Validation of the Perioperative Nutrition Screen (PONS) for Prediction of Postoperative Outcomes

Role of dietitians in optimizing medical nutrition therapy in cardiac surgery patients: A secondary analysis of an international multicenter observational study

BACKGROUND

Better understanding the impact of dietetic services on nutrition practices seems required as it may represent an opportunity for optimization in post-cardiac surgery patients. The present study aims to evaluate and compare nutrition practices and clinical outcomes in post-cardiac surgery intensive care unit (ICU) patients with and without dietetic services.

METHODS

This is a secondary analysis of a multinational prospective observational study in patients (n = 237) with >72 h of post-cardiac surgical ICU stay with and without dietetic services describing nutrition practices and outcomes up to 12 days after ICU admission.

RESULTS

Dietetic services were available in 61.5% (8 of 13) ICUs (1.0 ± 0.5 full-time equivalents/10 beds). Enteral nutrition was initiated <48 h from ICU admission in 49.6% and 59.1% of patients at sites with vs without dietetic services, respectively. Parenteral nutrition was started within 118.3 ± 56.5 and 131.5 ± 69.2 h at sites with vs without dietetic services, respectively. Energy target (23.7 ± 4.8 vs 24.6 ± 4.8 kcal/kg body weight/day) and actual supply (10.5 ± 6.7 vs 10.3 ± 6.2 kcal/kg body weight/day) did not differ between the groups. Protein targets (1.4 ± 0.4 vs 1.1 ± 1.3 g/kg body weight/day) and actual protein provision (0.6 ± 0.4 vs 0.4 ± 0.3 g/kg body weight/day) were higher in patients at sites with vs without dietetic services.

CONCLUSION

Improvements in medical nutrition therapy practices in patients after cardiac surgery are needed in ICUs with and without dietetic services. Appropriately staffed dietetic services as essential members of the medical care team may be crucial to transfer knowledge on adequate medical nutrition therapy strategies into practice.

Preoperative anemia is associated with prolonged hospital stay and increased facility discharges after glioblastoma resection

Background

Despite numerous operative and non-operative treatment modalities, patients with glioblastoma (GBM) have a dismal prognosis. Identifying predictors of survival and recurrence is an essential strategy for guiding treatment decisions, and existing literature demonstrates associations between hematologic data and clinical outcomes in cancer patients. As such, we provide a novel analysis that examines associations between preoperative hematologic data and postoperative outcomes following GBM resection.

Methods

We performed a retrospective analysis of patients who underwent GBM resection from January 2016 to December 2020. Standard demographic and clinical variables were collected, including pre-operative complete blood count (CBC), and inferential analyses were performed to analyze associations between CBC parameters and postoperative outcomes.

Results

One hundred and eighty nine (189) patients met inclusion criteria, with a mean age of 60.7 years. On multivariate regression analysis, controlling for age, gender, and performance status, we observed trends suggesting anemic patients may have longer lengths of stay (t statistic = 3.23, p = 0.0015) and higher rates of discharge to inpatient facilities [OR 3.01 (1.09-8.13), p = 0.029], though these associations did not reach statistical significance after correction for multiple comparisons (Bonferroni-corrected significance threshold p < 0.01).

Conclusion

Preoperative anemia may be a useful pre-operative predictor of postsurgical GBM outcomes. Further study is required to determine whether pre-operative hemoglobin optimization can improve postoperative clinical outcomes, and whether other hematologic and inflammatory markers are predictive of postoperative recovery and functional status.

Global Leadership Initiative in Sarcopenia (GLIS)-defined sarcopenia increases the mortality of esophageal cancer patients after esophagectomy: A Chinese real-world cohort study

OBJECTIVES

To assess the impact of the definition of the Global Leadership Initiative in Sarcopenia (GLIS) on mortality in esophageal cancer (EC) patients, postesophagectomy, within a Chinese cohort and to validate the effectiveness of a new GLIS framework in oncology.

METHODS

We performed an observational real-world cohort study in a single center at Daping Hospital of the Army Medical University in China, spanning from December 2014 to July 2022. We used the combined definition of muscle mass and muscle strength in a new GLIS framework for the diagnosis of sarcopenia. Potential covariates were identified through univariate and multivariate analyses. The association between GLIS-defined sarcopenia and mortality was estimated using Kaplan-Meier curves and Cox models. We also conducted stratified analyses to assess the stability of multivariable Cox models.

