Case Report - Volume 1 Issue 1

Assessing undernutrition of trauma patients with complex soft tissue defects treated at viet duc university hospital using prealbumin serum levels

Nguyen Duc Chinh1*; Tran Tuan Anh; Dao Van Hieu; Chu Thi Trang; Nguyen Duc Hieu2

1Viet Duc University Hospital, Hanoi, Vietnam.
2Taipei Medical University, Taipei, Vietnam.

Received Date : Oct 31, 2021
Accepted Date : Nov 16, 2021
Published Date: Nov 23, 2021
Copyright      :© Nguyen Duc Chinh 2021.

*Corresponding Author : Nguyen Duc Chinh, Viet Duc University Hospital, Hanoi, Vietnam


Purpose: Nutrition is playing an important role in mitigating trauma wounds, especially complex wounds. Undernutrition could cause a delay in the wound healing process and prolonged hospital stay. Thus we have conducted the study aiming to evaluate the nutritional status of trauma patients with complex soft tissue defects for the further recommendation of wound care improvement.

Materials and Methodology: A prospective study of patients with complex traumatic wounds who have been treated at the Department of Septic Surgery and Wound care of Viet Duc University Hospital from 2/2020 to 2/2021. Subjects enrolled in this study include both genders, over 18 years old, with trauma wounds, are evaluated the undernutrition by pre albumin serum levels. The data was processed by software SPSS.20.0.

Results: A total of 70 patients were diagnosed the complex traumatic wounds, of them, 57 males accounted for 81.4%; 13 females accounting for 18.6%; mean age was 37.1 ± 2.3. The main cause of injuries was road traffic accidents, accounting for 78 %, and occupational accidents accounting for 22%. 21.4% of patients were reported to have soft tissue wounds only, the remaining 78.6% were with complex lesions including tendon and bone damaged. Co-morbidities accounted for 20% (Mellitus diabetes), 15.7% (heart diseases). No one in serious status of undernutrition (pre albumin serum <5.0 mg/dL), however, 5.0 to 10.9 mg/dL accounted for 28.6%, and 15.0 to 35.0 mg/dL accounted for 71.4% respectively. Healing time <1 week was 8.6%, from 1-3 weeks in 72.9%, and more than 3 weeks in 18.5%. Complications with serious necrosis requiring more debridements accounted for 8.6%.

Conclusions and Recommendations: Results from the study show that nutritional evaluation is useful in complex traumatic wounds treatment. Careful and daily check of wounds, evaluation of healing progress as well as the patient nutritional status can make the appropriate treatments which might help to improve the healing progress.

Keywords: Wound care, wound healing, malnutritional risk assessment.


Wound care is an important part of treatment for surgical patients. Wound healing complications such as infection, delayed healing affecting the treatment process, causing prolonged hospital stay, increasing costs. According to a statistic in the US, the length of hospital stays increasing with an average of 7.4 days due to complications related to wound care cost an additional 130 million USD per year. In Vietnam, many recent studies have shown that wound care plays an important role in medical care, wound infection complications are most common among nosocomial infections, accounting for 12% in some large hospitals [1,2,3,4,].

According to the researches, many factors affect the quality of wound care and wound healing, including nutrition. For both chronic and acute wounds, appropriate nutrition is the key to accelerate the healing process. The undernutrition mostly affected wound healing and should be adjusted [1,5].

Viet Duc University Hospital is a special class surgical hospital, performs over 70,000 major operations per year in recent years, most common are related to trauma and injured wounds [6]. Despite wound care being an important issue of the hospital’s professional activities, however, not so many reports related to nutrition and wound care have been done. This is a common situation in Vietnam because clinical assessment of nutritional status has yet to become part of the routine clinical history taking and physical examination. Therefore, we conducted a study to assess undernutrition of trauma patients with complex soft tissue defects which have been treated at the Wound Care Unit - Department of Septic Surgery, Viet Duc University Hospital aiming to make recommendations for improving the quality of care in general, and in wound care in particular.

Materials and Methodology

Selection criteria
All patients aged from 18 years old, regardless of gender, with traumatic soft tissue wounds were treated at the Wound Care Unit - Department of Septic Surgery at Viet Duc Hospital during the period from February 2020 to February 2021.

