Comparison of Two Malnutrition Assessment Scales in Predicting Postoperative Complications in Elderly Patients Undergoing Noncardiac Surgery

Prognostic significance of preoperative nutritional status for postoperative acute kidney injury in older patients undergoing major abdominal surgery: a retrospective cohort study

BACKGROUND

The association between malnutrition and postoperative acute kidney injury (AKI) has not been well studied. In this study, the authors examined the association between preoperative nutritional status and postoperative AKI in older patients who underwent major abdominal surgery, as well as the predictive value of malnutrition for AKI.

MATERIALS AND METHODS

The authors retrospectively included patients aged 65 or older who underwent major elective abdominal surgery. The nutritional status of the patient was evaluated using three objective nutritional indices, such as the geriatric nutritional risk index (GNRI), the prognostic nutritional index (PNI), and the controlling nutritional status (CONUT). AKI was determined using the KDIGO criteria. The authors performed logistic regression analysis to investigate the association between preoperative nutritional status and postoperative AKI, as well as the predictive value of nutritional scores for postoperative AKI.

RESULTS

A total of 2775 patients were included in the study, of which 707 (25.5%), 291 (10.5%), and 517 (18.6%) had moderate to severe malnutrition according to GNRI, PNI, and CONUT calculations. After surgery, 144 (5.2%) patients developed AKI, 86.1% at stage 1, 11.1% at stage 2, and 2.8% at stage 3 as determined by KDIGO criteria. After adjustment for traditional risk factors, worse nutritional scores were associated with a higher AKI risk. In addition to traditional risk factors, these nutritional indices improved the predictive ability of AKI prediction models, as demonstrated by significant improvements in integrated discrimination and net reclassification.

CONCLUSIONS

Poor preoperative nutritional status, as assessed by GNRI, PNI, and CONUT scores, was associated with an increased risk of postoperative AKI. Incorporating these scores into AKI prediction models improved their performance. These findings emphasize the need for screening surgical patients for malnutrition risk. Further research is needed to determine whether preoperative malnutrition assessment and intervention can reduce postoperative AKI incidence.

The relationship of prognostic nutritional index with prognosis and inflammation in patient with heart failure and reduced ejection fraction

Background: Malnutrition is closely associated with heart failure, and known to be closely associated with mortality and morbidity in these patients. Aims: We investigated the relationship of the prognostic nutritional index (PNI), which is a criterion of nutritional status in patients with heart failure with reduced ejection fraction (HFrEF), with prognosis and parameters indicating inflammation. Methods: 139 patients admitted to the coronary intensive care unit with symptoms of decompensated congestive heart failure were included to the study. Patients were with heart failure with ejection fraction <%40 and decompensated for any reason. Patients who died within 1 year in hospital or follow-up were considered to have reached the endpoint. Groups were divided into 2 groups as Group 1, the exitus; (23 patients, 7 M, mean age; 69.2 ± 15.0 years) and group 2, the non-exitus; (116 patients, 57 M, mean age; 69.3 ± 11.5 years). PNI was calculated with the formula ALB(g/L) + 5 × Total lymphocyte count(109/L). Results: PNI was significantly lower in group 1. Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and systemic inflamatory index values were significantly higher in group 1. PNI was significantly associated with these parameters. Conclusion: Low PNI scores in HFrEF patients may be associated with a worse prognosis and hematological parameters indicating more negative inflammation. PNI was found to be an independent predictor of mortality.

Effects of sarcopenia and frailty on postoperative recovery in elderly patients: A prospective cohort study

BACKGROUND

Sarcopenia and frailty are both age-related declines in functional reserve that are linked to adverse health outcomes. It is critical to know about the outcomes of a combination of these conditions. The study aimed to investigate the effects of sarcopenia and frailty on postoperative recovery in elderly patients and to explore risk factors.

METHODS

This prospective cohort study was conducted among 608 patients aged ≥60 years, American Society of Anesthesiologists I-III, who were scheduled to undergo thoracic (non-cardiac) and abdominal surgery from 1 March 2022 to 31 October 2022 at the Affiliated Hospital of Xuzhou Medical University. Frailty was measured by the 28-item frailty index, and sarcopenia was assessed sarcopenia was assessed by skeletal muscle index in computed tomographic scan, handgrip strength and 6-m walk. Participants were classified as follows: Group A: both sarcopenia and frailty; Group B: sarcopenia only; Group C: frailty only; and Group D: neither frailty nor sarcopenia. The primary outcome was 90-day morbidity. Multivariable logistic regression model was used to estimate the association between sarcopenia, frailty and 90-day morbidity.

