why should the anesthesiologist evaluate nutritional status ?

© Acta Anæsthesiologica Belgica, 2016, 67, n° 1

Abstract : Background : The anesthesiologist’s involve-ment in perioperative medicine has significantly changed. In order to identify patients at risks of perioperative com-plications, the anesthesiologist has to consider, amongst others, screening and management of undernutrition. For this purpose knowledge of prevalence and risk factors, along with screening tools and guidelines for an adapted nutritional management and outcomes of renutrition are mandatory. The present review intends to provide these tools to the Anesthesiologists.Method : We conduct a literature review in Pubmed, Direct Science and Cochrane Library without limit of time related to undernutrition in the perioperative period. Results : Undernutrition is common in surgical patients. Undernutrition is associated with an increase of morbid-ity, mortality, length of hospital stay and costs. Undernu-trition could probably be detected during the anesthetic consultation with simple and rapid tests, such as SNAQ, MST, MUST and NRS-2002. Nevertheless, further stud-ies are needed to validate such tests in surgical patients. Waiting for these results, we prefer MUST. The imple-mentation of nutritional support recommendations would reduce postoperative complications.Conclusion : The anesthesiologist could play an impor-tant role in undernutrition screening and its management in order to reduce perioperative morbidity.

Key words : Undernutrition ; surgery ; prevalence ; screening ; guidelines.

Given the recent European Surgical Outcomes Study (EuSOS) showing high rates of postoperative mortality, anesthesiologists need to develop periop-erative strategies to improve outcomes (1). These include the identification of patients at risk of com-plications and the preoperative patient’s optimiza-tion in order to reduce morbidities, mortality and costs of healthcare. Detection of undernutrition is in this framework.

The prevalence of undernutrition in the hospi-tal setting is high. It varies between 20% and 60% depending on the population selected, the screening and the diagnostic criteria. In surgery, it fluctuates between 30% and 65% depending on the type of in-tervention (2, 3, 4). Moreover, undernutrition tends to worsen during hospitalisation (2, 5, 6).

Surprisingly, screening and assessment of un-dernutrition are not systematically performed. In 2002, in North European hospitals, 40% of patients were not assessed for their nutritional status, and only 25% of patients at risk for undernutrition re-ceived nutritional support (7).

Consequently, it appears of prime concern to conduct a review of the literature in order to raise the anesthesiologists’ awareness regarding peri-operative undernutrition. The present review in-cludes : definition, epidemiology, risk factors, and consequences in the surgical population. It also point out the key role of the anesthesiologist in screening preoperative nutritional status of the pa-tients and promoting efficient measures.

Methods

We conduct a large review of the literature in the following electronic databases : Pubmed, Direct Science and Cochrane Library. The keywords used were : undernutrition, malnutrition, surgery, preva-lence, screening, guidelines. The selection of arti-cles was not limited in time and was restricted to English and French. We consulted 349 articles and 114 of them were selected according to their rele-vance to the topic, to the referenced key words and the impact factor of the journals in which they orig-inate. The selection was completed by the review of the reference list of initially selected articles.

(Acta Anaesth. Belg., 2016, 67, 16-28)

Celine duMont, M.D. ; Dominique Lacrosse, M.D. ; Olivier siMonet, M.D. ; Jean-Luc schiLs, M.D. ; Marc de KocK, Ph.D.

(*) Cliniques Universitaires Saint-Luc, avenue Hippocrate 10, 1200, Woluwe-Saint-Lambert.

(**) Unité Transversal Nutrition CHU UCL Namur, Av. gaston Therasse 1, 5530 Yvoir.

(***) Centre Hospitalier de Wallonie picarde (CHwapi), avenue Delmée, 9 7500 Tournai.

(****) Centre Hospitalier de l’Ardenne, Avenue d’Houffalize 35, 6800 Libramont.

Correspondence address : Celine Dumont, Department of Anes thesiology, Cliniques Universitaires Saint-Luc, 1200 Woluwe-Saint-Lambert.

E-mail : [email protected]

Why should the anesthesiologist evaluate nutritional status ?

c. duMont (*), d. Lacrosse (**), o. siMonet (***), J.-L. schiLs (****) and M. de KocK

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nutritionaL status 17

39, 40, 41). Nevertheless, results are not always consistent in favour of nutritional support (42, 43, 44, 45, 46). This is due to the variety of definitions, the diversity of patients and their pathology, the screening tests, and the composition of nutritional support. However, a review of 35 randomized con-trolled trials conducted by ESPEN (European Soci-ety of Parenteral and Enteral Nutrition) concluded to a benefit of nutritional support in terms of the length of the hospital stay, infectious complications and cost when the patient is undernourished (9).

