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Part 2. Preparing for Anesthesia
Section B. Preoperative Evaluation of the Anesthesia Patient
Chapter 16. Evaluation of the Patient with Perioperative Malnutrition
Jacob T. Gutsche, MD, and Clifford S. Deutschman, MS, MD, FCCM
1. Although the incidence of malnutrition is unclear, the problem in patients presenting for surgery may be widespread. In addition, a large number of patients acquire protein-energy malnutrition (PEM) during hospitalization, which can alter the response to anesthetics.
2. In contrast to starvation, acute stress metabolism involves extensive neurohumoral modulation. Inflammation, surgery, trauma, or infection activates monokines, lymphokines, prostanoids, hormones, neural pathways, complement, and other endogenous mediators that "drive" metabolism and increase energy expenditure.
3. PEM is a metabolic disorder that affects virtually every organ system.
4. Decreased total circulating albumin has wide implications for drug administration and volume of distribution.
5. As a result of decreased microsomal enzyme activity and altered cytochrome P450/nicotinamide adenine dinucleotide phosphate (NADPH)-dependent transport mechanisms protein deficiency may reduce drug metabolism. Decreased transformation of compounds that are hepatically detoxified may lead to pathologic responses that require dosage alteration.
6. A number of studies confirm that decreased serum transport protein levels, anergy, and weight loss are associated with poor postoperative outcomes.
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