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(Acta Anaesth. Belg.

, 2016, 67, 16-28)

Why should the anesthesiologist evaluate nutritional status ?

C. Dumont (*), D. Lacrosse (**), O. Simonet (***), J.-L. Schils (****) and M. de Kock

Abstract : Background : The anesthesiologist’s involve- Surprisingly, screening and assessment of un-
ment in perioperative medicine has significantly changed. dernutrition are not systematically performed. In
In order to identify patients at risks of perioperative com- 2002, in North European hospitals, 40% of patients
plications, the anesthesiologist has to consider, amongst were not assessed for their nutritional status, and
others, screening and management of undernutrition. For only 25% of patients at risk for undernutrition re-
this purpose knowledge of prevalence and risk factors, ceived nutritional support (7).
along with screening tools and guidelines for an adapted Consequently, it appears of prime concern to
nutritional management and outcomes of renutrition are conduct a review of the literature in order to raise
mandatory. The present review intends to provide these the anesthesiologists’ awareness regarding peri­
tools to the Anesthesiologists.
operative undernutrition. The present review in-
Method : We conduct a literature review in Pubmed,
cludes : definition, epidemiology, risk factors, and
­Direct Science and Cochrane Library without limit of
consequences in the surgical population. It also
time related to undernutrition in the perioperative period.
point out the key role of the anesthesiologist in
Results : Undernutrition is common in surgical patients.
Undernutrition is associated with an increase of morbid-
screening preoperative nutritional status of the pa-
ity, mortality, length of hospital stay and costs. Undernu- tients and promoting efficient measures.
trition could probably be detected during the anesthetic
consultation with simple and rapid tests, such as SNAQ,
MST, MUST and NRS-2002. Nevertheless, further stud- Methods
ies are needed to validate such tests in surgical patients.
Waiting for these results, we prefer MUST. The imple- We conduct a large review of the literature in
mentation of nutritional support recommendations would the following electronic databases : Pubmed, Direct
reduce postoperative complications. Science and Cochrane Library. The keywords used
Conclusion : The anesthesiologist could play an impor- were : undernutrition, malnutrition, surgery, preva-
tant role in undernutrition screening and its management lence, screening, guidelines. The selection of arti-
in order to reduce perioperative morbidity. cles was not limited in time and was restricted to
English and French. We consulted 349 articles and
Key words : Undernutrition ; surgery ; prevalence ; 114 of them were selected according to their rele-
screening ; guidelines. vance to the topic, to the referenced key words and
the impact factor of the journals in which they orig-
inate. The selection was completed by the review of
Given the recent European Surgical Outcomes the reference list of initially selected articles.
Study (EuSOS) showing high rates of postoperative
mortality, anesthesiologists need to develop periop-
erative strategies to improve outcomes (1). These
include the identification of patients at risk of com- Celine Dumont, M.D. ; Dominique Lacrosse, M.D. ; Olivier
plications and the preoperative patient’s optimiza- Simonet, M.D. ; Jean-Luc Schils, M.D. ; Marc de Kock,
tion in order to reduce morbidities, mortality and Ph.D.
(*) Cliniques Universitaires Saint-Luc, avenue Hippocrate 10,
costs of healthcare. Detection of undernutrition is in 1200, Woluwe-Saint-Lambert.
this framework. (**) Unité Transversal Nutrition CHU UCL Namur, Av. gaston
The prevalence of undernutrition in the hospi- Therasse 1, 5530 Yvoir.
(***) Centre Hospitalier de Wallonie picarde (CHwapi), ­avenue
tal setting is high. It varies between 20% and 60% Delmée, 9 7500 Tournai.
depending on the population selected, the screening (****) Centre Hospitalier de l’Ardenne, Avenue d’Houffalize
and the diagnostic criteria. In surgery, it fluctuates 35, 6800 Libramont.
between 30% and 65% depending on the type of in- Correspondence address : Celine Dumont, Department of
Anes­thesiology, Cliniques Universitaires Saint-Luc,
tervention (2, 3, 4). Moreover, undernutrition tends 1200 Woluwe-Saint-Lambert.
to worsen during hospitalisation (2, 5, 6). E-mail : celinedumont@hotmail.be

