Serum prealbumin is considered to be a sensitive predictor of clinical outcomes and a quality marker for nutrition support. However, its susceptibility to inflammation restricts its usage in critically ill patients according to current guidelines. We assessed the performance of the initial value of prealbumin and dynamic changes for predicting the ICU mortality and the effectiveness of nutrition support in critically ill patients.

This monocentric study included patients admitted to the ICU between 2009 and 2016, having at least one initial prealbumin value available. Prospectively recorded data were extracted from the electronic ICU charts. We used both univariable and multivariable logistic regressions to estimate the performance of prealbumin for the prediction of ICU mortality. Additionally, the association between prealbumin dynamic changes and nutrition support was assessed via a multivariable linear mixed-effects model and multivariable linear regression. Performing subgroup analysis assisted in identifying patients for whom prealbumin dynamic assessment holds specific relevance.

We included 3136 patients with a total of 4942 prealbumin levels available. Both prealbumin measured at ICU admission (adjusted odds-ratio (aOR) 0.04, confidence interval (CI) 95% 0.01-0.23) and its change over the first week (aOR 0.02, CI 95 0.00-0.19) were negatively associated with ICU mortality. Throughout the entire ICU stay, prealbumin dynamic changes were associated with both cumulative energy (estimate: 33.2, standard error (SE) 0.001, p < 0.01) and protein intakes (1.39, SE 0.001, p < 0.01). During the first week of stay, prealbumin change was independently associated with mean energy (6.03e-04, SE 2.32e-04, p < 0.01) and protein intakes (1.97e-02, SE 5.91e-03, p < 0.01). Notably, the association between prealbumin and energy intake was strongest among older or malnourished patients, those suffering from increased inflammation and those with high disease severity. Finally, prealbumin changes were associated with a positive mean nitrogen balance at day 7 only in patients with SOFA <4 (p = 0.047).

Prealbumin measured at ICU admission and its change during the first-week serve as an accurate predictor of ICU mortality. Prealbumin dynamic assessment may be a reliable tool to estimate the effectiveness of nutrition support in the ICU, especially among high-risk patients.

Serum prealbumin has long been used as a marker of nutritional status. However, prealbumin is a negative acute phase reactant influenced by several non-nutritional-related factors including surgery, infection, and cancer. An increasing prealbumin has been correlated with a positive nitrogen balance in general surgery patients receiving parenteral nutrition (PN) with 88% specificity and 70% sensitivity. To date, no trial has evaluated the effect of concurrent cancer and surgery on the value of prealbumin in predicting nitrogen balance.

This study is a concurrent retrospective design of post-operative patients (≥ 19 years of age) identified by the nutrition support service who received PN for ≥ 5 days, had a baseline and follow-up serum prealbumin and C-reactive Protein (CRP) measured, as well as a 24-h urinary urea nitrogen (UUN) performed between days 5-10 of PN. Exclusion criteria include anuric renal failure, Child-Pugh Class C liver failure, pregnancy, and corticosteroid use. Prealbumin was correlated to nitrogen balance, measuring sensitivity, specificity, and negative and positive predictive values. Information was collected regarding patient demographics and presence or absence of metastatic cancer.

Thirty patients were identified and evaluated for this study from December 1st, 2010 to July 15th, 2011. Patients included in the study had a mean age of 57 years old (range 20-82), 53% male, with a mean weight of 84 kg (range 42-140) and body mass index (BMI) of 29 kg/m2 (range 14.9-56.8). The mean daily caloric dose of PN per actual body weight was 21 kcal/kg (range 10-34) and the mean daily protein dose was 1.4 g/kg (range 1-2). Forty seven percent of patients were obese (BMI > 30 kg/m2) and were prescribed high-protein hypocaloric PN. The most common indication for PN was post-operative ileus (23/30 patients). 24-h urine collection for UUN was performed on average of day 8 after PN initiation (range 5-10 days). Nitrogen balance as calculated from 24-h UUN was positive in 17/30 patients. A positive prealbumin change of greater than 2.8 mg/dL was found to have a statistically significant association with positive nitrogen balance (p = 0.02). At the cut off level of positive 2.8 mg/dL, the likelihood of a positive nitrogen balance had a sensitivity of 82% (95% confidence interval (CI) 64-100%); specificity of 62% (95% CI 35-88%); positive predictive value of 74% (95% CI 54-93%); negative predictive value of 73% (95% CI 46-99%). No absolute value for prealbumin level (e.g., > 20  mg/dL) was found to be a significant predictor of positive nitrogen balance. CRP levels at initiation of PN were significantly elevated with a mean level of 147 mg/dL.

These results indicate a positive change in serum prealbumin (> 2.8 mg/dL) has sufficient sensitivity (82%) to predict positive changes in nitrogen balance in the surgical oncology population. However, the low specificity (62%) makes it less useful in predicting a negative nitrogen balance. Absolute prealbumin levels were greatly affected by inflammation, as evidenced by CRP levels, and single values were not useful in predicting positive nitrogen balance.