Therefore it is mandatory to detect this condi-tion. As recommended by the Société Française d’Anesthésie-Réanimation (SFAR) (47), the anes-thetic consultation is a key moment for the screen-ing of the patient’s nutritional status (48). Remem-ber that the surgical population includes between 30 to 60% of undernourished patients (2, 3, 4). This consultation is probably the last opportunity before surgery to detect patients at risk of undernutrition or undernourished. At this point, the role of the anes-thesiologist is to refer patients to a professional of nutrition to realize a complete nutritional assess-ment in order to start a nutritional support in accor-dance with international guidelines.

For an effective screening by the anesthesiolo-gist, there are two prerequisites. First, the patient scheduled for elective surgery must meet an anes-thesiologist (48). This is not obvious in some coun-tries like Belgium since the pre-anesthetic consulta-tion is not mandatory. Second, the delay between consultation and surgery should be sufficient be-cause the nutritional support will be only effective after seven to ten days (9, 48). This implies coordi-nation between the different services (surgery, anes-thesia, nutritionists).

The first step to detect undernutrition is to rec-ognize clinical situations leading to this condition by causing an imbalance between need and nutri-tional intake. The most frequent situations are refer-enced in the table 1 (24, 49, 50, 51, 52).

These situations are, however, not all by them-selves the only way to diagnose undernutrition. A systematic approach including the recording of objective parameters must be established for each patient. These parameters are anthropometric, bio-chemical and clinical markers.

Many markers have been described, but we selected those being the most often included in screening tests since they are easy to use.

Anthropometric markers to consider are : weight and size used for the calculation of the BMI (Body Mass Index), and weight loss (17, 53, 54). The BMI values associated with undernutrition

resuLts

I. Definition and epidemiology

Undernutrition is defined as a state of deficien-cy of energy, proteins, or any other macro or micro-nutrients, resulting in a measurable change of body function and/or body composition associated with an aggravation of the prognosis (8).

Surgery is a stressful period for the organism characterized by an increase in stress hormones and release of inflammatory mediators (9). This leads to a catabolic state (10, 11) with a release of glucose, free fatty acids and amino acids. The aim of these metabolic changes is to ensure the availability of substrates for essential function during the postop-erative period, i.e. : healing (12), immune re-sponse (13), and functional recovery. This includes recovery of muscular strength (14), lung (15), car-diac and cognitive functions (16). When the patients is undernourished, the reserves in energy substrate are reduced and the recovery functions are conse-quently even more altered (10).

This is confirmed by numerous studies. Al-ready in 1936, Studley observed in patients who un-derwent a peptic ulcer operation, that weight loss of 20% resulted in increased mortality, from 3.5% to 33.5% (17). Undernutrition is recognized as an independent factor of mortality (18, 19, 20).

Etiologies underlying this undernutrition- induced exaggerated morbidity-mortality rate are : increased occurrence of infection (21), delayed wound healing (21, 22), decreased functional ca-pacity recovery (19, 21, 22), muscle weakness (21, 22), reoperations (18, 22), post-operative renal fail-ure (18, 22), prolonged mechanical ventilation (22) or pulmonary complications (23). According to some studies, the duration of hospitalisation in-creases from 40 to 70% in malnourished patients (5, 24, 25, 26). This increase is more pronounced if un-dernutrition is classified as severe (27). Conse-quently, health care costs increase from 35% to 300% (25, 28). In Europe, the costs of undernutri-tion are estimated at 170 billion euro yearly (29).

II. Screening tools and pre-anesthetic consultation

Despite these well-known negative effects of undernutrition, there is a significant lack of screen-ing and treatment of this condition in the preopera-tive period.

Most of the studies report that nutritional sup-port for undernourished surgical patients could im-prove outcomes (30, 31, 32, 33, 34, 35, 36, 37, 38,

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18 c. duMont et al.

sulting scores are considered either as screening tests, or as screening and assessment tests. It’s im-portant to differentiate these terms. A screening test evaluates the risk of undernutrition. It does not re-quire special skills in nutrition and can be performed by any health care professional. In contrast, an as-sessment test evaluates the presence of undernutri-tion. It’s a comprehensive approach performed by a professional in nutrition combining clinical data (medical, nutritional, and medication histories), physical examination, anthropometric measure-ments and laboratory data (68).

