Pre-operative nutritional assessment

Early postoperative serum albumin levels as predictors of surgical outcomes in head and neck squamous cell carcinoma

BACKGROUND

Malnutrition is a common issue in patients with head and neck squamous cell carcinoma and has a negative effect on surgical outcomes.

OBJECTIVE

We attempted to determine which malnutrition diagnostic variables can be used as predictors of postoperative complications in patients with head and neck squamous cell carcinoma.

METHODS

Forty-one patients undergoing surgery for head and neck squamous cell carcinoma were submitted to a prospective evaluation. Biochemical data, anthropometric measurements and evaluation of body composition were used in the nutritional analysis.

RESULTS

Twenty-two patients (53.6%) developed complications. Serum albumin measured on the first postoperative day was the only variable that significantly differed between groups. A cut-off value of 2.8 g/dL distinguished between patients with a complicated and uncomplicated postoperative course. Normalization of albumin levels occurred more frequently and more rapidly in the noncomplicated group.

CONCLUSION

Serum albumin measured on the first postoperative day was the only variable that was a predicter of postoperative complications after major head and neck squamous cell carcinoma surgery.

Validity of nutrition risk index as a malnutrition screening tool compared with subjective global assessment in end-stage renal disease patients on peritoneal dialysis

We undertook this study to compare subjective global assessment (SGA) and nutrition risk index (NRI) as malnutrition screening tools in peritoneal dialysis (PD) patients. Nutrition status of the patients was categorized into low, moderate and high risk of malnutrition based on both NRI and SGA. The sensitivity, specificity and predictive values of NRI were compared with SGA, an already validated tool of nutrition status assessment in PD patients. Two hundred and eighty-three end-stage renal disease patients (age 50.02 ± 13.76 years; 204 males, 150 diabetic) were included. Based on SGA, 71/283 (25.08%) had normal nutrition, 192/283 (67.84%) mild-moderate and 20/283 (7.07%) severe malnutrition. Based on NRI, 38/283 (13.43%) patients had normal nutritional status, 193/283 (68.20%) mild-moderate and 52/283 (18.37%) severe malnutrition. Twenty-three of 283 (8.1%) were correctly classified as normal by NRI (true negative) and 197/283 (69.6%) as malnourished (true positive), 15/283 (5.3%) as false negative, 48/283 (16.96%) were misclassified as malnourished (false positive). NRI has sensitivity of 92.9% and specificity of 32.39%. Positive predictive value and Negative predictive values (NPVs) of NRI are 80.41% and 60.53%, respectively. Accuracy of the test is 78%. The receiver operating characteristic curve of NRI is 0.63. To conclude, NRI carries high sensitivity but low specificity as compared to SGA. It can be used as screening tool but not as a diagnostic tool for assessment of nutritional status in PD patients because of its low specificity and NPV.

Surgical site infections after hysterectomy among HIV-infected women in the HAART era: a single institution's experience from 1999-2012

OBJECTIVE

We sought to determine risk factors associated with surgical site infection (SSI) among a cohort of human immunodeficiency virus (HIV)-infected women undergoing hysterectomy during the era of highly active antiretroviral therapy.

STUDY DESIGN

This is a retrospective study of HIV-infected women who underwent a hysterectomy for benign indications at a tertiary care center. Electronic medical records were reviewed from January 1999 through December 2012. SSI was defined using Centers for Disease Control and Prevention criteria.

RESULTS

There were 77 HIV-infected women who underwent a hysterectomy: 47 (61%) were abdominal; 16 (21%) were laparoscopic or robot-assisted; and 14 (18%) were vaginal. Acquired immune deficiency syndrome was diagnosed in 58% of patients, and 75% of patients self-reported use of highly active antiretroviral therapy at the time of surgery. There were 17 (22%) SSIs; 5 (29%) superficial incisional wound infections, 3 (18%) vaginal cuff cellulitis, and 9 (53%) pelvic abscesses were diagnosed. After multivariable logistic regression, preoperative albumin level (adjusted odds ratio [aOR], 0.14; 95% confidence interval [CI], 0.02-0.86) and minimally invasive hysterectomy (aOR, 0.16; 95% CI, 0.03-0.84) were associated with decreased SSI. Preoperative absolute CD4 count was not associated with SSI (aOR, 0.99; 95% CI, 0.99-1).

