RT Book, Section
A1 Scott, Benjamin K.
A1 Deutschman, Clifford S.
A2 Longnecker, David E.
A2 Brown, David L.
A2 Newman, Mark F.
A2 Zapol, Warren M.
SR Print(0)
ID 56625526
T1 Chapter 17. Evaluation of the Patient with Perioperative Malnutrition
T2 Anesthesiology, 2e
YR 2012
FD 2012
PB The McGraw-Hill Companies
PP New York, NY
SN 978-0-07-178513-6
LK accessanesthesiology.mhmedical.com/content.aspx?aid=56625526
RD 2024/04/24
AB Numerous  studies  suggest  that  malnutrition  in  the  perioperative  period  is  associated  with  poor  postoperative  outcomes,  including  increased  rates  of  infection,  poor  wound  healing  and  anastomotic  integrity,  increased  intensive  care  unit  and  hospital  length  of  stay,  increased  need  for  mechanical  ventilation,  and  increased  mortality  after  transplant  and  major  intra-abdominal  or  cardiothoracic  surgery.A  lack  of  standardized  definitions  and  indices  has  hampered  attempts  to  study  the  epidemiology  and  pathophysiology  of  malnutrition.  Nevertheless,  the  problem  appears  to  be  widespread  in  patients  presenting  for  surgery.  In  addition,  many  patients  will  acquire  protein-energy  malnutrition  (PEM)  during  hospitalization.Malnutrition  is  a  complex  metabolic  disorder,  involving  inflammatory  and  neurohumoral  mediators,  that  affects  virtually  every  organ  system.The  metabolic  and  physiologic  changes  accompanying  malnutrition  can  significantly  alter  response  to  anesthetics.Decreased  total  circulating  albumin  has  wide  implications  for  drug  administration  and  volume  of  distribution.As  a  result  of  decreased  microsomal  enzyme  activity  and  altered  cytochrome  P450/nicotinamide  adenine  dinucleotide  phosphate—dependent  transport  mechanisms,  protein  deficiency  may  reduce  drug  metabolism.  Decreased  transformation  of  compounds  that  are  hepatically  detoxified  may  lead  to  pathologic  responses  that  require  dosage  alteration.Uncertainty  surrounds  the  optimal  dose,  route,  and  timing  of  perioperative  nutritional  support,  but  there  is  increasing  evidence  that  reversal  of  perioperative  malnutrition,  especially  when  severe,  can  reduce  complications  and  improve  outcomes.Recent  interest  has  focused  on  the  use  of  immunonutrient  supplementation,  preoperative  oral  carbohydrate  loading,  and  selective  elimination  of  preoperative  fasting  in  an  effort  to  ameliorate  postoperative  catabolism  and  insulin  resistance.Accurate  estimation  of  the  presence  and  severity  of  PEM  remains  problematic  for  the  anesthesiologist,  whose  evaluation  of  the  patient  is  often  brief.  The  most  useful  tool  for  assessing  a  patient's  nutritional  status  is  a  well-performed  history  and  physical  examination.Anesthesiologists  have  an  important  role  to  play  in  perioperative  nutrition  and  should  ensure  that  patients  presenting  for  surgery  are  in  the  best  possible  condition  to  tolerate  the  surgical  stress  and  postoperative  recovery  period.  In  hospitalized  patients,  efforts  should  be  made  to  continue  enteral  or  parenteral  nutrition  when  appropriate.  Finally,  anesthesiologists  should  be  at  the  forefront  of  clinical  and  basic  science  research  on  perioperative  nutrition.