|Year : 2014 | Volume
| Issue : 3 | Page : 179-184
Assessment of nutritional status of critically ill neurosurgical patients and parameters predicting the outcome: An institutional observational study
Deepak Bandlish1, Sanjeev Attry1, Samarendranath Ghosh1, Harendranath Das2
1 Department of Neurosurgery, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
2 Department of Biochemistry, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
|Date of Submission||08-Dec-2013|
|Date of Acceptance||24-Jan-2014|
|Date of Web Publication||16-May-2014|
Room No. 422, Junior Doctors Hostel, 242 A. J. C Bose Road, Kolkata 700 020, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Backdrop: Nutritional status has been proven to affect surgical outcome in various studies worldwide. Accurate nutritional assessment tools can help the clinician in taking appropriate steps at the right time in order to improve the surgical outcome. This is especially relevant in neurosurgical cases because of the long hospital stay and high incidence of complications. In the present study we aim to find out the prevalence of severe malnutrition in the patients admitted to NICU and the correlation of the same with mortality. We also intend to find out the best predictor of mortality amongst the malnutrition parameters. Materials and Methods: This is a prospective observational study conducted at Bangur Institute of neurosciences (BIN), Kolkata on 50 patients who were admitted in NICU for more than 5 days. Various nutritional paramaters like SGA, albumin and transferrin values were studied. Statistical Analysis was performed with help of Epi Info (TM) 3.5.3. Chi-square test was used to find the associations. Odds Ratio (OR) with 95% confidence interval (CI) was calculated to find the risk factors. Results: Glioma and meningioma were the most common clinical conditions in the study populations followed by space occupying lesions of the CP angle and aneurysm, PF SOL and pituitary adenoma. Nearly 42% (21/50) were severely malnourished, 36% (18/50) were moderately malnourished whereas 22% (11/50) had a normal nutritional status. CP angle SOLs were most commonly associated with severe malnutrition followed by PF SOL and pituitary adenoma. Association of various parameters namely SGA, serum albumin and serum transferrin with mortality was found to be statistically significant. This association was found to be the strongest with severe malnutrition by SGA (Odds ratio-12.5 [3.10- 50.27]) as compared to serum transferrin and serum albumin levels (odds ratio of 4.37 (1.29-14.77) and 6.95 (0.80-60.13) respectively. Conclusion: In countries like India where malnutrition is very high in general and in critically ill patients, SGA is a potential tool for categorising patients with high risk of mortality at the time of admission. An early nutritional intervention thereafter might help in improving the outcome of such patients and might reduce the economic burden on part of the healthcare setting and the individual.
Keywords: Neurosurgery, nutritional status, outcome, subjective global assessment
|How to cite this article:|
Bandlish D, Attry S, Ghosh S, Das H. Assessment of nutritional status of critically ill neurosurgical patients and parameters predicting the outcome: An institutional observational study. Int J Nutr Pharmacol Neurol Dis 2014;4:179-84
|How to cite this URL:|
Bandlish D, Attry S, Ghosh S, Das H. Assessment of nutritional status of critically ill neurosurgical patients and parameters predicting the outcome: An institutional observational study. Int J Nutr Pharmacol Neurol Dis [serial online] 2014 [cited 2019 Aug 18];4:179-84. Available from: http://www.ijnpnd.com/text.asp?2014/4/3/179/132678
| Introduction|| |
The bearing of nutritional status on the outcome of critically ill medical and surgical patients has been amply emphasized in the literature. , The outcome of patients admitted to a neurosurgical intensive care unit (NICU) is varied with mortality ranging from 30% to 50% in case of head injury and 2-8% in case of elective surgical procedures done for aneurysms, glioma, meningioma and other conditions. , Malnutrition is known to affect the outcome adversely with malnourished patients having a higher incidence of post-operative complications and a timely assessment and intervention can be helpful in reducing the morbidity and mortality in the critically ill patients.  Various parameters suggestive of severe malnutrition such as serum albumin, transferrin and subjective global assessment (SGA) have been found to correlate well with the poor outcome of critically ill patients. ,, In the present study, we aim to find out the prevalence of severe malnutrition in patients admitted to NICU and the correlation of the same with mortality. We also intend to find out the best predictor of mortality amongst the malnutrition parameters.
| Materials and methods|| |
This is a prospective observational study conducted at Bangur Institute of Neurosciences, Kolkata.