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nutritional status 17

Results 39, 40, 41). Nevertheless, results are not always


consistent in favour of nutritional support (42, 43,
I. Definition and epidemiology 44, 45, 46). This is due to the variety of definitions,
the diversity of patients and their pathology, the
Undernutrition is defined as a state of deficien- screening tests, and the composition of nutritional
cy of energy, proteins, or any other macro or micro- support. However, a review of 35 randomized con-
nutrients, resulting in a measurable change of body trolled trials conducted by ESPEN (European Soci-
function and/or body composition associated with ety of Parenteral and Enteral Nutrition) concluded
an aggravation of the prognosis (8). to a benefit of nutritional support in terms of the
Surgery is a stressful period for the organism length of the hospital stay, infectious complications
characterized by an increase in stress hormones and and cost when the patient is undernourished (9).
release of inflammatory mediators (9). This leads to Therefore it is mandatory to detect this condi-
a catabolic state (10, 11) with a release of glucose, tion. As recommended by the Société Française
free fatty acids and amino acids. The aim of these d’Anesthésie-Réanimation (SFAR) (47), the anes-
metabolic changes is to ensure the availability of thetic consultation is a key moment for the screen-
substrates for essential function during the postop- ing of the patient’s nutritional status (48). Remem-
erative period, i.e. : healing (12), immune re- ber that the surgical population includes between 30
sponse (13), and functional recovery. This includes to 60% of undernourished patients (2, 3, 4). This
recovery of muscular strength (14), lung (15), car- consultation is probably the last opportunity before
diac and cognitive functions (16). When the patients surgery to detect patients at risk of undernutrition or
is undernourished, the reserves in energy substrate undernourished. At this point, the role of the anes-
are reduced and the recovery functions are conse- thesiologist is to refer patients to a professional of
quently even more altered (10). nutrition to realize a complete nutritional assess-
This is confirmed by numerous studies. Al- ment in order to start a nutritional support in accor-
ready in 1936, Studley observed in patients who un- dance with international guidelines.
derwent a peptic ulcer operation, that weight loss of For an effective screening by the anesthesiolo-
20% resulted in increased mortality, from 3.5% to gist, there are two prerequisites. First, the patient
33.5% (17). Undernutrition is recognized as an scheduled for elective surgery must meet an anes-
­independent factor of mortality (18, 19, 20). thesiologist (48). This is not obvious in some coun-
Etiologies underlying this undernutrition-­ tries like Belgium since the pre-anesthetic consulta-
induced exaggerated morbidity-mortality rate are : tion is not mandatory. Second, the delay between
increased occurrence of infection (21), delayed consultation and surgery should be sufficient be-
wound healing (21, 22), decreased functional ca- cause the nutritional support will be only effective
pacity recovery (19, 21, 22), muscle weakness (21, after seven to ten days (9, 48). This implies coordi-
22), reoperations (18, 22), post-operative renal fail- nation between the different services (surgery, anes-
ure (18, 22), prolonged mechanical ventilation (22) thesia, nutritionists).
or pulmonary complications (23). According to The first step to detect undernutrition is to rec-
some studies, the duration of hospitalisation in- ognize clinical situations leading to this condition
creases from 40 to 70% in malnourished patients (5, by causing an imbalance between need and nutri-
24, 25, 26). This increase is more pronounced if un- tional intake. The most frequent situations are refer-
dernutrition is classified as severe (27). Conse- enced in the table 1 (24, 49, 50, 51, 52).
quently, health care costs increase from 35% to These situations are, however, not all by them-
300% (25, 28). In Europe, the costs of undernutri- selves the only way to diagnose undernutrition. A
tion are estimated at 170 billion euro yearly (29). systematic approach including the recording of
­objective parameters must be established for each
II. Screening tools and pre-anesthetic consultation patient. These parameters are anthropometric, bio-
chemical and clinical markers.
Despite these well-known negative effects of Many markers have been described, but we
undernutrition, there is a significant lack of screen- selected those being the most often included in
­
ing and treatment of this condition in the preopera- screening tests since they are easy to use.
tive period. Anthropometric markers to consider are :
Most of the studies report that nutritional sup- weight and size used for the calculation of the BMI
port for undernourished surgical patients could im- (Body Mass Index), and weight loss (17, 53, 54).
prove outcomes (30, 31, 32, 33, 34, 35, 36, 37, 38, The BMI values associated with undernutrition