Retrospective and prospective study.

Research variables
General characteristics of subjects: age, gender, causes of injury.
Wound characteristics: sized from 5 cm in wide and damaged to subcutaneous layer (hypodermis) in-depth
Characteristics of nutritional status on admission and two days later based on pre-Albumin serum test. Levels of undernutrion according to Fuhrman MP [7]
<5.0 mg/dL: Severe requiring active intervention
5.0 to 10.9 mg/dL: Mild, requiring nutritional intervention
11.0 to 15.0 mg/dL: Moderate, retest every 2 weeks to adjust
15.0 to 35.0 mg/dL: No undernutrition,
Treatment outcomes

Data processing
The database was collected and processed by using SPSS 20.0 software.

Research ethics
The study protocol was approved by the hospital's Board of Directors, as well as relevant departments at the study sites.


Some demographics of subjects

Age-gender characteristics: 70 patients who met with criteria, were predominantly male: 57 males (81.4% ) and 13 female (18.6%). The average age was 37.1 ± 2.3, in which age group between 20 to 60 years old accounts for the vast majority,


Nutrition is essential for patients, affecting the quality of care and treatment in general. Many studies have shown that patients have nutritional problems (at risk of malnutrition or severe malnutrition) which range between 20 to 50% [7,9,10]. Malnutrition, especially undernutrition causes postoperative complications, prolonged hospital stay, and increases treatment costs. Despite the interest and advances in interventions, the undernutrition of patients is still not fully concerned. For surgical or trauma patients, nutrition plays an even more important role. Undernutrition increases the risk of postoperative complications such as surgical site infection, anastomotic leaks, delayed wound healing, etc. Besides, undernutrition is also associated with other nosocomial infections such as pneumonia, sepsis. Trauma patients with undernutrition are not being except with complications and mortality, prolonged hospital stay. In the studies conducted by Xin Chen in China in a large number of trauma patients in the plastic surgery department of Xinqiao Hospital, Chongqing [10], by Nguyen Tien Dung of the National Institute of Burns [4] in patients with wounds have shown the role of nutrition in wound healing. In the report of NV Pham [11] and colleagues on 438 surgical patients at some hospitals in the Mekong Delta region of Vietnam, the malnourished group had a higher rate of complications than the group without malnutrition problems, especially postoperative infectious complications.

According to dietetic experts, nutrients enhance the ability to rebuild connective tissue, promoting wound healing. Wound healing is a complicated process through three stages: Inflammatory phase - Proliferative phase - Remodelling phase, protein deficiency prolongs the inflammatory phase because protein contains nitrogen, stores amino acids, plays an important role in tissue reconstruction [12,13,14,15].

The causes of undernutrition are divided into 3 groups [14,15]:

Decreased nutrient tolerance due to anorexia: elderly, psychological, pathological patients; Decreased ability to digest and absorb: mainly related to gastrointestinal diseases such as short bowel, intestinal tuberculosis, cancer, sub-obstruction, drug side effects, after surgery ... Loss of nutrients: gastrointestinal fistula, burns, injury…

Increase metabolism due to trauma, burns, surgery

Administered ways: oral (enteral) or intravenous (parenteral).

It can be said that undernutrition has many combined causes, especially for trauma patients, the result of an imbalance between nutrient supply and nutrient consumption over a while, causing functional impairment body.

To improve nutritional status which helps to treatment outcomes, and to prevent the risk of complications, patients should be evaluated for nutritional status as soon as they are admitted to the hospital for adjustment nutrition regimen, it includes:

Rapid assessment of overall nutritional status: based on anthropometry such as BMI (Body Mass Index), NRS-2002 (Nutrition Risk Screening-2002), subjective nutritional assessment (SGA).

