SLR - April 2019 - Kevin Ragothaman

Hypoalbuminemia Is an Independent Risk Factor for 30-Day Mortality, Postoperative Complications, Readmission and Reoperation in the Operative Lower-Extremity Trauma Patient

Reference: Wilson J, Lunati M, Grabel Z, Schwartz AM, Schenker M. Hypoalbuminemia is an independent risk factor for 30-day mortality, postoperative complications, readmission and reoperation in the operative lower-extremity trauma patient. Journal of Orthopedic Trauma, 2019.

Scientific Literature Review

Reviewed By:
Kevin Ragothaman, DPM
Residency Program: MedStar Washington Hospital Center, Washington, DC

Podiatric Relevance: Malnutrition is a well-known risk factor for morbidity in surgical inpatients. Hypoalbuminemia (albumin <3.5 g/dL) has been associated with postoperative complications and prosthetic joint infections. The authors aim to determine the effect of hypoalbuminemia on outcomes in nongeriatric patients with lower-extremity trauma.  
Methods: This is a level III retrospective analysis of the NSQIP database of patients who underwent surgery for lower extremity orthopaedic trauma. Exclusion criteria included patients older than 65 years old and those who met sepsis criteria. Patient demographic data, complications, length of stay, reoperation and readmission rates were collected. Patient modified frailty index scores (mFI) were calculated.
Results: The average age was 46 years old, and average BMI was 29 kg/m^2. 5,673 out of 17,510 (32.4 percent) patients identified had albumin levels available for analysis. 1,678 (29.6 percent) of these patients had hypoalbuminemia. Patients were more likely to have low albumin levels if they were older, female, had low or high BMI or had a higher frailty index score. Ankle fractures had the lowest proportion of patients with albumin available.
Patients who were >45 years old, had a BMI of <20 kg/m^2 or >34 kg/m^2, had an mFI score of >0.08, had an open wound or infection, were active smokers, anemic, had acute renal failure or had a fracture other than an ankle or tibial shaft fracture were more likely to have hypoalbuminemia. Patients with hypoalbuminemia had higher rates of having at least one postoperative complication, including transfusion, cardiac arrest, renal insufficiency, sepsis, unplanned intubation and UTI.

Hypoalbuminemia was also associated with longer hospital length of stay and increased risk of readmission within 30 days.

Conclusion: Hypoalbuminemia is associated with postoperative morbidity and increases risk of overall complications following surgical intervention in nongeriatric patients with lower-extremity orthopaedic trauma. Notably, acute changes in serum marker levels due to stress from trauma and surgery may be better indicated by prealbumin, and this study shows that albumin is a useful marker for morbidity prognosis in this patient population. Optimization of nutrition is an important consideration in patients undergoing surgical intervention for lower-extremity trauma.

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