CONCLUSION

Low preoperative serum albumin levels and abdominal hysterectomy are associated with increased risk of SSIs in HIV-infected women.

Recommendations on current approach to gastric cancer

The management of gastric cancer has been updated by the Grupo Español de Tratamiento de Tumores Digestivos (TTD). A multidisciplinary approach is essential in these patients including a precise diagnosis and staging and correct nutritional evaluation. For resectable disease, surgical resection remains the treatment mainstay and both perioperatory chemotherapy and postoperatory chemo-radiotherapy are considered standard complementary treatments. In advanced disease chemotherapy should always be considered. There are different reference schemes (TCF, XC, ECF, EXC) and the therapeutic option has to be individualised. Recently a phase III trial has shown a significant improvement in overall survival when trastuzumab is added to cisplatin-capecitabine or cisplatin-5-fluorouracil in patients with HER2+ advanced gastric cancer. Currently, there are several ongoing clinical trials evaluating the role of other new drugs against cellular targets. It would be desirable to incorporate biomarker studies in these trials in order to identify the best treatment for each patient.

The Subjective Global Assessment: a review of its use in clinical practice

Many methods of evaluating malnutrition have been proposed that combine multiple components such as dietary and medical history, amount of weight loss, biochemical variables, and anthropometry. The Subjective Global Assessment (SGA), first described by Baker et al in 1982, SGA was introduced to assess the patient for malnutrition at the bedside, without the need for precise body composition analysis. Since it was developed, the SGA has been used in various different patient populations, including surgical and oncology patients. It remains the most reliable and efficient method of nutrition assessment. The authors present a review of the SGA and how it has been used in a variety of areas within medicine.

Nutritional assessment: its role in the provision of nutritional support

Generalised undernutrition is common in hospital patients and in the community. It is frequently unrecognised and is associated with a range of adverse consequences that contribute to increased morbidity and mortality. The National Institute for Health and Clinical Excellence recommends that all individuals engaging with healthcare or admitted to residential homes in the community should be screened for undernutrition. Laboratory investigations have little place in the diagnosis of undernutrition: this is primarily a clinical process. In particular, the measurement of serum albumin concentration, though widely promulgated in the past as an index of nutritional status, is worthless for this purpose. Laboratory investigations are, however, of importance: to diagnose specific nutritional deficiencies (eg, of trace elements) and to monitor the provision of nutritional support, to detect metabolic complications and to assess its adequacy (for which the measurement of serum prealbumin concentrations, particularly in conjunction with measurements of C-reactive protein, may be of value).

Nutritional assessment of patients before gastrointestinal surgery and nurses’ approach to this issue

AIMS AND OBJECTIVES

This study was conducted to evaluate the nutritional status of patients before gastrointestinal surgery and to reveal nurses' opinions about this issue.

BACKGROUND

Although there is increasing awareness that malnutrition constitutes an important problem, especially when it accompanies diseases, malnutrition in hospitalized patients is not being diagnosed or treated.

DESIGN

This study was descriptive.

METHODS

Subjective global assessment and anthropometric/biochemical measurements were used to evaluate the nutritional status of 57 patients hospitalized for gastrointestinal surgery. Related opinions of eight nurses were obtained via semi-structured interviews.

RESULTS

The malnutrition rate was high in patients before gastrointestinal surgery, and the nurses were not able to evaluate nutritional status properly. Furthermore, the nurses lacked knowledge.

CONCLUSIONS

This study indicates the importance of evaluating the nutritional status of patients before surgery and the necessity of developing nutritional support plans.