Concerning the various screening tests, it has immediately to be noted that none of these was con-sidered as the “gold standard” by the scientific soci-eties focused on nutrition. The explanation is to be found in the lack of reproducible validity. This is mainly due to the great heterogeneity of the studies on which validity assessments are based (69). First, the validity of the different screening tests is ascer-tained based on various methods for the diagnosis of undernutrition. In some studies, diagnosis tests such as Subjective Global Assessment (SGA) or Mini Nutritional Assessment (MNA) are used as reference (70, 71). In others, anthropometric param-eters or global assessment by a nutritionist are used (69, 72, 73). Second, the populations used are particularly heterogeneous from one study to an-other. They consider either geriatric subjects or hos-pitalized patients or patients at home (69, 73, 74, 75). Third, screening tests are used for assessment and the reverse (68). Finally, we are left with the same tests used in different populations, compared with different references, used indifferently as

are < 18.5 kg/m2 in the general population (55), < 21 kg/m2 in the elderly (70 and over) (51), and < 24 kg/m2 among cardiac patients (56). Weight loss values associated with undernutrition are 10% weight loss in 6 months or 5% in one month (9, 41).

The most frequently recorded biochemical marker is albumin. Although not specific of under-nutrition (57, 58), it is included in the nutritional assessment because a decrease is associated with increased postoperative morbidity and mortali-ty (59, 60, 61). The limit value is < 30 g/L (9) or 35 g/dL (47).

Some consider that prealbumin is a better marker because its half-life is shorter than albumin (2 days vs 20 days). It could be more sensitive to reflect changes in nutritional status. This is, how-ever, still under debate (51, 62).

Finally, clinical factors associated with under-nutrition include decreased food intake, previously described undernutrition risk factors, the functional consequences of undernutrition, experience of nu-tritional support, and the type of surgery (47, 63, 64). Assessing food intake can be easily performed during the anesthetic consultation with an visual analog scale of calorie intake (65). Functional consequences can be evaluated trough the Hand Grip test. This test reflects the muscle strength by measuring the amount of static force produced by the hand around a dynamometer (66, 67).

None of these parameters, taken alone, are specific to undernutrition.

For this reason, multifactorial scores are developed based on combination of these anthropo-metric, biochemical and clinical markers. The re-

Table 1 Risk factors of undernutrition

A. Patients comorbidities

1. Chronic diseasea. Cancer, particularly cancer of upper aerodigestive tract (ENT, oesphagus, stomach and pancreas)b. Organ insufficiency : kidney – liver – heart - lung – pancreatic failuresc. Digestive disorder with malabsorption (inflammatory bowel disease, celiac disease…)d. Neuromuscular disease

2. Persistent gastro-intestinal symptoms > 15 days (diarrhea,anorexia, dysphagia, nausea, vomiting)3. Medical past of gastrointestinal surgery (pancreatectomy, gastrectomy, bariatric surgery, bowel resection)4. Age > 70 years5. Cognitive disorders

B. Treatments

1. Polymedication (≥ 5 drugs)2. Chemotherapy3. Radiotherapy

C. Patient socio-economic status

1. Isolation2. Poor income

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medication, radiotherapy chemotherapy, corti-coids). And third, the nutritional risk caused by the surgeries inducing anatomic and/or functional changes of gut (ex : cephalic duodéno-pancréatectomy, extended intestinal reesection, to-tal gastrectomy, ENT surgery…) (47, 51). These parameters are combined to calculate a nutritional grade ranging between 1 to 4. Depending on this nutritional grade, nutritional support is pre-scribed (47, 51) (Table 3). This tool is interesting because it does not require special skills in nutrition and it incorporates the nutritional risk linked to the surgery. However, this test didn’t catch our atten-tion because they include biological parameter (al-bumin). Moreover, its sensitivity and specificity values have not been evaluated yet.

In order to find screening tests that meet the criteria we defined previously, we selected 4 recent studies. Our selection is based on the number of pa-tients included (reviews, meta-analysis) and their topics. Two reviews considering screening tests meeting our criteria (72, 76) and one meta-analysis about the screening tools in a general hospitalized population (69) are of interest. The last study stud-ied specifically the surgical population (3).

