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ORIGINAL PAPER
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 167-170

Use of serial monitoring of serum albumin and total leucocyte in predicting septicaemia in burns patients


Department of General Surgery, Government Medical College, Kozhikode, Kerala, India

Date of Submission08-Aug-2020
Date of Decision04-Oct-2020
Date of Acceptance13-Oct-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. Shabin Majeed
Revathy, TKMC P.O., Kollam - 691 005, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_22_20

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  Abstract 


Introduction: The most common complication of burns is infection-producing sepsis. Therefore, it is necessary that septicaemia be diagnosed early. Many biomarkers help to diagnose septicaemia early. Serum albumin levels and total leucocyte counts were commonly measured blood parameters in burn patients. This study was undertaken due to the dearth of information on the role of serum albumin levels and total leucocyte count in the diagnosis of septicaemia. Materials and Methods: This retrospective, correlational study used existing medical record data of 60 patients including the laboratory values admitted in the burns intensive care unit of the department of general surgery during the period January 2017–May 2019 and during the follow-up period. Results: Statistically significant association was observed between low serum albumin values and positive blood culture (P < 0.0001). Mean serum albumin had an excellent predictive validity in predicting blood culture indicated by area under the curve of 0.907. Similarly, septicaemia was correlated with a high total number of leucocytes and a statistically significant correlation (P < 0.0001). In predicting blood culture, mean total leucocyte counts demonstrated excellent predictive validity indicated by area under the curve of 0.985. Conclusion: Serial monitoring of serum albumin and total leucocyte count could be used in burn patients to predict septicaemia.

Keywords: Bio-markers, burns, septicaemia, serial monitoring, serum albumin, total leucocyte count


How to cite this article:
Majeed S, Gopi E V, Abdul Basith P T. Use of serial monitoring of serum albumin and total leucocyte in predicting septicaemia in burns patients. Kerala Surg J 2020;26:167-70

How to cite this URL:
Majeed S, Gopi E V, Abdul Basith P T. Use of serial monitoring of serum albumin and total leucocyte in predicting septicaemia in burns patients. Kerala Surg J [serial online] 2020 [cited 2020 Nov 26];26:167-70. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/167/300231




  Introduction Top


It is estimated that each year over 3,00,000 people die from fire-related burn injuries.[1] The majority of these occur in low- and middle-income countries and almost two thirds occur in the WHO African and South-East Asia regions.[2] Researches are being done to identify bio markers for the early identification of sepsis to initiate treatment.[3],[4],[5] The 'ideal biomarker should aid the identification of the disease (sepsis), aid direct therapy, stratify patients according to individual risk factors and be readily available for routine clinical use'.[4]

White blood cell count is the commonly used parameter to identify the underlying infectious process deduced by counts >12,000 cells/mm3 or <4000 cells/cu.mm.[5] Hypoalbuminaemia is typically seen in critically ill patients, especially in burn patients in addition to the changes in the blood counts.[6] Patients with major burns increase in mortality is associated with decreased serum albumin levels.[7] It is imperative that septicaemia is diagnosed early to improve the treatment and quality of life.


  Materials and Methods Top


This article was aimed to study the use of serial monitoring of serum albumin and total leucocyte count in predicting septicaemia in burns patients. It was a retrospective study of the records of 60 patients admitted in Burns intensive care unit in Government medical college Calicut, Kerala, India during the period of January 2017 to May 2019. Patients were between 13 and 60 years of age of both sexes with Grade II burns >20% and <50%, patients with uncontrolled diabetes, HIV-AIDS, patients on immunosuppressors, post-transplant patients and patients with hyperkalaemia and hyponatremia during first 21 days post-burns were excluded. The pro forma included sociodemographic characteristics, medical history, clinical examination findings comprising facial burns and depth of burns. Ethical clearance and patient consent were obtained. The results of laboratory tests conducted at intervals during the follow-up of first 30 days were also collected. Data were coded and entered in Microsoft Excel, and statistical analysis was done with the Statistical Package for the Social Sciences software version 18 using the appropriate statistical tests.


  Results Top


The mean serum albumin at day 1, day 3, day 7, day 14 and day 21 was 3.44 ± 0.22, 3.21 ± 0.36, 2.99 ± 0.46, 2.82 ± 0.57 and 2.71 ± 0.71, respectively. The minimum, maximum and the median values are described in [Table 1].
Table 1: Descriptive analysis of serum albumin at different follow up periods study population (n=60)

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The serum albumin showed a declining trend during the follow-up days [Figure 1]. The median total lymphocyte counts (TLCs) at day 1, day 3, day 7, day 14 and day 21 were 6000.00, 7000.00, 7900.00, 9800.00 and 10,100.00/mm3 respectively. Parameters such as mean, minimum and maximum values are described in [Table 2]. The total leucocyte count showed an increasing trend during the follow-up days [Figure 2].
Figure 1: Trend line diagram for serum albumin at different follow up periods study population (n = 60)