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18 c. dumont et al.
Table 1
Risk factors of undernutrition
A. Patients comorbidities
1.  Chronic disease
a. Cancer, particularly cancer of upper aerodigestive tract (ENT, oesphagus, stomach and pancreas)
b. Organ insufficiency : kidney – liver – heart - lung – pancreatic failures
c. Digestive disorder with malabsorption (inflammatory bowel disease, celiac disease…)
d. Neuromuscular disease
2.  Persistent gastro-intestinal symptoms > 15 days (diarrhea,anorexia, dysphagia, nausea, vomiting)
3.  Medical past of gastrointestinal surgery (pancreatectomy, gastrectomy, bariatric surgery, bowel resection)
4.  Age > 70 years
5.  Cognitive disorders

B. Treatments
1. Polymedication (≥ 5 drugs)
2. Chemotherapy
3. Radiotherapy
C. Patient socio-economic status
1. Isolation
2. Poor income

are  < 18.5 kg/m2 in the general population (55), sulting scores are considered either as screening
< 21 kg/m2 in the elderly (70 and over) (51), and tests, or as screening and assessment tests. It’s im-
< 24 kg/m2 among cardiac patients (56). Weight portant to differentiate these terms. A screening test
loss values ​​associated with undernutrition are 10% evaluates the risk of undernutrition. It does not re-
weight loss in 6 months or 5% in one month (9, 41). quire special skills in nutrition and can be performed
The most frequently recorded biochemical by any health care professional. In contrast, an as-
marker is albumin. Although not specific of under- sessment test evaluates the presence of undernutri-
nutrition (57, 58), it is included in the nutritional tion. It’s a comprehensive approach performed by a
­assessment because a decrease is associated with professional in nutrition combining clinical data
increased postoperative morbidity and mortali- (medical, nutritional, and medication histories),
ty (59, 60, 61). The limit value is < 30 g/L (9) or physical examination, anthropometric measure-
35 g/dL (47). ments and laboratory data (68).
Some consider that prealbumin is a better Concerning the various screening tests, it has
marker because its half-life is shorter than albumin immediately to be noted that none of these was con-
(2 days vs 20 days). It could be more sensitive to sidered as the “gold standard” by the scientific soci-
reflect changes in nutritional status. This is, how- eties focused on nutrition. The explanation is to be
ever, still under debate (51, 62). found in the lack of reproducible validity. This is
Finally, clinical factors associated with under- mainly due to the great heterogeneity of the studies
nutrition include decreased food intake, previously on which validity assessments are based (69). First,
described undernutrition risk factors, the functional the validity of the different screening tests is ascer-
consequences of undernutrition, experience of nu- tained based on various methods for the diagnosis
tritional support, and the type of surgery (47, 63, of undernutrition. In some studies, diagnosis tests
64). Assessing food intake can be easily performed such as Subjective Global Assessment (SGA) or
during the anesthetic consultation with an visual Mini Nutritional Assessment (MNA) are used as
analog scale of calorie intake (65). Functional reference (70, 71). In others, anthropometric param-
­consequences can be evaluated trough the Hand eters or global assessment by a nutritionist are
Grip test. This test reflects the muscle strength by used (69, 72, 73). Second, the populations used are
measuring the amount of static force produced by particularly heterogeneous from one study to an-
the hand around a dynamometer (66, 67). other. They consider either geriatric subjects or hos-
None of these parameters, taken alone, are pitalized patients or patients at home (69, 73, 74,
specific to undernutrition. 75). Third, screening tests are used for assessment
For this reason, multifactorial scores are and the reverse (68). Finally, we are left with the
­developed based on combination of these anthropo- same tests used in different populations, compared
metric, biochemical and clinical markers. The re- with different references, used indifferently as

