Journal of Parenteral and Enteral Nutrition http://pen.sagepub.com/

Instant Nutritional Assessment Murray H. Seltzer, J. Augusto Bastidas, David M. Cooper, Peter Engler, Bernadette Slocum and H. Stephen Fletcher JPEN J Parenter Enteral Nutr 1979 3: 157 DOI: 10.1177/014860717900300309 The online version of this article can be found at: http://pen.sagepub.com/content/3/3/157

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Vol. 3. No. 3 Printed in U.SA.

JOURNAL OF PARENTERAL AND ENTERAL NUTRXTXOX Copyright 0 1979 by the American Society of Parenteral and Enteral Nutrition

Instant Nutritional Assessment MURRAY H. SELTZER, M.D., J. AUGUSTOBASTIDAS, DAVID M. COOPER, PETER ENGLER, PH.D., BERNADETTE SLOCUM, R.N., AND H. STEPHEN FLETCHER, M.D. From the Division of Surgical Research, St. Barnabas Medical Center, Livingston, N.J. 07039

ABSTRACT: Instant nutritional assessment of the hospitalized patient is described based upon admission serum albumin levels and total lymphocyte counts. Abnormalities of these parameters are associated with markedly increased morbidity

and mortality in a series of 500 consecutively admitted patients. It is suggested that instant nutritional assessment be performed on all hospitalized patients with appropriate alterations and therapy being made to allow for nutritional repletion.

The extent of malnutrition in hospitals has been well documented by Butterworth and Blackburn,' Bistrian et a1: and Willcutts.4 T h e need for specialized nutritional support of the hospitalized patient is well recognized, however, despite such recognition there is a reluctance among many physicians to provide more than lip service to the concept of nutritional support. Such apathy may be based upon either an inability to recognize malnourished patients or a lack of the technical knowledge needed to administer nutritional therapy. Blackburn et a15have developed a rather sophisticated method for assessment of nutritional status. Kaminski and Winborn: Willcutts; and Clark and Sigman7 have presented more simplified schemes. Even simple assessment techniques become a t times too sophisticated for the novice or uninterested physician. The purpose of this paper is to describe a method of instant nutritional assessment using only those data acquired by routine hospital admission laboratory tests. Most institutions now use an SMA-12 which includes serum albumin, and virtually all do a white blood cell count and differential from which a total lymphocyte count is available. These two parameters, albumin (a measure of visceral protein) and total lymphocyte count (a poor man's assessment of immunocompetency) will form the basis of instant nutritional assessment.

RESULTS

The diagnoses of the 500 patients constituted a rather extensive listing of routine admissions expected in a large medical center. Table I categorizes the patient diagnoses into general areas. Twenty-seven patients incurred 31 complications (Table 11); 9 patients died. Two hundred sixty-three patients had operative procedures (Table 111) and the remainder of the patients were non-surgical. The entire population was initially evaluated to determine the relationship between either serum albumin or total lymphocyte count or a combination of both, as well as the incidence of complications and deaths (Table IV). Of the 500 patients, 7.6% had an abnormal serum albumin (i.e., less than 3.5 g%) and 30.2% had an abnormal total lymphocyte count (ie., less than 1500/mm3); 34% either had an abnormal albumin or an abnormal lymphocyte count. An abnormal albumin was associated with a 4-fold increase in complications and a 6-fold increase in deaths, both findings being statistically significant. An abnormd total lymphocyte count was associated with a n increase of 1.8 times in complications, which was not significant, and a 4-fold increase in deaths which was significant. When both serum albumin and total lymphocyte count were abnormal, an almost 4-fold increase in complications and a 20-fold increase in deaths were noted. These values again were statistically significant. The same parameters were then examined in similar MATERIALS AND METHODS fashion for surgical patients (Table V) and for non-surThe St. Barnabas Medical Center is a 750-bed general gical patients (Table VI). For surgical patients an abhospital, the largest of its kind in New Jersey, providing normal admission serum albumin was associated with an the entire spectrum of medical and surgical care. It has increase of 4.6 times in complications. The incidence of deaths was not affected by serum albumin levels, nor was approximately 30,000 admissions per year. A series of 500 consecutive admissions were reviewed the incidence of complications or incidence of deaths retrospectively for diagnosis, complications, incidence of affected by the lymphocyte count. When both serum death, operations, admission serum albumin levels and albumin and total lymphocyte count were below normal, admission total lymphocyte counts. These variables were a statistically significant increase of 3.5 times in complicross correlated and statistically evaluated by the Chi- cations was noted. For non-surgical patients (Table VI) an increase of 9.7 times in deaths was seen when the square test using Yates' Adjustment for continuity. serum albumin was abnormal. An increase of 19 times in deaths was observed when both the serum albumin and lymphocyte count were abnormal, both values again Received for publication, February 15, 1979 being statistically significant. The complication rate was Accepted for publics on, March 7,1979 157 Downloaded from pen.sagepub.com at UNIV CALIFORNIA DAVIS on May 11, 2014

158

SELTZER

TABLE I Diagnostic areas in 500 admissions No. patients

88 78 74 73 53 40 37 33

Pregnancy General and vascular surgical General medical Gynecologic Cardiac Surgical specialties (ENT, eye, neurosurgery plastic) Gastroenterologic Orthopedic Urological

500

TABLE I1

Complica tions in 27 p a tien IS No. complications

Complication of labor or pregnancy Cardiac Infect ion Pulmonary Gastrointestinal . Post-operative hemorrhage Lower extremity phlebitis Pneumothorax

-

Total

500

p value No. patients

9 (1.8)

4.001

3.5 >3.5 1500 4500

No. complications

No. deaths

Q

186 (50.7) 77 (29.3)

14 (7.5) 9 (11.7)

1 (0.5)

I (1.3)

263 23 2 The above data allow a physician to appreciate poten- --Total tial increases in complications and deaths prior to their p value NS NS actual occurrence, based upon admission laboratory data. The realization that an abnormal serum albumin her- Serum albu- Absolute Ijmpho- No. patients No. complicatiom No. deaths min cvte alds a 4-fold increase in complications and a 6-fold increase in deaths is striking. Evidence that an abnormal fi count/mma B lymphocyte count connotes a 4-fold increase in deaths is >3.5 >I500 176 (66.9) 10 (5.7) 1 (0.6) 4500 72 (27.4) 8 (11.1) l(1.4) again noteworthy. The combination of abnormal albumin >3.5 >1500 10 (3.8) 0 (0) 4 (40.0) level and abnormal lymphocyte count, providing a warn-

Instant nutritional assessment.

Journal of Parenteral and Enteral Nutrition http://pen.sagepub.com/ Instant Nutritional Assessment Murray H. Seltzer, J. Augusto Bastidas, David M. C...
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