Nutrition Risk in Critically Ill Versus the Nutritional Risk Screening 2002: Are They Comparable for Assessing Risk of Malnutrition in Critically Ill Patients?

Association Between Geriatric Nutrition Risk Index and 90-Day Mortality in Older Adults with Chronic Obstructive Pulmonary Disease: a Retrospective Cohort Study

Background

Malnutrition adversely affects prognosis in various medical conditions, but its implications in older adults with Chronic Obstructive Pulmonary Disease (COPD) in the ICU are underexplored. The geriatric nutritional risk index (GNRI) is a novel tool for assessing malnutrition risk. This study investigates the association between GNRI and 90-day mortality in this population.

Methods

We selected older adults with COPD admitted to the ICU from Medical Information Mart for Intensive Care (MIMIC)-IV 2.2 database. A total of 666 patients were categorized into four groups based on their GNRI score: normal nutrition (>98), mild malnutrition (92-98), moderate malnutrition (82-91), and severe malnutrition (≤81) groups. We employed a restricted cubic spline (RCS) analysis to assess the presence of a curved relationship between them and to investigate any potential threshold saturation effect.

Results

In multivariate Cox regression analyses, compared with individuals had normal nutrition (GNRI in Q4 >98), the adjusted HR values for GNRI in Q3 (92-98), Q2 (82-91), and Q1 (≤81) were 1.81 (95% CI: 1.27-2.58, p=0.001), 1.23 (95% CI: 0.84-1.79, p=0.296), 2.27 (95% CI: 1.57-3.29, p<0.001), respectively. The relationship between GNRI and 90-day mortality demonstrates an L-shaped curve (p=0.016), with an approximate inflection point at 101.5.

Conclusion

These findings imply that GNRI is a useful prognostic tool in older adults with COPD in the ICU. An L-shaped relationship was observed between GNRI and 90-day mortality in these patients.

Relation between nutritional status on clinical outcomes of critically ill patients: emphasizing nutritional screening tools in a prospective cohort investigation

BACKGROUND

Malnutrition is a significant concern reported in adult critically ill patients, yet there is no gold standard to assess nutritional status in this population. This study examines the association between nutritional status and clinical outcomes in intensive care unit (ICU) patients using nutritional risk assessment tools and aims to look for the best tool.

METHOD

In a single-center prospective cohort study among 165 patients, the predictive performance of high or low malnutrition risk assessed by Nutritional Risk Screening (NRS), Modified Nutrition Risk in Critically Ill (m-NUTRIC), Mini-Nutritional-Assessment Short-Form (MNA-SF), Controlling Nutritional status (CONUT), and Prognostic Nutritional Index (PNI) were evaluated and compared for mortality, organ failure, length of hospitalization, and mechanical ventilation (MV).

RESULTS

Different assessment tools showed various nutritional statuses. m-NUTRIC and NRS-2002 were found to be associated more strongly relative to other tools with mortality (RR = 1.72; 95% CI, 1.42-2.08) and (RR = 1.37; 95% CI, 1.08-1.72), organ failure (RR = 1.69; 95% CI, 1.44-1.96) and (RR = 1.22; 95% CI, 0.99-1.48), MV (RR = 1.46; 95% CI, 1.27-1.65) and (RR = 1.21; 95% CI, 1.04-1.39) respectively. There was no correlation between malnutrition levels assessed by mentioned tools except for NRS-2002 and length of hospitalization. In predicting mortality or illness severity, the cut points were different for some tools like NUTRIC-score and all assessed outcomes (3.5), MNA-SF and mortality (6.5), CONUT with mortality, and MV (6.5).

CONCLUSIONS

A considerable proportion of patients admitted to the ICU are at high risk for malnutrition. Compared to other tools, m-NUTRIC and NRS-2002 proved superior in predicting clinical outcomes in critically ill patients. Other tools overestimated the risk of malnutrition in the ICU so couldn't predict clinical outcomes correctly.

Nutritional status and feeding regimen of critically ill patients in General Hospital of Agriculture in Hanoi, Vietnam