A total of 50 patients who were admitted to the NICU for more than 5 days were enrolled from December 2011 to May 2013. This randomly chosen group of patients included those with glioma, meningioma, aneurysm, cerebello pontine (CP) angle tumors and pituitary adenoma amongst others. Patients <13 years of age and those unwilling to give a valid informed consent were excluded from the study.
The standard method as described by Detsky et al., was followed and the medical histories were recorded [Annexure] in a standardized format at the time of admission of the patient to the NICU. Scoring of loss of fat stores, muscle wasting, ascites and edema was done upon physical examination.
Albumin and transferrin values
The values of serum albumin and serum transferrin were recorded for all the enrolled patients. Albumin levels of <3.5 mg/dl and transferrin levels of <150 mg/dl were evaluated for association with high mortality in patients.
Statistical analysis was performed with the help of Epi Info™ 3.5.3, a public domain statistical software for epidemiology developed by CDC, Atlanta (http://www.cdc.gov/epiinfo/). Descriptive statistical analysis was done and the mean age, duration of hospital stay and duration of ICU stay were calculated. Chi-square (χ2 ) test was performed to find the associations. Odds ratio (OR) with 95% confidence interval was calculated to find the risk factors. P < 0.05 was considered to be statistically significant. Kappa analysis was done to find out the association between two tests.
| Results|| |
There were 50 patients of more than 13 years of age who were enrolled in the study, consisting of 29 (58%) males and 21 (42%) females. The mean age of the patients was 41 years and nearly two-thirds belonged to a low socio-economic status [Table 1].
The ICU stay of the patients ranged from 4 to 27 days and the median was 10.8 days. Glioma and meningioma were the most common clinical conditions in the study populations followed by space occupying lesions of the CP angle and aneurysm, posterior fossa space occupying lesion (PF SOL) and pituitary adenoma amongst others [Table 2].
Assessment of the nutritional status of patients by SGA protocol revealed that 42% (21/50) were severely malnourished, 36% (18/50) were moderately malnourished whereas 22% (11/50) had a normal nutritional status [Figure 1].
|Figure 1: Nutritional status of the patients according to subjective global assessment|
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A comparison of the nutritional status amongst various groups of patients showed that CP angle SOLs were most commonly associated with severe malnutrition followed by PF SOL and pituitary adenoma. Moderate malnutrition was found most commonly in patients with glioma and meningioma followed by those with aneurysm [Table 3].
|Table 3: Assessment of the nutritional status in various groups of patients by SGA|
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Association of various parameters namely SGA (severe malnutrition), serum albumin (levels <3.5 mg/dl) and serum transferrin (levels <150 mg/dl) with mortality was found to be statistically significant and was highly significant (P < 0.001) in case of SGA and transferrin levels [Table 4].
|Table 4: Association of various parameters with mortality in NICU patients|
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This association was found to be the strongest with severe malnutrition by SGA (OR: 12.5) when compared to serum albumin and serum transferrin levels (OR of 6.95 and 4.37 respectively).
Agreement between malnutrition by SGA and serum albumin levels of <3.5 mg/dl was found to be high (kappa = 0.93, P < 0.0001) [Table 5].
| Discussion|| |
Present study was based in a NICU in eastern India involving 50 randomly selected post-operative patients of more than 13 years of age with a median age 41.2 years. Median stay in the ICU was 10.8 days with the most common diagnosis being glioma and meningioma followed by CP angle SOL and aneurysm. Nearly two thirds of them belonged to a low socio-economic status. Most of these patients were malnourished with 36% having moderate malnutrition and 42% having severe malnutrition. A study by Kelly et al., (1984) found that the prevalence of malnutrition in hospitalized patients was >25% in academic hospitals in the United States.  Other studies like the one done by Mora RJ (1999) showed that 50% of hospitalized patients have moderate malnutrition, with 5-10% being severely malnourished.  High rates of malnutrition in our study might be due to the low socioeconomic status of the study population.
The overall mortality was 36% (18/50). Post-operative mortality for various conditions like aneurysms, gliomas, meningiomas and tumors has been reported to be from 2% to 10% in literature.  Difference in mortality in this study can be explained partly by the patient selection. In the present study, more than three-fourths of the patients were malnourished and severe malnutrition (SGA) was significantly associated with a higher mortality [Table 4]. The incidence of post-operative complications like ventilator associated pneumonia was high and these were the main cause of death in a high percentage of patients in the study.
Severe malnutrition as assessed by SGA, serum albumin <3.5 mg/dl and serum transferrin <150 mg/dl were significantly associated with higher mortality in the study population [Table 4]. The association of low serum albumin, low serum transferrin and SGA with a poor outcome has been documented by various researchers in the past few years. 
