Should patients take multivitamins (MVI) before elective surgery?

Multivitamins Prior to Elective Surgery

Multivitamins should generally be discontinued 2 weeks before elective surgery due to potential interactions with anesthetic medications and possible effects on bleeding risk, particularly for vitamin E. 1

Perioperative Management of Multivitamins

The Society for Perioperative Assessment and Quality Improvement (SPAQI) provides clear guidance on the management of dietary supplements, including multivitamins, before surgery:

Specific Vitamin Components of Concern

1. Vitamin E

   • Should be held for 2 weeks before surgery
   • May have antiplatelet effects through inhibition of protein kinase C
   • Effects are worsened when taken with aspirin
   • Higher serum levels are associated with bleeding in patients on anticoagulants 1

2. Other Vitamin Components

   • Many multivitamins contain multiple ingredients that may affect surgical outcomes
   • Some components may affect bleeding risk, blood glucose levels, or interact with anesthetics

Timing of Discontinuation

For standard multivitamins, the recommendation is to:

• Discontinue 2 weeks before elective surgery
• Resume only when the risk of postoperative bleeding is minimal 1

Special Considerations

Malnourished Patients

For patients who are malnourished or at nutritional risk:

• Nutritional support is indicated and should be prioritized 1
• Oral nutritional supplements (ONS) are preferred over multivitamins 1
• If malnutrition is diagnosed, surgery should ideally be delayed for 7-14 days to allow for intensive nutritional therapy 1

Specialized Nutritional Support

For patients requiring nutritional optimization before surgery:

• Enteral nutrition (EN) should be preferred over parenteral nutrition (PN) 1
• Specialized immune-modulating formulas (containing arginine, omega-3 fatty acids, and nucleotides) may be beneficial for patients undergoing major cancer surgery 1
• Standard oral nutritional supplements are recommended for most patients who cannot meet their nutritional needs from normal food 1

Common Pitfalls and Caveats

1. Not all supplements are equal:

   • Standard multivitamins and specialized bariatric multivitamins have different compositions and effects 2, 3
   • The risk profile depends on specific components in the multivitamin

2. Medication interactions:

   • Some multivitamin components may interact with perioperative medications
   • Patients on anticoagulants are at particular risk due to vitamin K and vitamin E content

3. Resumption timing:

   • Resuming multivitamins too early postoperatively may increase bleeding risk
   • Follow the principle that supplements that impair coagulation should be restarted only when the risk of postoperative bleeding is minimal 1

Practical Approach

1. Preoperative assessment:

   • Identify all multivitamin and supplement use during preoperative evaluation
   • Document specific brands and formulations

2. Discontinuation protocol:

   • Instruct patients to stop standard multivitamins 2 weeks before elective surgery
   • For malnourished patients, replace with appropriate medical nutrition therapy

3. Postoperative resumption:

   • Resume multivitamins only after the risk of bleeding complications has diminished
   • Consider individual patient factors and the specific surgical procedure

By following these evidence-based recommendations, clinicians can minimize the risk of perioperative complications while ensuring appropriate nutritional support for surgical patients.