Introduction: Hypoalbuminemia has been found to be associated with increased morbidity and mortality in acute surgical patients. Any surgical procedure induces a stressful and catabolic state. Wound healing is also a catabolic process requiring adequate protein and energy reserves. Severely malnourished patients often demonstrate impaired wound healing and an increased predisposition to infection and other postoperative complications. Aims: To evaluate the role of preoperative serum albumin levels as a predictor of postoperative outcomes in patients undergoing emergency surgeries. Materials and Methods: This hospital-based prospective study was conducted in the Department of General Surgery, AGMC & GBP Hospital, from January 2021 to June 2022. A total of 64 patients undergoing emergency abdominal surgeries were included. Serum albumin levels were measured preoperatively. Postoperative outcomes, including surgical site infection, pulmonary complications, ventilatory support, sepsis, ileus, cardiac events, hospital stay duration, and mortality, were recorded and analyzed in relation to albumin levels. Results: Patients with hypoalbuminemia (<3.5 gm/dL) had a significantly higher incidence of postoperative complications, including surgical site infections (p < 0.001), sepsis (p < 0.001), prolonged hospitalization (p < 0.001), and mortality (p < 0.001), compared to those with normal albumin levels. Mean serum albumin levels were significantly lower in patients with complications than those without. Conclusion: Preoperative serum albumin level is a simple, cost-effective, and reliable biochemical marker that can predict postoperative morbidity and mortality in emergency surgical patients. Early identification and nutritional optimization may improve surgical outcomes.
Hypoalbuminemia has been found to be associated with increased morbidity and mortality in acute surgical patients. [1] Any surgical procedure is stressful state & a catabolic process. Wound healing requires energy and is a catabolic process. Patients who are severely malnourished demonstrate impaired wound healing and predisposition to infection. They also suffer from deficient immune mechanisms. The catabolic effects of disease or injury can be reversed by adequate nutritional support. The degree of malnutrition is estimated on the basis of weight loss during the past 6 months, physical findings and plasma protein assessment.
Malnutrition is commonly seen in about 30 percent of surgical patients with gastrointestinal disease & upto 60 percent of those in whom hospital stay has been prolonged because of postoperative complications. There are various risk assessment general tests and scores that aim to identify morbidity Specific outcomes like surgical site infection, respiratory failure, anastomotic leak, delayed wound healing, sepsis etc. These complications are more in patients undergoing emergency surgery due to their poor nutritional status. The correct assessment of the nutritional status of such patients is crucial since malnutrition is a risk factor for morbidity & mortality.[2]
But there is no consensus on the best method for assessing the nutritional status when used alone. Serum Albumin level is the most readily available and clinically useful parameter. A Serum Albumin level greater than 3.5g/dl suggests adequate protein stores. A Serum albumin level less than 3.5 g/dl raises concern for potential surgical complications. Decrease in the serum albumin level preoperatively which is a risk factor for surgical complications is associated with increased hospital expenditure, increased length of hospital stay and decreased quality of life.[3]
One of the best biochemical parameters to assess nutritional status is estimating the serum albumin level and it is the simple and cost-effective. There are various preoperative assessment protocols available to identify patients with risk of operative morbidity and mortality. [4,5]
Total protein in the body is around 6 to 8 gm/dl out of which albumin contributes major part approximately 3.5 to 5.5gm/dl.[6] Serum albumin less than 3.5gram/dl is considered as hypoalbuminemia. [7]
Study Design: Hospital Based Prospective Study
Study Setting: Department of General Surgery, AGMC & GBP HOSPITAL
Study Duration: The study will be carried out for one and half years w. e. f. January, 2021 to June, 2022
Study Population: All patients who will be undergoing for emergency operation in this study period
Sample size: A total of 64 patients undergoing emergency surgeries were included in the study.
Sampling Technique: Consecutive Sampling Technique
Inclusion criteria:
Exclusion criteria:
Study Tools:
STATISTICAL ANALYSIS-
For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while Data were entered into Excel and analyzed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.