RELEVANCE TO CLINICAL PRACTICE

Our study showed that subjective global assessment is an easy and useful scale for evaluating the nutritional status of patients. Nurses are suitable team members for continuous nutritional care and therefore must not delegate this role.

Preoperative Nutritional Status Predicts the Severity of the Systemic Inflammatory Response Syndrome (SIRS) Following Major Vascular Surgery

OBJECTIVES

This study examined the relationship between pre-operative nutritional status and systemic inflammatory response syndrome (SIRS) or sepsis following major vascular surgery.

DESIGN AND METHODS

Subjects undergoing open AAA repair, EVAR or lower limb revascularisation were studied prospectively. Pre-operative nutrition was assessed clinically using Mini-Nutritional Assessment (MNA) and body composition was measured by dual energy X-ray absorptiometry (DEXA) scanning. SIRS severity was assessed for 5 post-operative days and sepsis noted within 30 days of surgery.

RESULTS

Using MNA, neither SIRS severity nor sepsis occurrence differed significantly between 'well-nourished' subjects and those 'at risk of malnutrition'. Using DEXA, negative associations existed between body mass index and both SIRS score and SIRS duration. Fat free mass (FFM) was negatively associated with SIRS score and duration. Negative associations also existed between skeletal muscle mass (SMM) and SIRS score and duration. SMM was also negatively correlated with post-operative length of stay in hospital. There were no significant correlations between sepsis and any nutritional indices.

CONCLUSIONS

Lower pre-operative nutritional indices, indicating protein energy malnutrition, were associated with more severe systemic inflammatory responses following major vascular surgery.

Nutritional assessment

Hospital-based malnutrition continues to be an important comorbidity affecting clinical outcomes. Knowledge of performing an appropriate nutrition assessment and implementing a rational nutrition therapy should be part of any patient's hospital plan of care. Familiarity with nutrition assessment scoring systems and nutrition assessment tools should be part of any gastroenterologist's expertise. Assessment of a patient's caloric and protein needs should be part of any hospital patient's clinical evaluation.

Malnutrition after vascular surgery: are patients with chronic renal failure at increased risk?

BACKGROUND

The deleterious effects of perioperative malnutrition on recovery after general surgery are established. Since the effects of perioperative malnutrition on recovery after vascular surgery are not known, we examined the effects of nutritional status, and risk factors predictive of malnutrition, on outcome after vascular surgery.

METHODS

The records of all open index vascular cases (abdominal aortic aneurysm [AAA] repair, carotid endarterectomy [CEA], lower extremity bypass) performed at the Veterans Affairs (VA) Connecticut between July 2004 and June 2005 were reviewed. The primary outcome was mortality; secondary outcomes included infection and nutritional risk index (NRI) scores.

RESULTS

Sixty-eight open vascular cases were performed during the study period. Nutritional depletion developed in 55% of patients and was more likely in patients undergoing AAA (85%) or bypass (77%) than CEA (30%; P = .0005). Patients who developed malnutrition had similar mortality as patients who did not develop postoperative malnutrition (6.1% vs. 3.7%; P = .68); however, malnourished patients had higher rates of postoperative infection (24.2% vs. 3.7%; P = .03). Chronic renal failure was the only patient-associated risk factor predictive of postoperative nutritional depletion (odds ratio 5.9, confidence interval 1.0 to 33.6; P = .04).

CONCLUSIONS

Patients undergoing major open vascular surgery have high rates of postoperative malnutrition, with patients undergoing AAA repair having the highest rates of postoperative malnutrition and infection. Patients with chronic renal failure undergoing vascular surgery are associated with increased risk for postoperative malnutrition and may be a group to target for perioperative risk factor modification and nutritional supplementation.

Nutritional supplementation and resistance training in nutritionally at risk older adults following lower limb fracture: a randomized controlled trial

OBJECTIVE

To describe the independent and combined effects of oral nutrition supplementation and resistance training on health outcomes in nutritionally at risk older adults following lower limb fracture.

DESIGN

Randomized controlled trial with 12-week masked outcome assessment.

SETTING

Teaching hospital.