Background: Fully nutrition support for patients in developing countries like Vietnam is challenging. Aim: To estimate the prevalence of patients with nutritional risk at admission and describe feeding regimen of critically ill patients in a suburban hospital in Hanoi, Vietnam. Methods: An observational study was conducted among 154 patients at department of Intensive Care Unit (ICU). The Nutrition Risk Screening 2002 (NRS2002) and Modified Nutrition Risk in Critically Ill (mNUTRIC) were used for screening nutritional risk at admission. Body Mass Index (BMI), Mild-Upper Arm Circumference (MUAC), and personal information were recorded. The feeding regimen of patients was monitored from the first to seventh day. Results: the patients were aged 66.5 ± 15.4 years, with an APACHEII of 13.0 ± 5.5 and SOFA 3.1 ± 2.6: 47.4% were malnutrition by MUAC, 16.2% had a severely low BMI (<17.8), 20.8% had low BMI (17.8 to <20). According to NRS2002 and mNUTRIC, the prevalence of patients with high nutritional risk was 53.9% and 13%, respectively. The proportion of patients receiving less than 25 kcal/kg/day was 84%, 60%, and 47% on the first, the fifth, and the seventh day. Protein intake below 1.3 g/kg/day was 50% on the seventh day. Up to 27.4% of patients had no nutrition support on the first day. Conclusions: ICU patients had nutritional risk with high rate. The feeding regimen for patients achieved a progressive energy and protein intake over the first 7 days.

Optimal Nutritional Support Strategy Based on the Association between Modified NUTRIC Score and 28-Day Mortality in Critically Ill Patients: A Prospective Study

Malnutrition in critically ill patients is closely linked with clinical outcomes. During acute inflammatory states, nutrition cannot reverse the loss of body cell mass completely. Studies on nutritional screening and strategy considering metabolic changes have not yet been conducted. We aimed to identify nutrition strategies using the modified Nutrition Risk in the Critically ill (mNUTIRC) score. Nutrition support data, laboratory nutrition indicators, and prognosis indices were prospectively collected on the 2nd and 7th day after admission. It was to identify the effect of the changes on the metabolic status and critical target of nutrition intervention. To discriminate the high-risk group of malnutrition, receiver operating characteristic curves were plotted. Risk factors associated with 28 day-mortality were evaluated using multivariable Cox proportional hazards regression. A total of 490 and 266 patients were analyzed on the 2nd and 7th day, respectively. Only the mNUTRIC score showed significant differences in nutritional risk stratification. The use of vasopressors, hypoprotein supply (<1.0 g/kg/day), high mNUTRIC score, and hypoalbuminemia (<2.5 mg/dL) in the recovery phase were strongly associated with a 28-day mortality. The implementation of the mNUTRIC score and protein supply in the post-acute phase is critical to improve 28-day mortality in critically ill patients.

[Parenteral supplementation with EPA/DHA omega-3 fatty acids improves recovery prognosis in critically ill patients]

Introduction

Introduction: the decision to supplement total parenteral nutrition (TPN) with emulsions of omega-3 (Ω3) eicosapentaenoic (EPA) and docosahexaenoic (DHA) fatty acids (FA) of marine origin is based on the clinical benefits obtained in different medical situations and surgical procedures, among which reductions in hospital stay, days of mechanical ventilation, incidence of infections and mortality stand out. However, the evidence in critically ill patients remains contradictory. Objective: the objective of this clinical trial was to analyze the effect of supplementation with EPA/DHA Ω3 FAs on clinical prognostic markers - medical, nutritional and biochemical - in critically ill patients, relating to outcome. Method: a clinical, controlled, randomized, single-center trial in 64 critically ill adult patients, of which 47 patients were randomized to receive TPN supplemented with EPA/DHA Ω3 FAs in doses of 0.1 g/kg/day (n = 23) and 0.2 g/kg/day (n = 24), compared with a historical control group with TPN without supplementation (n = 17). Clinical prognosis markers were determined at baseline and at the end of nutritional support (medical, nutritional and biochemical). Results: the two groups with supplementation showed a statistically significant reduction in mortality (p < 0.005); the clinical prognostic markers SOFA, APACHE II, SAPS 3, NUTRIC, RTL and CRS were consistent in showing a significant improvement (p < 0.005), of prognosis with doses of 0.1 and 0.2 g/kg/day of EPA/DHA Ω3 FAs, respectively. Conclusion: supplementation of parenteral nutrition with EPA/DHA Ω3 fatty acids at doses of 0.1 g and 0.2 g/kg/day improves recovery prognosis and the probability of survival in critically ill patients.

The global leadership initiative on malnutrition criteria for the diagnosis of malnutrition in patients admitted to the intensive care unit: A systematic review and meta-analysis

BACKGROUND

Malnutrition is associated with a high risk of morbidity and mortality in patients with critical illness. The nutrition status of patients in the intensive care unit (ICU) is challenging to assess. The Global Leadership Initiative on Malnutrition (GLIM) is a novel framework used for the diagnosis of malnutrition. However, its efficacy in patients with critical illness in the ICU has not been validated.

AIM

To investigate the use and validity of the GLIM criteria in adult patients admitted to the ICU.

