Preoperative nutrition Patricia Leung

91213

SUNY Downstate - Department of Surgery

Case presentation

bull 74 year old male

bull PMH multiple hospitalizations for SBO

bull PSH diverticulitis sp Hartmannrsquos procedure 2010 ex-lap takedown of enterocutaneous fistula small bowel resection 2011

bull No home meds

bull NKDA

bull Admitted 723 with complaints of abdominal pain nauseavomiting x1 day one week of poor PO intake

bull VS BP 11185 HR 97 RR 18 T 987

bull Gen no apparent distress thin cachectic man

bull Abdomen soft mildly distended minimally tender to palpation ostomy bag with air + stool enterocutaneous fistula with minimal drainage

Labs

WBC 77 Hct 47

Na 121 K 50 Cl 70 CO2 32 BUNCr 64428 Gluc 103

PT 10 INR 09 PTT 25

Albumin 45

Imaging

CT AP ndash dilated small bowel loops with transition point in RLQ cw SBO

bull HOD1 ndash NGT NPO IVF

bull HOD3 ndash PICC line placed TPN started

bull HOD5 ndashadvanced to clears prealbumin 9

bull HOD6-30 ndash nutritional optimization prealbumin 206 (826)

bull HOD31 (827) ndash exploratory laparotomy takedown of enterocutaneous fistula with primary anastomosis of small bowel oversewing of defect in Hartmannrsquos stump

bull POD1-2 ndash ICU for close monitoring

bull POD3 ndash transferred to floor ostomy working

bull POD4 ndash started on clears

bull POD6 ndash advanced to regular diet

bull POD10 ndash discharged home

Introduction

bull 1859 ndash Crimean war

bull 1930s ndash Studley observed direct relationship between preoperative weight loss and operative mortality rate independent of factors such as age impaired cardiorespiratory function and type of surgery

How do we define malnutrition

bull ldquomultifactorial syndrome characterized by severe body weight fat and muscle loss and increased protein catabolism due to underlying disease as well as inadequate consumption of nutrientsrdquo

Develops as consequence of bull Deficiency in dietary intake

bull Increased requirements associated with a disease state

bull Complications of an underlying illness

bull Combination

Skeleton in the hospital closet

bull 1976 ndash JAMA ndash Bistrian et al surveyed medical wards of urban teaching hospitals finding prevalence of malnutrition at 44

bull 2002 ndash 20 Queensland public acute-care facilities with malnutrition rates 31-35

bull 2005 ndash Sydney hospital study ndash 423

bull 2006 ndash German hospital malnutrition study ndash 1 in every 4 patients was malnourished

Negative outcomes

bull Higher infection and complication rates

bull Increased muscle loss

bull Decreased respiratory function

bull Impaired wound healing

bull Longer length of hospital stay

bull Increased morbidity and mortality

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Case presentation

bull 74 year old male

bull PMH multiple hospitalizations for SBO

bull PSH diverticulitis sp Hartmannrsquos procedure 2010 ex-lap takedown of enterocutaneous fistula small bowel resection 2011

bull No home meds

bull NKDA

bull Admitted 723 with complaints of abdominal pain nauseavomiting x1 day one week of poor PO intake

bull VS BP 11185 HR 97 RR 18 T 987

bull Gen no apparent distress thin cachectic man

bull Abdomen soft mildly distended minimally tender to palpation ostomy bag with air + stool enterocutaneous fistula with minimal drainage

Labs

WBC 77 Hct 47

Na 121 K 50 Cl 70 CO2 32 BUNCr 64428 Gluc 103

PT 10 INR 09 PTT 25

Albumin 45

Imaging

CT AP ndash dilated small bowel loops with transition point in RLQ cw SBO

bull HOD1 ndash NGT NPO IVF

bull HOD3 ndash PICC line placed TPN started

bull HOD5 ndashadvanced to clears prealbumin 9

bull HOD6-30 ndash nutritional optimization prealbumin 206 (826)

bull HOD31 (827) ndash exploratory laparotomy takedown of enterocutaneous fistula with primary anastomosis of small bowel oversewing of defect in Hartmannrsquos stump

bull POD1-2 ndash ICU for close monitoring

bull POD3 ndash transferred to floor ostomy working

bull POD4 ndash started on clears

bull POD6 ndash advanced to regular diet

bull POD10 ndash discharged home

Introduction

bull 1859 ndash Crimean war

bull 1930s ndash Studley observed direct relationship between preoperative weight loss and operative mortality rate independent of factors such as age impaired cardiorespiratory function and type of surgery