RESULTS

A total of 520 EC patients were included in the study, with a median follow-up of 48.7 months. A total of 229 EC patients (44.0%) were identified with GLIS-defined sarcopenia. Patients with GLIS-defined sarcopenia had significantly worse overall survival in Kaplan-Meier curves (log-rank P = 0.015). Age; sex; tumor, node, metastasis stage; blood glucose; bleeding volume in operation; and operating time were introduced as covariates in a fully adjusted Cox model. Multivariable-adjusted Cox models revealed that GLIS-defined sarcopenia was an independent prognostic factor for EC patients postesophagectomy (hazard ratio, 1.87, 95% confidence interval, 1.28-2.74, P = 0.001). Stratified analyses confirmed the stability of the relationship between GLIS-defined sarcopenia and mortality in EC patients.

CONCLUSIONS

GLIS-defined sarcopenia is prevalent among Chinese EC patients and is linked to increased mortality risk postesophagectomy. This finding offers compelling evidence and serves as a valuable reference for the establishment of an operational definition of GLIS sarcopenia.

Geriatric Nutritional Risk Index is a risk factor for long-term decreases in patient-reported outcome measures following total knee arthroplasty

Purpose

Total knee arthroplasty (TKA) is an effective treatment for alleviating pain and improving function in patients with end-stage knee osteoarthritis. However, factors influencing long-term patient-reported outcome measures (PROMs) remain underexplored. This study aimed to evaluate the relationship between preoperative nutritional status, specifically the Geriatric Nutritional Risk Index (GNRI), and the long-term decline in PROMs following TKA.

Methods

We conducted a retrospective cohort study including patients who underwent TKA between 2000 and 2009. PROMs were assessed using the Knee Society Score (KSS) at two time points: an initial evaluation in 2012 (median postoperative 4 years) and a follow-up in 2023 (median 13 years). Preoperative GNRI, body mass index (BMI), and other demographic and clinical data were collected from medical records. Statistical analysis included paired t-tests and multivariate logistic regression to identify independent risk factors for long-term decline in KSS scores.

Results

A total of 75 patients completed follow-up assessments. Over the 11-year follow-up period, there was a significant decrease in the KSS functional activity scores (p < 0.001), with 47 patients experiencing a decline exceeding the minimal clinically important difference. A multivariate analysis revealed low preoperative GNRI (p = 0.0043) as a significant risk factor for long-term decline in PROMs.

Conclusion

Preoperative malnutrition, as indicated by a low GNRI, is a significant risk factor for long-term decline in functional outcomes following TKA. These findings highlight the importance of preoperative nutritional interventions and rehabilitation for improving the long-term outcomes of patients undergoing TKA.

Level of Evidence

Level III, retrospective cohort study.

Nutritional Optimization of the Surgical Patient: A Narrative Review

An increasing body of literature supports the clinical benefit of nutritional assessment and optimization in surgical patients; however, this data has yet to be consolidated in a practical fashion for use by surgeons. In this narrative review, we concisely aggregate emerging data to highlight the role of nutritional optimization as a promising, practical perioperative intervention to reduce complications and improve outcomes in surgical patients. This review of the surgical nutrition literature was conducted via large database review. There were no distinct inclusion/exclusion criteria for this review; however, we focused on adult populations using up-to-date literature from high-quality systematic reviews or randomized controlled trials when available. Current perioperative management focuses on the mitigation of intraoperative and immediate postoperative complications. Well-defined risk calculators attempt to stratify patient surgical risk preoperatively to reduce adverse events directly related to surgical procedures, such as hemorrhage, cardiopulmonary compromise, or infection. However, there is a lack of standardization of prognostic tools, nutritional protocols, and guidelines governing the assessment, composition, and administration of nutritional supplementation. Substantial data exist demonstrating the clinical benefit in the operative setting. In this work, we provide a fundamental primer for surgeons to understand the clinical importance of nutritional optimization along with practical prognostic tools and recommendations for use in their practice. While the extent to which nutritional optimization improves patient outcomes is debatable, the evidence clearly demonstrates a clinically meaningful benefit. Evaluating nutritional status differs based on disease severity and etiology of presentation, thus surgeons must select the appropriate prognostic tools to assess their patients during the perioperative period. This information will catalyze subsequent work with a multidisciplinary team to provide personalized dietary plans for patients and spark research to establish protocols for specific presentations.

Utilizing machine learning approaches to investigate the relationship between cystatin C and serious complications in esophageal cancer patients after esophagectomy

BACKGROUND

The purpose of this study is to investigate the relationship between preoperative cystatin C levels and the risk of serious postoperative complications in esophageal cancer (EC) patients, utilizing advanced machine learning (ML) methodologies.