Assessment of adipose muscle and tests: Determination of body composition through muscle mass, fat by clinical or ultrasound check or muscle strength by assessment of hand force, biochemical tests by serum albumin/prealbumin levels. [16,17,18]

In which, the risk of undernutrition is assessed through easy-to-implement and valuable laboratory indicators, which is the measurement of serum prealbumin (transthyretin). It is a tryptophan-rich protein and, similar to albumin, it is synthesized in the hepatocytes of the liver and released in the blood [8,18]. It helps to carry certain hormones that regulate how the body uses energy and other substances through blood circulation. When prealbumin levels are lower than normal, it might be a sign of undernutrition and doctors will adjust protein supplements or fluids accordingly. For trauma and injured patients, assessment by weight, squeeze force, and fat muscle mass cannot be done because of many soft tissues already damaged and the patients should be immobilized on beds, therefore based on biochemical tests, it will be an easy way to perform. According to Albina JE (1994) [8], blood tests for albumin and prealbumin are also a way to assess nutrition for hospitalized patients when other measures are not possible to conduct. On the other hand, these two test indicators are also used to evaluate the effectiveness of post nutritional intervention for patients. Although no method of assessment is perfect, the application of the assessment of malnutrition will provide appropriate intervention and assist the physician in the wound care process. Besides, because the length of stay of trauma patients is not as long as the patients with chronic wounds, the assessment needs to be early and timely. The prealbumin's short half-life of 2 days, is suitable for evaluation.

Prealbumin is a misnomer; the correct name is transthyretin [3]. As it has a short half-life (2 days) and a relatively small pool, it might be a better indicator to assess nutritional status than the widely used albumin serum level [4].

In our series, males accounted for the vast majority of patients with 81.4%, females accounted for only 18.6% (Figure 1), most of the trauma patients were young and the average age was 37.1 ± 2.3, which related to traffic accidents accounted for the majority of 84% (Figure 2). The location of injury in the lower limb accounts for 78.6%, the upper limb is 15.7%, only 5.7% affects other parts of the body (Table 1). In our series, the characteristics of wounds were in Table 2 shown that complex wounds accounted for 78.6%, sized more than 10cm for 58.6%, and over 15cm was 10%. Risk factors were exudate for 75.3%.

Table 3 relates to co-morbidities diseases, the combined causes of delayed healing. This is similar to other reports showing that healing factors are strongly influenced by co-morbidities diseases such as Mellitus diabetes and cardiovascular disease [4,9,10,19].

Figure 1: Male and female ratio.

Figure 2: Causes of wound injuries.

Table 1: Location of wounds (n=70)

Table 2: Wound characteristics (n=70).

Table 3: Co-morbidities.

In particular, the study showed that the nutritional status of patients through assessment of prealbumin index that was different from studies related to chronic wounds. In our series, there were no patients who had severe undernutrition (Table 4: serum prealbumin level <5.0 mg/dL), however, mild undernutrition with serum prealbumin levels from 5.0 to 10.9 mg/dL accounted for 28.6%, and normal range with serum prealbumin from 15.0 to 35.0 mg/dL accounted for 71.4% respectively. In the study of AM Moghazy [18], prealbumin level was normal in 68% of those with normal albumin levels and 60% of those with hypoalbuminemia.

Features of laboratory tests
After appraising the serum prealbumin level in fifty burned patients undergoing graft in the Suez Canal University Hospital Burn Unit, AM Moghazy [18] concluded that this index was more valuable in assessing nutritional status than albumin. The author assessed the patient's serum prealbumin status before and after surgery on the 4th day of the patient having plastic surgery at the burn department. In young patients, the serum prealbumin concentration was higher in acute wounds, which was related to the healing process. If the patient's condition is stable, serum prealbumin is considered a predictor of scar healing with high sensitivity. According to Albina JE [8], serum albumin below 30mg/dl will delay the healing process as well as increase the risk of surgical site infection.
Healing time < 1 week accounted for 8.6%, from 1 to 3 weeks accounted for 72.9%, over 3 weeks only 18.5%. The main complication was the extension of necrotic tissue requiring multiple excisions, accounting for 8.6% (tables 5 and 6). The patients who healed the wounds in more than three weeks or complicated were all undernutrition.

Table 4: Serum pre-albumin levels (n=70).

Table 5:Complications (n=8)*

*Complications rate accounted for 11,4%. They are all undernutrition on admission.

Table 6: Healing time.

