Hypoalbuminemia Is Associated With Increased Postoperative Mortality and Complications in Hand Surgery

The combined risk predictive power of frailty and hypoalbuminemia in free tissue flap reconstruction: A cohort study of 34,571 patients from the NSQIP database

INTRODUCTION

Significant morbidity and mortality are hallmarks of the functional decline seen in physically frail patients. The modified frailty index 5 (mFI-5) represents a risk predictor score that has been validated as a comorbidity-based scale in surgery. Serum albumin levels of <3.5 g/dL (hypoalbuminemia) have also been implicated with poor postoperative outcomes. However, the association between these two parameters remains to be investigated. We aimed to elucidate the interdependence of preoperative albumin levels and frailty, as evaluated by the mFI-5 score, and its reliability to prognosticate postoperative results in free flap reconstruction (FFR).

METHODS

We conducted a multicenter, retrospective cohort study and accessed the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from 2008 to 2021. We identified all adult patients (≥18 years of age) who underwent a FFR. We extracted perioperative data and lab values including albumin. Multivariable linear and logistic regression analyses were performed to identify independent risk predictors. Main outcomes involved mortality, length of hospital stay, reoperation, medical and surgical complications, and discharge destination within the 30-day postoperative period.

RESULTS

A total of 34,571 patients were included in the study, with an average age of 53.9 years (standard deviation [SD] 12.2) and an average body mass index (BMI) of 28.8 (SD 6.1). Of these patients, 7484 were male (21.6%), whereas 22,363 (64.7%) had no frailty (mFI = 0). Additionally, 9466 patients had a frailty score of 1 (27.4%), 2505 had a score of 2 (7.2%), 226 had a score of 3 (0.7%), and 11 had a score of 4 or higher (0.0%). Albumin levels were available for 16,250 patients (47.0%), and among them, 1334 (8.2%) had hypoalbuminemia. Regression analyses showed that higher mFI scores were independent predictors of any, surgical, and medical complications, as well as increased rates of reoperations, unplanned readmissions, and prolonged hospital stays. Hypoalbuminemia independently predicted any, surgical, and medical complications, and higher mortality, reoperation, and longer hospital stay. When both frailty and albumin levels (mFI-5 and albumin) were considered together, this combined assessment was found to be a more accurate predictor of all major outcomes (any, medical and surgical complications, mortality, and reoperation). Further, our analysis identified a weak negative correlation between serum albumin levels and mFI scores (Spearman R: -.1; p < .0001).

CONCLUSION

In conclusion, this cohort study highlights the association of hypoalbuminemia with adverse postoperative outcomes, including those not directly related to frailty. Simultaneously, higher mFI scores independently predicted outcomes not associated with hypoalbuminemia. Stemming from these findings, we recommend considering both serum albumin levels and frailty in patients receiving FFR. This perioperative algorithm may help provide more individualized planning including multidisciplinary care and pre and posthabilitation.

The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes

» Identification of malnourished and at-risk patients should be a standardized part of the preoperative evaluation process for every patient.» Malnourishment is defined as a disorder of energy, protein, and nutrients based on the presence of insufficient energy intake, weight loss, muscle atrophy, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.» Malnutrition has been associated with worse outcomes postoperatively across a variety of orthopaedic procedures because malnourished patients do not have a robust metabolic reserve available for recovery after surgery.» Screening assessment and basic laboratory studies may indicate patients' nutritional risk; however, laboratory values are often not specific for malnutrition, necessitating the use of prognostic screening tools.» Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients.

Preoperative Serum Albumin as Predictor of Outcomes After Thyroidectomy

Objective

Albumin is considered to be a surrogate marker for inflammation and nutritional status. Levels usually decrease after surgery but little is known about the predictive value of preoperative albumin levels in patients undergoing thyroidectomy. This study aimed to investigate the 30-day incidence of postoperative outcomes in thyroidectomy patients with and without preoperative hypoalbuminemia.

