Presented and described in detail is a clinical technique called subjective global assessment (SGA), which assesses nutritional status based on features of the history and physical examination. Illustrative cases are presented. To clarify further the nature of the SGA, the method was applied before gastrointestinal surgery to 202 hospitalized patients. The primary aim of the study was to determine the extent to which our clinician's SGA ratings were influenced by the individual clinical variables on which the clinicians were taught to base their assessments. Virtually all of these variables were significantly related to SGA class. Multivariate analysis showed that ratings were most affected by loss of subcutaneous tissue, muscle wasting, and weight loss. A high degree of interobserver agreement was found (kappa = 0.78, 95% confidence interval 0.624 to 0.944, p less than 0.001). We conclude that SGA can easily be taught to a variety of clinicians (residents, nurses), and that this technique is reproducible.

http://www.nutricionclinica.sld.cu/Editoriales/DetskyASArticleOnSGA.pdf

What is subjective global assessment of nutritional status

Based on assessment of 161 nonemergency general surgical patients, a multiparameter index of nutritional status was defined relating the risk of postoperative complications to baseline nutritional status. When applied prospectively to 100 gastrointestinal surgical patients, this index provided an accurate, quantitative estimate of operative risk, permitting rational selection of patients to receive preoperative nutritional support.

Prognostic nutritional index in gastrointestinal surgery

An Endocrine Society Clinical Practice Guideline Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient:

The nutritional status of 59 randomly-selected general surgical ward patients (38 men, 21 women; mean age, 50.4 years) was studied (using both clinical assessment and objective analysis methods) to measure the reproducibility and validity of clinical assessment. Objective nutritional assessment included anthropometric and other (e.g., serum albumin, lymphocyte count, total-body nitrogen) measurements. Clinical status was assessed (history taking and physical exam) by 2 physicians before surgery. Clinical assessment reproducibility between the 2 physicians was demonstrated by independent agreement on clinical classification of 48 of the patients (81%). Validity was demonstrated by correlation of clinical classification with objective measurement of nutritional status; and with 3 measures of hospital morbidity (infection incidence, antibiotic use, and length of hospital stay). It is concluded that clinical assessment is reproducible and valid since it correlated well with objective measurements and morbidity. (wz)

Nutritional assessment: A comparison of clinical judgement and objective measurements

Context Several nutrients have been shown to influence immunologic and inflammatory responses in humans. Whether these effects translate into an improvement in clinical outcomes in critically ill patients remains unclear. Objective To examine the relationship between enteral nutrition supplemented with immune-enhancing nutrients and infectious complications and mortality rates in critically ill patients. Data Sources The databases of MEDLINE, EMBASE, Biosis, and CINAHL were searched for articles published from 1990 to 2000. Additional data sources included the Cochrane Controlled Trials Register from 1990 to 2000, personal files, abstract proceedings, and relevant reference lists of articles identified by database review. Study Selection A total of 326 titles, abstracts, and articles were reviewed. Primary studies were included if they were randomized trials of critically ill or surgical patients that evaluated the effect of enteral nutrition supplemented with some combination of arginine, glutamine, nucleotides, and omega-3 fatty acids on infectious complication and mortality rates compared with standard enteral nutrition, and included clinically important outcomes, such as mortality. Data Extraction Methodological quality of individual studies was scored and necessary data were abstracted in duplicate and independently. Data Synthesis Twenty-two randomized trials with a total of 2419 patients compared the use of immunonutrition with standard enteral nutrition in surgical and critically ill patients. With respect to mortality, immunonutrition was associated with a pooled risk ratio (RR) of 1.10 (95% confidence interval [CI], 0.93-1.31). Immunonutrition was associated with lower infectious complications (RR, 0.66; 95% CI, 0.54-0.80). Since there was significant heterogeneity across studies, we examined several a priori subgroup analyses. We found that studies using commercial formulas with high arginine content were associated with a significant reduction in infectious complications and a trend toward a lower mortality rate compared with other immune-enhancing diets. Studies of surgical patients were associated with a significant reduction in infectious complication rates compared with studies of critically ill patients. In studies of critically ill patients, studies with a high-quality score were associated with increased mortality and a significant reduction in infectious complication rates compared with studies with a low-quality score. Conclusion Immunonutrition may decrease infectious complication rates but it is not associated with an overall mortality advantage. However, the treatment effect varies depending on the intervention, the patient population, and the methodological quality of the study.

/pdf/should-immunonutrition-become-routine-in-critically-ill-4yk424lied.pdf

Should Immunonutrition Become Routine in Critically Ill Patients?A Systematic Review of the Evidence

http://www.balanseradstyrka.se/wp-content/uploads/2015/04/The-Harris-Benedict-equation-reevaluated-resting-energy-requirements-and-the-body-cell-mass..pdf

The Harris Benedict equation reevaluated: resting energy requirements and the body cell mass.