The review by Van VenrooiJ et al. (72) was designed to identify a simple and rapid screening test. These authors concluded that MST (Malnutri-tion Screening Tool) and SNAQ (Short Nutritional Assessment Questionnaire) tests are the most per-formant. Indeed, these are rapid (< 3 min), valid (sensitivity and specificity > 85%), and highly ap-plicable. MUST (Malnutrition Universal Screening

screening or diagnosis. This explains the lack of consensus and is the reason why the recommenda-tions differ depending on nutrition societies, coun-tries and targeted patients. The table 2 shows rec-ommendations for some recognized nutrition society or some countries using preferentially a par-ticular test.

III. Which tests can be used in anesthetic consulta-tion ?

None of the screening tests were specifically developed to detect undernutrition in patients sched-uled for surgery. Consequently, as part of this work, we will try to define the most convenient in this par-ticular situation. At our opinion, to be contributive during the pre-anesthetic consultation a screening test must meet the 3 following criteria : simplicity, rapidity and validity. Simplicity implies avoiding tests using specials skills in nutrition and rapidity suggests to avoid laboratory tests because there are not always available at the consultation time.

What can we learn from the scientific societ-ies ? Amongst these, only the SFAR (Société Fran-çaise d’Anesthésie-Réanimation) in collaboration with the Société Francophone Nutrition Clinique et Métabolisme (SFNEP) proposes its own screening test (47). It is based on three parameters. First, the patient’s nutritional status assessed by BMI, weight loss and albumin levels. Second, the risk factors of undernutrition including the comorbidities of the patient (age, cancer, digestive disease, chronic dis-ease, cognitive disorders…) and treatments (poly-

Table 2Recommandations for screening tests

Society – Country Screening Tests Population

ESPEN (European Society for Parenteral and Enteral Nutrition) (76)

MUST (Malnutrition Universal Screening Tool) (77) All settings, all adults patients

NRS-2002 (Nutritional Risk Screening 2002) (78) Hospitalized patients

MNA (Mini Nutritional Assessment) (79) Elderly patients (> 70 y)

BAPEN (British Association for Parenteral and Enteral Nutrition) (80)

MUST (Malnutrition Universal Screening Tool) (77) All settings, all adults patients

ASPEN (American Society for Parenteral and Enteral Nutrition) (81)

No particular tests All settings, all adults patients

Importance of the clinical judgement

The Netherlands (74) SNAQ (Short Nutritional Assessment Questionnaire) (74)

Hospitalized adults patients

New–Zealand and Australia (69) MST (Malnutrition Screening Tool) (82) Hospitalized adult patients

France (HAS, Haute Autorité de la Santé) (83) Evaluation based on BMI, weight loss, albumin All settings, all adults patients

MNA (Mini Nutritional Assessment) (79) Elderly patients (> 70 y)

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specificity and sensitivity. MUST is the best screen-ing test with sensitivity and specificity > 80% in half of the studies, and between 50% -80% in the other half. The NRS-2002, though recommended by ESPEN (European Society for Parenteral and En-teral Nutrition), gives conflicting data with sensi-tivities and specificities ranging between 35% and 93%. SNAQ and MST do however always get sen-sitivities and specificities below 80%. They are nonetheless not to be condemned, as the rapidity of their execution remains of importance.

In accordance to this review of the literature, we have identified four screening tests that can be performed during the anesthetic consultation : MUST (Malnutrition Universal Screening Tool) (78), SNAQ (Short Nutritional Assessment Questionnaire) (74), MST (Malnutrition Screening Tool) (79) and NRS 2002 (Nutritional Risk Screen-ing 2002) (80) (Annex 1). These four tests do not require special skills in nutrition (see annex 1) and they are quick, especially SNAQ, MST and MUST (72, 76). Concerning their validity, as de-scribed in the preceding studies, none of the four tests gives adequate sensitivity and specificity val-ues in a constant way.

Nevertheless no screening test is defined as the “gold standard” by the scientific community. For this reason, we advise that each hospital establishes its own standard for screening undernutrition. It will be defined by surgeons, anesthetists, and nutrition-ists. The medical teams have to choose of a screen-ing test among the four pre-selectioned tests (MST, MUST, NRS-2002, SNAQ) although they are not validated with certainty. Indeed, the diagnosis will be next validated by a professional of nutrition.