METHODS

A systematic review and meta-analysis were performed, and seven databases were searched for relevant studies. The selection criteria included studies that used the GLIM in adult patients admitted to the ICU. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

RESULTS

Five studies were included in the analysis. Approximately 15%-68% of patients were diagnosed with malnutrition using the GLIM criteria. Meanwhile, 48%-75% of patients with malnutrition were identified with the Subjective Global Assessment (SGA). The inflammation criterion was easily adjudicated due to critical status, and three studies compared the GLIM and the SGA. According to the QUADAS-2 tool, the nutritional assessment process was not explicit in the studies. The meta-analysis had an overall sensitivity of 65.3% (95% CI: 34.9%-86.9%) and an overall specificity of 88.8% (95% CI: 58.1%-97.8%). In the prospective validation, malnutrition assessed by the GLIM criteria, and the SGA was associated with mortality. However, the association between length of hospital stay and mechanical ventilation was unclear.

CONCLUSIONS

The use and validity of the GLIM criteria among patients admitted to the ICU is still limited. Moreover, some concurrent and predictive validation studies have methodological limitations. Further studies must be performed to validate the use of the GLIM criteria in the ICU.

Importance of nutritional assessment tools in the critically ill patient: A systematic review

Background

Among the risks of the critically ill patient, one of the aspects to be taken into account is the high probability of occurrence of malnutrition risk (40-50%). This process leads to increased morbimortality and worsening. The use of assessment tools allows the individualization of care.

Objective

To analyze the different nutritional assessment tools used during the admission of critically ill patients.

Methods

Systematic review of the scientific literature related to the nutritional assessment of critically ill patients. Between January 2017 and February 2022, articles were rescued from the electronic databases "Pubmed," "Scopus," "CINAHL" and "The Cochrane Library"; which will analyze which instruments are used during nutritional assessment in the ICU, as well as their impact on mortality and comorbidity of patients.

Results

The systematic review was made up of 14 scientific articles that met the selection criteria, obtained from seven different countries. The instruments described were: mNUTRIC, NRS 2002, NUTRIC, SGA, MUST and the ASPEN and ASPEN criteria. All the included studies demonstrated beneficial effects after nutritional risk assessment. mNUTRIC was the most widely used assessment instrument, with the best predictive validity for mortality and adverse outcomes.

Conclusion

The use of nutritional assessment tools makes it possible to know the real situation of patients, and by objectifying situations, to allow different interventions to improve the nutritional level of patients. The best effectiveness has been achieved using tools such as mNUTRIC, NRS 2002 and SGA.

Low phase angle in critically ill older patients is associated with late mortality: A prospective study

OBJECTIVES

The aim of this study was to ascertain the accuracy of phase angle (PhA) as a predictor of mortality during intensive care unit (ICU) stay (M_ICU) and at 28 (M₂₈) and 60 d (M₆₀) after ICU admission among patients aged >60 y.

METHODS

Patients aged >60 y who were under mechanical ventilation (MV) ≥48 h were included once they were hemodynamically stable. PhA was measured by single-frequency bioelectrical impedance analysis up to 48 h after admission. ICU prognostic scores, functional scale, and nutritional assessments were performed in the first 24 h. Patients were followed for 60 d after ICU admission.

RESULTS

We enrolled 102 patients into the present study. PhA was significantly higher (P < 0.001) in survivors at M_ICU, M₂₈, and M₆₀. Areas under the receiving operator characteristic curves for M_ICU, M_28, and M₆₀ were 0.77 (95% confidence interval [CI], 0.67-0.86), 0.71 (95% CI, 0.60-0.82), and 0.71 (95% CI, 0.60-0.81), respectively. The PhA cutoff to predict mortality was 3.29° for males at M_ICU, M₂₈, and M₆₀ and lower for females at M₂₈ (2.63°) and M₆₀ (3.01°). PhA better discriminated M₆₀ than conventional prognostic scores. Logistic regression showed that even after controlling for other factors, PhA was a protective factor against late mortality. Survival analysis at 60 d revealed that low PhA was associated with lower median survival (18 versus 58 d; log-rank P < 0.001).

CONCLUSIONS

Low PhA values are associated with higher late mortality and a short survival time at 60 d in critically ill older adults. Low PhA values can be considered a useful ICU prognostic score in similar populations.

Evaluation of the effectiveness of the modified nutrition risk in the critically ill (mNUTRIC) score in critically ill patients affected by COVID-19 admitted to the intensive care unit (ICU)

BACKGROUND

COVID-19 is a very harmful pandemic, and its recovery process is highly influenced by nutritional status; however, an appropriate nutritional scale has not yet been proposed for these patients. Therefore, the purpose of this study was to evaluate the effectiveness of the modified Nutrition Risk in the Critically ill (mNUTRIC) score in critically ill patients affected by COVID-19 admitted to the intensive care unit (ICU).