RESULTS

The median (interquartile range) age of participants was 68 (64-72) years, and 62.7% were men. The prevalence rates of sarcopenia and frailty were 32.8% and 47.6%, respectively. The 90-day morbidity in Group A was 58.5%, in Group B was 46.2%, in Group C was 42.0% and in Group D was 28.8%, and the difference was significant (P < 0.001). In the multivariable analysis, both sarcopenia and frailty [odds ratio (OR), 2.21; 95% confidence interval (CI), 1.26-3.89], sarcopenia only (OR, 1.84; 95% CI, 1.01-3.36), frailty only (OR, 1.77; 95% CI, 1.03-3.03), women (OR, 0.67; 95% CI, 0.45-0.99), body mass index (OR, 0.94; 95% CI, 0.88-0.99), pre-operative albumin (OR, 0.96; 95% CI, 0.91-1.00) and operative stress score (OSS) [OSS 3 (OR, 2.09; 95% CI, 1.21-3.67); OSS 4-5 (OR, 3.81; 95% CI, 2.31-6.42)] were independently associated with 90-day morbidity. In the multivariable analysis with inverse probability weighting adjusted cohort, sarcopenia and frailty were also significantly associated with 90-day morbidity.

CONCLUSIONS

Sarcopenia and frailty were associated with higher risks of postoperative 90-day morbidity in elderly patients alone and in combination. Sex, body mass index, pre-operative albumin and operative stress were also independent factors for postoperative morbidity within 90 days.

A preoperative prediction model based on Lymphocyte-C-reactive protein ratio predicts postoperative anastomotic leakage in patients with colorectal carcinoma: a retrospective study

Background & Aims

Lymphocyte-C-reactive Protein Ratio (LCR) has been demonstrated as a promising new marker for predicting surgical and oncological outcomes in colorectal carcinoma (CRC). However, anastomotic leakage (AL) is also likely related to this inflammatory marker. Herein, we aimed to identify preoperative predictors of AL and build and develop a novel model able to identify patients at risk of developing AL.

Methods

We collected 858 patients with CRC undergoing elective radical operation between 2007 and 2018 at a single center were retrospectively reviewed. We performed univariable and multivariable analyses and built a multivariable model that predicts AL based on preoperative factors. Propensity adjustment was used to correct the bias introduced by non-random matching of the LCR. The model's performance was evaluated by using the area under the receiver operator characteristic curves (AUROCs), decision curve analysis (DCA), Brier scores, D statistics, and R2 values.

Results

Age, nutrition risk screening 2002 (NRS2002) score, tumor location and LCR, together with hemoglobin < 90 g/l, were independent predictors of AL. The models built on these variables showed good performance (internal validation: c-statistic = 0.851 (95%CI 0.803–0.965), Brier score = 0.049; temporal validation: c-statistic = 0.777 (95%CI 0.823–0.979), Brier score = 0.096). A regression equation to predict the AL was also established by multiple linear regression analysis: [Age(≥ 60 year) × 1.281] + [NRS2002(≥ 3) × 1.341] + [Tumor location(pt.) × 1.348]-[LCR(≤ 6000) × 1.593]-[Hemoglobin(< 90 g/L) × 1.589]-6.12.

Conclusion

Preoperative LCR is an independent predictive factor for AL. A novel model combining LCR values, age, tumor location, and NRS2002 provided an excellent preoperative prediction of AL in patients with CRC. The nomogram can help clinical decision-making and support future research.

A nutritional screening threshold for optimal outcomes after Hartmann's reversal

PURPOSE

Determining is nutritionally replete enough for Hartmann's reversal (HR) can be controversial and multifactorial. While there are many preoperative nutritional screening tools, the impact of malnourishment on HR has not been evaluated. The study aims to clarify how often patients undergoing HR are high risk for malnourishment at the time of surgery and how this impacts postoperative outcomes.

METHODS

From 2012-2019, all elective HRs were identified in ACS-NSQIP. Patients were categorized in a malnourished group if they met one of the following criteria: (1) BMI < 18.5 kg/m², (2) albumin < 3.5 g/dL, or (3) > 10% body weight loss in the last 6 months. Bivariate associations of preoperative demographics and postoperative outcomes were analyzed. Multivariable logistic regression was performed to identify independent predictors for 30-day mortality and organ space wound infection.

RESULTS

8878 procedures were evaluated (well-nourished = 7116 and malnourished = 1762). The malnourished group had higher mortality (p < 0.001), shorter operating time (p < .001), longer length of stay (p = 0.016), and higher rates of infection (p = 0.011), reintubation (p = 0.002), bleeding (p < 0.001), sepsis (p = 0.001), and reoperation (p = 0.018). In multivariate regression models, malnourishment was an independent predictor for mortality (OR = 2.72, p < 0.001) and wound infection (OR = 1.19, p = 0.028).