Table 1: Test of normality for serum albumin
Parameter |
Kolmogorov-Smirnova |
Shapiro-Wilk |
||||
Statistic |
df |
Sig. |
Statistic |
Df |
Sig. |
|
Serum Albumin (gm/dl) |
.093 |
153 |
.002 |
.987 |
153 |
.184 |
Table 2: Comparing serum albumin levels between patients with and without preop presentation and respective post op complication
Serum Albumin (Mean ± S.D) |
|||||
|
|
YES |
NO |
T value |
P value |
Clinical symptoms and signs |
Pain abdomen |
3.21 ± 0.73 |
3.80 ± 0.81 |
2.091 |
0.038 |
Vomiting |
3.10 ± 0.67 |
3.55 ± 0.79 |
3.402 |
<0.001 |
|
Fever |
2.96 ± 0.69 |
3.42 ± 0.72 |
3.937 |
<0.001 |
|
P/A tenderness |
3.19 ± 0.71 |
3.92 ± 0.89 |
2.553 |
0.029 |
|
Postoperative complications |
Surgical site infection |
2.90 ± 0.71 |
3.46 ± 0.67 |
4.867 |
<0.001 |
Pulmonary complication |
2.78 ± 0.62 |
3.51 ± 0.67 |
6.81 |
<0.001 |
|
Ventilatory support |
2.62 ± 0.66 |
3.39 ± 0.68 |
5.776 |
<0.001 |
|
Sepsis |
2.53 ± 0.48 |
3.45 ± 0.67 |
7.686 |
<0.001 |
|
Prolonged ileus |
3.01 ± 0.74 |
3.32 ± 0.72 |
2.308 |
0.024 |
|
Cardiac complications |
2.32 ± 0.43 |
3.37 ± 0.68 |
9.332 |
<0.001 |
|
Prolonged hospitalization |
2.83 ± 0.68 |
3.46 ± 0.67 |
5.561 |
<0.001 |
|
Mortality |
2.29 ± 0.37 |
3.38 ± 0.68 |
6.993 |
<0.001 |
Table 3: Serum albumin associated with various pre-op clinical symptoms and signs
Serum Albumin |
||||||
Clinical symptoms and signs |
Normal |
Low |
χ2 |
P value |
||
Pain abdomen |
No |
4 |
3 |
0.707 |
0.453 |
|
Yes |
60 |
86 |
||||
Vomiting |
No |
29 |
17 |
12.165 |
0.001 |
|
Yes |
35 |
72 |
||||
Fever |
No |
48 |
44 |
10.147 |
0.002 |
|
Yes |
16 |
45 |
||||
P/A tenderness |
No |
7 |
3 |
3.489 |
0.095 |
|
Yes |
57 |
86 |
||||
Postoperative complications |
Surgical site infection |
No |
51 |
40 |
18.646 |
<0.001 |
Yes |
13 |
49 |
||||
Pulmonary complication |
No |
54 |
41 |
23.21 |
<0.001 |
|
Yes |
10 |
48 |
||||
Ventilatory support |
No |
60 |
62 |
13.369 |
<0.001 |
|
Yes |
4 |
27 |
||||
Sepsis |
No |
62 |
55 |
25.458 |
<0.001 |
|
Yes |
2 |
34 |
||||
Prolonged ileus |
No |
52 |
59 |
4.182 |
0.045 |
|
Yes |
12 |
30 |
||||
Cardiac complications |
No |
64 |
69 |
16.545 |
<0.001 |
|
Yes |
0 |
20 |
||||
Prolonged hospitalization |
No |
54 |
44 |
19.735 |
<0.001 |
|
Yes |
10 |
45 |
||||
Mortality |
No |
64 |
69 |
16.545 |
<0.001 |
|
Yes |
0 |
20 |
Figure 1: Line diagram showing the trend line of complication
Figure 2: Line diagram showing the trend line of survival
The Kolmogorov-Smirnov test showed a statistically significant result (Statistic = 0.093, df = 153, p = 0.002), suggesting deviation from normality. However, the Shapiro-Wilk test was not statistically significant (Statistic = 0.987, DF = 153, p = 0.184), indicating that the distribution of serum albumin values does not significantly deviate from normality. Given that the Shapiro-Wilk test is more appropriate for smaller sample sizes (n < 2000), the data can be considered approximately normally distributed. The mean serum albumin level in patients with pain abdomen was 3.21 ± 0.73 gm/dl, whereas in those without pain abdomen, it was 3.80 ± 0.81 gm/dl. The difference was found to be statistically significant (t = 2.091, p = 0.038). Patients who presented with vomiting had a significantly lower mean serum albumin level of 3.10 ± 0.67 gm/dl, compared to 3.55 ± 0.79 gm/dl in those without vomiting (t = 3.402, p < 0.001). The mean serum albumin level was significantly reduced in patients with fever (2.96 ± 0.69 gm/dl) compared to those without fever (3.42 ± 0.72 gm/dl) (t = 3.937, p < 0.001). P/A Tenderness: Patients with per abdominal tenderness had a lower mean serum albumin level (3.19 ± 0.71 gm/dl) compared to those without tenderness (3.92 ± 0.89 gm/dl), and this difference was statistically significant (t = 2.553, p = 0.029). Patients who developed surgical site infections had a significantly lower mean serum albumin level (2.90 ± 0.71 gm/dl) compared to those without infection (3.46 ± 0.67 gm/dl) (t = 4.867, p < 0.001). The mean serum albumin level in patients with pulmonary complications was 2.78 ± 0.62 gm/dl, which was significantly lower than those