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

Wischmeyer, Paul E., MD, EDIC*; Carli, Franco, MD, MPhil; Evans, David C., MD, FACS; Guilbert, Sarah, RD, LDN, CNSC§; Kozar, Rosemary, MD, PhD; Pryor, Aurora, MD, FACS; Thiele, Robert H., MD#; Everett, Sotiria, EdD, RD**; Grocott, Mike, BSc, MBBS, MD, FRCA, FRCP, FFICM††,‡‡,§§,‖‖; Gan, Tong J., MD, MHS, FRCA¶¶; Shaw, Andrew D., MB, FRCA, FCCM, FFICM##,***; Thacker, Julie K. M., MD†††; Miller, Timothy E., MB, ChB, FRCA‡‡‡; Hedrick, Traci L., MD, MS; McEvoy, Matthew D., MD; Mythen, Michael G., MBBS, MD, FRCA, FFICM, FCAI (Hon); Bergamaschi, Roberto, MD, PhD; Gupta, Ruchir, MD; Holubar, Stefan D., MD, MS; Senagore, Anthony J., MD, MS, MBA; Abola, Ramon E., MD; Bennett-Guerrero, Elliott, MD; Kent, Michael L., MD; Feldman, Liane S., MD; Fiore, Julio F. Jr, PhD for the Perioperative Quality Initiative (POQI) 2 Workgroup

doi: 10.1213/ANE.0000000000002743
Perioperative Medicine: Narrative Review Article

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.

From the *Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina

McGill University, Montreal, Québec, Canada

Department of Surgery, Division of Trauma, Critical Care, and Burn, Ohio State University, Columbus, Ohio

§Duke University Hospital, Durham, North Carolina

University of Maryland School of Medicine, Baltimore, Maryland

Department of Surgery, Stony Brook Medicine, Stony Brook, New York

#Departments of Anesthesiology and Biomedical Engineering, Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia

**Nutrition Division, Department of Family, Population, Preventive Medicine, Stony Brook Medicine, Stony Brook, New York

††Respiratory and Critical Care Research Area, National Institute of Health Research Biomedical Research Centre, University Hospital Southampton, Southampton, United Kingdom

‡‡Southampton National Health Service Foundation Trust, Integrative Physiology and Critical Illness Group, Southampton, United Kingdom

§§Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom

‖‖Morpheus Collaboration, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina

¶¶Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, New York

##Vanderbilt University School of Medicine, Nashville, Tennessee

***Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee

†††Department of Surgery, Division of Advanced Oncologic and Gastrointestinal Surgery

‡‡‡Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Durham, North Carolina.

Assistant Professor of Surgery, Co-Director Enhanced Recovery Program, Department of Surgery, University of Virginia Health System

Associate Professor of Anesthesiology, Vanderbilt University School of Medicine, Vice Chair for Educational Affairs, Department of Anesthesiology, Vanderbilt University Medical Center

Smiths Medical Professor of Anesthesia, University College London/University College London Hospital National Institute of Health Research Biomedical Research Centre, London, United Kingdom

Professor of Surgery, Division of Colon and Rectal Surgery, State University of New York, Stony Brook, NY

Assistant Professor of Anesthesiology, Stony Brook School of Medicine, Health Science Center, Stony Brook, NY

Director, Dartmouth Enhanced Recovery Program, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice

Professor and Vice Chair for Clinical Operations, Chief, Gastrointestinal and Oncologic Surgery, Co-Director Department of Surgery Clinical Outcomes Research Program, University of Texas Medical Branch.

Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY

Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY

Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD

Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada

Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada

Published ahead of print January 23, 2018.

Accepted for publication October 27, 2017.

Funding: The Perioperative Quality Initiative (POQI) meeting received financial assistance from the American Society for Enhanced Recovery (ASER).

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Members of the Perioperative Quality Initiative (POQI) 2 Workgroup are provided in the Appendix.

Reprints will not be available from the authors.

Address correspondence to Timothy E. Miller, MB, ChB, FRCA, Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to timothy.miller2@duke.edu.

© 2018 International Anesthesia Research Society
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