METHODS

We conducted an observational cohort study, involving 524 EC patients from December 2014 to July 2022. ML models, including logistic regression (LR) and multilayer perceptron (MLP), were applied to investigate the relationship between cystatin C and the serious postoperative complications. The predictive value of cystatin C was evaluated using receiver operating characteristic (ROC) analysis. Based on a restricted cubic spline (RCS) method, the potential nonlinear association was scrutinized.

RESULTS

The morbidity of serious postoperative complications was 8.78%. Bleeding volume, operating time, NRS2002 score, PONS score, and cystatin C were significantly associated with serious postoperative complications. The MLP model demonstrated superior predictive accuracy (AUC = 0.775, 95% CI: 0.701-0.849) compared to the LR model (AUC = 0.714, 95% CI: 0.630-0.798) and cystatin C alone (AUC = 0.612, 95% CI: 0.526-0.699). High cystatin C level independently predicted serious postoperative complications in EC patients. A positive and linear association was found between cystatin C and serious complications.

CONCLUSION

This research uncovers a notable correlation between cystatin C and the severe complications in EC patients after esophagectomy. Employing ML techniques offers a robust method for forecasting patient outcomes and emphasizes the potential of cystatin C as a predictive biomarker in medical practice.

Risk factors for major complications following pelvic exenteration: A NSQIP study

OBJECTIVES

Due to the rarity of pelvic exenteration surgery, it is challenging to predict which patients are at an increased risk for postoperative complications. We aimed to study the predictors for postoperative complications among women undergoing pelvic exenteration for gynecologic malignancy.

METHOD

We used the National Surgical Quality Improvement Program registry to evaluate postoperative course and complications of those patients undergoing pelvic exenteration in the period 2012-2022. The primary objective of the analysis was to estimate the major postoperative complications following pelvic exenteration.

RESULTS

Overall, 794 pelvic exenterations were included. Of those, 56.5 % were anterior exenteration, 43.5 % were posterior exenteration, and 13.9 % were a combined exenteration. The rate of minor complications was 72.5 % (n = 576), and the rate of major complications was 31.5 % (n = 250). The most common minor complications were blood transfusion (n = 538, 67.8 %), followed by superficial surgical site infections (SSI) and urinary tract infections (9.8 % and 9.4 %, respectively). Among the major complications, the most common was organ/space SSI (11.2 %), followed by sepsis (9.2 %), reoperation (8.6 %), and wound dehiscence (5.2 %). Death within 30 days occurred in 1.5 % of patients. In multivariable regression analysis, the following factors were independently associated with major complications: higher BMI [adjusted odds ratio (aOR) 1.03 95 % confidence interval (CI) (1.01-1.05)], diabetes [aOR 1.82 95 % CI (1.13-3.22)], low serum albumin [aOR 0.73 95 % CI (0.54-0.98)], and high serum creatinine [aOR 1.70 95 % CI (1.05-2.77)].

CONCLUSIONS

Major postoperative complications occur in approximately one third of pelvic exenterations for gynecologic malignancies. Our study highlights independent factors associated with major postoperative complications, of which some are potentially modifiable.

The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes

» Identification of malnourished and at-risk patients should be a standardized part of the preoperative evaluation process for every patient.» Malnourishment is defined as a disorder of energy, protein, and nutrients based on the presence of insufficient energy intake, weight loss, muscle atrophy, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.» Malnutrition has been associated with worse outcomes postoperatively across a variety of orthopaedic procedures because malnourished patients do not have a robust metabolic reserve available for recovery after surgery.» Screening assessment and basic laboratory studies may indicate patients' nutritional risk; however, laboratory values are often not specific for malnutrition, necessitating the use of prognostic screening tools.» Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients.

Impact of nutrition on skin wound healing and aesthetic outcomes: A comprehensive narrative review

Background

While current wound treatment strategies often focus on antimicrobials and topical agents, the role of nutrition in wound healing and aesthetic outcomes is crucial but frequently overlooked. This review assesses the impact of specific nutrients and preoperative nutritional status on surgical outcomes.

Methods

A comprehensive search was conducted in PubMed, Scopus, Web of Science, and the Cochrane Library, from the inception of the study to October 2023. The study focused on the influence of macronutrients and micronutrients on aesthetic outcomes, the optimization of preoperative nutritional status, and the association between nutritional status and postoperative complications. Inclusion criteria were English language peer-reviewed articles, systematic reviews, meta-analyses, and clinical trials related to the impact of nutrition on skin wound healing and aesthetic outcomes. Exclusion criteria included non-English publications, non-peer-reviewed articles, opinion pieces, and animal studies.

