient- A) ICU Admit, B)-ICU Day10. Note loss of muscle mass/size and lower muscle glycogen content at Day 10. Rectus femoris muscle shown: Pink areas (red arrows) = low muscle glycogen content; Purple areas (blue arrows) = high muscle glycogen content; White areas= intermuscular connective tissue; Grey areas= areas of muscle injury; Yellow areas = fascia

Figure 3.

Perioperative Nutritional Care Pathways used in Duke Perioperative Enhancement Team (POET) Nutrition Program. Includes Nutrition Pathway for Low Nutrition Risk Patients with PONS score < 1 and Nutrition Pathway for High Nutrition Risk Patients-– as defined by any positive response on the PONS score.