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nutritional status 19
Table 2
Recommandations for screening tests
Society – Country Screening Tests Population
ESPEN (European Society for Parenteral and Enteral MUST (Malnutrition Universal Screening Tool) (77) All settings, all adults patients
Nutrition) (76)
NRS-2002 (Nutritional Risk Screening 2002) (78) Hospitalized patients
MNA (Mini Nutritional Assessment) (79) Elderly patients (> 70 y)
BAPEN (British Association for Parenteral and Enteral MUST (Malnutrition Universal Screening Tool) (77) All settings, all adults patients
Nutrition) (80)
ASPEN (American Society for Parenteral and Enteral No particular tests All settings, all adults patients
Nutrition) (81)
Importance of the clinical judgement
The Netherlands (74) SNAQ (Short Nutritional Assessment Questionnaire) Hospitalized adults patients
(74)
New–Zealand and Australia (69) MST (Malnutrition Screening Tool) (82) Hospitalized adult patients
France (HAS, Haute Autorité de la Santé) (83) Evaluation based on BMI, weight loss, albumin All settings, all adults patients
MNA (Mini Nutritional Assessment) (79) Elderly patients (> 70 y)

screening or diagnosis. This explains the lack of medication, radiotherapy chemotherapy, corti-
consensus and is the reason why the recommenda- coids). And third, the nutritional risk caused by the
tions differ depending on nutrition societies, coun- surgeries inducing anatomic and/or functional
tries and targeted patients. The table 2 shows rec- changes of gut (ex : cephalic duodéno-
ommendations for some recognized nutrition pancréatectomy, extended intestinal reesection, to-
society or some countries using preferentially a par- tal gastrectomy, ENT surgery…) (47, 51). These
ticular test. parameters are combined to calculate a nutritional
grade ranging between 1 to 4. Depending on this
III. Which tests can be used in anesthetic consulta- nutritional grade, nutritional support is pre-
tion ? scribed (47, 51) (Table 3). This tool is interesting
because it does not require special skills in nutrition
None of the screening tests were specifically and it incorporates the nutritional risk linked to the
developed to detect undernutrition in patients sched- surgery. However, this test didn’t catch our atten-
uled for surgery. Consequently, as part of this work, tion because they include biological parameter (al-
we will try to define the most convenient in this par- bumin). Moreover, its sensitivity and specificity
ticular situation. At our opinion, to be contributive values have not been evaluated yet.
during the pre-anesthetic consultation a screening In order to find screening tests that meet the
test must meet the 3 following criteria : simplicity, criteria we defined previously, we selected 4 recent
rapidity and validity. Simplicity implies avoiding studies. Our selection is based on the number of pa-
tests using specials skills in nutrition and rapidity tients included (reviews, meta-analysis) and their
suggests to avoid laboratory tests because there are topics. Two reviews considering screening tests
not always available at the consultation time. meeting our criteria (72, 76) and one meta-analysis
What can we learn from the scientific societ- about the screening tools in a general hospitalized
ies ? Amongst these, only the SFAR (Société Fran- population (69) are of interest. The last study stud-
çaise d’Anesthésie-Réanimation) in collaboration ied specifically the surgical population (3).
with the Société Francophone Nutrition Clinique et The review by Van Venrooij et al. (72) was
Métabolisme (SFNEP) proposes its own screening designed to identify a simple and rapid screening
test (47). It is based on three parameters. First, the test. These authors concluded that MST (Malnutri-
patient’s nutritional status assessed by BMI, weight tion Screening Tool) and SNAQ (Short Nutritional
loss and albumin levels. Second, the risk factors of Assessment Questionnaire) tests are the most per-
undernutrition including the comorbidities of the formant. Indeed, these are rapid (< 3 min), valid
patient (age, cancer, digestive disease, chronic dis- (sensitivity and specificity > 85%), and highly ap-
ease, cognitive disorders…) and treatments (poly- plicable. MUST (Malnutrition Universal Screening

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20 c. dumont et al.
Table 3
Nutritional grade and nutrition care by SFAR
Nutritional Grade Nutritional care
NG 1 + Patient not malnourished No nutritional support
+ No risk factors of malnutrition
+ Surgery with low risk of complications

NG 2 + Patient not malnourished Depending on oral intake, dietary counseling


+ At least one of risk factor of and oral nutritional supplements malnutrition OR surgery with high risk of
complications

NG 3 + Patient malnourished Depending on oral intake, dietary counseling


+ Surgery with low risk of and oral nutritional supplements.
complications Planning for a route for enteral or parenteral nutrition in case of postoperative
nutritional support.
NG 4 + Patient malnourished Nutritional support
+ Surgery with high risk of complications