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Table 2: Descriptive analysis of TLC at different follow up periods in study population (n=60)

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Figure 2: Trend line diagram for total lymphocyte count at different follow up periods study population (n = 60)

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Among the study population 2 (3.33%), 17 (28.33%) and 18 (30.00%) had positive blood culture at day 7, day 14 and day 21, respectively. None of patients had positive blood culture on day 1 or day 3. Furthermore, during the follow-up periods of day 7–21 and day 1–21, 37 had positive blood culture [Figure 3].
Figure 3: Stacked bar graph for blood culture during follow up days in the study population (n = 60)

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The median serum albumin at day 14 in patients with positive and negative blood culture was 2.3 g/dl and 2.8 g/dl, respectively. The median TLC 14,000/mm3 and 8100/mm3 at day 14 in patients with positive and negative blood culture, respectively. The difference in median serum albumin and TLC at day 14 between positive and negative blood culture was statistically significant (P < 0.001).

The median serum albumin at day 21 in patients with positive and negative blood culture was 2.15 g/dl and 3.0 g/dl, respectively. The median TLC 136,000/mm3 and 7200/mm3 at day 21 in patients with positive and negative blood culture, respectively. The difference in median serum albumin and TLC at day 21 between positive and negative blood culture was statistically significant (P < 0.001). The relation of serum albumin, TLC and blood culture is shown in [Figure 4].
Figure 4: Predictive validity of serum albumin in predicting blood culture at day 21 (n = 60)

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On day 21, serum albumin had fair predictive validity in predicting blood culture, as indicated by the area under the curve of 0.789 (95% confidence interval [CI] 0.672–0.906, P < 0.001). Among the people with positive blood culture, 21 (77.78%) had low serum albumin and 4 (22.22%) had high serum albumin on day 21. 10 (27.03%) had low serum albumin and 27 (72.97%) had high serum albumin of the people with negative blood culture (day 21). The difference in the proportion of serum albumin between positive and negative culture on day 21 was statistically significant (P < 0.001).

On day 21, low and high serum albumin in predicting blood culture had the sensitivity of 77.78%, specificity 72.97%, and the total diagnostic accuracy was 74.55%. The TLC (day 21) had good predictive validity in predicting blood culture (day 21), as indicated by area under the curve of 0.803 (95% CI 0.683–0.924, P < 0.001).

Among the people with positive blood culture, 15 (83.33%) had high TLC and 3 (16.67%) had low TLC. Eight (21.62%) had high TLC and 29 (78.38%)) had low TLC of the people with negative blood culture on day 21. The difference in the proportion of TLC (day 21) between positive and negative cultures (day 21) was statistically significant (P < 0.001).

The mean serum albumin (day 7–21) had excellent predictive validity and mean serum albumin (day 1–21) had good predictive validity in predicting blood culture as indicated by area under the curve of 0.907 and 0.868, respectively.

In both the groups, patient's positive blood culture (day 7–21) and patient's positive blood culture (day 1–21), 29 (78.38%) had low mean serum albumin and 8 (21.62%) had high mean serum albumin. Similarly, in both groups with negative blood culture, 5 (21.74%) had low mean serum albumin and 18 (78.26%) had high mean serum albumin. The difference in the proportion of mean serum albumin between positive and negative culture in both groups was statistically significant (P < 0.001).

In Group 1 with positive blood culture, 36 (97.3%) participants had high mean TLC and 1 (2.7%) participant had low mean TLC, whereas people with negative blood culture, 1 (4.35%) participant had high mean TLC and 22 (95.65%) had low mean TLC. In the Group 2, 34 (91.89%) had high mean TLC and 3 (8.11%) had low mean TLC with positive blood culture, whereas 2 (8.7%) had high mean TLC and 21 (91.3%) had low mean TLC with negative blood culture. The difference in the proportion of mean TLC in both groups between positive and negative culture was statistically significant (P < 0.001).

In Group 1, high and low mean TLC had sensitivity of 97.30%, specificity 95.65%, and the total diagnostic accuracy of 96.67% in predicting blood culture while in Group 2 sensitivity was 91.89%, specificity was 91.30% and diagnostic accuracy was 91.67%.


  Discussion Top


In this study, a declining trend in daily serum albumin values was noted during follow-up of patients from day 1 to day 21. In patients with positive blood culture, statistically significant lower levels of median serum albumin were observed compared to patients with negative blood culture on days 14 and 21. Furthermore, the association between lower serum albumin levels and positive blood culture was statistically significant in other studies.[8],[9],[10],[11],[12]

During the follow-up of patients, this study illustrated an increasing trend of TLC from day 1 to day 21. On days 14 and 21, statistically significant higher levels of median TLC were found in patients with positive blood culture relative to patients with negative blood culture. There was also a statistically significant association between higher TLC and positive blood culture. Other authors also found that infection or sepsis in patients correlated with raised total leucocyte count.[13],[14] They observed significantly, higher TLC in non-survivors than in survivors.

