Nutritional guidelines lay roadmap for optimizing outcomes in surgical patients

February 28, 2018 – New comprehensive guidelines recommend how to optimize nutritional support before and after surgery.

Surgical nutrition guidelines published recently in Anesthesia & Analgesia, the official journal of the International Anesthesia Research Society, highlight how perioperative nutritional interventions can improve surgical outcomes and reduce infectious morbidity and mortality in surgical patients.

“Having major surgery is like running a marathon because of the stress it puts upon the human body and no one would ever imagine running a marathon without eating or drinking the night before or the morning of, but we ask our patients to do that all the time,” said Paul Wischmeyer, MD, director of perioperative research at the DCRI. “Patients who are fed early after surgery, have significantly less mortality than patients who are not. Still in the United States, patients are not only commonly starved before surgery, they are starved after surgery, sometimes for days. We have to change this.”

According to Wischmeyer, lead author of the guidelines, 1 in 3 people who come into a hospital in the United States are malnourished, and only 1 in 10 of those malnourished patients are ever diagnosed, and lastly, only 1 in 10 of those diagnosed receive any meaningful nutritional therapy. Collectively, only 1 in 100 patients with real malnutrition are being meaningfully treated for it.

“Major surgery and gastrointestinal surgery are perhaps the most urgent to address because 2 out of every 3 people are malnourished at the time of surgery, with very few being screened,” said Wischmeyer. “This is unfortunate because malnourished patients are three times more likely to develop complications and are five times more likely to die after surgery.”

Wischmeyer chaired the new Surgical Nutrition Guidelines for the Perioperative Quality Initiative, which together with the American Society for Enhanced Recovery, brought together a group of international experts – surgeons, anesthesiologists and dieticians – with the goal of providing consensus statements and recommendations on surgical nutrition screening and therapy.

The published guidelines propose a well chalked out plan of action before and after surgery. The researchers have developed and proposed the perioperative nutrition screen (PONS) score, which determines nutrition risk based on a patient’s body mass index, recent changes in weight, reported recent decrease in dietary intake and preoperative albumin level, which is a predictor of postoperative morbidity and mortality.

“The PONS can be administered quickly, in less than five minutes, by nursing staff in surgical or preoperative clinics and its results can be instantly uploaded into a patient’s electronic medical record, automatically triggering a nutritional consult and intervention,” said Wischmeyer. “We are currently using PONS at the Duke POET Perioperative Nutrition Clinic, which is designed exclusively for helping patients improve their nutritional health before and after they undergo surgical procedures,” he said.

According to Wischmeyer, there are well-studied high-protein supplements that everyone should drink before surgery to considerably improve surgical outcomes and to boost and restore the body’s immune response that is turned off soon after surgery. The researchers also recommend a high-protein diet via oral nutritional supplements (ONS) or a dietician-recommended nutritional regime both pre- and post-operatively for all patients, with a focus on those who are screened as being at nutritional risk before major surgery.

“Only 1 in 5 of all major hospitals in the United States have a pre-surgical nutrition screening process at all and only 1 in 5 of their patients are getting any preoperative nutritional intervention,” said Wischmeyer. “What is most troubling is that the diagnosis of malnutrition is not one U.S. doctors are trained to look for, because over 75 percent of all U.S. medical schools do not have any required nutrition classes and less than 15 percent of new doctors feel adequately prepared to discuss nutrition issues with their patients at all.

“This is one of the main reasons why, with the POET Perioperative Nutrition Clinic, we are trying to model at Duke what the future should look like and we hope we can build a care model that other hospitals can replicate and implement,” he said.

The end goal, according to Wischmeyer, is to screen all surgical patients in the United States before they have a major procedure into clinics that specialize in dealing with any nutritional issues, challenges and treatments, that would benefit and optimize a patient’s recovery from surgery and appropriately channel their postoperative care.

“No patient should ever have elective surgery without being screened for malnutrition and no malnourished patient should ever have elective surgery without their malnutrition being treated first,” said Wischmeyer.

In addition to Wischmeyer, other researchers included Franco Carli, David C. Evans, Sarah Guilbert, Rosemary Kozar, Aurora Pryor, Robert H. Thiele, Sotiria Everett, Mike Grocott, Tong J. Gan, Andrew D. Shaw, Julie K. M. Thacker and Timothy E. Miller.