MATERIAL AND METHODS

This was a cross-sectional study performed on 204 critically ill patients affected by COVID-19 admitted to the ICU wards. Evaluated indicators include the mNUTRIC Score as well as demographic, and biochemical indicators.

RESULTS

A high percentage of COVID-19 patients (67.2%) had severe disease. Hospital and ICU stay (p > 0.001) and PH (p > 0.001) values were significantly lower in non-survivors than in survivors. mNUTRIC score (p > 0.001), PCO2 (p = 0.003), and CRP levels (p = 0.021) were significantly higher in non-survivors than survivors. mNUTRIC score had a direct correlation with age (p > 0.001), AST (p = 0.000), LDH (p = 0.026), and CRP (p = 0.014) and an inverse correlation with hospital duration (p = 0.031), albumin (p = 0.003) and PH (p < 0.001). Furthermore, there was a non-significant correlation between the mNUTRIC score and mortality chance (OR = 1.085, 95%CI [0.83, 1.42], p = 0.552). While, patients with more severe COVID-19 disease (OR = 8.057, 95%CI [1.33, 48.64], p = 0.023) and higher PCO2 (OR = 1.042, 95%CI [1.01, 1.08], p = 0.023) levels had higher odds of mortality.

CONCLUSIONS

Our findings revealed that COVID-19 patients with higher CRP levels and lower PH had higher mortality and poor nutritional condition. Moreover, there was a non-significant association between the mNUTRIC score and mortality chance.

Prognostic significance of malnutrition risk in elderly patients with acute kidney injury in the intensive care unit

BACKGROUND

Malnutrition is common in critically ill patients, but nutrition status in critically ill patients with acute kidney injury (AKI) has been poorly studied. Our study aimed to investigate the relationship between malnutrition risk and the occurrence and prognosis of AKI in elderly patients in the intensive care unit (ICU).

METHODS

Data were extracted from the Beijing Acute Kidney Injury Trial (BAKIT). A total of 1873 elderly patients were included and compared according to the clinical characteristics of AKI and non-AKI groups, and those of survivors and non-survivors of AKI in this study. Receiver operating characteristic (ROC) curves were used to analyse the predictive value of the modified Nutrition Risk in Critically Ill (mNUTRIC) score for the occurrence and 28-day prognosis of AKI. Multivariate Cox regression analysis was used to evaluate the effect of the mNUTRIC score on the 28-day mortality in AKI patients.

RESULTS

Compared with the non-AKI group, AKI patients had higher mNUTRIC scores, and non-survivors had higher mNUTRIC scores than survivors in AKI population. Moreover, multivariate Cox regression showed that 28-day mortality in AKI patients increased by 9.8% (95% CI, 1.018-1.184) for every point increase in the mNUTRIC score, and the mNUTRIC score had good predictive ability for the occurrence of AKI and 28-day mortality in AKI patients. The mortality of AKI patients with mNUTRIC > 4 was significantly increased.

CONCLUSIONS

The elderly patients are at high risk of malnutrition, which affects the occurrence and prognosis of AKI. Adequate attention should be given to the nutritional status of elderly patients.

TRIAL REGISTRATION

This study was registered at www.chictr.org.cn (registration number Chi CTR-ONC-11001875) on 14 December 2011.

Practical parameters that can be used for nutritional assessment in patients hospitalized in the intensive care unit with the diagnosis of chronic obstructive pulmonary disease: Prognostic nutritional index, neutrophil-to-lymphocyte, platelet-to-lymphocyte, and lymphocyte-to-monocyte ratio

Malnutrition is an important condition in patients diagnosed with chronic obstructive pulmonary disease (COPD). There is a need for practical and objective nutritional assessment methods in patients hospitalized in the intensive care unit with the diagnosis of COPD. In this study, it was aimed to determine the parameters that can practically evaluate the nutritional status of these patients. It was aimed to determine the relationship between prognostic nutritional index (PNI), and nutritional risk screening (NRS)-2002, nutrition risk in the critical ill (Nutric) Score and to determine a cut-off value for PNI, neutrophil-to-lymphocyte (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and other complete blood count parameters.Hemogram values, albumin values, NLR, PLR, LMR, NRS-2002, PNI and modified Nutric Score calculations of the patients hospitalized in the intensive care unit due to COPD were recorded. The relationship between PNI and NRS-2002 and modified Nutric Score, as well as the relationship between NLR, PLR, LMR, hemogram parameters and PNI were analyzed using statistical methods.The PNI cut-off value for nutritional assessment in patients hospitalized in the intensive care unit due to COPD was determined as 38.5 (area under curve = 0.891, sensitivity 80.8%, specificity 88.1%, positive predictive value 92.9%, negative predictive value 88%). High-risk group according to PNI compared to low-risk group, lymphocyte count (P < .001), basophil count (P = .004), red blood cell (P < .001), hemoglobin (P < .001), hematocrit (P < .001), and LMR (P = .001) were statistically significantly lower, while NLR (P < .001) and PLR (P = .001) were statistically significantly higher. Cut-off values for lymphocyte count, basophil count, NLR, PLR, and LMR were found to be 1.18, 0.035, 7.97, 291.10, and 2.606, respectively.Nutritional risk assessment can be made in a practical way by using PNI in patients hospitalized in intensive care unit due to COPD. For this, the PNI cut-off value was determined as 38.5 in our study. In addition, NLR, PLR, LMR, basophil and lymphocyte values, which can be calculated using complete blood count parameters, may also be useful in the evaluation of nutritional status in these patients. In our study, the cut-off values determined for NLR, PLR, LMR, basophil and lymphocyte were 7.97, 291.10 and 2.606, 0.035 and 1.18, respectively. We think that the results we have obtained can provide preliminary information for future research.