Mean serum albumin of day 7–21 had excellent predictive validity and mean serum albumin of day 1–21 had good predictive validity in predicting blood culture was observed in this study. Others [9],[15] demonstrated that albumin levels showed the highest sensitivity and specificity for predicting mortality.

It was observed in this study that mean TLC in had excellent predictive validity in predicting blood culture. In Group 1, high and low mean TLC had sensitivity of 97.30%, specificity 95.65%, and the total diagnostic accuracy of 96.67% in predicting blood culture, whereas in Group 2, sensitivity was 91.89%, specificity was 91.30% and diagnostic accuracy was 91.67% showing that mean TLC could predict septicaemia in relatively well. This was similar to other studies.[16] White blood cell count and neutrophil percentage were statistically predictive of bloodstream infection when collecting blood cultures but with lesser predictive value.


  Conclusion Top


Serial monitoring of serum albumin and total leucocyte could predict septicaemia in burns patients. The mean age of the study population was 40.72 ± 12.62 years with majority in the age group of 31–30 years. Majority were female patients. Flames were the most common type of burns. Mean total body surface area involved in the study population was 39.58% ± 8.5%.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Peck M, Molnar J, Swart D. A global plan for burn prevention and care. Bull World Health Organ 2009;87:802-3.  Back to cited text no. 1
    
2.
Burns. Available from: https://www.who.int/news-room/fact-sheets/detail/burns. [Last accessed on 2019 Oct 24].  Back to cited text no. 2
    
3.
Hedegaard SS, Wisborg K, Hvas AM. Diagnostic utility of biomarkers for neonatal sepsis – A systematic review. Infect Dis (Lond) 2015;47:117-24.  Back to cited text no. 3
    
4.
Dupuy AM, Philippart F, Péan Y, Lasocki S, Charles PE, Chalumeau M, et al. Role of biomarkers in the management of antibiotic therapy: An expert panel review: I-currently available biomarkers for clinical use in acute infections. Ann Intensive Care 2013;3:22.  Back to cited text no. 4
    
5.
Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992;101:1644-55.  Back to cited text no. 5
    
6.
Cartwright MM. The metabolic response to stress: A case of complex nutrition support management. Crit Care Nurs Clin North Am 2004;16:467-87.  Back to cited text no. 6
    
7.
Kim GH, Oh KH, Yoon JW, Koo JW, Kim HJ, Chae DW, et al. Impact of burn size and initial serum albumin level on acute renal failure occurring in major burn. Am J Nephrol 2003;23:55-60.  Back to cited text no. 7
    
8.
David G Levitt and Micheal D Levitt. Human serum albumin homeostasis: a new look at the roles of synthesis, catabolism, renal and gastrointestinal excretion, and the clinical value of serum albumin measurements Int J Gen Med. 2016;9:229-55  Back to cited text no. 8
    
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Gounden V, Jialal I. Hypoalbuminemia; 27 October 2018.  Back to cited text no. 9
    
10.
Barret KM, Barman SM, Boitano S, Brooks HL. et al. Ganong's review of medical physiology. 25th edition published 2016, McGraw Hill education;chapter 31, Blood as a Circulatory Fluid & the Dynamics of Blood & Lymph Flow; page 555.  Back to cited text no. 10
    
11.
Blumenreich MS. The white blood cell and differential count. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods; The History, Physical and Laboratory Examinations. Ch. 153. 3rd ed.. Boston; Butterworths; 1990.  Back to cited text no. 11
    
12.
McCarthy DA, Perry JD, Melsom RD, Dale MM. Leucocytosis induced by exercise. Br Med J (Clin Res Ed) 1987;295:636.  Back to cited text no. 12
    
13.
Dale DC. Neutrophilia. In: Beutler E, Marshal AL, Barrys C, Thomas JK, editors, Hematology. 5th ed.., New York:McGraw-Hill, Inc.; 1995;826-8.  Back to cited text no. 13
    
14.
Asadollahi K, Hastings IM, Beeching NJ, Gill GV, Asadollahi P et al. Leukocytosis as an Alarming Sign for Mortality in Patients Hospitalized in General Wards Published in Iran. J Med Sci 2011;36:45-9.  Back to cited text no. 14
    
15.
Nickson C. Sepsis Definitions and Diagnosis; 13 April 2019.  Back to cited text no. 15
    
16.
Jones AE, Trzeciak S, Kline JA et al. The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med 2009;37:1649 54. PMCID: PMC2703722.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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