Nothing new today — ESPEN surgical nutrition and the ESAIC cardiac biomarker guideline

No new guidelines from tracked societies today. Fourteen journals swept for 3–5 September. The two hits were both already in the archive: the EHJ “Weekly Journal Scan” (a commentary) and the ACC/AHA tactical athlete statement, noted yesterday.

Continuing the landmark backlog. Two of the previously unchecked societies — ESPEN and ESAIC — turned out to have directly relevant perioperative guidelines this archive had never surfaced. Both have deposited abstracts, so both are covered first-hand.

ESPEN guideline on clinical nutrition in surgery — Update 2025

Society · Published: European Society for Clinical Nutrition and Metabolism. Clinical Nutrition, 3 September 2025 — exactly one year old Weimann, Bezmarevic, Braga, Correia, Gianotti, Gillis, Hübner, Klek et al.

44 recommendations for elective and non-elective surgery, with decision-making flowcharts, and new sections on frailty assessment, sarcopenia diagnosis and prehabilitation.

The guideline’s own framing of perioperative metabolic care:

• Early oral feeding is the preferred mode for surgical patients
• Avoiding nutritional therapy risks underfeeding after major surgery, and both malnutrition and underfeeding are risk factors for postoperative complications
• Nutritional therapy is mandatory for any surgical patient at nutritional risk, especially in upper gastrointestinal surgery

Its eight key aspects of perioperative care: integrating nutrition into overall management; avoiding long preoperative fasting; re-establishing oral feeding as early as possible; starting nutritional therapy as soon as risk is apparent; metabolic control including blood glucose; reducing factors that exacerbate stress-related catabolism or impair gastrointestinal function; minimising time on paralytic agents postoperatively; and early mobilisation to support protein synthesis and muscle function.

Interpretation. Two items here belong to anaesthesia rather than dietetics, and are easy to overlook in a nutrition guideline.

“Avoidance of long periods of preoperative fasting” is an anaesthetic decision, not a nutritional one — and it lands the same week as a BJA paper on paediatric one-hour clear-fluid fasting that appeared in yesterday’s sweep. The direction of travel is consistent and has been for years; the gap between guidance and what actually happens on the ward at 06:00 remains the real problem.

“Minimized time on paralytic agents in the postoperative period” appearing in a nutrition guideline is telling: it is there because neuromuscular blockade impairs gastrointestinal function and delays feeding. That is a downstream consequence of an intraoperative and ICU decision, and it is the kind of cross-domain link that gets lost when each specialty reads only its own guidelines.

Read alongside the AAST/ACS trauma nutrition protocol sent on 29 August. The two agree on early enteral feeding and on individualising in shock; ESPEN adds the elective-surgery and prehabilitation side that the trauma protocol does not cover.

Read the guideline · PMID 40957230

ESAIC focused guideline — cardiac biomarkers in perioperative risk evaluation

Society · Published: European Society of Anaesthesiology and Intensive Care. European Journal of Anaesthesiology, 1 June 2023 — ~3 years old; endorsed by the Scandinavian society in Acta Anaesthesiologica Scandinavica in June 2024 Lurati Buse, Bollen Pinto, Abelha, Abbott, Ackland, Afshari, De Hert, Fellahi, Longrois et al.

Guidance on pre-, post- and combined pre-and-postoperative use of cardiac troponin and B-type natriuretic peptides in adults undergoing noncardiac surgery. GRADE methodology, modified Delphi defining 12 critical outcomes, systematic search returning over 25,000 hits of which 115 full-text articles formed the evidence base.

The structural choice that matters: the panel separated three distinct scopes of application —

1. biomarkers as prognostic factors
2. biomarkers as tools for risk prediction
3. biomarker-enhanced management strategies

— and found “a relevant gradient in the certainty of evidence across the three scopes.” Where evidence was too limited for a recommendation, they issued clinical practice statements instead.

Interpretation. That three-way split is the most useful thing in the document, and it is the distinction most often collapsed in practice. Troponin is well established as a prognostic marker — a raised postoperative troponin identifies a patient at higher risk, and that is close to settled. It is much weaker as a basis for a management strategy, because knowing the risk is not the same as knowing what to do about it, and MANAGE remains close to the only randomised attempt at the question. The certainty gradient across the three scopes is an honest way of saying: measure it to prognosticate, be careful about measuring it to act.

This guideline is now three years old and about to be overtaken. The Fifth Universal Definition of Myocardial Infarction published on 28 August replaces the numerical MI types with primary, secondary and procedure-related categories — and perioperative myocardial injury after noncardiac surgery sits squarely in the new secondary and procedure-related categories, with a 30-day window on the latter. Any guidance built on the fourth definition’s vocabulary will need re-expressing. Worth watching for an ESAIC update, and worth knowing which definition a paper is using when the two are cited side by side.

Read the guideline · PMID 37265332 · Scandinavian endorsement

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Also identified and not yet covered: the joint ESAIC/ESRA guideline on regional anaesthesia in patients on antithrombotic drugs (2022) — primary scope, added to the outstanding list.