Results

Omega-3 fatty acids and specific amino acids were linked to enhanced wound-healing and immune function. Vitamins A, B, and C and zinc positively influenced healing stages, while vitamin E showed variable results. Polyphenolic compounds showed anti-inflammatory effects beneficial for recovery. Malnutrition was associated with increased postoperative complications and infections, whereas preoperative nutritional support correlated with reduced hospital stays and complications.

Conclusion

Personalized nutritional plans are essential in surgical care, particularly for enhanced recovery after surgery protocols. Despite the demonstrated benefits of certain nutrients, gaps in research, particularly regarding elements such as iron, necessitate further studies. Nutritional assessments and interventions are vital for optimal preoperative care, underscoring the need for more comprehensive guidelines and research in nutritional management for surgical patients.

Nutritional risk predicts postoperative complications and length of stay, whereas sarcopenia risk predicts need for step-down care in a mixed elective surgery population

BACKGROUND

Malnutrition and poor functional reserves place patients at risk for negative surgical outcomes. In this prospective study we aimed to measure preoperative nutritional and sarcopenia risk and evaluate their impact on postoperative outcomes.

METHODS

Adults scheduled to undergo elective general and gastrointestinal surgery were screened for nutrition risk using the Malnutrition Universal Screening Tool screening tool. Sarcopenia risk was measured using the SARC-F tool and hand-grip strength. Patients were followed postoperatively. Incidence of complications, length of stay (LOS), readmission rates, and need for step-down care were recorded.

RESULTS

One hundred and twenty-two patients were included. Mean age was 53.8 years (standard deviation [SD] 16.44). Sixty-six (54%) were scheduled for day-case procedures, and 56 (46%) for nonday-case procedures. About 18.9% (n = 23) were at nutritional risk preoperatively. Ten patients (8.2%) had probable sarcopenia based on SARC-F, whereas seven (5.7%) had measurably reduced HG. Incidence of postoperative complications was 23.8% (n = 29). Nutrition risk was associated with the development of complications (p = 0.018). In the nonday-case group, nutritional risk was associated with greater LOS (p = 0.013). Older age was associated with need for step-down care (p = 0.002) as was SARC-F (p = 0.003).

CONCLUSIONS

Preoperative nutritional screening can predict postoperative complications and LOS, whereas sarcopenia screening is predictive of the need for step-down care after discharge. Screening tools are quick and inexpensive and could provide valuable information to clinicians and allow patients the opportunity to enhance their physical preparedness for surgery thereby mitigating their risk for negative surgical outcomes.

More Than a Perioperative Surgical Home: An Opportunity for Anesthesiologists to Advance Public Health

Public health and the medical specialty of anesthesiology have been closely intertwined throughout history, dating back to the 1800s when Dr. John Snow used contact tracing methods to identify the Broad Street Pump as the source of a cholera outbreak in London. During the COVID-19 pandemic, leaders in anesthesiology and anesthesia patient safety came forward to develop swift recommendations in the face of rapidly changing evidence to help protect patients and healthcare workers. While these high-profile examples may seem like uncommon events, there are many common modern-day public health issues that regularly intersect with anesthesiology and surgery. These include, but are not limited to, smoking; chronic opioid use and opioid use disorder; and obstructive sleep apnea. As an evolving medical specialty that encompasses pre- and postoperative care and acute and chronic pain management, anesthesiologists are uniquely positioned to improve patient care and outcomes and promote long-lasting behavioral changes to improve overall health. In this article, we make the case for advancing the role of the anesthesiologist beyond the original perioperative surgical home model into promoting public health initiatives within the perioperative period.

Optimizing Nutritional Status of Patients Prior to Major Surgical Intervention

In patients undergoing elective cardiovascular and thoracic surgery, malnutrition and the deterioration of nutritional status are associated with negative outcomes. Recognition of the contributory factors and the complications stemming from surgical stress is important for the prevention and management of these patients. We have reviewed the literature available and focused on the nutritional and metabolic aspects affecting surgical patients, with emphasis on the recommendations of enhanced recovery protocols. The implementation of enhanced recovery protocols and nutritional support guidelines focusing on the surgical patient as part of a multidisciplinary approach would improve the nutritional status of surgical patients at risk for negative outcomes.