Tool) and NRS-2002 (Nutritional Risk Screen- specificity and sensitivity. MUST is the best screen-
ing-2002) were not included in the study because ing test with sensitivity and specificity > 80% in
these didn’t encounter an inclusion criterion, name- half of the studies, and between 50% -80% in the
ly specificity and sensitivity > 65%. other half. The NRS-2002, though recommended by
The recent review by Skipper et al. (76) com- ESPEN (European Society for Parenteral and En-
pared 11 screening tests considered as easy and teral Nutrition), gives conflicting data with sensi-
quick. They identified only one test as valid and re- tivities and specificities ranging between 35% and
liable : the MST (Malnutrition Screening Tool), 93%. SNAQ and MST do however always get sen-
with a sensitivity and a specificity greater than sitivities and specificities below 80%. They are
>90%. Its reliability is defined by a κ score of 0.83– nonetheless not to be condemned, as the rapidity of
0.88. The second test considered as valid is the their execution remains of importance.
MNA-SF (Mini Nutritional Assessment Short In accordance to this review of the literature,
Form) with sensitivity (> 83%) and specificity we have identified four screening tests that can be
(> 90%). It was however not analysed for reliabili- performed during the anesthetic consultation :
ty. MNA- SF (Mini Nutritional Assessment Short MUST (Malnutrition Universal Screening
Form) was not considered in this work because it Tool) (78), SNAQ (Short Nutritional Assessment
screens undernutrition specifically in the geriatric Questionnaire) (74), MST (Malnutrition Screening
population (77). Note that, according to their study, Tool) (79) and NRS 2002 (Nutritional Risk Screen-
SNAQ (Short Nutritional Assessment Question- ing 2002) (80) (Annex 1). These four tests do not
naire) (74) was excluded because it had not been require special skills in nutrition (see annex 1) and
compared to a standard reference. they are quick, especially SNAQ, MST and
In 2012, Almeida et al. (3) compared 5 screen- MUST (72, 76). Concerning their validity, as de-
ing tools in the surgical population : BMI, recent scribed in the preceding studies, none of the four
weight loss (> 5% in the previous 6 months), NRS- tests gives adequate sensitivity and specificity val-
2002, MUST and NRI (Nutritional Risk Index). ues in a constant way.
NRS-2002, MUST and weight loss were valid. The Nevertheless no screening test is defined as the
sensitivity of NRS-2002 vs SGA was 80% (p < “gold standard” by the scientific community. For
0.001) and the specificity was 89% (p < 0.001). The this reason, we advise that each hospital establishes
sensitivity of MUST vs SGA was 85% (p < 0.001) its own standard for screening undernutrition. It will
and the specificity was (93%) (p < 0.001). The be defined by surgeons, anesthetists, and nutrition-
­reliability of NRS-2002 and MUST by k score was ists. The medical teams have to choose of a screen-
respectively 0.853 and 0.912. ing test among the four pre-selectioned tests (MST,
In 2014, van Bokhorst et al. (69) conducted a MUST, NRS-2002, SNAQ) although they are not
large meta-analysis on screening tests in hospital- validated with certainty. Indeed, the diagnosis will
ized patients. They compared 32 tests. The authors be next validated by a professional of nutrition.
conclude that the results of the studies are too con- At our opinion, the MUST test is a good
tradictory to take a position on the matter. No choice. It is retained as valid in two studies of our
screening test gets correct and constant values ​​of selection (3, 69), it is a quick test (72, 76) and it is a

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nutritional status 21

Table 4
Proposed algorithm for nutritional management for the preoperative time
By anesthesiologists By nutritionists (based on ESPEN and SFAR guidelines)
Fasting rules Nutritional support
–  Drink liquid up until 2 hours before surgery (water, caloric or not, –  Oral nutritional supplement :
fat- and alcohol free such as soft drinks, tea, coffee, of fruit juice     o  10-14 days to patients at risk of undernutrition or with ingestats <
without pulp) 60% of energy requirements.
–  Eat solid up until 6 hours before surgery
–  Not recommended for pregnant woman, patients with diabetes –  Enteral nutrition :
mellitus or gastro-oesophageal reflux.     o  Patients with severe nutritional risk, 10-14 days before a majore
elective surgery. Delay surgical intervention if necessary (medico-
Carbohydrates loading surgical discussion).
–  Drink 800 ml the evening before and 400 ml 2-3 hours of carbohydrates     o  Patient with prevision of no intake more than 7 days perioperatively,
drinks before major elective surgery. without obvious undernutrition.
–  Not recommended for patients with diabetus mellitus.     o  Patient with oral intake < 60% of nutritional requirements more than
10 days perioperatively.

