A 68-year-old man is admitted for elective gastrectomy. On admission the nursing team completes the Malnutrition Universal Screening Tool (MUST). His BMI is 19.4 kg/m², he has lost 8% of his body weight over the past four months, and he is expected to have little or no nutritional intake for more than five days around surgery. What does this screening imply and what should follow?
- AHe is at low risk; routine hospital diet is all that is required
- BScreening tools have no role; only serum albumin defines malnutrition
- CHe should be tube-fed immediately without further assessment
- DNutritional state cannot meaningfully be improved before surgery, so nothing should delay the operation
- EHe scores high risk: dietitian referral for formal assessment, with pre-operative nutritional support seriously considered before major surgery
Show answer and explanation
Correct answer: E
MUST combines three elements — BMI (a score of 2 below 18.5, 1 for 18.5 to 20), unintentional weight loss over three to six months (1 for 5 to 10%, 2 for over 10%), and an acute disease effect score of 2 when intake is likely to be absent for more than five days. He scores at least 4: high risk. Screening is the trigger, not the treatment: high risk mandates referral for formal dietetic assessment and a documented care plan — food-first measures, oral nutritional supplements, and escalation to enteral or parenteral routes as indicated. The surgical significance is the examinable core: malnutrition impairs immune function, wound healing and respiratory muscle strength, and severely malnourished patients undergoing major GI surgery benefit from 7 to 14 days of pre-operative nutritional support, a delay usually worth taking even in cancer surgery. ERAS principles then minimise the perioperative fasting insult.
Why the others are wrong: A — his score is high-risk on all three axes. B — albumin is a negative acute-phase protein reflecting inflammation and dilution far more than nutrition; screening tools exist precisely because it misleads. C — route and intensity follow assessment; 'tube-feed everyone' skips the pathway. D — pre-operative support in the severely malnourished measurably reduces complications; the fatalism is false.
Key point: MUST scores BMI, weight loss and anticipated starvation; a high-risk score before major surgery mandates dietetic assessment and consideration of pre-operative nutritional support — and albumin is an inflammation marker, not a nutrition test.
Guidelines: NICE nutrition support guidance (CG32) and BAPEN: a high MUST score triggers dietitian referral and a nutrition care plan; significant weight loss with reduced intake before major surgery merits preoperative nutritional support.