without such complications (3.51 ± 0.67 gm/dl) (t = 6.810, p < 0.001). Patients requiring ventilatory support had significantly lower serum albumin levels (2.62 ± 0.66 gm/dl) compared to those not requiring support (3.39 ± 0.68 gm/dl) (t = 5.776, p < 0.001). Those who developed sepsis had a markedly reduced serum albumin level (2.53 ± 0.48 gm/dl) versus those without sepsis (3.45 ± 0.67 gm/dl) (t = 7.686, p < 0.001). Patients with prolonged ileus showed significantly lower serum albumin levels (3.01 ± 0.74 gm/dl) than those without (3.32 ± 0.72 gm/dl) (t = 2.308, p = 0.024). A significantly lower serum albumin level was observed in patients with cardiac complications (2.32 ± 0.43 gm/dl) compared to those without (3.37 ± 0.68 gm/dl) (t = 9.332, p < 0.001). Patients who experienced prolonged hospitalization had a mean serum albumin level of 2.83 ± 0.68 gm/dl, significantly lower than those with shorter stays (3.46 ± 0.67 gm/dl) (t = 5.561, p < 0.001). Patients who died had a significantly lower mean serum albumin level (2.29 ± 0.37 gm/dl) compared to survivors (3.38 ± 0.68 gm/dl) (t = 6.993, p < 0.001). Among patients without pain abdomen, 4 had normal and 3 had low serum albumin levels. Among those with pain abdomen, 60 had normal and 86 had low albumin levels. The association was not statistically significant (χ² = 0.707, p = 0.453). In patients without vomiting, 29 had normal and 17 had low serum albumin, while in those with vomiting, 35 had normal and 72 had low levels. The difference was statistically significant (χ² = 12.165, p = 0.001), indicating a strong association between vomiting and low serum albumin. Among patients without fever, 48 had normal and 44 had low serum albumin levels. Among those with fever, 16 had normal and 45 had low levels. This association was statistically significant (χ² = 10.147, p = 0.002). Patients without abdominal tenderness included 7 with normal and 3 with low serum albumin, while those with tenderness included 57 with normal and 86 with low levels. Although more patients with tenderness had low albumin, the association was not statistically significant (χ² = 3.489, p = 0.095). Among patients without surgical site infection, 51 had normal and 40 had low serum albumin levels, while among those with infection, 13 had normal and 49 had low levels. This association was statistically significant (χ² = 18.646, p < 0.001), indicating a strong link between low albumin and surgical site infections. In patients without pulmonary complications, 54 had normal and 41 had low serum albumin, whereas in those with complications, 10 had normal and 48 had low levels. The association was statistically significant (χ² = 23.210, p < 0.001). Among patients who did not require ventilatory support, 60 had normal and 62 had low serum albumin. In contrast, among those who required ventilatory support, 4 had normal and 27 had low levels. This difference was statistically significant (χ² = 13.369, p < 0.001). Patients without sepsis included 62 with normal and 55 with low serum albumin, while those with sepsis included only 2 with normal and 34 with low albumin. This association was highly significant (χ² = 25.458, p < 0.001). Among patients without prolonged ileus, 52 had normal and 59 had low serum albumin, while among those with ileus, 12 had normal and 30 had low levels. The association was statistically significant (χ² = 4.182, p = 0.045). All patients with cardiac complications (n = 20) had low serum albumin, while among those without cardiac complications, 64 had normal and 69 had low levels. This association was highly significant (χ² = 16.545, p < 0.001). Among patients without prolonged hospitalization, 54 had normal and 44 had low albumin; among those with prolonged hospitalization, 10 had normal and 45 had low albumin. The difference was statistically significant (χ² = 19.735, p < 0.001). All patients who died (n = 20) had low serum albumin, while survivors included 64 with normal and 69 with low levels. The association between low albumin and mortality was statistically significant (χ² = 16.545, p < 0.001).
