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minimum two out of six characteristics were required for diagnosis of adult
malnutrition:
• Insuffi cient energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Localized or generalized fl uid accumulation that may sometimes mask weight loss
• Diminished functional status as measured by handgrip strength
The infl uence of malnutrition on operative mortality and morbidity in general
surgery (Studley
1936 ; Mullen et al. 1980 ; Gibbs et al. 1999 ; Stijn et al. 2013 ) and
colorectal surgery patients (Schwegler et al. 2010 ; Lohsiriwat et al. 2008 ; Planas
et al. 2007 ) has been extensively reported. Nutrients are crucial in the synthesis of
proteins involved in the immune response to surgery and the infl ammatory phase of
wound healing (Haydock and Hill 1986 ; Scrimshaw and San Giovanni 1997 ; Rai
et al. 2002 ). Malnutrition is a risk factor for overall complications, specifi cally nos-
ocomial infections (Pessaux et al. 2003 ; Schneider et al. 2004 ) and impaired respi-
ratory muscle function (Windsor and Hill 1988 ), leading to higher rates of surgical
site infection and postoperative pneumonia.
Patients with malnutrition have signifi cantly longer hospital stays, likely
associated with an increased risk of complications and delayed recovery from such
Definition Etiology Clinical examples
Malnutrition
Starvation-related
Chronic disease-related
Chronic organ failure
Pancreatic cancer
Rheumatoid arthritis
Sarcopenic obesity
Acute disease- or
injury-related
Anorexia nervosa
Burns
Trauma
Sepsis
Closed head injury
Fig. 4.1 Defi nition of malnutrition
Y.-L. Cheah et al.
45
complications (Chima et al. 1997 ; Braunschweig et al. 2000 ; Middleton et al. 2001 ;
Kyle et al. 2005 ; Pirlich et al. 2006 ; Kudsk et al. 2003b ). The treatment cost of com-
plications and the longer lengths of hospital stay in malnourished patients increase
the economic burden of their hospitalization. The cost of treating a patient at risk of
malnutrition is estimated to be 20–36 % higher than the average of the respective
diagnosis-related group (Chima et al. 1997 ; Amaral et al. 2007 ). A study of patients
in 25 Brazilian hospitals revealed a 60.5 % increase in daily expenses (US$138) for
malnourished patients (Correia and Waitzberg 2003 ). Patients at nutritional risk
were also more likely to require home health-care services or transfer to a transi-
tional facility upon discharge.
Some groups have taken the opposite approach and analyzed the benefi ts of
nutrition therapy on patients at risk of malnutrition. Adequate preoperative and
postoperative nutrition therapy based on a standardized nutritional assessment
model signifi cantly decreased overall complications, major septic complications,
and mortality in surgical patients (Mullen et al.
1980 ). The Veterans Affairs Total
Parenteral Nutrition Cooperative Study Group demonstrated fewer noninfectious
complications in the severely malnourished patients treated with perioperative total
parenteral nutrition (PN) (The Veterans Affairs Total Parenteral Nutrition
Cooperative Study Group 1991 ).
4.3 Transdisciplinary Clinical Nutrition Education
and Nutrition Support Team (NST)
Despite the high occurrence and negative impact of malnutrition on clinical out-
comes and hospitalization costs, the nutritional status of patients remains poorly
identifi ed and documented (Waitzberg et al. 2001 ; Singh et al. 2006 ; Gout et al.
2009 ). This highlights the need for a continuing education program in clinical nutri-
tion for health-care providers, which should begin in medical and nursing schools
(Acuna et al. 2008 ) and extend into residency and nursing training curricula.
Medical societies and quality improvement organizations have proposed structured
guidelines to screen, identify, and treat malnutrition. Crucial to the successful imple-
mentation of these guidelines is the formation of nutrition support teams (Nehme
1980 ; Schneider 2006 ). The NST represents a model of transdisciplinary management
where specialists from multiple disciplines combine their knowledge and expertise to
achieve management decisions and outcomes superior to those obtained in isolation.