–  Parenteral nutrition :
    o  In patient with contraindication (intestinal obstruction or ileus,
severe shock, intestinal ischemia, intractable vomiting, peritonitis)
of EN according to the indications of EN prementioned.
    o  In complement of EN if this does not meet the energy requirements.

EN : enteral nutrition ; PN : parenteral nutrition ; NS : nutritional support.

test recommended as standard by some nutrition so- a. Preoperative period (Table 4)


cieties, namely by the ESPEN for non hospitalized
During the preoperative period, anesthesiolo-
patients (81) and by the BAPEN for all the pa-
gists must enforce the recent fasting rules including
tients (82). However, we have to note that the
carbohydrate loading.
MUST does not include the risk of postoperative
Nutritionists take part in optimizing the nutri-
denutrition caused by surgery, instead of the NRS-
tional status of the patient by given an adequate
2002. But this last is more time consuming because
­nutritional support according to the risk of under­
it includes two parts and takes more parameters into
nutrition.
account. Therefore, its specificity and sensitivity
values are considered as correct in only one pro-
Fasting rules
spective study (3) instead of two studies (one meta-
analysis and one prospective study) for the Fasting from midnight has for long been rec-
MUST (3, 69). Finally, NRS-2002 is recommended ommended in order to minimize the risk of regurgi-
by only one society (ESPEN) and for a select popu- tation and inhalation of gastric contents. But the
lation : the hospitalized patients. standards have changed since it was proven that
fasting increases insulin resistance, does not reduce
IV. What does nutritional care include for a surgi- gastric volume, nor prevent acid secretion or de-
cal patient ? creased the complications rate (86, 87). Internation-
al Societies of anesthesiology recommend clear liq-
As developed in the ERAS protocols (En- uids oral intakes up to two hours before surgery
hanced Recovery After Surgery), nutrition manage- (water, caloric or not, fat- and alcohol free) such as
ment must be part of the care of surgery patients to soft drinks, tea, coffee, of fruit juice without pulp,
achieve a rapid recovery by reducing stress induced and solid intake up to six hours before surgery (87,
by surgery (83, 84, 85). Nutritional care includes a 88). This reduces the sensation of thirst, discomfort,
nutritional support adapted to nutritional status, the and resistance to insulin (83, 84, 85, 87, 89). Some
prescription of recent fasting rules, and adequate reserves are made concerning the application of
postoperative realimentation. Both nutritionists and these rules to patients with risk of a delayed gastric
anesthesiologists take part for these nutritional mea- emptying. This includes pregnant women and pa-
sures spread during the preoperative and postopera- tient with systemic disease such as diabetes mellitus
tive periods. or with gastrointestinal symptoms like gastro-­

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22 c. dumont et al.
Table 5
Proposed algorithm for nutritional management for the postoperative time
By anesthesiologists By nutritionists (based on ESPEN and SFAR guidelines)
Postoperative feeding Nutritional support
–  Early oral and enteral nutrition within the 24 hours after surgery. –  Situations at risk to require postoperative NS :
–  Adaptate to the individual tolerance gastro-intestinal function and type    o Severe trauma
of surgery.    o Major head and neck surgery
   o Gastrointestinal surgery for cancer
Postoperative nutritional support    o Severe undernutrition detected at the time of surgery
–  Placement of a tube feeding during the surgery if a postoperative EN     o  Patient with oral intake < 60% of normal requirements.
is required.
–  Placement of a central catheter during the surgery if a postoperative –  Prefer EN. PN is prescribed in contraindication of EN or in addition
PN is required. of EN as described in table 4.