Study Design

Retrospective cohort study.

Setting

TriNetX Database.

Methods

TriNetX, a federated deidentified database, was retrospectively queried to identify patients who underwent thyroidectomy. Postoperative outcomes within 30 days of thyroidectomy, based on International Classification of Disease, 10th Revision and Current Procedural Terminology codes, in patients with preoperative hypoalbuminemia (≤3.4 g/dL) (cohort 1) were analyzed and compared to patients without hypoalbuminemia (cohort 2).

Results

After propensity score matching, 2398 patients were identified in each cohort. Hypoalbuminemia patients were more likely to have postoperative pneumonia (odds ratio, OR: 3.472, 95% confidence interval, CI [2.016-5.978]), acute renal failure (OR: 3.872, 95% CI [2.412-6.217]), venous thromboembolism (OR: 1.766, 95% CI [1.016-2.819]), and surgical site infection (OR: 2.353, 95% CI [1.282-4.32]). Rates of recurrent laryngeal nerve injury were comparable between cohorts.

Conclusion

Patients undergoing thyroidectomy with preoperative hypoalbuminemia have a higher prevalence of postoperative complications compared to patients without preoperative hypoalbuminemia. While not routinely assessed, preoperative evaluation of serum albumin levels may help guide expectations and optimal management of thyroidectomy patients.

An evidence-based review of optimal perioperative practices in minor hand surgery

BACKGROUND

Like many surgical subspecialties, there have been frequent advancements and discoveries in the field of hand and upper extremity surgery. With a rapidly growing literature base, it can be difficult to remain updated on the latest recommendations.

METHODS

A comprehensive literature search was completed on PubMed using MeSH terms. Topics included nutrition management, anticoagulation, immunosuppressive medication management, antibiotic use, skin preparation, splinting, tourniquet use, and suture choice. Data from articles with a level of evidence 1A-3 C were included.

RESULTS

A total of 42 articles were identified and reviewed to provide evidence for recommendations regarding various aspects of pre-, intra-, and post-operative care.

CONCLUSIONS

The objective of this manuscript is to serve as a resource for evidence-based recommendations by the findings of recent evidence related to perioperative care in elective hand surgery. Additional studies are required in certain areas of the literature in order to provide stronger recommendations.

Malnutrition and Postoperative Outcomes Following Transcervical Zenker Diverticulectomy

OBJECTIVES

Hypoalbuminemia has been used as a proxy for poor nutrition, and has been associated with poor postoperative outcomes in varying surgical procedures. This study investigates the association between albumin status and complications following transcervical Zenker diverticulectomy.

STUDY DESIGN

Retrospective database review.

METHODS

The National Surgical Quality Improvement Program database was queried for patients who underwent transcervical Zenker diverticulectomy between 2005 and 2018. Univariate and multivariable analyses were conducted to determine associations between albumin status and postoperative complications.

RESULTS

318 patients undergoing transcervical Zenker diverticulectomy with available albumin values were queried. The mean serum albumin was 3.90 g/dL (SD = 0.56). Univariate analysis showed that hypoalbuminemia was associated with increased age (77.68 vs. 70.03 years) and female gender (54.4% vs. 45.6%), as well as sepsis (p = 0.045), reintubation (p = 0.040), urinary tract infection (p = 0.017), any medical complication (p < 0.001), any life-threatening complication (p = 0.017), and mortality (p = 0.012). Multivariable analyses found no associations between hypoalbuminemia and mortality (OR 33.136, 95% CI N/A, p = 1.000), any medical complication (OR 1.154, 95% CI 0.326-4.079, p = 0.824), any life-threatening complication (OR 0.604, 95% CI 0.079-4.586, p = 0.604), and length of stay (p = 0.249).

CONCLUSIONS

This study suggests no association between hypoalbuminemia and postoperative complications in transcervical Zenker diverticulectomy. Hypoalbuminemia and malnutrition may not be a contraindication for surgery correcting Zenker diverticulectomy.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:1402-1408, 2023.