Positive changes in serum prealbumin levels have previously been associated with a positive nitrogen balance (NB) in surgical patients receiving parenteral nutrition (PN); however, it is unclear if this is true in oncologic surgery patients. This study highlights how changing levels of serum prealbumin and C-reactive protein correlates to NB for cancer patients in the post-operative period requiring PN. Changes in prealbumin levels from baseline showed sufficient sensitivity, but not specificity to utilize routinely for predicting NB in this population.

The hypermetabolic and hypercatabolic responses to severe burns put nutrition support at the forefront of treatments. When left untreated, severe weight loss, increased infection, and wound healing failure can occur. Enteral nutrition is the primary method of nutrition support in such patients. Meeting caloric needs and a positive nitrogen balance are short-term goals of nutrition support, with long-term goals of minimizing lean body mass loss and maximizing wound healing. High-carbohydrate and low-fat nutrition received evidence from randomized controlled trials of aiding in decreasing pneumonia rates and was found to promote positive nitrogen balance, which lipids do not do. We go through the macronutrient and micronutrient needs of the burn patient as well as techniques for meeting these needs in the modern intensive care unit, with some discussion of alterations in these techniques that are required in the austere environment.

Hypoalbuminemia has been described as a modifiable factor to optimize postoperative outcomes after major inpatient surgeries. Nevertheless, the role of hypoalbuminemia on outpatient procedures is not well defined. The purpose of this study was to examine the impact of hypoalbuminemia on postoperative outcomes of patients undergoing low-risk outpatient surgery.

Patients were extracted from the American College of Surgeons National Surgical Quality Improvement Program database who had outpatient surgery from 2018 and recorded preoperative albumin levels. The primary outcome was a composite of any major complications including: 1) unplanned intubation, 2) pulmonary embolism, 3) ventilator use > 48 hr, 4) progressive renal failure, 5) acute renal failure, 6) stroke/cerebrovascular accident, 7) cardiac arrest, 8) myocardial infarction, 9) sepsis, 10) septic shock, 11) deep venous thrombosis, and 12) transfusion. Death, any infection, and readmissions were secondary outcomes.

A total of 65,192 (21%) surgical outpatients had albumin collected preoperatively and 3,704 (1.2%) patients had levels below 3.5 g⋅dL-1. In the albumin cohort, 394/65,192 (0.6%) patients had a major medical complication and 68/65,192 (0.1%) patients died within 30 days after surgery. Albumin values < 3.5 g⋅dL-1 were associated with major complications (adjusted odds ratio [aOR], 1.92; 95% confidence interval [CI], 1.44 to 2.57; P < 0.001; death-adjusted OR, 3.03; 95% CI, 1.72 to 5.34; P < 0.001); any infection (aOR, 1.49; 95% CI, 1.23 to 1.82; P < 0.001); and readmissions (aOR, 1.82; 95% CI, 1.56 to 2.14; P < 0.001). In addition, when evaluated as a continuous variable in a multivariate analysis, for each increase in albumin of 0.10 g⋅dL-1, there was an associated reduction of major complications (aOR, 0.94; 95% CI, 0.92 to 0.96; P < 0.001).

Hypoalbuminemia is associated with major complications and death in outpatient surgery. Since hypoalbuminemia is a potential modifiable intervention, future clinical trials to evaluate the impact of optimizing preoperative albumin levels before outpatient surgery are warranted.

Postnatal early overnutrition (EO) is a risk factor for future obesity and metabolic disorders. Rats raised in small litters (SLs) develop overweight, hyperphagia, hyperleptinemia, hyperinsulinemia and hypertension when adults. As obesity is related to hyperleptinemia, leptin resistance and metabolic syndrome, we aimed to investigate body composition, plasma hormone levels, glucose tolerance and the leptin signaling pathway in hypothalamus from early overfed animals at weaning and adulthood. To induce postnatal EO, we reduced litter size to three pups/litter (SL), and the groups with normal litter size (10 pups/litter) were used as control. Rats had free access to standard diet and water postweaning. Body weight and food intake were monitored daily, and offspring were killed at 21 (weaning) and 180 days old (adulthood). Postnatal EO group had higher body weight and total and visceral fat mass at both periods. Lean mass and serum high-density lipoprotein cholesterol (HDL-C) were higher at 21 days and lower at 180 days. Small litter rats presented higher levels of globulins at both periods, while albumin levels were higher at weaning and lower at adulthood. There was higher leptin, insulin and glucose serum concentrations at 21 days old, while no glucose intolerance was observed in adulthood. Leptin signaling pathway was unaffected at weaning. However, postnatal EO induced lower JAK2 and p-STAT3, and higher SOCS3 expression in adult animals, indicating central leptin resistance in adulthood. In conclusion, postnatal EO induces obesity, higher total and visceral fat mass, lower HDL-C and central leptin resistance in adult life.

Surrogate nutrition markers are used to assess adequacy of nourishment and to define malnutrition despite evidence that fails to link nourishment, surrogate markers, and outcomes. Markers such as serum levels of albumin, prealbumin, transferrin, and IGF-1 and delayed hypersensitivity and total lymphocyte count may be valid to help stratify risk. However, it is not appropriate to consider these as markers of adequacy of nourishment in the sick patient.

