Neutrofil-Limfosit Ratio (NLR) is a simple indicator for study inflammatory status easily in patient. An increasing value of neutrophils and decreasing value of lymphocytes is a physiological response in the immune system to systemic inflammation. Materials and Methods: This study was an analytical observational quantitative study using a prospective cohort approach, involving 51 patients pediatric surgery from age ≥1 months until ≤18 years who had done elective operation clean and clean contaminated criteria and after 6 hours operation, the subject had differential counted blood examination. Then we checked the outcome after first, third and seventh day after surgery, whether the condition improved (without complication) or worsen conditions (with complication). Results: From the total 51 patients, there was a significant result for gender in variable post operation in this research (OR = 3.968; 95%CI = 1.160-13.579; p = 0,028), whether female patient were more risky 3,968 times to become worsen condition (with complication) than male patient. About 34 patients with RNL <5 consists of 25 patients (73.5%) got improved condition (without complication), whether 17 patients who got worsen condition (with complication) with RNL >5 consist of 12 patients (70,6%). Sensitivity rate was 0,735 and specificity rate was 0,706 and prevalence ratio was 1,716. From this research we got RNL>5 (OR = 6.667; 95%CI = 1.832-24.264; p = 0,004) were more risky 6.667 times to become worsen (with complication) than RNL<5. From chi square result we got p value=0,003 (p<0,05) that’s mean there was a significant relationship between RNL and outcome of pediatric surgery patients age ≥1 months until ≤18 years who had done elective operation. Normal value of NLR would give better outcome. Conclusion: There was a significant relationship between RNL and outcome operation in pediatric surgery age ≥1 month-≤18 years that was done elective operation with clean and clean contaminated surgery criteria, whether normal value of NLR would give improved outcome (without complication).
Neutrophil-Lymphocyte Ratio (NLR) is a simple parameter to easily assess the inflammatory status of a patient, by dividing the absolute value of neutrophils by the absolute value of lymphocytes. An increase in the value of neutrophils and a decrease in the value of lymphocytes is a physiological response in the immune system to systemic inflammation. In endotoxemic patients after 4-6 hours there would be a decrease in the number of lymphocytes by about 85% and neutrophils would increase by about 300% [1]. As a result of increasing the number of neutrophils and decreasing the number of lymphocytes, there would be an increase in the absolute ratio of neutrophils and lymphocytes when compared to patients who do not experience a systemic inflammatory reaction:
Interpretation of NLR [2]:
1-3: Normal
4-5: Borderline
6-9: Mild Stres (example: patient with acute appendicitis/without complication)
≥9: Seriously ill
Based on National Academy of Sciences/National Research Council Wound Classification [3], the degree of contamination at operation wound consist of Table 1.
Table 1: NAS/NRC Wound Classification showing the Four Degrees of Operative Wound Contamination
Degree of Contamination |
|
Clean Wounds | Uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow no penetrating (blunt) trauma should be included in this category if they meet the criteria |
Clean- Contaminated Wounds | Operative wounds in which the respiratory, alimentary, genital or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered. |
Contaminated Wounds | Include open, fresh, accidental wounds, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, non-purulent inflammation is encountered. |
Dirty or Infected Wounds | Include old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing post-operative infection were present in the operative field before the operation. |
Estimated Risk of Infection | Clean wounds 1–5% Clean–contaminated wounds 3–11% Contaminated wounds 10–17% Dirty or infected wounds > 27% |
Sources:Haley et al. [2]
Objectives of the Study
This study was conducted to determine whether the post doperative Neutrophil-Lymphocyte Ratio can be a predictor of the outcome of elective surgery in clean and clean contaminated categories operation in Pediatric Surgery patients at Moewardi Hospital Surakarta.
This was an analytical observational quantitative study using a prospective cohort study approach. The subjects in this study were Pediatric Surgery patients aged 1 month to 18 years who had elective surgery in clean and clean contaminated operation categories. 6 hours after surgery, differential counting was performed on their blood examination, then we followed up the outcome of elective post-operative treatment, whether improvement or deterioration of the condition, seen from the patient's medical record data.
Samples were separated into 2 groups, namely NLR≤5 and NLR≥5. Then we proceed with making a 2×2 cross tabulation to get the value of sensitivity and specificity, it considered good if the value was >80%. The p value <0,05 was considered significant.