Association between postoperative hypoalbuminemia and postoperative pulmonary imaging abnormalities patients undergoing craniotomy for brain tumors: a retrospective cohort study

Hypoalbuminemia is associated with poor outcome in patients undergoing surgery intervention. The main aim for this study was to investigate the incidence and the risk factors of postoperative hypoalbuminemia and assessed the impact of postoperative hypoalbuminemia on complications in patients undergoing brain tumor surgery. This retrospective study included 372 consecutive patients who underwent brain tumors surgery from January 2017 to December 2019. The patients were divided into hypoalbuminemia (< 35 g/L) and non-hypoalbuminemia group (≥ 35 g/L) based on postoperative albumin levels. Logistic regression analyses were used to determine risk factors. Of the total 372 patients, 333 (89.5%) developed hypoalbuminemia after surgery. Hypoalbuminemia was associated with operation time (OR 1.011, P < 0.001), preoperative albumin (OR 0.864, P = 0.015) and peroperative globulin (OR 1.192, P = 0.004). Postoperative pulmonary imaging abnormalities had a higher incidence in patients with than without hypoalbuminemia (41.1% vs 23.1%, P = 0.029). The independent predictors of postoperative pulmonary imaging abnormalities were age (OR 1.053, P < 0.001), operation time (OR 1.003, P = 0.013) and lower postoperative albumin (OR 0.946, P = 0.018). Pulmonary imaging abnormalities [OR 19.862 (95% CI 2.546–154.936, P = 0.004)] was a novel independent predictors of postoperative pneumonia. Postoperative hypoalbuminemia has a higher incidence with the increase of operation time, and may be associated with postoperative complications in patients undergoing brain tumor surgery.

Hypoalbuminemia Predicts Adverse Events following Unicompartmental Knee Arthroplasty

Hypoalbuminemia is a potentially modifiable risk factor associated with adverse events following total knee arthroplasty. The present study aimed to evaluate whether hypoalbuminemia similarly predisposes to adverse events following unicompartmental knee arthroplasty (UKA). Patients who underwent UKA during 2006-2018 were identified through the American College of Surgeons National Surgical Quality Improvement Program. Only patients with preoperative serum albumin concentration were included. Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration < 3.5 g/dL). All associations were adjusted for demographic, comorbidity, and laboratory differences between populations. A total of 11,342 patients were identified, of whom 6,049 (53.3%) had preoperative serum albumin laboratory values available for analysis. After adjustment for potential confounders, patients with hypoalbuminemia had a greater than 2-fold increased probability for occurrence of any complication (7.02% vs. 2.23%, p = 0.009) and a 4-fold increased probability of receiving a blood transfusion (1.81% vs. 0.25%, p = 0.045). Among procedures performed as inpatients, mean postoperative length of stay (LOS) was longer in patients with hypoalbuminemia (2.2 vs. 1.8 days; p = 0.031). Hypoalbuminemia is independently associated with complications and increased LOS following UKA and a marker for patients at higher risk of postoperative complications. Patients should be screened for hypoalbuminemia and nutritional deficiencies addressed prior to UKA.

The Association of Preoperative Opioid Use With Revision Surgery and Complications Following Carpometacarpal Arthroplasty

PURPOSE

Preoperative opioid use has been shown to be associated with poor outcomes following different upper-extremity surgeries. We aimed to examine the relationship between preoperative opioid use and outcomes following carpometacarpal (CMC) arthroplasty. We hypothesized that patients prescribed higher daily average numbers of preoperative oral morphine equivalents (OMEs) would show higher rates of complications and revision surgery.

METHODS

In the Truven Health MarketScan Database, we identified all patients who underwent CMC arthroplasty from 2009 to 2018. We separated them into cohorts based on average daily OMEs prescribed in the 6 months prior to the surgery: opioid naïve, <2.5, 2.5 to 5, 5 to 10, and >10 OMEs per day. We retrieved 90-day complications and 3-year revision surgery data, and we compared these outcomes by opioid-use groups.

