If your clients are scheduled for elective surgery, have you already screened for malnutrition?
The NICE guidelines for perioperative care in adults state that nutritional screening should be carried out for anyone undergoing intermediate or major/complex surgery. 1 Improving a person’s nutritional status before and after surgery is a modifiable risk factor associated with improved surgical outcomes.2
Nutritional screening should be carried out at least 6 weeks before elective surgery (but ideally as soon as the decision for surgery is made). Indeed, blood tests will need to be performed and it will take a minimum of 4 weeks to correct any nutritional deficiencies.3 If clients are severely malnourished, it may take several months to improve their nutritional status and immune function sufficiently to withstand the stress of malnutrition. surgery. It is too late to wait until the preoperative appointment to screen clients for malnutrition, as this leaves little (if any) time to correct the identified problems. Clients then run the risk of having their surgery delayed because they are deemed “unfit for surgery” at the pre-operative appointment.
Suboptimal nutrition increases surgical risk and can lead to: (2, 4)
- Increased risk of postoperative complications.
- Prolonged length of hospital stay.
- Higher readmission rates.
- Increased incidence of postoperative death.
- Increase in hospital costs.
To reduce complications and speed recovery, it is important that clients are in optimal nutritional status to withstand the metabolic stresses of surgery.4,5 If clients are severely malnourished, surgery should be delayed until as the person’s nutritional status improves. If this is not possible, even 5 to 10 days of preoperative nutritional therapy can result in a 50% reduction in postoperative morbidity and a decrease in surgical site infections.2
BEFORE SURGERY -> screening for malnutrition (2, 4, 6, 7)
There are several screening tools that case managers can use to screen clients for malnutrition. The Malnutrition Universal Screening Tool (MUST) or the Perioperative Nutrition Screen (PONS) are two of the most suitable tools. The content of the two screening tools is summarized below.
NOTE: Please ensure that all oral nutritional supplements are approved by the surgical team at the pre-operative appointment.
1. Clients at LOW RISK of malnutrition meet ALL of the following criteria:
- BMI greater than 20 kg/m2; AND
- No unplanned weight loss in the last 6 months; AND
- Consume 50-100% of their normal food and fluid intake.
Recommendations:
- No referral to a dietitian is required, but encourage the person to eat a nutritious diet with sufficient protein.
- Some surgical procedures may still require high-protein oral nutritional supplements or immunonutrition supplements (containing arginine and fish oil) for 5 to 14 days before and after surgery.
2. Clients at MODERATE RISK of malnutrition answer yes to one of the following questions:
- BMI between 18.5 and 20 kg/m2; OR
- Weight loss of 5% in the last 3 to 6 months.
Recommendations:
- Refer to a dietitian for further evaluation; AND
- Ask the GP to start giving clients high-protein oral nutritional supplements or immunonutrition supplements (containing arginine and fish oil) for 5 to 14 days before and after surgery.
3. Clients at HIGH RISK of malnutrition answer yes to ONE (or more) of the following:
- BMI is less than 18.5 kg/m2 (if you are between 18 and 64 years old); AND/OR
- BMI is less than 20 kg/m2 (if you are 65 years or older); AND/OR
- Unintentional weight loss greater than 10% in the last 3 to 6 months (even if the person is considered overweight/obese); AND/OR
- BMI is less than 20 kg/m2 AND unintentional weight loss greater than 5% in the last 3 to 6 months; AND/OR
- Eat less than 50% of your normal intake for at least 1 week; AND/OR
- Albumin level less than 30 g/L; AND/OR
- Have low absorption capacity and/or high nutrient losses and/or increased nutritional needs (e.g., Crohn’s disease, chronic diarrhea).
Recommendations:
- Delay surgery until nutritional status improves; AND
- Refer to a dietitian; AND
- Ask the GP to start giving clients oral nutritional supplements for weeks/months before and after surgery; AND
- Help clients improve their dietary intake.
AFTER SURGERY -> implement these nutritional strategies (2, 3, 5, 8)
Postoperative nutritional therapy is also part of the “enhanced recovery after surgery” protocol. This is to prevent postoperative malnutrition, promote wound healing, improve immune response, preserve muscle mass and facilitate rapid healing and recovery.
Recommendations (after surgeon approval):
- Start a high-protein oral intake within 24 hours after surgery; AND
- Take high-protein oral nutritional supplements (or immunonutrition supplements – containing arginine and fish oil) within 24 hours of surgery and continue for at least 5-7 days after surgery. operation ; AND
- Monitor weight at discharge and then weekly for at least 4 weeks to ensure weight is stable.
NHS and private hospitals vary widely in the type of nutritional screening and/or dietary intake offered (if any) prior to any type of elective surgery. For this reason, it is strongly recommended that case managers screen ALL clients for malnutrition as part of their immediate needs assessments and refer them to an NHS or private dietitian if clients are identified as being at medium risk or high in malnutrition. This is especially important if elective surgery is planned.
To refer a case management client for dietary support before elective surgery, contact Specialist Nutrition Rehab on 0121 384 7087 or [email protected].
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