At our opinion, the MUST test is a good choice. It is retained as valid in two studies of our selection (3, 69), it is a quick test (72, 76) and it is a

Tool) and NRS-2002 (Nutritional Risk Screen-ing-2002) were not included in the study because these didn’t encounter an inclusion criterion, name-ly specificity and sensitivity > 65%.

The recent review by sKipper et al. (76) com-pared 11 screening tests considered as easy and quick. They identified only one test as valid and re-liable : the MST (Malnutrition Screening Tool), with a sensitivity and a specificity greater than >90%. Its reliability is defined by a κ score of 0.83–0.88. The second test considered as valid is the MNA-SF (Mini Nutritional Assessment Short Form) with sensitivity (> 83%) and specificity (> 90%). It was however not analysed for reliabili-ty. MNA- SF (Mini Nutritional Assessment Short Form) was not considered in this work because it screens undernutrition specifically in the geriatric population (77). Note that, according to their study, SNAQ (Short Nutritional Assessment Question-naire) (74) was excluded because it had not been compared to a standard reference.

In 2012, aLMeida et al. (3) compared 5 screen-ing tools in the surgical population : BMI, recent weight loss (> 5% in the previous 6 months), NRS-2002, MUST and NRI (Nutritional Risk Index). NRS-2002, MUST and weight loss were valid. The sensitivity of NRS-2002 vs SGA was 80% (p < 0.001) and the specificity was 89% (p < 0.001). The sensitivity of MUST vs SGA was 85% (p < 0.001) and the specificity was (93%) (p < 0.001). The reliability of NRS-2002 and MUST by k score was respectively 0.853 and 0.912.

In 2014, Van BoKhorst et al. (69) conducted a large meta-analysis on screening tests in hospital-ized patients. They compared 32 tests. The authors conclude that the results of the studies are too con-tradictory to take a position on the matter. No screening test gets correct and constant values of

Table 3Nutritional grade and nutrition care by SFAR

Nutritional Grade Nutritional care

NG 1 + Patient not malnourished No nutritional support + No risk factors of malnutrition + Surgery with low risk of complications

NG 2 + Patient not malnourished Depending on oral intake, dietary counseling + At least one of risk factor of and oral nutritional supplements malnutrition OR surgery with high risk of complications

NG 3 + Patient malnourished Depending on oral intake, dietary counseling + Surgery with low risk of and oral nutritional supplements. complications Planning for a route for enteral or parenteral nutrition in case of postoperative nutritional support.

NG 4 + Patient malnourished Nutritional support + Surgery with high risk of complications

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a. Preoperative period (Table 4)

During the preoperative period, anesthesiolo-gists must enforce the recent fasting rules including carbohydrate loading.

Nutritionists take part in optimizing the nutri-tional status of the patient by given an adequate nutritional support according to the risk of under-nutrition.

Fasting rules

Fasting from midnight has for long been rec-ommended in order to minimize the risk of regurgi-tation and inhalation of gastric contents. But the standards have changed since it was proven that fasting increases insulin resistance, does not reduce gastric volume, nor prevent acid secretion or de-creased the complications rate (86, 87). Internation-al Societies of anesthesiology recommend clear liq-uids oral intakes up to two hours before surgery (water, caloric or not, fat- and alcohol free) such as soft drinks, tea, coffee, of fruit juice without pulp, and solid intake up to six hours before surgery (87, 88). This reduces the sensation of thirst, discomfort, and resistance to insulin (83, 84, 85, 87, 89). Some reserves are made concerning the application of these rules to patients with risk of a delayed gastric emptying. This includes pregnant women and pa-tient with systemic disease such as diabetes mellitus or with gastrointestinal symptoms like gastro-

test recommended as standard by some nutrition so-cieties, namely by the ESPEN for non hospitalized patients (81) and by the BAPEN for all the pa-tients (82). However, we have to note that the MUST does not include the risk of postoperative denutrition caused by surgery, instead of the NRS-2002. But this last is more time consuming because it includes two parts and takes more parameters into account. Therefore, its specificity and sensitivity values are considered as correct in only one pro-spective study (3) instead of two studies (one meta-analysis and one prospective study) for the MUST (3, 69). Finally, NRS-2002 is recommended by only one society (ESPEN) and for a select popu-lation : the hospitalized patients.