How do we define malnutrition

bull ldquomultifactorial syndrome characterized by severe body weight fat and muscle loss and increased protein catabolism due to underlying disease as well as inadequate consumption of nutrientsrdquo

Develops as consequence of bull Deficiency in dietary intake

bull Increased requirements associated with a disease state

bull Complications of an underlying illness

bull Combination

Skeleton in the hospital closet

bull 1976 ndash JAMA ndash Bistrian et al surveyed medical wards of urban teaching hospitals finding prevalence of malnutrition at 44

bull 2002 ndash 20 Queensland public acute-care facilities with malnutrition rates 31-35

bull 2005 ndash Sydney hospital study ndash 423

bull 2006 ndash German hospital malnutrition study ndash 1 in every 4 patients was malnourished

Negative outcomes

bull Higher infection and complication rates

bull Increased muscle loss

bull Decreased respiratory function

bull Impaired wound healing

bull Longer length of hospital stay

bull Increased morbidity and mortality

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

bull Admitted 723 with complaints of abdominal pain nauseavomiting x1 day one week of poor PO intake

bull VS BP 11185 HR 97 RR 18 T 987

bull Gen no apparent distress thin cachectic man

bull Abdomen soft mildly distended minimally tender to palpation ostomy bag with air + stool enterocutaneous fistula with minimal drainage

Labs

WBC 77 Hct 47

Na 121 K 50 Cl 70 CO2 32 BUNCr 64428 Gluc 103

PT 10 INR 09 PTT 25

Albumin 45

Imaging

CT AP ndash dilated small bowel loops with transition point in RLQ cw SBO

bull HOD1 ndash NGT NPO IVF

bull HOD3 ndash PICC line placed TPN started

bull HOD5 ndashadvanced to clears prealbumin 9

bull HOD6-30 ndash nutritional optimization prealbumin 206 (826)

bull HOD31 (827) ndash exploratory laparotomy takedown of enterocutaneous fistula with primary anastomosis of small bowel oversewing of defect in Hartmannrsquos stump

bull POD1-2 ndash ICU for close monitoring

bull POD3 ndash transferred to floor ostomy working

bull POD4 ndash started on clears

bull POD6 ndash advanced to regular diet

bull POD10 ndash discharged home

Introduction

bull 1859 ndash Crimean war

bull 1930s ndash Studley observed direct relationship between preoperative weight loss and operative mortality rate independent of factors such as age impaired cardiorespiratory function and type of surgery

How do we define malnutrition

bull ldquomultifactorial syndrome characterized by severe body weight fat and muscle loss and increased protein catabolism due to underlying disease as well as inadequate consumption of nutrientsrdquo

Develops as consequence of bull Deficiency in dietary intake

bull Increased requirements associated with a disease state

bull Complications of an underlying illness

bull Combination

Skeleton in the hospital closet

bull 1976 ndash JAMA ndash Bistrian et al surveyed medical wards of urban teaching hospitals finding prevalence of malnutrition at 44

bull 2002 ndash 20 Queensland public acute-care facilities with malnutrition rates 31-35

bull 2005 ndash Sydney hospital study ndash 423

bull 2006 ndash German hospital malnutrition study ndash 1 in every 4 patients was malnourished

Negative outcomes

bull Higher infection and complication rates

bull Increased muscle loss

bull Decreased respiratory function

bull Impaired wound healing

bull Longer length of hospital stay

bull Increased morbidity and mortality

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Labs

WBC 77 Hct 47

Na 121 K 50 Cl 70 CO2 32 BUNCr 64428 Gluc 103

PT 10 INR 09 PTT 25

Albumin 45

Imaging

CT AP ndash dilated small bowel loops with transition point in RLQ cw SBO

bull HOD1 ndash NGT NPO IVF

bull HOD3 ndash PICC line placed TPN started

bull HOD5 ndashadvanced to clears prealbumin 9

bull HOD6-30 ndash nutritional optimization prealbumin 206 (826)

bull HOD31 (827) ndash exploratory laparotomy takedown of enterocutaneous fistula with primary anastomosis of small bowel oversewing of defect in Hartmannrsquos stump

bull POD1-2 ndash ICU for close monitoring

bull POD3 ndash transferred to floor ostomy working

bull POD4 ndash started on clears

bull POD6 ndash advanced to regular diet

bull POD10 ndash discharged home

Introduction

bull 1859 ndash Crimean war

bull 1930s ndash Studley observed direct relationship between preoperative weight loss and operative mortality rate independent of factors such as age impaired cardiorespiratory function and type of surgery