Malnutrition Screening and Assessment

Malnutrition is a serious problem with a negative impact on the quality of life and the evolution of patients, contributing to an increase in morbidity, length of hospital stay, mortality, and health spending. Early identification is fundamental to implement the necessary therapeutic actions, involving adequate nutritional support to prevent or reverse malnutrition. This review presents two complementary methods of fighting malnutrition: nutritional screening and nutritional assessment. Nutritional risk screening is conducted using simple, quick-to-perform tools, and is the first line of action in detecting at-risk patients. It should be implemented systematically and periodically on admission to hospital or residential care, as well as on an outpatient basis for patients with chronic conditions. Once patients with a nutritional risk are detected, they should undergo a more detailed nutritional assessment to identify and quantify the type and degree of malnutrition. This should include health history and clinical examination, dietary history, anthropometric measurements, evaluation of the degree of aggression determined by the disease, functional assessment, and, whenever possible, some method of measuring body composition.

[Assessment and technical monitoring of nutritional status of patients in intensive and intermediate care units : Position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI)]

Die Erhebung des Ernährungsstatus zum Zeitpunkt der Aufnahme im Intensiv- oder Intermediate Care Bereich hat sowohl prognostische als auch therapeutische Relevanz im Hinblick auf die Planung einer individualisierten medizinischen Ernährungstherapie (engl. „medical nutrition therapy“, MNT). Diese Planung wird im Rahmen der Erstversorgung eines vital bedrohlichen Krankheitsbilds nachvollziehbar nicht priorisiert, jedoch im weiteren Verlauf häufig auch oft nicht mehr angemessen durchgeführt. Vor allem bei längerer Verweildauer besteht das Risiko einer Mangelernährung mit Aufbau eines kumulativen, prognoserelevanten Makro- und/oder Mikronährstoffdefizits. Bisher gibt es für Patient*innen auf Intensiv- und Intermediate Care Einheiten keine strukturierten Empfehlungen zur Erhebung des Ernährungsstatus. Das vorliegende Positionspapier der Sektion Metabolismus und Ernährung der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) beinhaltet konsensbasierte Empfehlungen zur Erfassung und zum apparativen Monitoring des Ernährungsstatus von Patient*innen auf Intensiv- und Intermediate Care Stationen. Diese Empfehlungen ergänzen die aktuelle S2k-Leitlinie „Klinische Ernährung in der Intensivmedizin“ der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) und der DIVI.

Preoperative Point-of-Care Ultrasound to Identify Frailty and Predict Postoperative Outcomes: A Diagnostic Accuracy Study

BACKGROUND

Frailty is increasingly being recognized as a public health issue, straining healthcare resources and increasing costs to care for these patients. Frailty is the decline in physical and cognitive reserves leading to increased vulnerability to stressors such as surgery or disease states. The goal of this pilot diagnostic accuracy study was to identify whether point-of-care ultrasound measurements of the quadriceps and rectus femoris muscles can be used to discriminate between frail and not-frail patients and predict postoperative outcomes. This study hypothesized that ultrasound could discriminate between frail and not-frail patients before surgery.

METHODS

Preoperative ultrasound measurements of the quadriceps and rectus femoris were obtained in patients with previous computed tomography scans. Using the computed tomography scans, psoas muscle area was measured in all patients for comparative purposes. Frailty was identified using the Fried phenotype assessment. Postoperative outcomes included unplanned intensive care unit admission, delirium, intensive care unit length of stay, hospital length of stay, unplanned skilled nursing facility admission, rehospitalization, falls within 30 days, and all-cause 30-day and 1-yr mortality.