IV. What does nutritional care include for a surgi-cal patient ?

As developed in the ERAS protocols (En-hanced Recovery After Surgery), nutrition manage-ment must be part of the care of surgery patients to achieve a rapid recovery by reducing stress induced by surgery (83, 84, 85). Nutritional care includes a nutritional support adapted to nutritional status, the prescription of recent fasting rules, and adequate postoperative realimentation. Both nutritionists and anesthesiologists take part for these nutritional mea-sures spread during the preoperative and postopera-tive periods.

Table 4Proposed algorithm for nutritional management for the preoperative time

By anesthesiologists By nutritionists (based on ESPEN and SFAR guidelines)

Fasting rules – Drink liquid up until 2 hours before surgery (water, caloric or not,

fat- and alcohol free such as soft drinks, tea, coffee, of fruit juice without pulp)

– Eat solid up until 6 hours before surgery– Not recommended for pregnant woman, patients with diabetes

mellitus or gastro-oesophageal reflux.

Carbohydrates loading– Drink 800 ml the evening before and 400 ml 2-3 hours of carbohydrates

drinks before major elective surgery.– Not recommended for patients with diabetus mellitus.

Nutritional support– Oral nutritional supplement : o 10-14 days to patients at risk of undernutrition or with ingestats <

60% of energy requirements.

– Enteral nutrition : o Patients with severe nutritional risk, 10-14 days before a majore

elective surgery. Delay surgical intervention if necessary (medico-surgical discussion).

o Patient with prevision of no intake more than 7 days perioperatively, without obvious undernutrition.

o Patient with oral intake < 60% of nutritional requirements more than 10 days perioperatively.

– Parenteral nutrition : o In patient with contraindication (intestinal obstruction or ileus,

severe shock, intestinal ischemia, intractable vomiting, peritonitis) of EN according to the indications of EN prementioned.

o In complement of EN if this does not meet the energy requirements.

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

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results show a reducing of length of stay, insulin re-sistance, and time for recovery of a gastrointestinal transit. However, no improvement was found concerning the postoperative complications. They mentioned a lack of an adequate blinding of the studies. Other randomized controlled trials are so required to further strengthen the evidence about the improvement on postoperative complications with carbohydrates loading.

Nutritional support

According to the nutritional status, the profes-sional of nutrition applies nutritional assistance. It can be dietary advice, oral nutritional supplements, and enteral or parenteral nutrition.

Oral nutritional supplements are solutions pro-viding calories, proteins, vitamins and minerals. It is recommended to prescribe them preoperatively 10-14 days to patients at risk of undernutrition or to patients who do not meet 60% of their nutritional requirements (103, 104).

The ESPEN (9) and the SFAR (47) recom-mend preoperative enteral and parenteral nutrition to patients with severe nutritional risk and sched-uled for a major surgery. The optimal duration for this nutritional support is 10-14 days (9, 47). In this condition, the surgery must be delayed if it is sched-uled before 10-14 days. This postponement con-cerns only the major elective surgery and must be balanced with its emergency.

Nutrition support is also to be started immedi-ately without obvious undernutrition, if a period of 7-10 days of pre-, postoperative fasting is expected, or if the patient does not meet 60% of his nutritional needs more than 10 days (9).

If the digestive tract is functional, enteral ad-ministration is preferred to parenteral administra-tion. Their effectiveness is identical, but the cost of

oesophageal reflux (89). The studies showing the absence of an increase of complications in such pa-tients are cohort studies or case control and therefore, have not sufficient power to be demonstrative (87).

Carbohydrates should be part of preoperative fasting protocols. European Societies of Anesthesi-ology (87, 89), the BAPEN (British Association for Parenteral and Enteral Nutrition) (90), ESPEN (9) and the ERAS (Enhanced Recovery After Sur-gery) (83, 84, 85) recommend oral carbohydrates before major elective surgeries. These major surger-ies are not defined by the societies but most of stud-ies concerns gastrointestinal surgery, cardiac sur-gery and orthopedic surgery (91). Carbohydrates are mainly composed of maltodextrins whose con-centration is approximately 12.5% (9) . They are ad-ministered at a rate of 800 mL the evening before surgery and 400 mL 2-3 hours before surgery (9). The gastric emptying is complete after 90 minutes and causes no risk of inhalation if the patient has a conserved transit (92). It is not recommended for patients with diabetes because of the risk of hyper-glycemia and delay in transit (83, 84, 85). The ad-vantages of the loading carbohydrates are numer-ous. It gives a fed state to patient and leads to reducing insulin resistance that occurs after a surgery (93, 94, 95). It avoids postoperative hyper-glycemia known to increase postoperative compli-cations (96). Carbohydrates preserve also muscle mass (97, 98), muscle strength (99) and pro-teins (100). They decrease the length of hospitaliza-tion (98, 101), accelerate transit recovery (98) and could be cardioprotective in cardiac surgery (102). Some studies showed an improved well-being, re-duced preoperative anxiety, and a reduction of post-operative nausea and vomiting (115, 116, 117) but these results have not been confirmed (114, 117, 118). In a recent Cochrane review (91) about clini-cal effects of preoperative carbohydrates loading,