*Healing time more than 3 weeks was also in a group of patients with undernutrition


Undernutrition caused by increase metabolism in patients having trauma, burns, surgery affects treatment results, especially for patients with traumatic wounds, which delayed the healing process. For promoting wound healing, the patients need to be assessed earlier the undernutrition risk for timely intervention. Among the assessments of malnutrition status, serum prealbumin levels are effective, simple, and suitable for trauma patients. The combination of nutrition assessment and daily check of wound healing progress becomes one part of wound care procedures to improve the quality of treatment. However, further studies with a large sample size are recommended for developing the protocol of wound care, including the malnutrition assessment.

Conflict of interest: The authors declare no financial support or benefits.

Acknowledgement: The contribution of all staff and colleagues in the departments of Orthopedic, Septic surgery and Wound care and Dietetic of Viet Duc University Hospital.


  1. Shankar M, Ramesh B, Kumar D R, et al. Wound healing and its importance-a review. Der Pharmacologia Sinica. 2014; 1(1):24-30.
  2. Ozturk F, Ermertcan A T. Wound healing: a new approach to the topical wound care. Cutan Ocul Toxicol. 2011; 30(2):92-99.
  3. Nguyễn Tiến Dũng, Nguyễn Thị Bích Phượng, Phạm Quang Thịnh. Application of self-made suction for VAC for chronic wound care. Second scientific conference on wound healing II, 2015; Tr.82-91
  4. Monaco J L, Lawrence W T (2003). Acute wound healing an overview. Clin Plast Surg. 2003; 30(1):1-12.
  5. Rippon M G, Ousey K, Cutting K. Wound healing and hyper-hydration: a counterintuitive model. Journal of wound care. 2016; 25(2):68-75.
  6. Nguyễn Đức Chính. Remarks on care of road traffic accident victims at Viet Duc University Hospital. Conference on road traffic safety of Vietnam. 2018; 3:37-39.
  7. Fuhrman MP, Charney P, Mueller CM. Hepatic proteins and nutrition assessment. J Am Diet Assoc, 2004; 104(8):1258-1264.
  8. Albina JE. Nutrition and Wound Healing . J Parenter Enter Nutr. 1994; 18(4):367-376.
  9. Broughton G, 2nd, Janis J E, Attinger C E. Wound healing: an overview. Plast Reconstr Surg. 2006; 117(7):1e-S-32e-S.
  10. Xin Chen, Xin Zhou, Xin Xia, Yao Chen, Tongchun Mao, Xiaohua Shi, Yiming Zhang, Dongli Fan. Retrospective analysis of related factors affecting skin wound healing. Int J Clin Exp Med 2018; 11(8):8615-8621
  11. N V Pham , P L M Cox-Reijven, J W Greve, P B Soeters. Application of subjective global assessment as a screening tool for malnutrition in surgical patients in Vietnam. Clin Nutr. 2006 Feb; 25(1):102-8.
  12. Lưu Ngân Tâm. Role of nutrition in wound healing. Guidelines in wound care for soft tissues. Publisher : National University, HCM City. 2019; 84-92.
  13. Mackay D, Miller AN. Nutritional support for wound healing. Alternative Medicine Review. 2003; 8(4):359-377.
  14. Claire Acton. The importance of nutrition in wound healing. Wounds UK. 2013; 9(3): 61-64.
  15. Alexandra Bishop, Sarah Witts, Tanya Martin. The role of nutrition in successful wound healing. JCN 2018; 32(4):44-50.
  16. Sapna Makhija 1, Jeffrey Baker. The Subjective Global Assessment: a review of its use in clinical practice. Nutr Clin Pract. Aug-Sep 2008;2 3(4):405-9. [DOI: 10.1177/08845336083].
  17. Araújo-Junqueira and Daurea A. De-Souza. Enteral nutrition therapy for critically ill adult patients; critical review and algorithm creation. Nutr Hosp. 2012; 27(4):999-1008.
  18. A M Moghazy , O A Adly, A H Abbas, T A Moati, O S Ali, B A Mohamed. Assessment of the relation between prealbumin serum level and healing of skin-grafted burn wounds. Burns. 2010 Jun; 36(4):495-500.
  19. Lưu Ngân Tâm, Nguyễn Thị Quỳnh Hoa. Nutritional status of patients on admission at Cho Ray hospital. Journal of Practical Medicine Ho Chi Minh City. Extra Edition. 2009; 13(1):305-3011.