Nascent to novel methods to evaluate malnutrition and frailty in the surgical patient

Preoperative nutrition status is an important determinant of surgical outcomes, yet malnutrition assessment is not integrated into all surgical pathways. Given its importance and the high prevalence of malnutrition in patients undergoing surgical procedures, preoperative nutrition screening, assessment, and intervention are needed to improve postoperative outcomes. This narrative review discusses novel methods to assess malnutrition and frailty in the surgical patient. The Global Leadership Initiative for Malnutrition (GLIM) criteria are increasingly used in surgical settings although further spread and implementation are strongly encouraged to help standardize the diagnosis of malnutrition. The use of body composition (ie, reduced muscle mass) as a phenotypic criterion in GLIM may lead to a greater number of patients identified as having malnutrition, which may otherwise be undetected if screened by other diagnostic tools. Skeletal muscle loss is a defining criterion of malnutrition and frailty. Novel direct and indirect approaches to assess muscle mass in clinical settings may facilitate the identification of patients with or at risk for malnutrition. Selected imaging techniques have the additional advantage of identifying myosteatosis (an independent predictor of morbidity and mortality for surgical patients). Feasible pathways for screening and assessing frailty exist and may determine the cost/benefit of surgery, long-term independence and productivity, and the value of undertaking targeted interventions. Finally, the evaluation of nutrition risk and status is essential to predict and mitigate surgical outcomes. Nascent to novel approaches are the future of objectively identifying patients at perioperative nutrition risk and guiding therapy toward optimal perioperative standards of care.

Nutritional Risk Screening 2002 predicts surgical outcomes in 1532 patients undergoing total joint arthroplasty: A retrospective cohort study

BACKGROUND

Limited information exists about the predictive effect of Nutritional Risk Screening (NRS) 2002 on orthopedic surgery. The aim of the present study is to explore the role of NRS 2002 in postoperative complications and resource utilization in patients with total joint arthroplasty (TJA).

METHODS

We retrospectively collected the demographics and surgical results of nearly 2000 TJA patients admitted from 2016 to 2020 and assessed the differences in short- and long-term complications and resource utilization parameters. Multivariate linear, logistic regression, and subgroup analysis were subsequently used to control for potential confounders. Survival analysis was performed to further verify the cumulative incidence of postoperative complications.

RESULTS

We identified 1532 patients receiving TJA, 8.7% of which were at nutrition risk (NRS 2002 score ≥3 out of 7). Preoperative nutrition risk was associated with an increased risk of systemic complications, incisional complications, surgical site infection (SSI), incisional SSI, periprosthetic joint infection, dislocation, and periprosthetic fracture after TJA (odds ratio [OR], 3.62-31.99; all P < 0.05). Preoperative nutrition risk was further associated with an increased risk of cardiac complications, respiratory complications, urinary complications, and arthroplasty-related reoperation (OR, 3.16-12.29; all P < 0.01). Moreover, preoperative nutrition risk was associated with increased costs and length of stay, and increased risk of unplanned intensive care unit admission, arthroplasty-related readmission, infection-related readmission, and SSI-related readmission.

CONCLUSIONS

NRS 2002 is associated with an elevated risk of postoperative complications and increased resource utilization, following TJA. Thus, routine screening is recommended to identify nutrition risk statuses of patients undergoing elective TJA.

A nutritional screening threshold for optimal outcomes after Hartmann's reversal

PURPOSE

Determining is nutritionally replete enough for Hartmann's reversal (HR) can be controversial and multifactorial. While there are many preoperative nutritional screening tools, the impact of malnourishment on HR has not been evaluated. The study aims to clarify how often patients undergoing HR are high risk for malnourishment at the time of surgery and how this impacts postoperative outcomes.

METHODS

From 2012-2019, all elective HRs were identified in ACS-NSQIP. Patients were categorized in a malnourished group if they met one of the following criteria: (1) BMI < 18.5 kg/m², (2) albumin < 3.5 g/dL, or (3) > 10% body weight loss in the last 6 months. Bivariate associations of preoperative demographics and postoperative outcomes were analyzed. Multivariable logistic regression was performed to identify independent predictors for 30-day mortality and organ space wound infection.

RESULTS

8878 procedures were evaluated (well-nourished = 7116 and malnourished = 1762). The malnourished group had higher mortality (p < 0.001), shorter operating time (p < .001), longer length of stay (p = 0.016), and higher rates of infection (p = 0.011), reintubation (p = 0.002), bleeding (p < 0.001), sepsis (p = 0.001), and reoperation (p = 0.018). In multivariate regression models, malnourishment was an independent predictor for mortality (OR = 2.72, p < 0.001) and wound infection (OR = 1.19, p = 0.028).

CONCLUSION

A large percentage of patients undergoing HR were classified as being high-risk for malnutrition. Malnourishment was associated with some worse postoperative compilations including death and wound infection. Surgeons should routinely use preoperative screening for malnutrition to identify and attempt to optimize nutritional status prior to undergoing Hartmann's Reversal.