Testing for Vitamin C and Thiamin deficiency in surgical patients: from explaining to preventing complications
Author(s):
Hugo Bonatti; Sridhar Gona; Aaron George
Background:
Vitamin C (VC) and B1 (VB1) deficiency are rare conditions in developed countries. In surgical patients these deficiencies may lead to poor wound healing (VC) and cardiac or neurological complications (VB1).
Hypothesis:
VC and B1 deficiency may be underestimated in surgical patients, leading to detrimental complications. Intensified testing strategies prior to surgery may detect patients at risk and by thus prevent complications.
Methods:
Following the death of a patient with Scurvy and a case of Wernicke encephalopathy in a gastric bypass patient, an increasing number of individuals at our hospital were tested for VC and B1 levels. During the initial phase, most patients were tested after they developed surgical complications. During the 2nd phase, testing was increasingly done prior to surgery and patients identified with VC and/or B1 deficiency were supplemented before the procedure. A data base was created including demographic, clinical and outcome data.
Results:
Following the death of a patient with Scurvy and a case of Wernicke encephalopathy in a gastric bypass patient, testing for VC and B1 levels significantly increased. Between fall 2018 and December 2022, 794 VC tests were performed. Whereas the average number of tests sent by medical teams remained stable at around 80 cases annually, the number of tested surgical patients increased form initially <20 per year to almost 300 in 2022. Surgical patients and medical patients had similar median ages of approximately 53 years but percentage of male patients tested was 37% for surgical and only 21% for medical patients. Using “profiling” for patients at risk, in the surgical cohort 29.1% of patients were found VC deficient and another 20% were borderline deficient, whereas in the medical cohort only 16% of patients were deficient and 7% were borderline deficient. Within the surgical cohort, subsets of patients were found at excessive risk for VC deficiency including patients with foregut pathologies particularly those with paraesophageal hernias and overfilled gastric bands as well as perforated marginal ulcers after gastric bypass and patients with major surgical pathologies such as malignancies experiencing weight loss. In these cohorts up to 80% of patients were found VC and in most cases also VB1 deficient.
Conclusions:
VC and B1 deficiency is a much more common condition than expected in surgical patients in our rural setting with detrimental consequences if unrecognized. Using an algorithm based on clinical parameters, CV&B1 defiency can be predicted. A prospective multicenter trial including urban populations and academic centers is needed to determine the incidence of these deficiencies and the significance in surgical patients nationwide.