Univariate Analysis
Characteristics of Research Subject Data: The Table 2 explained that the age of the 34 patients who experienced improvement were mostly aged 1 year to <5 years, i.e. There were 16 patients (47.1%), while the age of the 17 patients who did not experience improvement/worsen condition occurred mostly with age <1 years there were 8 patients (47.1%).
Table 2: Distribution of Clinical Improvement versus Worsening among Patients by Age Group
| Variable | Outcome | Total | |
Improvement Condition (without complication) (n = 34) | Deterioration Condition (with complication) (n = 17) | ||
Age | |||
<1 y.o | 15 (44.1%) | 8 (47.1%) | 23 (45.1%) |
1 y.o - <5 y.o | 16 (47.1%) | 5 (29.4%) | 21 (41.2%) |
>5 y.o | 3 (8.8%) | 4 (23.5%) | 7 (13.7%) |
Gender | |||
Boy | 25 (73.5%) | 7 (41.2%) | 32 (62.7%) |
Girl | 9 (26.5%) | 10 (58.8%) | 19 (37.3%) |
RNL | |||
<5 | 25 (73.5%) | 5 (29.4%) | 30 (58.8%) |
>5 | 9 (26.5%) | 12 (70.6%) | 21 (41.2%) |
The gender of the 34 patients who experienced improvement were mostly male, namely 25 patients (73.5%), while of the 17 patients who experienced worsening, most of them were female, namely there were 10 patients (58.8%).
The Neutrophil Lymphocyte Ratio (RNL) of 34 patients who experienced improvement condition (without complication) were mostly with RNL<5, namely 25 patients (73.5%), while of the 17 patients who had worsened condition (with complication) most with RNL>5, there were 12 patients (70.6%).
Bivariat and Multivariat Analysis
In the bivariate analysis the variables that were not significantly related to the outcome of pediatric surgery patients who had elective surgery were clean and clean contaminated categories (clean and clean contaminated), namely the age variable from 1 year to <5 years (OR = 0.586; 95%CI = 0.156-2.195; p = 0.428 and age>5 years (OR = 2500; 95%CI = 0.445-14.037; p = 0.298). The variable that was significantly associated with postoperative outcome was gender (OR = 3.968; 95%CI = 1.160-13.579; p = 0.028), where female patients were 3,968 times more likely to have an outcome without improvement compared to male patients and RNL (OR = 6.667; 95%CI = 1.832-24, 264; p = 0.004) where patients with RNL>5 were 6,667 times more at risk of no improvement in outcome compared to RNL<5 (Table 3).
Table 3: Bivariate Analysis of Age, Gender, and RNL as Predictors of Postoperative Outcomes in Pediatric Elective Surgery Patients
| Variable | Bivariat | Multivariat | ||
| OR (95%CI) | p-value | OR (95%CI) | p-value | |
| Age | ||||
| Ref. | 0.428 | |||
| 0 .586 (0.156- 2.195) | ||||
| 2.500 (0 .445- 14.037) | 0.298 | |||
| Gender | ||||
| Boy | Ref. | 0.028* | Ref. | 0.037* |
| Girl | 3.968 (1.160- 13.579) | 4.366 (1.089- 17.493) | ||
| RNL | ||||
| <5 | Ref. | 0.004* | Ref. | 0.005* |
| >5 | 6.667 (1.832-24.264) | 7.165 (1.793-28.636) | ||
Based on the description above, it can be seen that RNL can be used as a predictor of outcome for pediatric surgical patients who have undergone elective surgery in clean and clean contaminated categories, because both bivariate and multivariate analysis, RNL remains a variable related to outcome and is not affected by confounding variables of age and gender.
Sensitivity and Spesificity RNL
Results of Cross Tabulation between NLR and Outcome of Surgical Patients Children aged 1 month- 18 years who had elective surgery performed clean and clean contaminated categories (Table 4).
