Is BMI < 20.5?
Yes
No
Has the patient lost weight within the last 3 months?
Has the patient had a reduced dietary intake in the last week?
Is the patient severely ill? (e.g., in intensive therapy)
Yes: If the answer is “Yes” to any question, the screening in Table 41.2 is performed
No: If the answer is “No” to all questions, the patient is rescreened at weekly intervals. If the patient is scheduled for a major operation, a preventative nutritional care plan is considered to avoid the associated risk status
Impaired nutritional status | Severity of disease (≈increase in requirements) | ||
|---|---|---|---|
Absent Score 0 | Normal nutrition status | Absent Score 0 | Normal nutritional requirements |
Mild Score 1 | Wt loss > 5 % in 3 months or food intake below 50–70 % of normal requirement in preceding week | Mild Score 1 | Hip fracture; chronic patients with acute complications; cirrhosis; COPD; chronic hemodialysis; diabetes, oncology |
Moderate Score 2 | Wt loss > 5 % in 2 months or BMI 18.5–20.5 + impaired general condition or food intake 25–60 % of normal requirement in preceding week | Moderate Score 2 | Major abdominal surgery; stroke; severe pneumonia; hematologic malignancy |
Severe Score 3 | Wt loss > 5 % in 1 month or BMI < 18.5 + impaired general condition or food intake below 50–70 % of normal requirement in preceding week | Severe Score 3 | Head injury; bone marrow transplantation; intensive care patients (APACHE > 10) |
Score: [Nutritional status score] + [Disease severity score] = Total score | |||
Age If ≥ 70 years: add 1 to total score above = Age-adjusted total score | |||
Score ≥ 3: the patient is nutritionally at risk and a nutritional care plan is initiated Score < 3: weekly rescreening of the patient. If the patient, e.g., is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status | |||
PERIOPERATIVE MANAGEMENT
Optimizing Nutrition Status Prior to Surgery
Preoperative Enteral and Parenteral Nutrition
Patients with severe malnutrition (defined as nutritional risk screen [NRS] greater than three or weight loss of 10–15 % of total body mass in the past six months or BMI <18.5) undergoing major elective surgery (i.e., gastrointestinal surgery, cardiothoracic surgery, complex head and neck surgery) benefit from supplemental nutrition prior to surgery [6]. Just 5 to 7 days of adequate preoperative nutrition can prepare the body for the metabolic insult and stress of surgery and results in improved surgical outcomes including reduced rates of infection and surgical complications [7].
Enteral nutrition is preferred to parenteral nutrition as it has lower risk of infection, is less expensive, and maintains the integrity of the gut mucosal lining. Supplemental nutrition (as oral supplements or by tube feeds) should provide 25 kcal/kg/day of calories and 1.5–2 g/kg/day of protein [7].
If enteral nutrition is contraindicated (bowel obstruction, bowel ischemia, acute peritonitis) and the patient is severely malnourished, surgery should be delayed for 5 to 7 days to administer parenteral nutrition, if feasible.
Parenteral nutrition should be stopped 2–3 h prior to surgery and then resumed the morning after surgery [8].
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