Nutritional management: when and how should we become involved?

Preoperative preparation for patients with nutritional disorders

Eating disorders are very common today. An increasing number of patients that undergo anesthesia and surgery have some nutritional disorder. These disorders are very versatile starting from obesity to anorexia. Significant changes in all organ systems are present. These pathophysiological changes are increased with the duration of the disease. There are many changes in the functioning of the cardiovascular system in all these diseases and there are significant. Respiratory and ventilatory functions are changed too. There are also many endocrine disorders. As a final result, there are many serious biochemical and coagulation disorders. These patients are often under some drug treatment. Patients could be under psychiatric therapy (psychiatric drugs) and/or could take drugs for relieving symptoms related to the pathophysiological changes in different organ systems. Preoperative preparation of patients must be detailed. All changes must be improved to optimal condition. In addition, it is necessary to think about the possible influence of used drugs on the anesthesia.

Pennington Lecture Teams, strategies and networks: developments in nutritional support; a personal perspective

Chris Pennington was an archetypal team player, strategist and networker. Clinical nutritional support has progressed remarkably since the 1970s and it has been a privilege to work in this field over this period during which teamwork, strategy development and networking have been crucial. British experience has been characterised by groups of individuals of differing professions and specialties coming together to enable progress to be made. This approach was initially in the form of nutrition support teams orientated to patient-centred ward-based care, then as hospital strategic committees and the concept of the ‘patient journey’. Indeed, the formation of the British Association for Parenteral and Enteral Nutrition (now known as BAPEN) in 1992 required the statesmanlike burying of jealousies as societies came together into a multiprofessional association. With the understanding that disease-related malnutrition was highly prevalent it became apparent that it must be managed on a broad and organised clinical front. In the Organisation of Food and Nutritional Support in Hospitals a group of professionals developed for BAPEN concepts of hospital-wide organisation to tackle malnutrition that were based on previous reports, both national and international, and were made easily accessible from the BAPEN website, especially the ‘Malnutrition Universal Screening Tool’ and the National Institute for Health and Clinical Excellence nutrition guidelines. The coming together of six national clinical societies to develop evidence-based consensus guidelines for intravenous saline therapy (also on the BAPEN website) has shown that BAPEN can catalyse opinion well beyond its own nutritional constituency. In England Chris Pennington's Scottish lead is being followed by developing a patient-centred strategic framework for a managed home parenteral nutrition and intestinal failure national network. In research, education or clinical practice the engines of progress have been teams, strategies and networks.

Managing the Patient Journey through Enteral Nutritional Care

Nutritional support provision does not happen by accident. Clinical dimensions include screening and assessment, estimation of requirements, identification of a feeding route and the subsequent need for monitoring. Patients may need different forms of nutritional intervention during the course of their illness. Furthermore, these may need to be provided in different locations as their clinical status changes. If this is not properly managed there is potential for inappropriate treatment to be given. Clinical processes can only be effectively implemented if there is a robust infrastructure. The clinical team need to understand the different elements involved in effective service provision and this depends on bringing together disciplines which do not feature overtly on the clinical agenda including catering, finance and senior management. Excellent communication skills at all levels, financial awareness and insight into how other departments function are fundamental to success. Practice needs to be reviewed constantly and creativity about all aspects of service delivery is essential. Finally, it is important that key stakeholders are identified and involved so that they can support any successes and developments. This will raise awareness of the benefits of nutritional intervention and help to ensure that the right resources are available when they are needed.