An effective NST is a physician-led team of doctors, nurses, dieticians, and pharma-
cists who actively manage patients through daily clinical rounds using evidence-based
protocols (Gales and Gales 1994 ). These teams are expected to interact closely with
referring physicians, promote awareness, and improve the education of health-care
providers in all aspects of nutrition care. The exact composition and roles of team
members should be adapted to fi t local demands and resources.
Successful NST practice has led to an increase in the appropriate use of PN and
reduction in catheter-related complications and metabolic derangements (Nehme
1980 ; Gales and Gales 1994 ; Sriram et al. 2010 ). The implementation of an NST
4 Transdisciplinary Management of Perioperative Nutrition
46
and nutritional clinical practice guidelines in a set of patients undergoing elective
surgery for colorectal cancer resulted in a signifi cant reduction in postoperative
complications and hospital length of stay (Planas et al. 2007 ). It is important for
each NST to determine performance goals or aims in terms of clinical nutrition
outcomes of their patients. Regular audit of performance indicators will identify
areas which require improvement or a change in clinical practice (Schneider
2006 ).
4.4 Clinical Pathway for Nutrition Risk Screening,
Assessment, Therapy, and Monitoring
Nutrition screening is a simple process to identify patients at risk of malnutrition
who will require a more thorough and detailed nutrition assessment to determine
nutritional status (Kondrup et al. 2003 ). Many guidelines recommend screening in
all cancer patients during the initial preoperation evaluation, either in the inpatient
or outpatient setting. It is often challenging, however, to accurately measure nutri-
tional status. Several markers have been explored as an indicator of nutritional sta-
tus including albumin, prealbumin, and total lymphocyte counts (Elia 2000 ), but no
single clinical or laboratory marker can be recommended as a comprehensive indi-
cator of nutritional status. Levels of laboratory markers may be lowered during the
acute phase response in infl ammatory conditions making them unreliable in patients
presenting with an acute colorectal problem (Fuhrman 2002 ).
In the 1990s, The Joint Commission mandated nutrition screening within
24 hours of admission, followed by a full nutrition assessment if found to be at
nutritional risk. This guideline has since been widely adopted; however, colorectal
patients who are undergoing elective procedures on the day of admission ought to
be screened preoperatively in the outpatient clinic (Kudsk et al. 2003a ). Nutrition
screening tools should be easy to use, cost-effective, valid, reliable, and sensitive.
Several nutrition screening tools have been described including the Mini Nutritional
Assessment (MNA) (Vellas et al. 1999 ), the Malnutrition Universal Screening Tool
(MUST) (Ferguson et al. 1999 ), and the Nutritional Risk Screening (Kondrup et al.
2003 ). The main limitations of these tools are the dependency on subjective param-
eters and clinical judgment and the variable evidence of their accuracy and
reliability.
After nutrition screening, patients who are identifi ed to be at risk of malnutrition
should receive a more detailed nutritional assessment by a nutrition expert. This is
a complete and systematic examination of the metabolic, nutritional, or functional
variables which allows the NST to create an appropriate nutritional plan for each
patient (Kondrup et al. 2003 ). ASPEN recommends using the Subjective Global
Assessment (SGA), which is an assessment tool that consists of both the patient’s
history and physical assessment (Fig. 4.2 ). Patients are subjectively classifi ed as A
(well nourished), B (moderate malnutrition), or C (severe malnutrition) (Detsky
et al. 1987 ). The SGA is a validated and simple assessment that predicts postopera-
tive complications with high accuracy (Baker et al. 1982 ).
Y.-L. Cheah et al.
47
Fig. 4.2 Subjective Global Assessment
4 Transdisciplinary Management of Perioperative Nutrition
48
Patients assessed to be malnourished will require a nutrition therapy care plan,
which should be delivered by a transdisciplinary team of nutrition experts, espe-
cially for those requiring PN. Regular reassessments of nutritional status must be
conducted throughout the hospital stay to identify any changes in clinical or nutri-
tional status, which may impact current nutrition status and therapy (Fig. 4.3 ).