How do we define malnutrition

bull ldquomultifactorial syndrome characterized by severe body weight fat and muscle loss and increased protein catabolism due to underlying disease as well as inadequate consumption of nutrientsrdquo

Develops as consequence of bull Deficiency in dietary intake

bull Increased requirements associated with a disease state

bull Complications of an underlying illness

bull Combination

Skeleton in the hospital closet

bull 1976 ndash JAMA ndash Bistrian et al surveyed medical wards of urban teaching hospitals finding prevalence of malnutrition at 44

bull 2002 ndash 20 Queensland public acute-care facilities with malnutrition rates 31-35

bull 2005 ndash Sydney hospital study ndash 423

bull 2006 ndash German hospital malnutrition study ndash 1 in every 4 patients was malnourished

Negative outcomes

bull Higher infection and complication rates

bull Increased muscle loss

bull Decreased respiratory function

bull Impaired wound healing

bull Longer length of hospital stay

bull Increased morbidity and mortality

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

bull HOD1 ndash NGT NPO IVF

bull HOD3 ndash PICC line placed TPN started

bull HOD5 ndashadvanced to clears prealbumin 9

bull HOD6-30 ndash nutritional optimization prealbumin 206 (826)

bull HOD31 (827) ndash exploratory laparotomy takedown of enterocutaneous fistula with primary anastomosis of small bowel oversewing of defect in Hartmannrsquos stump

bull POD1-2 ndash ICU for close monitoring

bull POD3 ndash transferred to floor ostomy working

bull POD4 ndash started on clears

bull POD6 ndash advanced to regular diet

bull POD10 ndash discharged home

Introduction

bull 1859 ndash Crimean war

bull 1930s ndash Studley observed direct relationship between preoperative weight loss and operative mortality rate independent of factors such as age impaired cardiorespiratory function and type of surgery

How do we define malnutrition

bull ldquomultifactorial syndrome characterized by severe body weight fat and muscle loss and increased protein catabolism due to underlying disease as well as inadequate consumption of nutrientsrdquo

Develops as consequence of bull Deficiency in dietary intake

bull Increased requirements associated with a disease state

bull Complications of an underlying illness

bull Combination

Skeleton in the hospital closet

bull 1976 ndash JAMA ndash Bistrian et al surveyed medical wards of urban teaching hospitals finding prevalence of malnutrition at 44

bull 2002 ndash 20 Queensland public acute-care facilities with malnutrition rates 31-35

bull 2005 ndash Sydney hospital study ndash 423

bull 2006 ndash German hospital malnutrition study ndash 1 in every 4 patients was malnourished

Negative outcomes

bull Higher infection and complication rates

bull Increased muscle loss

bull Decreased respiratory function

bull Impaired wound healing

bull Longer length of hospital stay

bull Increased morbidity and mortality

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

bull POD1-2 ndash ICU for close monitoring

bull POD3 ndash transferred to floor ostomy working

bull POD4 ndash started on clears

bull POD6 ndash advanced to regular diet

bull POD10 ndash discharged home

Introduction

bull 1859 ndash Crimean war

bull 1930s ndash Studley observed direct relationship between preoperative weight loss and operative mortality rate independent of factors such as age impaired cardiorespiratory function and type of surgery

How do we define malnutrition

bull ldquomultifactorial syndrome characterized by severe body weight fat and muscle loss and increased protein catabolism due to underlying disease as well as inadequate consumption of nutrientsrdquo

Develops as consequence of bull Deficiency in dietary intake

bull Increased requirements associated with a disease state

bull Complications of an underlying illness

bull Combination

Skeleton in the hospital closet

bull 1976 ndash JAMA ndash Bistrian et al surveyed medical wards of urban teaching hospitals finding prevalence of malnutrition at 44

bull 2002 ndash 20 Queensland public acute-care facilities with malnutrition rates 31-35

bull 2005 ndash Sydney hospital study ndash 423

bull 2006 ndash German hospital malnutrition study ndash 1 in every 4 patients was malnourished