RESULTS

A total of 32 patients and 20 healthy volunteers were included. Frailty was identified in 18 of the 32 patients. Receiver operating characteristic curve analysis showed that quadriceps depth and psoas muscle area are able to identify frailty (area under the curve-receiver operating characteristic, 0.80 [95% CI, 0.64 to 0.97] and 0.88 [95% CI, 0.76 to 1.00], respectively), whereas the cross-sectional area of the rectus femoris is less promising (area under the curve-receiver operating characteristic, 0.70 [95% CI, 0.49 to 0.91]). Quadriceps depth was also associated with unplanned postoperative skilled nursing facility discharge disposition (area under the curve 0.81 [95% CI, 0.61 to 1.00]) and delirium (area under the curve 0.89 [95% CI, 0.77 to 1.00]).

CONCLUSIONS

Similar to computed tomography measurements of psoas muscle area, preoperative ultrasound measurements of quadriceps depth shows promise in discriminating between frail and not-frail patients before surgery. It was also associated with skilled nursing facility admission and postoperative delirium.

EDITOR’S PERSPECTIVE

A high neutrophil to lymphocyte ratio at ICU admission is associated with nutritional risk in COVID-19 patients

Background

Inflammation plays a crucial role in nutrition status and can be useful in early nutrition risk screening of patients during the coronavirus disease 2019 (COVID‐19) pandemic. Thus, this study aimed to assess the association between systemic inflammatory markers and nutrition risk tools in intensive care unit (ICU) patients with COVID‐19.

Methods

Patients with confirmed COVID‐19 and ICU admission were enrolled in a retrospective, observational, cross‐sectional study. The medians of C‐reactive protein (CRP; ≥13.8 mg/dl) and the neutrophil‐to‐lymphocyte ratio (NLR; ≥12.6) upon admission were used to dichotomize patients.

Results

Of the 73 patients, 63% were men; the average age was 56 years, and the median length of hospital stay was 10 (25th: 4; 75th: 17) days. When nutrition risk screening tools were used, 85% were at risk according to Nutritional Risk Screening (≥3 points), whereas 42% had high risk according to the Modified Nutrition Risk in the Critically Ill (mNUTRIC; ≥5 points), and 57% were moderately or severely malnourished according to the Subjective Global Assessment (B or C). Mortality was higher in the group with NLR ≥12.6 than in the group with NLR <12.6, with no difference between CRP groups. A significant association was found only between NLR and mNUTRIC, even when adjusted by sex, age, and body mass index (odds ratio, 1.36; 95% CI, 1.06–1.76; P = 0.016), but not between CRP and nutrition risk.

Conclusion

Although the inflammatory marker CRP is the most used in hospital clinical practice, we found that only NLR was associated with nutrition risk (NUTRIC score).

Nutrition support for critically ill patients

Nutrition support is an important aspect of the management of critically ill patients. This review highlights the emerging evidence on critical care nutrition and focuses on the pathophysiologic interplay between critical illness, the gastrointestinal tract, and nutrition support and the evidence on the best route, dose, and timing of nutrition. Although indirect calorimetry is recommended to measure energy expenditure, predictive equations are commonly used but are limited by their inaccuracy in individual patients. The current evidence supports early enteral nutrition (EN) in most patients, with a gradual increase in the daily dose over the first week. Delayed EN is warranted in patients with severe shock. According to recent trials, parenteral nutrition seems to be as effective as EN and may be started if adequate EN is not achieved by the first week of critical illness. A high protein dose has been recommended, but the best timing is unclear. Immuno-nutrition should not be routinely provided to critically ill patients. Patients receiving artificial nutrition should be monitored for metabolic derangements. Additional adequately powered studies are still needed to resolve many unanswered questions.

Use of modified-NUTRIC score to assess nutritional risk in surgical intensive care unit

BACKGROUND

Modified Nutrition Risk in the Critically Ill (m-NUTRIC) score is used to evaluate the nutritional risk of patients in intensive care units (ICUs). This study aimed to investigate whether m-NUTRIC can be used as a predictive factor related to the outcome of patients in surgical ICU (SICU) and to identify which patients will benefit from aggressive nutritional intervention according to the results of m-NUTRIC score.

METHODS

A total of 205 patients who were admitted to surgical ICU (SICU) with ventilator use for more than 24 hours were enrolled. The m-NUTRIC score data were calculated the day when the patients were admitted to SICU. Patients were divided into two groups according to their m-NUTRIC score: the low-risk group (<5 points, 116 patients) and the high risk group (≥5 points, 89 patients).

