Nutrition screening and assessment of surgical patients
Surgical Nutrition Training Module
Level 1
Philippine Society of General Surgeons
Committee on Surgical Training

Objectives
• To discuss body composition analysis in surgical patients
• To discuss ways to improve body composition and function to improve outcomes in surgery

Muscle and fat mass, all ages

Body compartments in health and disease
CARBO +
OTHER (1%)
PROTEIN (6%)
PROTEIN (14%) PROTEIN (14%) PROTEIN (12%)
FAT (15%) FAT (23%)
FAT (25%)
FAT (30%)
WATER (60%)
WATER (55%)
WATER (72%)
WATER (70%)
NORMAL OBESE STARVATION CRITICAL CARE

Loss of lean body mass = ↑mortality
Loss of
Total LBM
10%
Complications
20%
30%
Decreased immunity
Increased infections
Decrease in healing, increase
In weakness, infection
Too weak to sit, pressure ulcers,
Pneumonia, lack of healing
40% Death, usually from pneumonia
LBM=Lean Body Mass
Associated
Mortality
10%
30%
50%
100%
Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty 2009;9:e9.

Principles in surgical nutrition
• Surgery causes cellular damage and metabolic responses that increase energy and nutrient needs
• Immunosuppression increases susceptibility to bacterial and other infectious agent intrusion with their corresponding side effects
• Wound healing requires increased energy and nutrient needs
• Malnutrition affects surgical outcome(s)
• Optimum outcome is dependent on preparation, operative method, and adequate support

Malnutrition detection tools
Nutrition screening Nutritional assessment

The surgical nutrition process
All admitted patients are nutritionally screened
All nutritionally at risk patients are assessed
All high risk patients are given nutrition care plans
Monitoring of the nutrition process is done
Nutrition care plan modification / Discharge

STEP 1: NUTRITION SCREENING
Goal: To identify the nutritionally at risk patients

The surgical nutrition process
All admitted patients are nutritionally screened
All nutritionally at risk patients are assessed
All high risk patients are given nutrition care plans
Monitoring of the nutrition process is done
Nutrition care plan modification / Discharge

Basic data requirements
• Body Mass Index
– <18.5 underweight
– 18.5 – 24.9 normal
– 25 – 29.9 overweight
– 30+ obese
• Severe weight loss
– >5% in 1 month
– >7.5% in 3 months
– >10% in 6 months
• Mid Arm Circumference
– Male: <17.6 cm
– Female: <17.1 cm
Height and weight taken from regularly calibrated instruments

Nutrition
Screening
Form for
Adult and
Geriatric patients

Nutrition
Screening
Form for
Pediatric patients boys

Nutrition
Screening
Form for
Pediatric patients girls

Outcome: nutrition surveillance

NUTRITIONAL ASSESSMENT
Goal: To identify the nutritionally HIGH RISK patients

The surgical nutrition process
All admitted patients are nutritionally screened
All nutritionally at risk patients are assessed
All high risk patients are given nutrition care plans
Monitoring of the nutrition process is done
Nutrition care plan modification / Discharge

Nutritional
Assessment and Risk Level
Form

Outcome: complication prediction
Predicting post-operative complications based on surgical nutritional risk level using the SNRAF in colon cancer patients - a Chinese General Hospital & Medical Center experience. Ocampo R B, Kadatuan Y, Torillo MR,
Camarse CM, Malilay RB, Cheu G, Llido LO, Gilbuena AA. Yr 2007.

A filtering process

CASE DISCUSSION: NUTRITION
SCREENING AND ASSESSMENT

Gastric CA
• FM, 68 y/o, admitted because of gastric mass and admitted to undergo gastrectomy
• Ht - 1.65m; Wt. 46 kg; BMI=16.9
• Previous wt 4 months - 52 kg; % weight loss = 11%
• Ancillary procedures:
– Chest Xray: old (?) PTB
– ECG: Normal heart
– CBC: Hb=10; WBC=6,000; Platelets=250,000; N%=70; L%=10
– Electrolytes: Na=130; K=3.2
– BUN =25; Creatinine=1.2
– Albumin - 3

Nutrition screening
1. Is the BMI <18.5 or >30?
2. Has the patient lost weight within the last three (3) months?
3. Did the patient have a reduced dietary intake in the last week?
4. Is the patient severely ill
(e.g. in intensive therapy)
1. YES: BMI = 16.9
2. YES: lost weight (11% in the last 4 months)
3. YES: reduced dietary intake
4. NO: not severely ill
NUTRITION SCREEN RESULT:
NUTRITIONALLY AT RISK

Nutritional assessment/Risk Level
SGA: Weight loss: >10% and gastro symptoms =
(grade C) (3 pts) → severe malnutrition
BMI=16.9 (2 pts)
Albumin=3 (less than 3: 2 pts)
TLC=600 (less than 900: 2 pts)
Total Risk Score=9
Nutritional Assessment = Severe malnutrition
Risk Level =High Risk of developing nutrition related complications

Final decision
• Nutrition build up of this patient is mandatory for at least 5 to 10 days
• Other options:
– Do surgery then continuous post-operative nutrition maintenance and build up
– Needs a Nutrition Care Plan
• Rationale: body composition and reserves cannot provide optimum condition for good healing and fast recovery plus reduction of complications
(infection, dehiscence, fistula formation)

THANK YOU