Preoperative albumin and surgical site identify surgical risk for major postoperative complications

The Effect of Malnutrition on Morbidity after Surgery for Chronic Pancreatitis

Protein-energy malnutrition is a notable problem in the management of patients with chronic pancreatitis. The effect of malnutrition on pancreatic surgery is not well known. The records of 313 consecutive patients who underwent lateral pancreaticojejunostomy (LPJ, n = 152), pancreaticoduodenectomy (PD, n = 78), or distal pancreatectomy (DP, n = 83) for chronic pancreatitis were retrospectively reviewed and analyzed. Subjective Global Assessment, Nutritional Risk Index, and Instant Nutritional Assessment were used to assess the nutritional state. An average of all three nutritional indexes was established, and patients were categorized into well nourished (n = 101) as well as mild (n = 91), moderate (n = 94), and severe malnourished (n = 27). Poor nutritional state was associated with an increase in postoperative complication rate (LPJ: well nourished 14%, mild 25%, moderate 31%*, severe 50%*; PD: well nourished 44%, mild 44%, moderate 60%, severe 88%*; DP: well nourished 17%, mild 13%, moderate 30%, severe 55%*; * P < 0.045 vs well nourished). Low serum albumin levels also increased operative morbidity. The increase in morbidity was reflected by a higher rate of infectious complications as well as increased ICU stay. Body mass index and weight loss did not contribute to change in outcome. Malnutrition was associated with a higher incidence of postoperative complications after surgery for chronic pancreatitis. An increase in operative morbidity might be related to decreased protein synthesis and impaired immunocompetence.

Serum albumin and clinical outcome in pediatric cardiac surgery

OBJECTIVE

We evaluated the behavior of serum albumin concentrations in response to metabolic stress that is associated with cardiac surgery and the role of this protein as a predictor of clinical outcome in children at high surgical risk who undergo operative correction of congenital heart defects.

METHODS

Serum albumin concentrations were measured in 30 children who had heart disease and were at high surgical risk. Analyses were performed before surgery, on the second postoperative day, and on discharge from the intensive care unit. Preoperative serum concentrations of albumin were compared with those of a control group that consisted of 20 healthy and well-nourished children.

RESULTS

Preoperative albumin concentrations of patients were lower than those of the control group (3.4+/-0.25 g/dL versus 4.0+/-0.18 g/dL, P<0.05). Serum levels decreased on the second postoperative day and at discharge from the intensive care unit (3.1+/-0.65 g/dL and 3.2+/-0.44 g/dL, P<0.05) compared with preoperative concentrations. Preoperative concentrations lower than 3.0 g/dL were associated with increased postsurgical infection (P=0.0026) and with increased mortality (P=0.0138). Patients whose postoperative levels were lower than 3.0 g/dL had longer hospital stays compared with those whose concentrations were higher than 3.0 g/dL (14.5+/-1.3 d versus 10+/-2.2 d, P<0.05).

CONCLUSION

The results suggest that hypoalbuminemia is common among children who have heart disease and are at high surgical risk, and serum albumin concentrations lower than 3 g/dL may be related to outcome in the period after cardiac surgery.

Fit for surgery: an expert panel review on optmising patients prior to surgery, with a particular focus on nutrition

This article represents the views of an international group of surgeons on the need for pre-operative optimisation of patient's nutritional status prior to elective surgery as a means of reducing post-operative infective complications.

The Incidence and Impact of Pre-Existing Protein Energy Malnutrition on Outcome in the Elderly Burn Patient Population

Protein energy malnutrition (PEM) and involuntary weight loss is a common problem in the elderly population. Our purpose was to determine the incidence and the effect on outcome of PEM in the elderly burn patient population. A chart review and review of the burn data registry was undertaken to determine the incidence and effect of PEM in patients older than 65 years of age with major burns from 1% to 30% TBSA. PEM was diagnosed using standard physiological and biochemical markers. Data were compared with those from a well-nourished elderly burn group to assess the impact. Of the 123 patients studied, we found that PEM was present in 61%. There was a significant increase in infection rate, decrease in the rate of healing of a standard skin graft donor site, and an increase in length of stay in the PEM group compared with the nourished elderly burn group. Mortality with PEM was 17% compared with 9% without PEM, a significant increase. We conclude that PEM is a common comorbid factor in the elderly burn population that increases morbidity and mortality.

