Examples

Malnutrition and Complication in the Elderly Surgical Trauma Patient

 

Student

Gregory R. English, Class of 2007
HMC Box #613
717-531-8878, 215-990-1132
gre116@psu.edu

Primary Sponsor

Shawn M. Terry, M.D. FACS
Trauma and Critical Care Services, York Hospital
717-851-2610
sterry@wellspan.org

PSCOM Sponsor

Gordon L. Kauffman, M.D.
Division of General Surgery
717-531-8815
gkauffman@psu.edu

Research Period

Summer 2004

Hypothesis

A large percentage of elderly patients seen by the trauma surgery staff at York hospital are malnourished and that these malnourished trauma patients are more likely to have complications during their hospitalization.

Objectives

  1. To determine the percent of elderly adults that are malnourished following trauma.
  2. Ascertain whether malnourished elderly trauma patients have a higher risk of developing complications during their hospitalization compared to other nutritionally sound senior trauma patients.

 

Background

Recent studies have shown that malnutrition in the trauma patient may lead to adverse outcomes in patient care, especially within the elderly population. Many elderly trauma patients are not able to undergo surgery because the risk of operating on the malnourished patient often outweighs the possible benefits. Malnourished elderly patients who are able to receive surgical intervention may even have a higher risk of complications following treatment. Because of this, nutritional support in the early stages of trauma treatment may be needed in order to lessen these potential adverse effects. Therefore, it is important to determine if a significant amount of elderly patients are malnourished at the time of trauma and does malnourishment affect their recovery following surgical treatment (e.g. increase their chances of complications postoperatively). Complications are defined as any event in the hospital course that prolongs the hospitalization or compromises the outcome of treatment.
Malnutrition is defined as any nutritional disorder caused by insufficient or unbalanced diet, or by the impaired absorption or assimilation of nutrients by the body. Malnutrition among the elderly is a growing problem. A 1993 study by the Urban Institute estimated that nearly 5 million elderly Americans do not get enough to eat. The Nutrition Screening Initiative estimates that one in four senior citizens living in the United States is suffering from malnutrition. It is estimated that 55% of seniors admitted to hospitals are malnourished at the time of entry. Factors that contribute to the increased amount of malnutrition among the elderly include increased social isolation for people who live independently, decreased mobility, cognitive problems, problems chewing or swallowing, depression, the consumption of alcohol, and economic instability. Demographics such as whether the patient is married, single, or recently suffered the death of a spouse will also have an impact on the nutritional status of the patient. Because of this growing problem, it is important to identify if the patient is malnourished, especially following trauma.

Routine trauma screens performed on patients after trauma at York Hospital check three parameters in order to define a patient’s nutritional status. These markers used by York Hospital for overall nutritional status include albumin, prealbumin, and urine urea nitrogen. Albumin is the major protein synthesized in the liver and carries out significant functions as a carrier protein and provides oncotic pressure. Its half-life is approximately 20 days so it does not reflect recent changes in nutritional status. However, it does help to indicate long-term nutritional status. Prealbumin has a half-life of 24 hours, and can be used to reflect changes in nutritional status over short periods of time. Prealbumin is often used to watch nutritional changes over the short-term as patients receive nutritional support to assess response to therapy. Urine urea nitrogen levels are also useful when analyzing a patient’s nutrition.

An albumin level of equal to or greater than 3.4 g/dL is considered normal. Levels from 3.0 g/dL to 3.4 g/dL indicate significant malnutrition, while levels below 3.0 g/dL indicate a severe albumin deficiency. However, the albumin level is only reliable shortly after trauma and before surgery because a significant amount of albumin can be lost in any situation where there is hemorrhaging. Prealbumin values between 18-35.7 mg/dL are considered normal. Prealbumin levels lower than this may indicate significant malnutrition. Urine nitrogen balance levels (UUN) are also useful when analyzing nutritional standing. 24-hour UUN values of greater than 3 are considered to represent an anabolic state, the goal for adequate nutrition. Decreased UUN levels are most commonly due to inadequate protein intake or malabsorption.