PARTICIPANTS

One hundred nutritionally at risk older adults hospitalized following a fall-related lower limb fracture.

INTERVENTION

Commenced seven days after injury. Consisted of daily multinutrient energy-dense oral supplement (6.3 kJ/mL) individually prescribed for six weeks (n = 25), tri-weekly resistance training for 12 weeks (n = 25), combined treatment (n = 24) or attention control plus usual care and general nutrition and exercise advice (n = 26).

MEASUREMENTS

Weight change, quadriceps strength, gait speed, quality of life and health care utilization at completion of the 12-week intervention.

RESULTS

At 12 weeks, all groups lost weight: nutrition -6.2% (-8.4, -4.0); resistance training -6.3% (-8.3, -4.3); nutrition and resistance training -4.7% (-7.4, -2.0); attention control -5.2% (-9.0, -1.5). Those receiving resistance training alone lost more weight than those receiving the combined treatment (P= 0.029). Significant weight loss was prevented if supplement was consumed for at least 35 days. Groups were no different at 12 weeks for any other outcome.

CONCLUSION

Frail, undernourished older adults with a fall-related lower limb fracture experience clinically significant weight loss that is unable to be reversed with oral nutritional supplements. Those receiving a programme of resistance training without concurrent nutrition support are at increased risk of weight loss compared with those who receive a combined nutrition and resistance training intervention. In this high-risk patient group it is possible to prevent further decline in nutritional status using oral nutritional supplements if strategies are implemented to ensure prescription is adequate to meet energy requirements and levels of adherence are high.

Bioelectric impedance and individual characteristics as prognostic factors for post-operative complications

BACKGROUND AND AIMS

Malnutrition increases morbidity and mortality in surgical patients, and for this reason, several nutritional markers have been used as prognostic tools to identify surgical patients under a higher risk to develop complications in post-operative period. Few studies show the impact of nutritional markers after controlling for others variables, such as age and severity of disease. A new method, bioelectric impedance analysis (BIA), and its parameter, phase angle, have been described as a prognostic tool in several clinical situations, but they have never been studied in surgical population. The objective of this work is to assess the importance of nutritional variables and parameters from BIA as predictors of post-operative complications in a multivariable regression model.

METHODS

The nutritional status of 225 adult patients scheduled to undergo gastrointestinal surgery was assessed by several methods, including bioelectric impedance analysis and subjective global assessment. Potential confounding factors were also studied. Patients were screened for post-operative complications until hospital discharge.

RESULTS

Weight loss greater than 10%, subjective global assessment, nutritional risk assessment, ECM/BCM ratio and phase angle (from BIA) were the prognostic factors significantly associated with post-operative complications in the crude analysis. After adjusting for sex, age, marital status, tumors and pre-operative infections, only phase angle remained as a prognostic factor (RR=4.3; CI95% 1.6-11.8 for phase angle <-0.8 sd), while the other nutritional variables lost their association with post-operative complications.

CONCLUSION

Phase angle remains as an important prognostic factor for postoperative complications, even after adjusting for other individual predictors and confounders. Its utility in the identification of patients eligible for nutritional therapy has now to be evaluated.

Does nutritional risk, as assessed by Nutritional Risk Index, increase during hospital stay? A multinational population-based study

BACKGROUND

Progressive nutritional depletion has been reported during hospital stay. This prospective study compared the proportion of nutritional risk at hospital admission in three European countries and further evaluated nutritional risk at late versus early phase of hospitalization in one hospital.

METHODS

Nutritional risk was determined in Geneva, Switzerland (n = 652), Berlin, Germany (n = 621) and Nice, France (n = 107) at hospital admission, and during hospital stay (0-100 d) in Nice (n = 527) by the Nutritional Risk Index (NRI) = (1.519 x serum albumin, g/l)+41.7 x (present weight/usual weight). NRI score of >100: no risk (NR); 97.5-100: mild risk; 83.5-97.5: moderate risk (MR); 83.5: severe risk (SR). Logistic regressions were used to determine the odds ratios (OR) between MR or SR and length of hospital stay (LOS) 16d compared to 1-15 d or nutritional assessment at 16-100 d compared to 1-15 d of hospitalization.