4.5 Calculating Nutritional Requirements
The crucial element in designing a nutrition therapy care plan is the calculation of a
patient’s daily energy requirement. The daily requirement depends on resting energy
rate, diet-induced thermogenesis, and physical activity (Manchanda 2003 ).
The resting energy expenditure of patients after major colorectal surgery increased
by 13 % compared to those in healthy volunteers, with no difference in urinary
Admission
Nutrition screening
With 24 h
using screening tools
Nutrition assessment
e.g. SGA
Nutrition therapy
care plan
Transdisciplinary approach
Nutrition therapy
implementation
Patient monitoring
Reassesment & updating
nutrition care plan
Termination of therapy
Discharge planning
Continued inpatient care
Periodic rescreening
Detect changes in
clinical or nutrition status
At risk
Change in status
Goals achieved
Ye s
No
Not at risk
Not at risk
Fig. 4.3 Clinical pathway for nutrition risk screening, assessment, therapy, and monitoring
Y.-L. Cheah et al.
49
nitrogen losses (Soop et al. 2004 ). The change in the energy expenditure of cancer
patients is variable and is dependent on body composition and tumor type and stage
(Elia 2005 ).
Indirect calorimetry represents the gold standard for measuring energy expendi-
ture in the clinical setting. This machine, however, is often unavailable due to its
high cost. Most nutrition therapists use predictive equations to estimate energy
expenditure; the components of these equations usually include characteristics
which infl uence the amount of fat-free mass including body weight, height, age, and
gender. Many equations have been developed for healthy individuals (Table 4.1 ) and
can be adjusted for sick patients using stress factors (Frankenfi eld et al. 2004 ).
ESPEN recommends the use of 25 kcal/kg ideal body weight as an approximate
estimation of daily energy requirements and 30 kcal/kg ideal body weight during
severe stress. ESPEN guidelines also recommend 1.2–1.5 g/kg ideal body weight/
day of protein to limit nitrogen losses in surgical patients (Braga et al. 2009 ).
In addition to calorie and protein requirements, patients should receive daily
recommended amounts of fl uids, electrolytes, trace elements, and vitamins
(Tables 4.2 , 4.3 , and 4.4 ) (Langley 2007 ; Clark 2007 ).
4.6 Preoperative Management of Nutrition in Colorectal
Surgery
4.6.1 Immediate Preoperative Management
Routine prolonged periods of fasting before surgery should be avoided. It is now
known that consuming fl uids up to 2 h before general anesthesia does not increase
the risk of aspiration (Jones et al. 2011 ). There is also a lack of evidence to show
harm when this is performed in patients at risk of refl ux and gastroparesis, such as
those with diabetes mellitus, gastroesophageal refl ux disease, and obesity (Smith
et al. 2011 ).
In addition, providing carbohydrate calories just before surgery in the form of a
carbohydrate drink has been shown to shorten the length of hospitalization, reduce
Table 4.1 Common energy expenditure equations
Equation (year) Calculation
Harris–Benedict (1919) Men: Wt (13.75) + Ht (5) – age (6.8) + 66
Women: Wt (9.6) + Ht (1.8) – age (4.7) + 655
Miffl in–St Jeor (1990) Men: Wt (10) + Ht (6.325) – age (5) + 5
Women: Wt (10) + Ht (6.25) – age (5) – 161
Penn State (1998, 2004,
2001)
Age ≥ 60 with BMI ≥ 30 kg/m
2
: Miffl in (0.71) + Tmax (85) + Ve
(63) – 3,085
All others: Miffl in (0.96) + Tmax (167) + Ve (31) – 6,212
Wt weight (kg), Ht height (cm), BMI body mass index, Tmax maximum body temperature in the
previous 24 h (degree Celsius), Ve minute ventilation recorded from ventilator (L/min)
4 Transdisciplinary Management of Perioperative Nutrition
50
Table 4.2 Daily electrolytes requirements, etiologies, and clinical consequences of abnormalities
Electrolyte
Recommended daily intake Abnormal levels Causes
Clinical consequences
Sodium 1–2 mmol/kg/day Low Replacement of lost solute with water Malaise
SIADH Delirium
Renal failure Seizures
Medications Coma
Respiratory arrest
High Loss of water Lethargy
Iatrogenic (e.g., excessive use of hypertonic saline) Irritability
Seizures
Coma
Potassium 1–2 mmol/kg/day Low Increased GI/GU losses Muscle weakness
Medications (e.g., insulin, nebulizers) Ileus
Carbohydrate loading Cardiac arrhythmias
Rhabdomyolysis
High Increased intake Muscle weakness
Reduced urinary excretion (e.g., renal failure,
medications)
Paralysis
Cardiac arrhythmias
Magnesium 4–10 mmol/day Low Impaired intestinal absorption Tetany
Increased renal excretion Seizures
Cardiac arrhythmias
Sudden cardiac death
High (rare) Chronic kidney disease Bradycardia
Hypotension
Asystole
Y.-L. Cheah et al.