In this IRB approved study at York Hospital, albumin, prealbumin, and UUN will be used to determine the elderly patients nutritional status following trauma. These values will also help to determine whether malnutrition in elderly trauma patients leads to an increased risk of complications when compared to elderly trauma patients who are properly nourished. This study may help future researchers to decide if it would be advantageous to do a study that alters the current nutritional support practice guidelines administered during post-trauma hospitalization in hopes of mediating this additional nutrition debt. 

Methods

Data will be used from approximately 50-75 elderly trauma patients (>60 years old) who were operated on by the trauma surgery staff at York Hospital over the period of 6 months from January ‘04 to July ‘04. Patient lab values for albumin, prealbumin, and 24-hour urine nitrogen balance will be obtained in a routine trauma panel for all elderly trauma patients seen over the 6 month period. From this data, the patient’s nutritional status will be determined. Demographic findings such as whether the patient is married, single, lives alone, etc. will be analyzed for any trends involving malnutrition.

Using the above data, the amount of malnourished elderly patients who suffer from trauma can be determined. At this point, we will see if there are a large number of elderly patients who are malnourished and subsequently sustain trauma. Data from malnourished patients will then be separated from the data of patients with sound nutritional standing. Any complications following surgery will be recorded and the type of complication will be noted for both the nourished and malnourished group. This data will be analyzed using an Excel spreadsheet to see if malnourished elderly trauma patients are more likely to suffer complications postoperatively after trauma surgery when compared to the nourished group of patients. This will most likely involve the use of a T-test.

 Student Responsibilities

  1. Become familiar with nutritional parameters in the elderly surgical trauma patient.
  2. Collect and organize data taken by the by the trauma staff at York Hospital.
  3. Compare complication rates in the malnourished versus the nourished elderly trauma patient.
  4. Use Excel to statistically evaluate the data.
  5. Possibly help to create an abstract and poster in conjunction with a trauma resident from York Hospital for the Trauma Symposium sponsored by Penn State on September 17, 2004.
  6. Prepare final MSR project report.

 

Sponsor Responsibilities

  1. Supply information and data from trauma patients seen from January to present.
  2. Provide access to the computer system and other resources at York Hospital.
  3. Aid in statistical analysis and interpretation of data.
  4. Provide help and guidance throughout the project.

 

References

  1. Watters JM and McClaran JC. The Elderly Surgical Patient. In Wilmore DW, Cheung LY, Harken AH, Holcroft JW, and Meakins JL (eds), Scientific American Surgery. New York, Scientific American, 1996.
  2. Trujillo EB, Robinson MK, Jacobs DO. Nutritional Assessment in the Critically Ill. In: Merritt RJ, ed. The ASPEN Nutrition Support Practice Manual. Silver Spring, Md: ASPEN Publishers; 1998:1801-1814.
  3. Cohen et al, "Hunger and Food Insecurity Among the Elderly," The Urban Institute. 1993
  4. Cope, Kathy, Malnutrition in the Elderly: A National Crisis, U.S. Administration on Aging.
  5. Coats KG, Morgan SL, Bartolucci AA, Weinsier RL. Hospital-associated malnutrition: a reevaluation 12 years later. J Am Diet Assoc. 1993; 93:27-33.
  6. James WPT, Hay AM. Albumin metabolism: effect of the nutritional state and the dietary protein intake. J Clin Invest. 1968;47:1958-1972.
  7. Doweiko JP, Nompleggi DJ. The role of albumin in human physiology and pathophysiology, Ill: albumin and disease states. JPEN J Parenter Enteral Nutr. 1991;15:476-483.
  8. Fletcher JP, Little JM, Guest PK. A comparison of serum transferrin and serum prealbumin as nutritional parameters. JPEN J Parenter Enteral Nutr. 1987;11:144-147.
  9. Baker JP, Detsky AS, Wesson DL, et al. Nutritional assessment: a comparison of clinical judgment and objective measurements. N Engl J Med. 1988;306:969-973.
  10. Benotti P, Blackburn GL. Protein and caloric or macronutrient metabolic management of the critically ill patient. Crit Care Med. 1979;7:520-525.