Physiologic hypoalbuminemia, defined as a plasma albumin (pl-ALB) of 1.0 to 2.5 g/dL, is a component of the injury response. A consensus on the need for albumin supplementation in this setting is lacking.

We examined 27 consecutive children (age, 7 +/- 6 years) with > 40% body surface burns (mean, 59 +/- 18%) during their initial 4 weeks of care. Patients were managed with an albumin-supplementation protocol that tolerated profound physiologic hypoalbuminemia. Intravenous albumin was administered by infusion of 1 to 2 g/kg/d when pl-ALB fell below 1.0 g/dL, or below 1.5 g/dL in the presence of enteral feeding intolerance or pulmonary dysfunction. Supplementation was stopped when pl-ALB reached 2.0 g/dL.

Mean pl-ALB was 1.7 g/dL overall. Infusion for pl-ALB < 1.0 g/dL was needed for 70% (n = 19) of the patients. Profound physiologic hypoalbuminemia was constant, that is, mean weekly pl-ALB never exceed 2.5 g/dL in any patient. Mean plasma globulin rose during the 4 week period from 2.3 +/- 0.1 at week 1 to 3.1 +/- 0.1 at week 4. Diarrhea was negligible (19 of 756 patient days), nasogastric feedings were well tolerated, PaO2/FiO2 ratios remained well above 150, wounds healed satisfactorily, and all children survived and have been discharged home.

Profound physiologic hypoalbuminemia (pl-ALB of 1.0-2.5 g/dL) does not have adverse effects on pulmonary or gut function, wound healing, or outcome in severely burned children, perhaps because of a compensatory increase in acute-phase proteins reflected in plasma globulin.

In the burned patient, the critical threshold over which a correction of hypoalbuminemia is required has not yet been clearly defined. The level of 30 g.L-1 of albumin is usually admitted. According to the extent of the burn, albumin is not indicated in patients with a burn size below 15% of the total body surface. It is essential, from the very beginning of management in patients with a burn size over 50%. Its administration can be postponed to the 8th, 12th or even 24th hour in case of a burn size between 15 and 50%.

A prospective, randomized trial was performed to determine whether maintaining serum albumin levels in burned pediatric patients had any effect on morbidity and mortality. Patients < 19 years of age with burns > 20% total body surface area were randomized to receive supplemental albumin to maintain levels 2.5 to 3.5 g/dL ("High Albumin") or were given albumin only if levels dropped < 1.5 g/dL ("Low Albumin") after completing burn shock resuscitation. The 36 patients in the Low Albumin group were well matched for age, burn size, depth of injury, and inhalation injury when compared with the High Albumin group (34 patients). As expected, serum albumin levels were significantly lower in the Low Albumin group when compared with the High Albumin group. No differences between groups were noted for resuscitation needs, maintenance fluid requirements, urine output, tube feedings received, days of antibiotic treatment, or ventilatory requirements. No differences in hematology, electrolytes, or nutritional laboratories were found. Finally, length of stay, complication rate, and mortality were not affected by albumin treatment. Albumin supplementation to maintain normal serum levels does not seem to be warranted in previously healthy children who suffer severe burns and who receive adequate nutrition.

Weight loss resulting from the hypermetabolic response to burn injury is not unusual and is often unavoidable. The loss of retroperitoneal fat has been postulated as a major factor in the cause of the uncommon complication of superior mesenteric artery syndrome. This syndrome is frequently treated nonoperatively with aggressive nutrition support. Nasojejunal feeding past the point of obstruction should be considered as the primary method of nutrition support. Alternatively, total parenteral nutrition or a combination of enteral and parenteral feeding may be necessary to meet nutritional needs until the duodenal obstruction resolves. This case study describes the nutrition management of a burn patient who developed superior mesenteric artery syndrome.

Estimations of total urinary nitrogen from measured urinary urea nitrogen are commonly used in calculating nitrogen balance. Recently published studies suggest the urinary urea nitrogen/total urinary nitrogen relationship is inconstant and total urinary nitrogen must be directly measured in burned patients. This study addresses the relationship of urinary urea nitrogen to total urinary nitrogen after thermal injury. Two hundred random 24-hour urine collections obtained from 45 thermally injured patients (mean burn size 59 +/- 28%, mean age 40.5 +/- 17.2 years) between 1 and 354 days postburn were analyzed for total urinary nitrogen and urinary urea nitrogen. Regression analysis relating total urinary nitrogen to estimated total urinary nitrogen (urinary urea nitrogen x 1.25) revealed a linear relationship (r = .936, p < .001). The mean urinary urea nitrogen/total urinary nitrogen ratio was 0.77 +/- 0.10 and was not significantly correlated with percent burn, age, or postburn day. Mean nitrogen balance calculated from measured urinary urea nitrogen in these patients was -5.7 g, and that calculated from measured total urinary nitrogen was -6.3 g. This difference, although statistically significant, is of little consequence for clinical use. Contrary to recent reports, we found the urinary urea nitrogen to be sufficiently predictive of total urinary nitrogen for practical application, and do not consider routine total urinary nitrogen measurements necessary for the nutritional care of thermally injured patients.