American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway

Abstract

Perioperative malnutrition has proven to be challenging to define, diagnose, and treat. Despite these challenges, it is well known that suboptimal nutritional status is a strong independent predictor of poor postoperative outcomes. Although perioperative caregivers consistently express recognition of the importance of nutrition screening and optimization in the perioperative period, implementation of evidence-based perioperative nutrition guidelines and pathways in the United States has been quite limited and needs to be addressed in surgery-focused recommendations. The second Perioperative Quality Initiative brought together a group of international experts with the objective of providing consensus recommendations on this important topic with the goal of (1) developing guidelines for screening of nutritional status to identify patients at risk for adverse outcomes due to malnutrition; (2) address optimal methods of providing nutritional support and optimizing nutrition status preoperatively; and (3) identifying when and how to optimize nutrition delivery in the postoperative period. Discussion led to strong recommendations for implementation of routine preoperative nutrition screening to identify patients in need of preoperative nutrition optimization. Postoperatively, nutrition delivery should be restarted immediately after surgery. The key role of oral nutrition supplements, enteral nutrition, and parenteral nutrition (implemented in that order) in most perioperative patients was advocated for with protein delivery being more important than total calorie delivery. Finally, the role of often-inadequate nutrition intake in the posthospital setting was discussed, and the role of postdischarge oral nutrition supplements was emphasized.

Pre‐operative nutrition and the elective surgical patient: why, how and what?

“…Surgical nutrition guidelines, such as the European Society for Clinical Nutrition and Metabolism , American Society of Parenteral Enteral Nutrition and the American Society for Enhanced Recovery with Peri‐operative Quality Initiative all provide details on selecting nutrition screening tools, malnutrition assessment tools, and treatment for malnourished and at‐risk patients. Nearly all guidelines suggest systematic, routine screening for malnutrition and subsequent nutrition assessment with a validated malnutrition assessment tool or a comprehensive nutrition assessment by a registered dietician if the nutrition screen is positive.…”

“…Examples of an existing tool, the Peri‐operative Malnutrition Score , used to identify malnutrition risk, and a nutrition optimisation programme for patients at risk of peri‐operative malnutrition at Duke University, the Peri‐Operative Enhancement Team clinic, are shown in Figs. and .…”

Implementation of an Enhanced Recovery After Surgery Program Can Change Nutrition Care Practice: A Multicenter Experience in Elective Colorectal Surgery

“…1,13 ERAS programs are recognized as important drivers of standardized perioperative nutrition care and have provided the foundation of key perioperative nutrition care elements, which have been incorporated into clinical practice guidelines for surgical patients. [1][2][3][4]6,14 Despite the recognized benefits of ERAS programs, 1,3,4 implementation of evidence-based guidelines is a continual challenge. 2,4,8 ERAS programs are complex; they must be adapted to local contexts and require extensive education, cooperation, and collaboration between the patient, healthcare provider, and health system.…”

Perioperative medicine: a changing model of care

“…11 Wischmeyer and colleagues on behalf of the American Society for Enhanced Recovery and Perioperative Quality Initiative 2 (POQI-2) released a joint consensus statement on nutrition screening and therapy within a surgical enhanced recovery pathway. 12 The need for routine preoperative screening to identify patients in need of nutritional optimisation was highlighted, as was the key role of oral nutritional supplements, protein delivery rather than total calorie delivery, and early initiation of postoperative nutrition.…”