Negative outcomes

bull Higher infection and complication rates

bull Increased muscle loss

bull Decreased respiratory function

bull Impaired wound healing

bull Longer length of hospital stay

bull Increased morbidity and mortality

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Introduction

bull 1859 ndash Crimean war

bull 1930s ndash Studley observed direct relationship between preoperative weight loss and operative mortality rate independent of factors such as age impaired cardiorespiratory function and type of surgery

How do we define malnutrition

bull ldquomultifactorial syndrome characterized by severe body weight fat and muscle loss and increased protein catabolism due to underlying disease as well as inadequate consumption of nutrientsrdquo

Develops as consequence of bull Deficiency in dietary intake

bull Increased requirements associated with a disease state

bull Complications of an underlying illness

bull Combination

Skeleton in the hospital closet

bull 1976 ndash JAMA ndash Bistrian et al surveyed medical wards of urban teaching hospitals finding prevalence of malnutrition at 44

bull 2002 ndash 20 Queensland public acute-care facilities with malnutrition rates 31-35

bull 2005 ndash Sydney hospital study ndash 423

bull 2006 ndash German hospital malnutrition study ndash 1 in every 4 patients was malnourished

Negative outcomes

bull Higher infection and complication rates

bull Increased muscle loss

bull Decreased respiratory function

bull Impaired wound healing

bull Longer length of hospital stay

bull Increased morbidity and mortality

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

How do we define malnutrition

bull ldquomultifactorial syndrome characterized by severe body weight fat and muscle loss and increased protein catabolism due to underlying disease as well as inadequate consumption of nutrientsrdquo

Develops as consequence of bull Deficiency in dietary intake

bull Increased requirements associated with a disease state

bull Complications of an underlying illness

bull Combination

Skeleton in the hospital closet

bull 1976 ndash JAMA ndash Bistrian et al surveyed medical wards of urban teaching hospitals finding prevalence of malnutrition at 44

bull 2002 ndash 20 Queensland public acute-care facilities with malnutrition rates 31-35

bull 2005 ndash Sydney hospital study ndash 423

bull 2006 ndash German hospital malnutrition study ndash 1 in every 4 patients was malnourished

Negative outcomes

bull Higher infection and complication rates

bull Increased muscle loss

bull Decreased respiratory function

bull Impaired wound healing

bull Longer length of hospital stay

bull Increased morbidity and mortality

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Skeleton in the hospital closet

bull 1976 ndash JAMA ndash Bistrian et al surveyed medical wards of urban teaching hospitals finding prevalence of malnutrition at 44

bull 2002 ndash 20 Queensland public acute-care facilities with malnutrition rates 31-35

bull 2005 ndash Sydney hospital study ndash 423

bull 2006 ndash German hospital malnutrition study ndash 1 in every 4 patients was malnourished

Negative outcomes

bull Higher infection and complication rates

bull Increased muscle loss

bull Decreased respiratory function

bull Impaired wound healing

bull Longer length of hospital stay

bull Increased morbidity and mortality

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Negative outcomes

bull Higher infection and complication rates

bull Increased muscle loss

bull Decreased respiratory function

bull Impaired wound healing

bull Longer length of hospital stay

bull Increased morbidity and mortality

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

What are our nutritional markers

Retinal binding protein

Prealbumin

Transferrin

Albumin

HALF-LIFE

12 hours

2-3 days

8-10 days

14-20 days

COST $285

$85 $25

$12

Portable Chest XR $50

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Other parameters

bull Recent weight loss over 3 months of gt 10 normal body weight bull Nitrogen balance determination bull Indirect calorimetry bull Midarm muscle circumference bull Delayed hypersensitivity reactions to injected antigens bull Functional impairment of ventilatory effort or muscle response by electrical

stimulation bull History and physical examination

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Subjective Global Assessment

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Nutrition Risk Index

Screening tool to assess risk of complications bull Useful in patients undergoing noncardiac abdominal surgery bull NRI = (1519 x albumin) + (417 x present wgtusual wgt) ndash NRI gt100 normal ndash NRI 975-100 mild malnutrition ndash NRI 835-975 moderate ndash NRI lt835 severe

Our patient

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

ldquoIf the gut works use itrdquo

bull Patients who canrsquot eat

bull Patients who wonrsquot eat

bull Patients who shouldnrsquot eat

bull Patients who donrsquot eat enough

TPN

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Indications for TPN

bull Enterocutaneous fistula bull Bowel obstruction bull Inflammatory bowel disease bull Acute radiation enteritis bull Short gut syndrome bull Major traumaburns bull Severe pancreatitis bull Patients who canrsquot tolerate enteral feeds bull Nutritional optimization prior to surgery