CONCLUSION

A large percentage of patients undergoing HR were classified as being high-risk for malnutrition. Malnourishment was associated with some worse postoperative compilations including death and wound infection. Surgeons should routinely use preoperative screening for malnutrition to identify and attempt to optimize nutritional status prior to undergoing Hartmann's Reversal.

Relationship between Mini Nutritional Assessment Score and Infection in Critical Care Patients

Background: Nutrition and infectious diseases are 2 influential factors. Mini nutritional assessment (MNA) score is one of the indicators for assessing the nutritional status of the patients. The present study aimed to evaluate the relationship between MNA- short form (SF) and the infectious status of patients admitted to the intensive care unit (ICU) of Hazrat-e-Rasoul hospital in Tehran. Methods: This was a cross-sectional study performed at Hazrat-e-Rasoul hospital in Tehran from 2019 to 2020. Each patient completed the MNA-SF questionnaire. The questionnaire has 6 factors with a score range of 0 to 14, with 12 to 14 indicating "normal nutrition," 8 to 11 indicating "at risk of malnutrition," and 0 to 7 indicating "malnutrition." The patients were monitored for clinical and paraclinical signs and symptoms of infectious disease for the first 14 days after being admitted to the ICU. Then, the relationship between infection level and MNA-SF scores were recorded and the chi-square, independent samples t test, and Pearson correlation test were used. Results: In this study, 119 patients (60 men and 59 women), with a mean age of 53.82 ± 19.76 years were selected, and 71 (59.67%) of the patients had an infection. Women without infection were significantly more than men (p=0.021). In the assessment of the MNA-SF questionnaire, we found that 62 (52.1%) patients had "normal nutrition" status, 30 (25.2%), and 27 (22.7%) had "at risk for malnutrition" and "malnutrition" status, respectively. MNA-SF scores were significantly different in different age groups (p=0.040). There was a significant relationship between weight loss, mobility, and neuropsychological problems with age (p<0.001). Also, there was a meaningful relationship between nutritional status and infection (p=0.032). The results determined that noninfected cases among the patients with "normal nutrition" status were more than those "at risk for malnutrition" (p=0.007). The results of this study showed that clinical outcomes had a significant relationship with nutritional status (p=0.043). Conclusion: Based on the present study, good nutritional status can reduce infection and mortality in patients who are admitted to ICU, and the nutritional status assessed with MNA-SF can play an essential role in patients' susceptibility to infection.

Dynamic variables predict fluid responsiveness in pre-school and school children undergoing neurosurgery: a prospective observational study

BACKGROUND

The evidence that plethysmographic variability index (PVI), pulse pressure variation (PPV), FloTrac/Vigileo-derived stroke volume variation (SVV), and Ea_dyn (dynamic arterial elastance) predict fluid responsiveness in children is limited by conflicting results. We aim to evaluate their accuracy and reliability to predict fluid responsiveness after induction in children aged 4-9 years undergoing major neurosurgery.

METHODS

Children aged 4-9 years undergoing intracranial epileptic foci excision were enrolled. After the induction of anesthesia, fluid loading with 10 mL/kg of Ringer's solution over 10 min was administered before surgical incision. PVI, PPV, SVV, and Ea_dyn were measured before and within 5 min after fluid loading. Respiratory variation in aortic blood flow peak velocity (∆Vpeak) >15% at baseline, measured using transthoracic echocardiography, identified fluid "responders". The abilities of dynamic variables to predict an increase in mean arterial pressure (MAP) of >10% following fluid loading were also assessed.

RESULTS

Fourteen (31.8%) of forty-four patients were responders defined by a baseline ∆Vpeak >15%. Before fluid loading, only the PVI value was significantly different between R and NR (P=0.017). Baseline PVI showed fair diagnostic accuracy for fluid responsiveness, with an area under the curve (AUROC) of 0.735 and the cutoff value of 13%. The R group showed a significantly greater absolute change in PPV and SVV after fluid loading from baseline compared with the NR group (P=0.021 and 0.040, respectively). The absolute change in the PPV and SVV values from baseline was greater in R than those in NR (P=0.021 and 0.040, respectively). Twenty (45.5%) showed a MAP increase of >10% following fluid loading and were defined as responders. Baseline ∆Vpeak and SVV showed fair predictive values for a MAP increase of >10% (AUROC =0.758 and 0.715, respectively).

CONCLUSIONS

PVI at baseline showed fair reliability to predict fluid responsiveness after anesthesia induction in mechanically ventilated children aged 4-9 years undergoing neurosurgery. Baseline ∆Vpeak and SVV were fairly predictive for an increase in MAP following fluid loading.