Table 4: Association between RNL and Postoperative Outcomes, showing Higher RNL Linked to Worsening Condition with Significant Chi-Square Results
| RNL | Outcome | Total | p | |
Improvement Condition (without complication) | Deterioration Condition (with complication) | |||
<5 | 25 | 5 | 30 | 0,003 |
>5 | 9 | 12 | 21 | |
Total | 34 | 17 | 51 |
|
Sensitivity | 0.735 |
|
| |
Spesificity | 0.706 | |||
Prevalention Ratio | =a/(a+b) : c/(c+d) | 1.716 |
|
|
The RNL of 34 patients who experienced improvement were mostly with RNL<5, namely 25 patients (73.5%), while of the 17 patients who had worsened most of them with RNL>5, there were 12 patients (70.6%). The result of sensitivity is 0.735 and specificity is 0.706 and prevalence ratio is 1.716. The results of the chi square test obtained a value of p = 0.003 (p<0.05) which means that there is a significant relationship between RNL and outcome of pediatric surgical patients aged 1 month- ≤18 years who have had elective surgery, where normal NLR tends to give positive results without complication (improvement outcomes).
The neutrophil-lymphocyte ratio is the ratio of different and complementary pathways of the immunological system, which integrates the role of neutrophils responsible for non-specific inflammatory reactions and lymphopenia, which are markers of severe physiological stress and poor body condition. This neutrophil-lymphocyte ratio represents two important and predictive pathways of the immunological system compared to only one parameter [4].
This study found that there was a significant relationship between the Neutrophil-Lymphocyte Ratio and the outcome of pediatric surgery patients aged 1 month-≤18 years who had elective surgery in clean and clean contaminated categories, where normal NLR tended to provide improved outcomes of the patient’s condition (without complications).
The value of the neutrophil to lymphocyte ratio differs between sexes at the same age. The ratio of neutrophil to lymphocyte in women was higher in the age group <50 years compared to the male sex. This is related to the cortisol response to physical stress in women which is higher than in men. However, in the age group >50 years, the neutrophil to lymphocyte ratio in males is higher than in females. This occurs because of changes in hematopoiesis at different levels of estrogen during menopause. Sex hormones represented by estrogen and progesterone can increase the recruitment of neutrophils from the bone marrow significantly in women aged >40 years. A decrease in the number of neutrophils in postmenopausal women with a relatively unchanged lymphocyte count results in a decrease in the value of the neutrophil to lymphocyte ratio [5].
This is consistent with the results in this study where the variables that were significantly related to postoperative outcomes were gender, where patients with female sex were 3,968 times more at risk of worsening outcomes compared to men and RNL where patients with RNL>5 were more at risk. 6,667 times worsened outcome compared with RNL<5.
The multivariate analysis that followed in this study analyzed that gender was significantly related to outcome, where female patients were 4,755 times more at risk of worsening outcomes compared to men. RNL of patients in which RNL>5 had a 7,165 times greater risk of adverse outcome compared with RNL<5 [6].
Based on the explanation above, it can be concluded that the Neutrophil Lymphocyte Ratio can be one of the predictors of elective postoperative conditions in the clean and clean contaminated category in Pediatric Surgery patients at Dr Moewardi hospital.
There is a significant relationship between RNL and outcome of pediatric surgery patients aged 1 month-≤18 years who have undergone elective surgery in clean and clean contaminated categories, where normal NLR tends to provide improved outcomes (without complications).
Jilma B. et al. “Regulation of adhesion molecules during human endotoxemia.” American Journal of Respiratory and Critical Care Medicine, vol. 159, no. 3, 1999, pp. 857–863.
Haley R.W. et al. “Update from the SENIC project hospital infection control: Recent progress and opportunities under prospective payment.” American Journal of Infection Control, vol. 13, no. 3, 1985, pp. 97–108.
Forget P. et al. “What is the normal value of the neutrophil-to-lymphocyte ratio?” BMC Research Notes, vol. 10, 2017, p. 12.
Gwak M.S. et al. “Effects of gender on white blood cell populations and neutrophil-lymphocyte ratio following gastrectomy in patients with stomach cancer.” Journal of Korean Medical Science, vol. 22, suppl., 2007, pp. 104–108.
“Neutrophil-Lymphocyte Ratio (NLR).” EMCrit, emcrit.org/pulmcrit/nlr/. Accessed 5 September 2020.
Download PDF
Download PDF
Download PDF
Download PDF
Download XML