EN : enteral nutrition ; PN : parenteral nutrition ; NS : nutritional support.

oesophageal reflux (89). The studies showing the results show a reducing of length of stay, insulin re-
absence of an increase of complications in such pa- sistance, and time for recovery of a gastrointestinal
tients are cohort studies or case control and therefore, transit. However, no improvement was found
have not sufficient power to be demonstrative (87). ­concerning the postoperative complications. They
Carbohydrates should be part of preoperative mentioned a lack of an adequate blinding of the
fasting protocols. European Societies of Anesthesi- studies. Other randomized controlled trials are so
ology (87, 89), the BAPEN (British Association for required to further strengthen the evidence about the
Parenteral and Enteral Nutrition) (90), ESPEN (9) improvement on postoperative complications with
and the ERAS (Enhanced Recovery After Sur- carbohydrates loading.
gery) (83, 84, 85) recommend oral carbohydrates
before major elective surgeries. These major surger- Nutritional support
ies are not defined by the societies but most of stud-
According to the nutritional status, the profes-
ies concerns gastrointestinal surgery, cardiac sur-
sional of nutrition applies nutritional assistance. It
gery and orthopedic surgery (91). Carbohydrates
can be dietary advice, oral nutritional supplements,
are mainly composed of maltodextrins whose con-
and enteral or parenteral nutrition.
centration is approximately 12.5% (9)​​. They are ad-
Oral nutritional supplements are solutions pro-
ministered at a rate of 800 mL the evening before
viding calories, proteins, vitamins and minerals. It
surgery and 400 mL 2-3 hours before surgery (9).
is recommended to prescribe them preoperatively
The gastric emptying is complete after 90 minutes
10-14 days to patients at risk of undernutrition or to
and causes no risk of inhalation if the patient has a
patients who do not meet 60% of their nutritional
conserved transit (92). It is not recommended for
requirements (103, 104).
patients with diabetes because of the risk of hyper-
The ESPEN (9) and the SFAR (47) recom-
glycemia and delay in transit (83, 84, 85). The ad-
mend preoperative enteral and parenteral nutrition
vantages of the loading carbohydrates are numer-
to patients with severe nutritional risk and sched-
ous. It gives a fed state to patient and leads to
uled for a major surgery. The optimal duration for
reducing insulin resistance that occurs after a
this nutritional support is 10-14 days (9, 47). In this
­surgery (93, 94, 95). It avoids postoperative hyper-
condition, the surgery must be delayed if it is sched-
glycemia known to increase postoperative compli-
uled before 10-14 days. This postponement con-
cations (96). Carbohydrates preserve also muscle
cerns only the major elective surgery and must be
mass (97, 98), muscle strength (99) and pro-
balanced with its emergency.
teins (100). They decrease the length of hospitaliza-
Nutrition support is also to be started immedi-
tion (98, 101), accelerate transit recovery (98) and
ately without obvious undernutrition, if a period of
could be cardioprotective in cardiac surgery (102).
7-10 days of pre-, postoperative fasting is expected,
Some studies showed an improved well-being, re-
or if the patient does not meet 60% of his nutritional
duced preoperative anxiety, and a reduction of post-
needs more than 10 days (9).
operative nausea and vomiting (115, 116, 117) but
If the digestive tract is functional, enteral ad-
these results have not been confirmed (114, 117,
ministration is preferred to parenteral administra-
118). In a recent Cochrane review (91) about clini-
tion. Their effectiveness is identical, but the cost of
cal effects of preoperative carbohydrates loading,

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dumont-.indd 22 5/04/16 10:46


