Introduction
Once upon a time, when the world was young and IV bottles were yellow, surgeons gave lots of vitamins; most postoperative patients received a daily cocktail of B-complex and C vitamins. A lot of internists, too -not just surgeons- ordered B and C vitamins routinely, on the grounds that the water-soluble vitamins weren't stored in the body and that they needed to be given every day. It couldn't hurt, went the refrain, and it might do some good.

Don't be too surprised. Many people, especially those who are nutritionally oriented, take a multivitamin pill every day. Is there any evidence for the practice? No? Then why do they do it?

Now back to perioperative vitamins. Along came cost containment, and evidence-based medicine. Can't prove that vitamins are any good? Out they go! Today, surgeons no longer give vitamin supplementation routinely. But the question for today is, should they? And if so, to which patients should surgeons give vitamin supplements?

At this point, a major issue arises. Not only aren't there very many studies about vitamins in the perioperative patient, but the few studies there are don't prove much. The problem is this. To determine whether or not vitamins really make a difference would require a study of several thousand patients, and frankly, nobody is going to fund such a study. So, in the absence of a prospective, randomized study, we have to glean whatever we can from the existing literature.

The Effect of Surgery on Vitamin Levels
There is evidence that major operations lower vitamin levels. Two studies from Japan showed lowered vitamin levels in general surgical patients¹ and in cardiac surgical patients.² The cardiac surgical study compared patients with and without vitamin supplementation, and showed significant decreases in vitamins A, C, and E postsurgery, thought to be due to increased consumption and decreased uptake from surgical stress. Supplementation with multivitamin infusion (MVI) in the cardiac study prevented the deficiencies.

Nanji and colleagues compared morbidly obese patients having gastric bypass with normal patients undergoing major abdominal surgery.³ There was no difference between the groups, but both groups showed a 50% perioperative reduction in serum vitamin A levels. In a study by Zunic, serum vitamin E was compared preoperatively and postoperatively in a group of patients. There was a significant drop with significantly lower values observed even 4 days after surgery.⁴

Notice that all of these studies are somewhat counter to the old practice of supplementing only water-soluble vitamins. Levels of the fat-soluble vitamins A and E appear to drop as well. From these studies of serum vitamin levels, we may infer that body stores are not as great as we supposed them to be 20 or 30 years ago.

Vitamin Deficiencies
Many patients seeking medical treatment can present with some existing vitamin deficiencies. A study by Jamieson looked at patients requiring emergency admission to the medical ward.⁵ Average levels of thiamine, riboflavin, and pyridoxine were depressed, and half the patients studied had multiple deficiencies of the B-complex vitamins. Van Asselt found a 10% to 15% incidence of B12 deficiency in the elderly.⁶ A study by Thomas of 290 medical inpatients at Massachusetts General Hospital showed a prevalence of vitamin D deficiency in 57% of patients.⁷ Admittedly, Boston doesn't get much sun in the winter still, a high incidence.

There have actually been deaths from beriberi-thiamine deficiency- in the United States within the last 2 decades. Two episodes of nationwide intravenous vitamin shortages occurred recently, in 1988 and again in 1996. Clinical cases of beriberi were reported during both years.^8,9 Also, thiamine deficiency is an occasional diagnosis in inner-city hospitals.^10,11

Vitamin K deficiency can produce anticoagulation. I recall discovering, when a resident, that a patient was completely anticoagulated after about 3 weeks on TPN without vitamin K supplementation. Unfortunately, we discovered the problem in the operating room during an emergency operation. While vitamin K stores will usually last longer than 3 weeks, in the stressed patient, and particularly in those who are already depleted, a clinical deficiency can appear relatively soon. A study by Jatoi measured phylloquinone levels as a measure of vitamin K. Half of already-hospitalized adult patients admitted to the hospital from the gastroenterology or internal medicine service had subclinical vitamin K deficiency.¹²

Conclusions
So-what can we conclude about perioperative vitamin supplementation? Hospitalized patients are often deficient in the B-complex vitamins and vitamin C, and in vitamin D. Operative surgery can cause losses of vitamins A and E. We also know that it is difficult to diagnose vitamin deficiency. Symptoms are nonspecific. Serum levels are not easy to determine, and not readily available. In fact, it's actually more cost-effective to simply give the vitamins, rather than to do the tests.

Are there identifiable subgroups of patients who should definitely be supplemented? Yes, although a qualification must go with any listing of subgroups. Anyone who is poorly nourished must be suspected of having vitamin deficiencies. It is certainly justifiable to administer perioperative vitamins to patients with cancer, chronic GI diseases, severe weight loss, cirrhosis, or alcoholism. One must be very cautious about vitamins in end-stage renal disease, however. Fat-soluble vitamins should be given very sparingly, if at all; water-soluble vitamins can be given. Even apparently well-nourished people can have vitamin deficiencies and treating only the obviously malnourished patients will not eliminate all vitamin deficiencies. At the end of the day, we come, perhaps reluctantly, to the conclusion that the old approach wasn't so bad. If half our patients are deficient in one vitamin or another, perhaps the prophylactic approach should be tried again. We give prophylactic antibiotics with less justification and regard them as an essential part of surgical care.

In summary, we can recommend giving perioperative vitamins to patients who are at high risk, and we can advise a high index of suspicion in everyone else. And maybe we should be instructing our elective patients to take multivitamins for 2 or 3 weeks prior to their scheduled surgery. Can't hurt now, can it?