51
Calcium 5–7.5 mmol/day Low Chronic kidney disease Hypoparathyroidism Tetany
Vitamin D defi ciency Hypoactive refl exes
Alcoholism Anxiety
Hyperphosphatemia Hallucinations
Hypotension
High Malignancy Hyperparathyroidism Constipation
Muscle weakness
Confusion
Lethargy
Phosphate 20–40 mmol/day Low Increased renal elimination Delirium
Refeeding syndrome Seizures
Respiratory alkalosis Respiratory failure
Cardiac failure
Cardiac arrhythmias
High Chronic kidney disease Hypocalcemia
Hypoparathyroidism ECG changes
Paresthesia
SIADH syndrome of inappropriate antidiuretic hormone secretion, GI gastrointestinal, GU genitourinary
4 Transdisciplinary Management of Perioperative Nutrition
52
Table 4.3 Daily trace element requirements, function, and clinical consequences of defi ciency
Trace element
Recommended daily intake Function
Defi ciency
Chromium 10–15 mcg Glucose and lipid metabolism Rare
Potentiation of insulin action Enhances tyrosine
phosphorylation of the insulin receptor
Weight loss
Neuropathy
Impaired glucose tolerance
Glucosuria
Hyperlipidemia
Copper 0.3–0.5 mg Oxidation–reduction and electron transfer reactions
involving oxygen
Uncommon
Component of metalloenzymes (used for collagen and
elastin production, dopamine conversion to
norepinephrine)
Defects in connective tissue
Anemia
Leukopenia
Neutropenia
Hypercholesterolemia
Cardiac dysfunction
Manganese 60–100 mcg Component of metalloenzymes (arginase, used for urea
production; manganese superoxide dismutase, provides
antioxidant function; pyruvate carboxylase, used in
carbohydrate synthesis)
Rare
Neurotoxicity
Poor reproductive performance
Abnormal bone and cartilage formation
Ataxia
Growth retardation
Defects in carbohydrate and lipid metabolism
Y.-L. Cheah et al.
53
Selenium 20–60 mcg Defense against oxidative stress Keshan disease (cardiomyopathy in pediatric
population)
Regulation of thyroxine Skeletal muscle disorders
Regulation of the redox status of vitamin C and other
molecules
Zinc 2.5–5 mg Component of enzymes (RNA polymerase, alkaline
phosphatase)
Growth retardation
Structural role in protein folding Hair loss
Lipid peroxidation Diarrhea
Apoptosis, cellular proliferation, and differentiation Delayed sexual maturation and impotence
Immune function Eye and skin lesions
Loss of appetite
Delayed wound healing
Iron 8–18 mg Oxidative metabolism Impaired physical work performance
Heme proteins (hemoglobin, myoglobin, cytochromes) Mental delay
Electron transfer Cognitive impairment
Hypochromic–microcytic anemia
4 Transdisciplinary Management of Perioperative Nutrition