Serum albumin has been considered the best method and has been practiced the most by surgeons and physicians to predict the patients outcome.  However in the present study, it was found that SGA (OR: 12.5) was more strongly associated with mortality as compared to serum albumin (OR: 6.95). Therefore, SGA seems to be a better modality when compared to others to assess the nutritional status and predict the outcome. The agreement of SGA and serum albumin levels was of high degree (kappa = 0.93).
Previous studies comparing SGA with other indices like transferrin, albumin levels as the means to assess pre-operative nutritional status have shown that SGA has the best sensitivity and specificity in predicting the outcome of patients and combining various other objective measurements such as albumin levels, transferrin levels, anthropometry, creatinine height index with SGA into a single index did not increase the discriminatory (or predictive) power over that of SGA alone in a clinically significant way. 
Thus, a poor outcome of critically ill patients might be due to malnutrition rather than lack of cutting edge technology. Therefore, an early nutritional intervention strategy for patients with malnutrition should be in place and might help in improving the outcome. SGA seems to be a cost-effective and sensitive tool for categorizing patients with high risk of mortality and should be relied upon rather than the more commonly used parameters like serum albumin and serum transferrin in various NICU set ups.
Strengths of the study are that (i) the study population is a good representative of the majority of the population in a poor country like India and throws light on a very crucial (yet neglected) concept of nutritional guidelines formulation for the hospitals. (ii) The present study compares association of three parameters namely SGA, serum albumin and serum transferrin) with mortality.
Limitations of the study are that (i) the sample size was small and (ii) the study population did not have a good representation of head trauma patients.
| Conclusions|| |
In countries like India where malnutrition is very high in general and in critically ill patients, SGA is a potential tool for categorizing patients with high risk of mortality at the time of admission. An early nutritional intervention thereafter might help in improving the outcome of such patients and might reduce the economic burden on the part of the health care setting and the individual.
| References|| |
|1.||Neumann CG, Lawlor GJ Jr, Stiehm ER, Swenseid ME, Newton C, Herbert J, et al. Immunologic responses in malnourished children. Am J Clin Nutr 1975;28:89-104. |
|2.||Mullen JL, Buzby GP, Waldman MT, Gertner MH, Hobbs CL, Rosato EF. Prediction of operative morbidity and mortality by preoperative nutritional assessment. Surg Forum 1979;30:80-2. |
|3.||Becker DP, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R. The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 1977;47:491-502. |
|4.||Hammers R, Anzalone S, Sinacore J, Origitano TC. Neurosurgical mortality rates: What variables affect mortality within a single institution and within a national database? J Neurosurg 2010;112:257-64. |
|5.||Culebras JM. Malnutrition in the twenty-first century: An epidemic affecting surgical outcome. Surg Infect (Larchmt) 2013;14:237-43. |
|6.||Ching N, Grossi CE, Angers J, Zurawinsky HS, Jham G, Mills CB, et al. The outcome of surgical treatment as related to the response of the serum albumin level to nutritional support. Surg Gynecol Obstet 1980;151:199-202. |
|7.||Buzby GP, Schunn CD. "Perioperative nutritional support." Nutrition for the Hospitalized Patient: Basic Science and Principles of Practice; 1995. p. 425. |
|8.||Hickman DM, Miller RA, Rombeau JL, Twomey PL, Frey CF. Serum albumin and body weight as predictors of postoperative course in colorectal cancer. JPEN J Parenter Enteral Nutr 1980;4:314-6. |
|9.||Kelly SM, Rosa A, Field S, Coughlin M, Shizgal HM, Macklem PT. Inspiratory muscle strength and body composition in patients receiving total parenteral nutrition therapy. Am Rev Respir Dis 1984;130:33-7. |
|10.||Mora RJ. Malnutrition: Organic and functional consequences. World J Surg 1999;23:530-5. |
|11.||Engelman DT, Adams DH, Byrne JG, Aranki SF, Collins JJ Jr, Couper GS, et al. Impact of body mass index and albumin on morbidity and mortality after cardiac surgery. J Thorac Cardiovasc Surg 1999;118:866-73. |
|12.||Detsky AS, Baker JP, Mendelson RA, Wolman SL, Wesson DE, Jeejeebhoy KN. Evaluating the accuracy of nutritional assessment techniques applied to hospitalized patients: Methodology and comparisons. JPEN J Parenter Enteral Nutr 1984;8:153-9. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]