RESULTS

We identified 40,141 patients. The majority (55.9%) were opioid naïve, with the next most common group receiving a daily average of <2.5 OMEs (19.2%). Complications increased with increased preoperative OMEs. Multivariable analysis revealed that patients taking >10 OMEs per day had a 1.45% increase in 3-year revision surgery compared with opioid-naïve patients, which equated to 2.12 (confidence interval [CI]: 1.33-3.36) times increased odds. Additionally, patients taking >10 OMEs had increased odds of an emergency department visit (odds ratio [OR]: 1.60, CI: 1.43-1.78), a 90-day hospital admission (OR: 2.34, CI: 1.97-2.79), and surgical site infection (OR, 2.02, CI: 1.59-2.54) compared with opioid-naïve patients, with absolute differences of 4.53%, 2.78%, and 1.22% compared with opioid-naïve patients, respectively. Additionally, preoperative opioid use predicted both number of prescriptions filled in the short term and long term continued opioid use.

CONCLUSIONS

Preoperative opioid use of >10 OMEs per day is associated with a higher risk for complications and revision surgery following CMC arthroplasty. Our findings demonstrate a dose-dependent relationship between opioid use and postoperative complications. Further study is necessary to determine if reducing opioid use prior to CMC arthroplasty may reduce the likelihood of these negative outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Perioperative Laboratory Markers as Risk Factors for Surgical Site Infection After Elective Hand Surgery

PURPOSE

The purpose of this study was to test the null hypothesis that there is no association between perioperative laboratory markers (serum albumin and hemoglobin A1c [HbA1c]) and incidence of surgical site infection (SSI) after soft tissue upper extremity surgery.

METHODS

We analyzed patient-level data from a large, insurance-based database containing supplemental laboratory results. We identified patients undergoing soft tissue upper extremity surgery (defined as carpal tunnel release, trigger finger release, wrist ganglion excision, cubital tunnel release, Dupuytren partial fasciectomy, or first dorsal compartment release) with serum albumin or HbA1c measurements within 90 days of surgery. We stratified patients into cohorts based on serum albumin concentration (<3.5 g/dL) and HbA1c (≥7%) thresholds. The primary outcome was incidence of SSI within 30 days following surgery. We constructed multivariable logistic regression models to adjust for patient demographics and baseline comorbidities using the Elixhauser comorbidity index.

RESULTS

Patients with hypoalbuminemia experienced an SSI incidence of 3.5% compared to 0.9% in patients with normal serum albumin. In multivariable analysis, the odds ratio of SSI with hypoalbuminemia was 3.32 (95% CI, 2.32-4.65). Patients with HbA1c ≥ 7% experienced an SSI incidence of 1.1% compared to 0.7% in patients with HbA1c < 7%. Multivariable analysis revealed odds ratios for SSI of 1.47 (95% CI, 1.02-2.11) in patients with HbA1c ≥ 7% compared to those with HbA1c < 7%.

CONCLUSIONS

Hypoalbuminemia and elevated HbA1c (in patients with diabetes) are risk factors for SSI within 30 days following soft tissue upper extremity surgery. Preoperative measurement of these laboratory markers may be a useful tool for risk stratification and identification of high-risk patients for nutritional or glycemic optimization.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Hypoalbuminaemia in orthopaedic trauma patients in a rural hospital in South Africa

BACKGROUND

The deleterious effects of hypoalbuminaemia in the peri-operative period are well documented. We aimed to review serum albumin levels in a cohort of orthopaedic trauma patients to determine the prevalence of hypoalbuminaemia. Secondarily, we aimed to identify factors associated with an increased risk of hypoalbuminaemia.

METHODS

A retrospective cross-sectional study was performed of data collected prospectively at a regional hospital serving primarily a rural population in South Africa.