RESULTS

Patients, assessed at hospital admission, who were hospitalized >16d were more likely (P < 0.001) to be at MR (OR 2.0, CI 1.4-3.0) or SR (OR 3.3, CI 1.7-6.2) than patients hospitalized 1-15 d. Nice patients assessed at 16-100 d were more likely (P < 0.001) to be at MR (OR 5.4, CI 2.1-14.3) and SR (OR 14.7, CI 5.4-40.0) than patients assessed at 1-15 d of hospitalization.

CONCLUSIONS

The risk of MR or SR by NRI was greater in patients assessed during hospitalization than in patients assessed at hospital admission, which suggests that patients evaluated later during hospitalization are at greater risk than patients evaluated in the early phase of hospitalization. Ongoing assessment during hospitalization seems important to identify patients who are at increased risk for complications.

[Subjective nutrition assessment: Part 1 - A review of its validity after two decades of use]

BACKGROUND

The subjective global assessment is a clinical method for nutritional assessment that considers not only body composition alterations but also changes in physiological function. The method is simple, inexpensive and non-invasive, and it can be performed at bedside, and its use was described for the first time almost two decades ago.

AIM

To review the validity studies of subjective global assessment described in literature in the last two decades of its use.

METHODS

It was performed a systematic review in MEDLINE, using "subjective global assessment" as search term and the most relevant papers were selected.

RESULTS

Being a subjective method, its precision depends on the observer's experience. Nevertheless, the method showed a good diagnostic precision when performed by trained observers. Subjective global assessment was validated by convergent validity, when this method was compared to other objective nutritional assessment methods, and by predictive validity, showing that subjective global assessment could identify patients who were at high risk for developing postoperative complications.

CONCLUSIONS

Subjective global assessment has been a good option in nutritional assessment in surgical patients and some modifications have been suggested to adjust the method to other clinical situations. The observer experience is of extreme importance, since the precision of the method depends on it.

Nutritional care: implications and recommendations for nursing

Nutrition is a basic human requirement with both physiological and psychosocial dimensions that affect well-being. In times of illness ensuring adequate nutrition is particularly important because of the central part it plays in healing and recovery. This article explores the premise that current nutritional care in nursing practice is often inadequate with the result that patients' nutritional requirements are not met. It investigates the causative factors of poor nutritional care in nursing practice, the implications of such practice for both the patient and the professional, and proposes a number of recommendations for future change.

Contribution of body composition to nutritional assessment at hospital admission in 995 patients: a controlled population study

Body weight, weight changes and BMI are easily obtainable indicators of nutritional status, but they do not provide information on the amount of fat-free and fat masses. The purpose of the present study was to determine if fat-free mass (FFM) and fat mass were depleted in patients with normal BMI or serum albumin at hospital admission. A group of 995 consecutive patients were evaluated for malnutrition by BMI, serum albumin, and 50 kHz bioelectrical impedance analysis and compared with 995 healthy adults, matched for age and height, and then compared with FFM and fat mass percentiles previously determined in 5225 healthy adults. A BMI of <or=20 kg/m2 was noted in 17.3 % of patients and serum albumin of <or=35 g/l was found in 14.9 % of patients. In contrast, 31 % of all patients were below the tenth percentile for FFM, compared with 10.1 % of controls (chi2, P=0.0001), while 73 % of patients with BMI <or=20 kg/m2 and 31 % of patients with BMI 20-24.9 kg/m2 fell below the tenth percentile for FFM. Furthermore, the FFM was lower in patients than controls and the differences with age in FFM (lower) and fat mass (higher) were greater in patients than in controls. BMI and albumin significantly underestimated the prevalence of malnutrition in patients at hospital admission compared with body composition measurements. Optimal nutritional assessment should therefore include objective measurement of FFM and fat mass.