[Preoperative screening and nutritional support of nutritional deficiencies]

Nutritional deficiencies have to be considered as an independent risk factor for postoperative morbidity. Peri-operative nutritional support reduce this risk in elective abdominal surgery for cancer and cardiac surgery. Preoperative nutritional support for 7-10 days reduce postoperative complications in undernourished patients by 10% but is not operant when administered after surgery. Enteral route is as effective. Recent studies using immunonutrients conclude that a short preoperative oral intake is able to reduce complications even in well-nourished patients. Then, a preoperative nutritional screening must be routinely performed leading to a nutritional programme.

Low apolipoprotein A-I level at intensive care unit admission and systemic inflammatory response syndrome exacerbation*

OBJECTIVE

Examine whether a low serum level of apolipoprotein A-I at intensive care unit (ICU) admission is associated with a further increase of the number of systemic inflammatory response syndrome (SIRS) criteria.

DESIGN

Prospective observational study.

SETTING

A 20-bed, university-affiliated, surgical ICU.

PATIENTS

Patients admitted after major surgery, multiple trauma, or acute pancreatitis without septic shock.

INTERVENTIONS

We defined as the SIRS Exacerb group patients who presented a further increase of the number of SIRS criteria during their ICU stay or, in the presence of four SIRS criteria at ICU admission, those who presented a further aggravation of organ failure. Other patients were attributed to the SIRS No Exacerb group. From day 1 to 6, we measured apolipoprotein A-I, high-density lipoprotein and total cholesterol, triglycerides, C-reactive protein, procalcitonin, serum amyloid A, interleukin 6, interleukin-1 receptor antagonist, albumin, and other nutrition-linked variables. We looked at laboratory values or factors present at ICU admission according to the two groups.

MEASUREMENTS AND MAIN RESULTS

From 63 patients analyzed, 29 (46%) were assigned to the SIRS Exacerb group. Age, sex, and SAPS II and SIRS scores at ICU admission did not differ between the groups. Patients in the SIRS Exacerb group presented more often a septic event (5/29 vs. 0/34, p =.02), had a higher hospital mortality (6/29 vs. 0/34, p =.007), and had a longer ICU stay (p =.0023). At admission, inflammatory variables such as the C-reactive protein, serum amyloid A, interleukin 6, interleukin-1 receptor antagonist plasma levels, and other lipid or nutrition-linked variables were similar between the two groups. Apolipoprotein A-I levels were lower in the SIRS Exacerb group (median [interquartile range]: 68 [56-81] vs. 84 [69-94] mg/dL, p =.028).

CONCLUSION

A low serum level of apolipoprotein A-I at ICU admission is associated with an increase of the number of SIRS criteria during the ICU stay.

Nutritional assessment in the hospitalized patient

PURPOSE OF REVIEW

Malnutrition is highly prevalent in hospitalized patients. Despite this, it is not routinely assessed in most hospitals worldwide. One of the reasons that might explain this fact is that there is no gold-standard nutritional assessment tool, and much has been written advocating this or that technique. The main topic of this review is discussion of the advantages and disadvantages of each of the available tools.

RECENT FINDINGS

Several studies have recently reinforced the relationship between poor nutritional status and higher incidences of complications, mortality, length of hospital stay and costs. Therefore, it is of the utmost importance to be able to diagnose malnutrition early.

SUMMARY

The evaluation of nutritional status is a broad topic that encompasses several clinical variables. In order to be ideal, the method should be able to predict patient outcome, should be able to be performed by most care-givers, should be inexpensive, and should not be time-consuming. Unfortunately, most nutritional assessment instruments were published with insufficient details regarding their intended use and method of derivation, and with an inadequate assessment of their effectiveness. Therefore, health professionals should be critical when defining which instrument should be adopted by an institution, and several factors should be taken into consideration.

Controversy of immunonutrition for surgical critical-illness patients

Specific nutrients such as arginine, glutamine, dietary nucleotides, and omega-3 fatty acids have been shown to influence infectious morbidity, antibiotic use, and hospital length of stay. The combination of these nutrients into one enteral formulation has become known as immune-enhancing diets. Consensus guidelines developed by a number of clinical investigators and published in 2001 concluded that immune-enhancing diets were beneficial in moderate to severely malnourished patients undergoing elective gastrointestinal surgery and patients sustaining severe blunt and penetrating torso trauma. The purpose of this article is to review data published between February 1, 2001, and January 31, 2003, to determine whether new studies substantiated or refuted the current recommendations for the use of immune-enhancing diets in surgical, critically injured, and critically ill patients. Results confirmed the benefits of preoperative administration of immune-enhancing diets in surgical patients but also demonstrated that postoperative administration offered no advantages. Decreased infectious complications were also observed in critically ill patients receiving immune-enhancing diets. Accumulating evidence supports the use of immune-enhancing diets in these specific patient populations.