Indraneil Basu, Padmanabhan Subramanian, Matthew Prime, Charlie Jowett, Brian Levack
.
DOI: 10.4236/ss.2011.22019   PDF    HTML     6,292 Downloads   11,362 Views   Citations

Abstract

Nutritional status influences surgical outcome and complication rates. The National Institute of Clinical Excellence (NICE) recommends screening patients on admission; yet traditional nutritional screening tools are underutilised. This retrospective case-control study investigates the association between biochemical factors and adverse outcomes in orthopaedic patients to ascertain whether they could provide more suitable alternatives to traditional screening tools. 66 patients with fractured neck of femur were investigated. Adverse outcomes including Length of Stay (LOS), and deaths were recorded. Total Lymphocyte Counts (TLC), Serum Albumin Levels and Haemoglobin levels, were recorded pre-operatively (pre-op) and post-operatively (post-op). Adverse outcomes in those with normal and abnormal biochemical values were compared using Chi Squared and T Testing. Linear associations were tested for using Pearson rank correlation. Automated Nutrition Scores Beta (ANSB) were calculated and their relationship to adverse outcomes investigated. Protein energy malnutrition was common on admission. However, only 2 patients were nutritionally screened during admission. Those patients with abnormal pre-op TLC had an increased LOS in hospital. Those with abnormal albumin and/or TLC had increased mortality rates. Abnormal albumin levels were associated with a significant 3 fold increase in mortality (p = 0.009) and post-operative TLC were found to be negatively correlated with LOS (r = –0.3, p = 0.038). ANSB were also found to correlate with increased adverse outcomes although this was not significant. This study demonstrates that nutritional status is poorly assessed on admission in orthopaedic patients and consequently that provision of nutritional supplements is suboptimal. This study also demonstrates a highly significant relationship between abnormal albumin and adverse outcomes and identifies a new correlation between post-operative TLC and LOS. This study confirms that individual biochemical parameters and biochemical scores can be used to identify orthopaedic patients at particular risk of adverse post-op outcomes. These biochemical screening methods may be a more efficient and reliable way of stratifying malnutrition associated risk on admission.

Keywords

Nutrition, MUST, Mortality, Lymphocyte count, Albumin, ANS Beta

Share and Cite:

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	D. Thiebaud, “Importance of Albumin, 25(OH)-vitamin D and IGFBP-3 As Risk Factors in Elderly Women and Men with Hip Fracture,” Osteoporosis International, Vol. 7, No. 5, 1997, pp. 457-462.
[2]	B. M. Patterson, “Protein Depletion and Metabolic Stress in Elderly Patients Who Have A Fracture of the Hipp,” Journal of Bone and Joint Surgery, Vol. 74, No. 2, 1992, pp. 251-260.
[3]	K. J. Koval, “The Effects of Nutritional Status on Outcome after Hip Fracture,” Journal of Orthopaedic Trauma, Vol. 13, No. 3, 1999, pp. 164-169. doi:10.1097/00005131-199903000-00003
[4]	K. J. Koval, “An AOA Critical Issue: Geriatric Trauma: Young Ideas,” Journal of Bone and Joint Surgery, Vol. 85, No. 7, 2003, pp. 1380-1388.
[5]	S. S. Porben, “The State of the Provision of Nutritional Care to Hospitalized Patients-Results from the Elan-Cuba Study,” Clinical Nutrition, Vol. 25, No. 6, 2006, pp. 1015-1029. doi:10.1016/j.clnu.2006.04.001
[6]	L. J. Grossbard, “Lymphocytopenia in the Surgical Intensive Care Unit Patient,” American Journal of Surgical Pathology, Vol. 50, No. 4, 1984, pp. 209-212.
[7]	M. R. Foster, “A Prospective Assessment of Nutritional Status and Complications in Patients with Fractures of the Hipp,” Journal of Orthopaedic Trauma, Vol. 4, No. 1, 1990, pp. 49-57. doi:10.1097/00005131-199003000-00009
[8]	D. T. Dempsey and J. L. Mullen, “Prognostic Value of Nutritional Indices,” Journal of Parenteral and Enteral Nutrition, Vol. 11, No. 5, 1987, pp. 109-114. doi:10.1177/014860718701100517
[9]	R. T. Lewis and H. Klein, “Risk Factors in Postoperative Sepsis: Significance of Preoperative Lymphocytopenia,” Journal of Surgical Research, Vol. 26, No. 4, 1979, pp. 365-371. doi:10.1016/0022-4804(79)90021-0
[10]	M. Lumbers, “Nutritional Status and Clinical Outcome in Elderly Female Surgical Orthopaedic Patients,” Clinical Nutrition, Vol. 15, No. 3, 1996, pp. 101-107. doi:10.1016/S0261-5614(96)80033-1
[11]	R. C. Smith and R. Hartemink, “Improvement of Nutritional Measures during Preoperative Parenteral Nutrition in Patients Selected by the Prognostic Nutritional Index: A Randomized Controlled Trial,” Journal of Parenteral and Enteral Nutrition, Vol. 12, No. 6, 1988, pp. 587-591. doi:10.1177/0148607188012006587
[12]	L. Brugler, “A Simplified Nutrition Screen for Hospitalized Patients Using Readily Available Laboratory and Patient Information,” Nutrition, Vol. 21, No. 6, 2005, pp. 650-658. doi:10.1016/j.nut.2004.10.012
[13]	P. P. D. Symeonidis and D. Clark, “Assessment of Malnutrition in Hip Fracture Patients: Effects on Surgical Delay, Hospital Stay and Mortality,” Acta Orthopaedica Belgica, Vol. 72, No. 4, 2006, pp. 420-427.
[14]	R. C. Smith, “An Effective Automated Nutrition Screen for Hospitalized Patients,” Nutrition, Vol. 25, No. 3, 2009, pp. 309-315. doi:10.1016/j.nut.2008.09.007
[15]	P. P. H. Katelaris, G. B. Bennett and R. C. Smith, “Prediction of Postoperative Complications by Clinical and Nutritional Assessment,” Australian and New Zealand Journal of Surgery, Vol. 56, No. 10, 1986, pp. 743-747. doi:10.1111/j.1445-2197.1986.tb02319.x