Haines Krista L, Lao William, Nguyen Benjamin P, Krishnamoorthy Vijay, Williams David, Gallagher Scott, Agarwal Suresh, Wischmeyer Paul E
Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA; The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, USA.
Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
Clin Nutr. 2021 Mar;40(3):1367-1375. doi: 10.1016/j.clnu.2020.08.026. Epub 2020 Aug 27.
Malnutrition remains a critical public health issue in the US, particularly in surgery where perioperative malnutrition is commonly underdiagnosed and undertreated. In 2016, the Global Leadership Initiative on Malnutrition (GLIM) proposed a set of consensus criteria for the diagnosis of malnutrition. Our project aims to assess the post-operative outcomes of patients meeting a modified GLIM-defined (mGLIM) malnutrition criteria undergoing emergent gastrointestinal surgery (EGS) in the NSQIP database. Current GLIM-criteria were modified with addition of admission albumin (a NSQIP-defined malnutrition variable).
Adapting NSQIP data, mGLIM criteria are (1) BMI of ≤20 for age ≤ 70 and BMI ≤22 for age ≥ 71, (2) weight loss > 10% within the past 6 months, (3) admission albumin ≤ 3.5, and (4) emergent bowel surgery as etiologic criteria of acute disease/injury. All patients undergoing emergent small bowel, colon, and rectal procedures were extracted from the NSQIP database and included in the study. Multivariate linear and logistic regression models controlling for relevant covariates were developed to evaluate mGLIM criteria on length of stay (LOS), mortality, and overall complication rates.
We included 31,029 patients who underwent emergent bowel surgeries from years 2011-2016. Demographically, 53.6% (n = 16,622) were female, 13.0% (n = 4023) were African American, and 78.3% (n = 24,292) were Caucasian. Case composition included 71.5% colon operations, 28.0% small bowel, and 0.5% rectal cases. Overall, 1.7% (n = 517) had data necessary to qualify as malnourished as per mGLIM. Controlling for covariates, multivariate linear and logistic regression analyses show that these patients have significantly higher mortality for both colon (p < 0.001, CI 1.55 | 2.61) and small bowel (p = 0.022, CI 1.08 | 2.67) procedures, longer LOS for colon (p < 0.001, CI 1.93 | 4.33) operations, and higher post-operative complications for both colon (p < 0.001, CI 1.61 | 2.62) and small bowel (p < 0.001, CI 1.57 | 3.37) cases.
This analysis shows that mGLIM criteria malnutrition is associated with poor clinical outcomes following EGS affecting LOS and mortality. Our data indicates the new mGLIM criteria can be a powerful and simple predictive score for malnutrition that can be used to predict malnutrition-related risk of poor outcomes after EGS.
营养不良在美国仍然是一个严重的公共卫生问题，尤其是在外科手术领域，围手术期营养不良常常未得到充分诊断和治疗。2016年，全球营养不良问题领导倡议组织（GLIM）提出了一套营养不良诊断的共识标准。我们的项目旨在评估国家外科质量改进计划（NSQIP）数据库中符合改良GLIM定义（mGLIM）的营养不良标准并接受急诊胃肠手术（EGS）的患者的术后结局。当前的GLIM标准通过添加入院时白蛋白水平（一个NSQIP定义的营养不良变量）进行了修改。
采用NSQIP数据，mGLIM标准为：（1）年龄≤70岁时BMI≤20，年龄≥71岁时BMI≤22；（2）过去6个月内体重减轻>10%；（3）入院时白蛋白≤3.5；（4）急诊肠道手术作为急性疾病/损伤的病因标准。从NSQIP数据库中提取所有接受急诊小肠、结肠和直肠手术的患者并纳入研究。建立了控制相关协变量的多变量线性和逻辑回归模型，以评估mGLIM标准对住院时间（LOS）、死亡率和总体并发症发生率的影响。
我们纳入了2011年至2016年期间接受急诊肠道手术的31029例患者。从人口统计学角度来看，53.6%（n = 16622）为女性，13.0%（n = 4023）为非裔美国人，78.3%（n = 24292）为白种人。病例构成包括71.5%的结肠手术、28.0%的小肠手术和0.5%的直肠手术。总体而言，1.7%（n = 517）的患者有数据符合mGLIM定义的营养不良标准。在控制协变量后，多变量线性和逻辑回归分析表明，这些患者在结肠手术（p < 0.001，CI 1.55 | 2.61）和小肠手术（p = 0.022，CI 1.08 | 2.67）中的死亡率显著更高，结肠手术（p < 0.001，CI 1.93 | 4.33）的住院时间更长，结肠手术（p < 0.001，CI 1.61 | 2.62）和小肠手术（p < 0.001，CI 1.57 | 3.37）的术后并发症发生率更高。
该分析表明，mGLIM标准定义的营养不良与急诊胃肠手术后影响住院时间和死亡率的不良临床结局相关。我们的数据表明，新的mGLIM标准可以成为一个强大且简单的营养不良预测评分，可用于预测急诊胃肠手术后与营养不良相关的不良结局风险。