Table 5Proposed algorithm for nutritional management for the postoperative time

By anesthesiologists By nutritionists (based on ESPEN and SFAR guidelines)

Postoperative feeding– Early oral and enteral nutrition within the 24 hours after surgery.– Adaptate to the individual tolerance gastro-intestinal function and type

of surgery.

Postoperative nutritional support– Placement of a tube feeding during the surgery if a postoperative EN

is required.– Placement of a central catheter during the surgery if a postoperative

PN is required.

Nutritional support– Situations at risk to require postoperative NS : o Severe trauma o Major head and neck surgery o Gastrointestinal surgery for cancer o Severe undernutrition detected at the time of surgery o Patient with oral intake < 60% of normal requirements.

– Prefer EN. PN is prescribed in contraindication of EN or in addition of EN as described in table 4.

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

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evaluation should include the type of nutrition (enteral or parenteral) and the route (probe, stoma, intravenous) to allow early postoperative nutrition (within 24 hours) (110).

concLusion

Undernutrition is common in hospital setting, especially among surgical patients. Moreover, this condition tends to worsen during the hospital stay. Undernutrition is associated with an increased mor-bidity, mortality and length of hospital stay and de facto, with increased costs. Nevertheless, it remains underdiagnosed and not treated. However, an adapt-ed nutritional support improves outcomes. Pre- anesthetic consultation is the last opportunity for the screening of this condition. Screening tests are numerous and recommendations are not unanimous. MST, MUST, SNAQ and NRS-2002 are fast and simple tools that can easily be performed during anesthesia consultations. Additional studies are re-quired in order to determine which test is the most valid for the surgical population and if a nutritional care based on this score is associated with improved outcomes. Waiting for these results, we preconize to choose MUST to screen undernutrition. The imple-mentation of the nutritional management of surgical patients implies a multidisciplinary work bringing together anesthesiologists, nutritionists and sur-geons.

References

1. Pearse R. M., Moreno R. P., Bauer P., Pelosi P., Metnitz P., Spies C., Vallet B., Vincent J. L., Hoeft A., Rhodes A., European Surgical Outcomes Study group for the Trials groups of the European Society of Intensive Care M., and the European Society of A., Mortality after surgery in Europe : a 7 day cohort study, Lancet, 380, 1059-65, 2012.

2. Correia M. I., Caiaffa W. T., da Silva A. L., Waitzberg D. L., Risk factors for malnutrition in patients undergoing gastroenterological and hernia surgery : an analysis of 374 patients, nutr. hosp., 16, 59-64, 2001.

3. Almeida A. I., Correia M., Camilo M., Ravasco P., Nutritional risk screening in surgery : valid, feasible, easy !, cLin. nutr., 31, 206-11, 2012.

4. Kuzu M. A., Terzioglu H., Genc V., Erkek A. B., Ozban M., Sonyurek P., Elhan A. H., Torun N., Preoperative nutritional risk assessment in predicting postoperative outcome in patients undergoing major surgery, WorLd J. surg., 30, 378-90, 2006.

5. Weinsier R. L., Hunker E. M., Krumdieck C. L., Butterworth C. E., Jr., Hospital malnutrition. A prospec-tive evaluation of general medical patients during the course of hospitalization, aM. J. cLin. nutr., 32, 418-26, 1979.

enteral nutrition is lesser. Moreover, enteral nutri-tion causes fewer complications in terms of infec-tions and mortality (105, 106). Enteral nutrition ‘s main disadvantage is the risk linked to gastric re-siduals such as regurgitation and inhalation. It can be done via a nasogastric/naso-jejunal tube, a jeju-nostomy or gastrostomy tube (106, 107).