nutritional status 23
enteral nutrition is lesser. Moreover, enteral nutri- evaluation should include the type of nutrition
tion causes fewer complications in terms of infec- ­(enteral or parenteral) and the route (probe, stoma,
tions and mortality (105, 106). Enteral nutrition ‘s intravenous) to allow early postoperative nutrition
main disadvantage is the risk linked to gastric re- (within 24 hours) (110).
siduals such as regurgitation and inhalation. It can
be done via a nasogastric/naso-jejunal tube, a jeju-
nostomy or gastrostomy tube (106, 107). Conclusion
Parenteral nutrition will only be required in
case of contraindications for enteral nutrition such Undernutrition is common in hospital setting,
as intestinal obstruction, ileus, intestinal ischemia, especially among surgical patients. Moreover, this
peritonitis, intractable vomiting, severe shock (9, condition tends to worsen during the hospital stay.
105, 107). It will also be given in addition to enteral Undernutrition is associated with an increased mor-
nutrition if nutritional requirements are not met (9, bidity, mortality and length of hospital stay and de
47). In the case of parenteral nutrition, overfeeding facto, with increased costs. Nevertheless, it remains
must be avoided as it leads to hyperglycemia, in- underdiagnosed and not treated. However, an adapt-
creased energy expenditure and CO2 production. It ed nutritional support improves outcomes. Pre-­
can also induce steatosis, hypertriglyceridémia and anesthetic consultation is the last opportunity for
derogatory effects on immunity (11). the screening of this condition. Screening tests are
numerous and recommendations are not unanimous.
b) Postoperative period (Table 5) MST, MUST, SNAQ and NRS-2002 are fast and
simple tools that can easily be performed during
The nutritional management of postoperative
­anesthesia consultations. Additional studies are re-
period includes the initiation of a rapid enteral nutri-
quired in order to determine which test is the most
tional supported by the anesthesiologists and nutri-
valid for the surgical population and if a nutritional
tional support conducted by the nutritionists. If a
care based on this score is associated with improved
postoperative nutritional support is waiting, the
outcomes. Waiting for these results, we preconize to
­anesthesiologists must consider the placement of a
choose MUST to screen undernutrition. The imple-
tube feeding or a central catheter during the surgical
mentation of the nutritional management of surgical
procedure.
patients implies a multidisciplinary work bringing
together anesthesiologists, nutritionists and sur-
Postoperative feeding
geons.
During the postoperative period, early oral or
enteral nutrition within the 24 hours is recommend-
ed, including for gastrointestinal surgery (9, 47).
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28 c. dumont et al.
Annex 1 : Screening tests
Screening tests Score Total score
MST (Malnutrition Sreening Tool)
Has the patient lost weight recently without trying ? < 2 : not at risk of malnutrition
Unsure 2
If yes, how much weight (kg) has the patient lost ?
1-5 1 ≥ 2 : at risk of malnutrition
6-10 2
11-15 3
16-20 4
Unsure 2
Has the patient been eating poorly because of decreased appetite ?
Yes 1
SNAQ (Short Nutritional Assessment Questionary)
Did the patient lose weight unintentionnally ? < 2 : well nourished
More than 6 kg in the last 6 mo 3
More than 3 kg in the last mo 2
Did the patient experience a decreased appetite over the last mo ? ≥ 2 : moderately malnourished
Yes 1
Did the patient use supplemental drinks or tube feeding over the last mo ? ≥ 3 : severely malnourished
Yes 1
MUST (Malnutrition Universal Screening Tool)
BMI score (kg/m2 ) 0 : low risk of malnutrition
18,5-20,0 1
< 18,5 2
Did the patient experience unplanned weight loss in past 3-6 months ? 1 : medium risk of malnutrition
5-10% 1
> 10% 2
Is the patient acutely ill and has the patient been or is he likely to have no ≥ 2 : high risk of malnutrition
nutritionnal intake for > 5 days ?
Yes 2
NRS 2002 (Nutritional Risk Screening 2002)
Part 1 : initial screening
Is BMI (kg/m2 ) < 20,5 ?
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 ?
If the answer is yes to any question, the final screening is performed
Part 2 : final screening
Score of nutritional status < 3 : not at risk of malnutrition
− WL > 5% in 3 mo or FI < 50-75% of normal requirement in preceding week 1
− WL > 5% in 2 mo or BMI 18,5-20,5 + impaired general condition or 2
FI < 25-60% of normal requirement in preceding week
− WL > 5% in 1 mo (>15% in 3 mo) or BMI < 18,5 + impaired general 3
condition or FI 0-25% of normal requirement in preceding week
Score of severity of disease ≥ 3 : at risk of malnutrition
− Hip fracture, chronic patients, in particular with acute complications : 1
cirrhosis, chronic obstructive pulmonary disease, chronic hemodialysis,
diabetes, oncology
− Major abdominal surgery, stroke, severe pneumonia, hematologic malignancy 2
− Head injury, bone marrow, transplantation, intensive care patient 3
(APACHE > 10)
Age ≥ 70 years 1
  BMI : body mass index ; WL : weight loss ; mo : months ; FI : food intake.

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