The BMI is calculated as body weight in kilograms divided by the height in square centimeters. A BMI less than 22 increases the risk of malnutrition, and a BMI less than 19 gives clear evidence of malnutrition (10).
Patients who have lost less than 6% of their ideal body weight do not need preoperative nutritional intervention. However, patients who have lost more than 10% of their ideal body weight in 6 months meet the definition of severely malnourished and should be considered for preoperative intervention (11). Patients who have lost between 6% and 10% should undergo further studies to determine if preoperative intervention is needed. Laboratory assessments of albumin, transferrin, and prealbumin may be obtained in addition to the routine preoperative tests. The degree of malnutrition can in part be determined by serum concentrations of albumin, transferrin, and prealbumin. The levels of these serum proteins are greatly inﬂuenced by the patient’s level of hydration. Prealbumin has the shortest half-life, at 2 to 3 days, and levels of this protein are depressed very early in comparison with serum transferrin and albumin, which have half-lives of 8 and 20 days, respectively (12). Serum albumin is a substitute for the Prognostic Nutritional Index, which is a time-consuming calculation, in assessing malnutrition in women with gynecologic malignancies (13). A serum albumin level of 3.5 to 5.0 is in the normal range, 2.8 to 3.4 is considered to indicate mild malnutrition, 2.1 to 2.7 moderate malnutrition, and less than 2.1 severe malnutrition (14). Hypoalbuminemia is correlated with morbidity, mortality, and increased postoperative complication rates in data from the National Surgical Quality Improvement Program (15). Decisions regarding the need for nutritional support should be based on several individualized factors. These factors include the patient’s prior nutritional state, the anticipated length of time in which the patient will not be able to eat, the severity of surgery, and the likelihood of complications. The nutritional assessment should determine whether the cause of the malnutrition is increased enteral loss (malabsorption, intestinal fistula), decreased oral intake, increased nutritional requirements as a result of hypermetabolism (sepsis, malignancy), or a combination of these factors. Severe malnutrition, if not corrected, can further complicate the postoperative problem by causing altered immune function, chronic anemia, impaired wound healing, and eventually multiple organ system failure and death.