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

bull Prospective randomized controlled trial bull 395 malnourished patients bull Malnourished if score lt100 on Nutrition Risk Index or if a) current weight

95 of ideal weight or less or b) serum albumin 39 gdL or less or c) prealbumin of 186 mgdL or less

bull Required laparotomy or non-cardiac thoracotomy bull Receive either TPN for 7-15 days before surgery and 3 days afterward vs no

TPN bull Outcomes Rate of complications and mortality within first 90 days after

surgery

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Results

bull Hyperglycemia 38 vs 3 bull Post-operative infection 14 vs 64 (p=001) bull Mortality 134 (31231) vs 105 (24228) at 90 days [p 73 vs 49

within 30 days bull No significant reduction in morbidity or mortality with TPN bull For mildly malnourished patients risk of major infectious complications 144

vs 37 (p 0004) bull Severely malnourished patients - risk of major non-infectious

complications 53 vs 429 (p=003)

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Recent literature

bull 1997 ndash Klein et al - meta-analysis of 13 RCTs with 1250 patients 7-10 days of preoperative TPN led to 10 reduction in post-operative

complications with no effect on mortality

bull 2001 ndash Koretz et al ndash meta-analysis of 61 RCTs of perioperative TPN TPN failed to improve outcomes did not cause harm

bull 2001 ndash Heyland et al ndash meta-analysis of 27 RCTs with 2907 patients Lower rate of post-operative complications but no difference in mortality

bull Enterocutaneous fistulas Crohnrsquos disease cancer patients patients who canrsquot tolerate enteral nutrition

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

SCCMASPEN Guidelines

bull Severe stress or malnutrition NPO gt4-5 days

bull Moderate stress or malnutrition NPO gt 5-7 days

bull Non-stressednormal nutrition NPO gt7-10 days

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity

JAMA Surgery Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F

bull Prospective observational study

bull 44 tertiary care VA medical centers

bull 54215 major noncardiac surgery cases

bull Outcome 30 day operative mortality and morbidity

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Patient demographics bull 971 male bull Mean age 61 years bull 76 white 18 black 6 other

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Results bull Mean preoperative serum albumin level 38 gdL bull 23 had albumin lt 35 gdL Univariate analysis bull Mortality rate increases from lt1 for albumin levels 46 gdL or higher to 28 for albumin levels below 21 gdL bull Morbidity increases from 10 to 65 at albumin 46 gdL vs 21 gdL Multivariate analysis bull Decrease in albumin level of 1 gdL is associated with more than 2-fold increase in

odds of dying and odds of a complication

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Subgroup Patients who were bull lt70 years old bull ASA 1 or 2 bull Independent functional status bull No reported weight loss gt10 within last 6 months prior to surgery bull Women (n=1575)

bull 15555 patients bull Negative association (plt0001) between serum albumin level and mortality

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

Summary

bull Malnutrition is very prevalent

bull Enteral nutrition is preferred

bull No clear evidence to support preoperative TPN

bull TPN may be indicated in subgroup of patients

bull Albumin can be used as a predictor of operative morbidity and mortality

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991

References

bull Robertson and Smaill Nutrition in Surgery Canad M AJ Jan 1947

bull Bistrian BR Blackburn GL Vitale J Cochran D Naylor J Prevalence of malnutrition in general medical patients JAMA 1976 Apr 12235(15)1567-70

bull Lisa A Barker1 Belinda S Gout1 and Timothy C Crowe2 Malnutrition Prevalence Identification and Impact on Patients and the Healthcare System Int J Environ Res Public Health 2011 February 8(2) 514ndash527 Hospital

bull Pirlich M Schuumltz T Norman K Gastell S The German hospital malnutrition study Clin Nutr 2006 Aug25(4)563-72 Epub 2006 May 15

bull Badia MB Preoperative albumin as a predictor of outcome in gastrointestinal surgery ndash European Journal of Clinical Nutrition and Metabolism Oct 2009

bull Stig Bengmark Nutrition of the Critically IllmdashA 21st-Century Perspective Nutrients 2013 January 5(1) 162ndash207

bull Gibbs J Cull W Henderson W Daley J Hur Kwan Shukri F Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity JAMA Surgery

bull Perioperative TPN in surgical patients NEJM 1991