RESULTS

In this study, a total of 205 patients were enrolled for analysis, including patients in the low-risk group (n = 116) and those in the high risk group (n = 89). The mean duration of ventilator use was 3.6 ± 6.5 days, and average SICU stays for all patients was 5.1 ± 7.4 days. The SICU mortality was significantly higher in the high-risk group (10.3% vs 1.7%). Comparison between survivals and nonsurvivals was carried out, and the data showed that the AKI, Vasopressors, SOFA, APACHE-II, m-NUTRIC score, and shock patient were all significantly associated with higher mortality. The multivariate analysis revealed that acute kidney injury (OR = 13.16; 95% confidence intervals = 3.69-46.92; p < 0.0001) and m-NUTRIC score were independent factors of ICU mortality in these patients. A receiver operating characteristic curve was used to calculate the area under the curve, which was 0.801. The data indicated that high m-NUTRIC score were significantly associated with SICU mortality with the cutoff score > 4 (sensitivity = 90.5%, specificity = 62.3%, p < 0.001).

CONCLUSION

We found in this study that the high m-NUTRIC score is an independent factor of ICU mortality, and m-NUTRIC score can be used as an initial screening tool for nutritional assessment in patients admitted to surgical ICU. Further investigations to evaluate whether the aggressive nutritional intervention would be beneficial in the SICU patients with higher m-NUTRIC score is mandatory.

Association between nutrition delivery, modified Nutrition Risk in Critically Ill score, and 28-day mortality

BACKGROUND

Nutrition delivery, is a key component in the management of critical illness. Traditional scoring systems are inadequate in the intensive care unit (ICU), as patients are sedated. Our study examines the associations between calorie and protein adequacy, 28-day mortality, and modified Nutrition Risk in Critically Ill (mNUTRIC) score and identify at-risk ICU patients who may benefit more from nutrition intervention.

METHODS

Prospective observational study of adults admitted for >24h to the ICU of a tertiary care hospital during a period of 7 months. Data were collected on nutrition delivery, mNUTRIC score, use of mechanical ventilation, and ICU/hospital length of stay (LOS). Multivariate logistic regression analysis was done with 28-day mortality as the primary outcome.

RESULTS

Two hundred forty-eight patients were recruited for the study with 60% male, 40% female, mean age 60.8 ± 14.7, and body mass index of 24.2 ± 4.8. Patients with inadequate calorie and protein delivery had significantly higher 28-day mortality than those with adequate provision (P=.032 and P =. 017). In bivariate logistic regression analysis, mNUTRIC score (odds ratio [OR], 1.802; 95% CI, 1.042-3.117; P = .035) and adequacy of energy (OR, 1.92) and protein (OR, 2.49) correlate with 28-day mortality. The Kaplan-Meier survival curve showed a survival benefit in the ≥80% energy and protein group among the total patients and was also significantly associated with lower hospital and ICU LOS, even after matching (log-rank test, P < 0.001).

CONCLUSION

Adequacy of energy and protein to ≥80% may shorten ICU/hospital LOS and reduce 28-day mortality among both high and low nutrition risk patients.

Translation and adaptation of the modified NUTRIC score for critically ill patients

BACKGROUND & AIMS

Some critically ill patients are at high nutritional risk, and early identification of these patients is needed to reduce morbidity and mortality related to underfeeding. The Modified NUTrition Risk in Critically ill (mNUTRIC) score is the first nutritional risk assessment tool developed and validated specifically for ICU patients. This study aims to translate and adapt the Modified NUTRIC (mNUTRIC) Score into Persian to facilitate use in Iranian Intensive Care Units and assess its efficiency in a pilot sample.

METHOD

The translation process followed standardized steps: initial translation, synthesis of translations, back -translation to the English language, revision and cultural adaptation of the tool by language specialist and expert committee. A pilot study was conducted on the application of the tool in 46 critically ill patients from three ICUs in Iran hospitals.

RESULTS

The translation and adaptation process generated a feasible version of the mNUTRIC Score in the Persian language.The translated version was easily introduced into Iranian ICUs. The prevalence of patients with a mNUTRIC score of five or more was 43% (n = 46).

CONCLUSION

Translation of mNUTRIC Score from English into Persian, following internationally accepted methodology, has provided the ICU care in Iran with a comprehensive and useful instrument.

Risks in Management of Enteral Nutrition in Intensive Care Units: A Literature Review and Narrative Synthesis

Critically ill patients in the intensive care unit (ICU) have a high risk of developing malnutrition, and this is associated with poorer clinical outcomes. In clinical practice, nutrition, including enteral nutrition (EN), is often not prioritized. Resulting from this, risks and safety issues for patients and healthcare professionals can emerge. The aim of this literature review, inspired by the Rapid Review Guidebook by Dobbins, 2017, was to identify risks and safety issues for patient safety in the management of EN in critically ill patients in the ICU. Three databases were used to identify studies between 2009 and 2020. We assessed 3495 studies for eligibility and included 62 in our narrative synthesis. Several risks and problems were identified: No use of clinical assessment or screening nutrition assessment, inadequate tube management, missing energy target, missing a nutritionist, bad hygiene and handling, wrong time management and speed, nutritional interruptions, wrong body position, gastrointestinal complication and infections, missing or not using guidelines, understaffing, and lack of education. Raising awareness of these risks is a central aspect in patient safety in ICU. Clinical experts can use a checklist with 12 identified top risks and the recommendations drawn up to carry out their own risk analysis in clinical practice.