RESULTS

Two hundred ninety-five patients were included in the study. Twenty-nine per cent of the cohort was found to have hypoalbuminaemia. Femur neck fractures (p < 0.001), intertrochanteric fractures (p = 0.004), tibial plateau fractures (p = 0.034) and polytrauma (p = 0.013) were associated with hypoalbuminaemia. The mean albumin level was lower in HIV-positive patients when compared to HIV-negative patients (35.7 g/L vs 37.5 g/L, p = 0.007). The presence of comorbidities other than HIV, like diabetes mellitus (p = 0.001), previous pulmonary tuberculosis (p = 0.034) and chronic renal failure (p = 0.007) was associated with hypoalbuminaemia.

CONCLUSION

In this cohort of orthopaedic trauma patients from rural South Africa, we found a 29% prevalence of hypoalbuminaemia at the time of presentation. High-risk subgroups include patients with pre-existing comorbidities and increased age, as well as patients presenting with polytrauma, femoral neck, intertrochanteric femur or tibial plateau fractures.

The Impact of Malnutrition on 30-Day Postoperative Complications following Surgical Fixation of Distal Radius Fractures

Introduction  Distal radius fractures (DRFs) are increasingly managed surgically among fragility fractures due to prolonged life expectancy and surgical advancements. Yet, malnutrition can impact postoperative outcomes and complications. We sought to determine the impact of malnutrition on open reduction and internal fixation (ORIF) of DRFs during the perioperative and 30-day postoperative periods. Materials and Methods  Using the National Surgical Quality Improvement Program database, all patients who underwent ORIF of a DRF between January 1, 2008, and December 31, 2016, were identified and stratified by preoperative serum albumin levels: normal (≥3.5 g/dL; n = 2,546) or hypoalbuminemia (<3.5 g/dL; n = 439). Demographical and perioperative data were compared. Operative complications were stratified into major and minor complications, and data were analyzed using descriptive statistics and multivariate regression models. Results  Compared with patients with normal levels, a higher proportion of hypoalbuminemia patients had ASA scores > 3 (9.1 vs. 2%) and a longer mean length of stay (3.16 vs. 0.83 days). Hypoalbuminemia patients also had 625% greater odds for developing major complications during the 30-day postoperative period (odds ratio = 7.25; 95% confidence interval: 1.91-27.49). Conclusion  Malnutrition significantly affected outcomes and complications of distal radius ORIF. This study highlights the importance of prevention and treatment of malnutrition in the setting of fragility fractures.

Low serum cholinesterase predicts complication risk after orthopedic surgery in elderly patients: an observational pilot study

BACKGROUND

Serum cholinesterase (ChE) in elderly adults is associated with geriatric conditions such as sarcopenia and malnutrition. The aim of this study is to examine the impact of preoperative serum ChE on the development of complications after noncardiac surgery in elderly patients without liver cirrhosis.

METHODS

We retrospectively identified all patients aged ≥ 65 years who underwent orthopedic surgery over a 1.5-year period in our hospital. The main outcome was postoperative complications, defined as a deviation from the normal postoperative course within 30 days postoperatively.

RESULTS

A total of 313 patients (median age 79 years) were included. The incidence of all-cause postoperative complications was 15.7% (49/313 patients). Receiver operating characteristic curve analysis showed that serum ChE was a univariable factor that predicted all-cause complications with moderate accuracy (area under the curve = 0.694, 95% confidence interval (CI) 0.604-0.783), with an optimal serum ChE cutoff level of 200 units/L. After multivariate analyses adjusted by baseline characteristics, low serum ChE remained a significant risk factor for postoperative complications (odds ratio = 2.99, 95% CI 1.41-6.33, P = 0.004).

CONCLUSIONS

Low serum ChE (< 200 unit/L) is a significant risk factor for postoperative complications after orthopedic surgery in patients aged ≥ 65 years.