Nutritional status after 238 gastric operations designed to reduce caloric intake and body weight to within 30% of ideal was assessed by measuring body composition using the multiple isotope dilution technique. Body cell mass (BCM) and body fat were quantitated before and at 24 months after operation. Malnutrition was defined as a total exchangeable sodium (Nae) to total exchangeable potassium (Ke) ratio greater than 1.22. Data were collected on 96 patients. All had lost a mean of 26% of preoperative weight by 24 months. Significant malnutrition occurred in 47 patients whose Nae/Ke ratio ranged from 1.23 to 2.17 (1.45 +/- 0.03). There was a 34% reduction in body fat. The malnourished patients lost 10% more BCM by 24 months than did the normally nourished group. Malnutrition resolved as the stoma enlarged in 19 patients, and dietary counselling helped eight patients. Eighteen patients required reoperation to establish a larger orifice, and endoscopic dilatation was successful in two patients. Administration of a liquid diet via the gastrostomy was required for prolonged periods in some malnourished patients. Seventeen patients who had lost weight rapidly over a short time had low vitamin B12, thiamine, and serum and RBC folate levels. One patient had a markedly decreased serum thiamine level with neuropathy. Symptoms of weakness, easy fatigability, and lassitude were found in the malnourished patients. Low thiamine and serum folate levels were also seen in patients ingesting a liquid diet of 750 kcal with a standard multivitamin supplement. Malnutrition was not seen in these patients. In the 49 patients who remained well nourished, BCM decreased by 19%, but the Nae/Ke remained normal. Weight loss was well tolerated, and no patients required reoperation or supplemental liquid diet to increase caloric or protein intake. The degree of malnutrition in patients after gastric operations is as great as following intestinal bypass but is not associated with liver failure. Malnutrition with vitamin deficiency is a great potential hazard in patients who undergo intake-limiting operations, especially if the goal of the operation is to restore near-normal weight. Current operations are successfully designed to maintain a small orifice size, so that the risks of malnutrition are likely to increase in the future.

Nutrition following gastric operations for morbid obesity.

Objective A 20-year follow-up was conducted on research into the implications of a lack of a delayed-type hypersensitivity (DTH) skin test response among surgical patients. Summary Background Data The authors' original report showed that a failed DTH response was associated with increased hospital mortality, but the role of specific and nonspecific host defense elements, comorbid factors, nutritional supplementation, and the mechanism for anergy in this adverse outcome was unknown. Methods A data base of 4292 patients was analyzed and reported on individual studies designed to answer some of the above questions. Results Prospective studies showed a strong association between the DTH response and mortality : reactive patients, 2.9% (75/2576) ; anergic patients, 20.9% (239/1142, chi square = 265, p < 0.0000001). Antibody response to protein antigens was reduced in anergic patients. Antibody response to polysaccharide antigens was normal in all patients. The hallmark of anergy is a lack of T cells in the skin, as measured by mRNA signal (CD3) for T cells. The nonspecific component of host defense, as measured by circulating and exudate polymorphonuclear cell function, showed no statistically significant difference between elective reactive and elective anergic patients. Notwithstanding some mild malnutrition in anergic patients, parental nutrition failed to correct the DTH response or many of the cellular immune functions measured. Conclusions Over the last 5 years, because of a reduction in overall patient mortality, the contribution of a reduced DTH response to septic related mortality has lost statistical significance in elective surgical patients. A reduced DTH response maintains its strong association to sepsis-related mortality in intensive care/trauma patients, and this is the group on which future research efforts should be concentrated.

The delayed hypersensitivity response and host resistance in surgical patients. 20 years later.

Serum albumin concentration is frequently used to define nutritional status. To validate this relationship, 161 body composition studies were performed on 102 patients simultaneously with protein electrophoresis. The body cell mass represented by the exchangeable potassium to total body water ratio correlated significantly (p < 0.001) with the serum albumin concentration (r = 0.59) and significantly (p < 0.001) to total protein (r = 0.59). However, in both cases the 95% confidence limits about the regression were wide. In 24 of 54 patients (44%) with a normal nutritional state, as defined by body composition, the serum albumin was abnormal. In 12 of 107 (11.2%) patients with malnutrition, the serum albumin was normal. Patients with more than one study were divided into 3 groups depending on the changes in their nutritional state as defined by their body composition. Serum albumin did not consistently reflect the significant body compositional changes observed. The data indicate that serum albumin is a valid measure of nutritional state for epidemiological surveys. However, due to the low sensitivity and specificity it is a poor parameter for evaluating the individual patient's nutritional state.

Serum Albumin and Nutritional Status

Skin tests (ST) in 1332 patients are associated with increased morbidity from sepsis. Patients with normal skin tests had a 7% major sepsis rate and 2% mortality rate. Thirty-six per cent of anergic (A) patients and 21% of relatively anergic (RA) patients died; 52% of A patients and 34% of RA patients had sepsis. These data include all patients studied and represent their worst skin test. Two studies were done. The first was a retrospective evaluation of effect of surgery upon 49 anergic patients with biliary tract disease, colon cancer, bowel obstruction, hypovolemia and visceral abscesses. The patients did not receive total parenteral nutrition (TPN). The data show that surgery without TPN can reverse the anergic state and did so in 84% of patients reported. The second study was a prospective, double-blind, randomized trial of the effect of levamisole on skin tests, neutrophil chemotaxis (CTX), sepsis and mortality iin 39 preoperative anergic patients. Major sepsis was significantly increased in placebo group (p less than 0.05). Mortality, minor sepsis, restoration of skin tests and chemotaxis were somewhat better in levamisole patients but not statistically so. These studies show that in addition to TPN, surgery and immunorestorative drugs are viable approaches to the management of selected anergic patients.

Harry M. Shizgal

Papers

The Harris Benedict equation reevaluated: resting energy requirements and the body cell mass.

Nutrition following gastric operations for morbid obesity.

The delayed hypersensitivity response and host resistance in surgical patients. 20 years later.

Serum Albumin and Nutritional Status

Therapeutic approaches to anergy in surgical patients. Surgery and levamisole.