It was a Hospital Based Prospective Study this study was conducted from January, 2021 to June, 2022 Department of General Surgery, AGMC & GBP HOSPITAL .64 Patients were included in this study
Proper nutritional support is very important for post-operative outcome of patients. Nutritional assessment is vital part of surgical patient’s management. Different types of nutritional indices are there to predict patient’s outcome. In my study preoperative serum albumin is used for nutritional assessment for emergency operated patients.
The present study was compared with the study done by James Gibbs et al ‘Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity’. They collected 46 preoperative, 12 operative and 24 postoperative variables for 87,078 major surgery cases between October 1, 1991, and December 31, 1993. The present study used 1 preoperative variable and 8 postoperative variables.[2]
Males constituted 88.2% of the study population of the present study in comparison to 97.1 % (52,642) of the similar study by Gibbs et al. The median age of the present study was 36 years and that of the study by Gibbs et al was 61years.
All relationships were statistically significant (P <0.001) in the study by Gibbs et al. In the present study only variables like requirement of ventilatory support, sepsis, pulmonary complications and cardiac complications showed statistical significance (P <0.05). This difference could be attributed to the large sample size taken by the Gibbs et al. [2]
On comparing with the similar study conducted by Gibbs et al.[2] the present study showed a low mean serum albumin level depicting a poor nutritional status of our patients leading to high morbidity & mortality rate. Maximum patients were males in both the studies. The morbidity rate of both studies decreased with increase in serum albumin levels as shown in the table 29 & 30. Better the serum albumin levels better were the postoperative outcome. The mortality rate was highest in severe hypoalbuminemic group in the present study.
Lohsiriwat V et al.,[6] suggested that pre-operative hypoalbuminemia (<3.5 g/dl) is an independent risk factor for post-operative complications following rectal cancer surgery.
A retrospective study by Kudsk et al.[8] showed serum albumin levels below 3.25gm/dl correlated immensely with complications, length of hospital stay, postoperative stay and mortality.
According to the study conducted by Foley et al., their data suggest that albumin therapy for the treatment of hypoalbuminemia in critically ill patients, despite its demonstrated value in raising the serum albumin concentration, has no beneficial impact on a variety of outcome variables, including mortality, complication rate, hospital stay, ventilator dependence, or tolerance of enteral feeding. [9]
Mullen et al.[10] studied the impact of BMI on preoperative outcome in patients undergoing major intra-abdominal surgery. Being underweight & lower serum albumin level were associated with higher mortality and wound infection.
Truong A et al.[11] in their study of preoperative hypoalbuminemia in colorectal surgery, found that hypoalbuminemia significantly influences the length of hospital stay & complication rates, specifically surgical site infection , enterocutaneous fistula and DVT formation .
Samuel Lalhruaizela et al.[12] showed in their study that patients with pre-operative serum albumin <3 gm/dl had statistically significant early and late post-operative complications. The rate of complication was 100 % in patients with serum albumin <2.1 gm/dl.
In a study done by Davenport DL et al.[13] on 183,069 patients subjected to general and vascular surgeries, it was found that a serum albumin < 3.5 g/dl & weight loss > 10% was associated with cardiac complication with a significant p-value (0.0001)
Takagi et al.[14] examined the presence of infectious complications in 103 patients who underwent oesophagectomy for thoracic oesophageal cancer. They showed that postoperative day 21 serum albumin level was significantly higher in patients without infectious complications compared with those who had infection.
The present study therefore showed that postoperative morbidity and mortality could be predicted by preoperative serum albumin. It showed that patients with serum albumin less than 2.95 g/dl had more postoperative complications than patients with serum albumin >2.95 g/dl who had less postoperative complications which was statistically significant.
The study found that pre-operative serum albumin can be a powerful biomarker for emergency surgical patients, predicting complications and mortality. Patients with a serum albumin level below 2.95 g/dl had higher complications. A higher value predicted no postoperative complications and survival. Serum albumin is a good nutritional indicator, but early detection of hypoalbuminemia requires better nutritional support and post-operative care.