Parenteral nutrition will only be required in case of contraindications for enteral nutrition such as intestinal obstruction, ileus, intestinal ischemia, peritonitis, intractable vomiting, severe shock (9, 105, 107). It will also be given in addition to enteral nutrition if nutritional requirements are not met (9, 47). In the case of parenteral nutrition, overfeeding must be avoided as it leads to hyperglycemia, in-creased energy expenditure and CO2 production. It can also induce steatosis, hypertriglyceridémia and derogatory effects on immunity (11).

b) Postoperative period (Table 5)

The nutritional management of postoperative period includes the initiation of a rapid enteral nutri-tional supported by the anesthesiologists and nutri-tional support conducted by the nutritionists. If a postoperative nutritional support is waiting, the anesthesiologists must consider the placement of a tube feeding or a central catheter during the surgical procedure.

Postoperative feeding

During the postoperative period, early oral or enteral nutrition within the 24 hours is recommend-ed, including for gastrointestinal surgery (9, 47). This early nutrition forms an integral part of ERAS protocols (Enhanced Recovery After Surgery) (83, 84, 85). In colorectal surgery, it is demonstrated that it enables enhancement of survival, faster resump-tion of transit, faster resumption of solid food diet, decreased postoperative complications and reduced length of stay (108, 109). This early recovery must nevertheless be adapted to individual tolerance (risk of vomiting), to the gastrointestinal function and to the type of surgery (9, 47, 110).

Nutritional support

The ESPEN (9) and SFAR (47, 110) identified situations potentially needing an artificial support : major head and neck surgery, gastrointestinal sur-gery for cancer, severe trauma, undernutrition at the time of surgery, oral ingestion < 60% of energy needs for more than 7-10 perioperative days. The need for postoperative artificial nutritional support should be anticipated preoperatively. Preoperative

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Annex 1 : Screening tests

Screening tests Score Total scoreMST (Malnutrition Sreening Tool)Has the patient lost weight recently without trying ? < 2 : not at risk of malnutrition

Unsure 2If yes, how much weight (kg) has the patient lost ?

1-5 1 ≥ 2 : at risk of malnutrition6-10 2

11-15 316-20 4

Unsure 2Has the patient been eating poorly because of decreased appetite ?

Yes 1SNAQ (Short Nutritional Assessment Questionary)Did the patient lose weight unintentionnally ? < 2 : well nourished

More than 6 kg in the last 6 mo 3More than 3 kg in the last mo 2

Did the patient experience a decreased appetite over the last mo ? ≥ 2 : moderately malnourishedYes 1

Did the patient use supplemental drinks or tube feeding over the last mo ? ≥ 3 : severely malnourishedYes 1

MUST (Malnutrition Universal Screening Tool)BMI score (kg/m2 ) 0 : low risk of malnutrition

18,5-20,0 1< 18,5 2

Did the patient experience unplanned weight loss in past 3-6 months ? 1 : medium risk of malnutrition5-10% 1> 10% 2

Is the patient acutely ill and has the patient been or is he likely to have no nutritionnal intake for > 5 days ?

≥ 2 : high risk of malnutrition

Yes 2NRS 2002 (Nutritional Risk Screening 2002)Part 1 : initial screening

Is BMI (kg/m2 ) < 20,5 ?Has the patient lost weight within the last 3 months ?

Has the patient had a reduced dietary intake in the last week ?Is the patient severely ill ?

If the answer is yes to any question, the final screening is performedPart 2 : final screeningScore of nutritional status < 3 : not at risk of malnutrition− WL > 5% in 3 mo or FI < 50-75% of normal requirement in preceding week 1− WL > 5% in 2 mo or BMI 18,5-20,5 + impaired general condition or

FI < 25-60% of normal requirement in preceding week2

− WL > 5% in 1 mo (>15% in 3 mo) or BMI < 18,5 + impaired general condition or FI 0-25% of normal requirement in preceding week

3

Score of severity of disease ≥ 3 : at risk of malnutrition− Hip fracture, chronic patients, in particular with acute complications :

cirrhosis, chronic obstructive pulmonary disease, chronic hemodialysis, diabetes, oncology

1

− Major abdominal surgery, stroke, severe pneumonia, hematologic malignancy 2− Head injury, bone marrow, transplantation, intensive care patient 3

(APACHE > 10)Age ≥ 70 years 1

BMI : body mass index ; WL : weight loss ; mo : months ; FI : food intake.

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why should the anesthesiologist evaluate nutritional status ?

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