Validation of GLIM malnutrition criteria for diagnosis of malnutrition in ICU patients: An observational study

BACKGROUND & AIMS

Patients in the Intensive Care Unit (ICU) are at high risk of malnutrition. The only validated malnutrition assessment tool is the Subjective Global Assessment (SGA). The Global Leadership Initiative on Malnutrition (GLIM) is a new malnutrition assessment tool. The present study compares the nutrition-related parameters of the following tools: GLIM tool, SGA, Phase Angle (PA), Low Fat-Free Mass Index (FFMI), and Patient- and Nutrition-Derived Outcome Risk Assessment score (PANDORA), in an attempt to validate an objective tool.

METHODS

Eighty-four ICU patients were included. The tools mentioned above were assessed for their validity in diagnosing malnutrition. All patients were defined as suffering from acute disease and received medical nutrition therapy. To evaluate whether there is a correlation between the GLIM criteria, SGA, PA, and low FFMI, we compared the SGA, PA, and low FFMI to the GLIM criteria using Spearman correlation coefficients and a Chi-square test. Also, a Mann-Whitney U test was used to test the mean differences between the GLIM criteria and the PANDORA. The area under the curve (AUC) of the proposed parameters was evaluated for diagnosis of malnutrition to seek cutoff points that yield good sensitivity and specificity.

RESULTS

Mean age was 50 ± 20 years, BMI 25.3 ± 5.1 kg/m², APACHE II 20.5 ± 7.7, PANDORA score 32 ± 8.5. GLIM malnutrition criteria were significantly correlated with the gold standard SGA assessment and with low FFMI, with PA (Phase Angle), and with the PANDORA score. The area under the curve, by using the ROC curve analysis for GLIM criteria stratified by the SGA results, was 0.85 (P < 0.001). Sensitivity was 85%, and specificity 79%. However, when comparing the low FFMI, PA, and PANDORA to the GLIM criteria, the ROC curve analysis results were considered poor rank.

CONCLUSIONS

The SGA malnutrition assessment highly validated the GLIM criteria framework combined with the two-criteria diagnosis of malnutrition with a high level of precision. The GLIM malnutrition assessment seems to be acceptable in the ICU setting.

Nutritional Assessment: A Primary Component of the Multidimensional Geriatric Assessment in the Intensive Care Unit

The importance of evaluating and adjusting the nutritional state of critically ill patients has become a core principle of care. This article focuses on tools for the nutritional assessment of geriatric intensive care unit patients, including a review of imaging and other standardized techniques for evaluation of muscle mass, an indicator of malnutrition and sarcopenia. It concludes with a discussion of the interplay of malnutrition, reduced muscle mass/sarcopenia, and frailty. The goal of this multidimensional assessment is to identify those at risk and thereby initiate interventions to improve outcomes.

Comparison of Modified NUTRIC, NRS-2002, and MUST Scores in Iranian Critically Ill Patients Admitted to Intensive Care Units: A Prospective Cohort Study

BACKGROUND

There are no data on the validity of the modified Nutrition Risk in the Critically Ill (m-NUTRIC)-score and Nutritional Risk Screening 2002 (NRS-2002)-score in Iranian intensive care unit (ICU) patients. The Malnutrition Universal Screening Tool (MUST) is still used in most Iranian ICUs. Our goal was to test the validity of these tools in the Iranian ICU population.

METHODS

The association between nutrition risk scores and outcomes (longer length of stay [LOS], prolonged mechanical ventilation [MV], and 28-day mortality) was assessed using the multivariable logistic regression. The performance of nutrition risk tools to predict 28-day mortality was assessed using the receiver operating characteristic curve. A logistic regression model was used to test the interaction between nutrition risk category, energy adequacy, and 28-day mortality.

RESULTS

Four hundred forty patients were included. Both the m-NUTRIC and NRS-2002 scores were significantly associated with all 3 outcomes (all P < .001). However, no significant association was identified between the MUST and all 3 outcomes (P > .05). The area under the curve for predicting 28-day mortality was 0.806 (95% CI, 0.756-0.851), 0.695 (95% CI, 0.632-0.752), and 0.551 (95% CI, 0.483-0.612) for m-NUTRIC, NRS-2002, and MUST, respectively. Greater energy adequacy was associated with a lower 28-day mortality rate in patients with high m-NUTRIC but not in those with low m-NUTRIC score (P interaction = .015).

CONCLUSION

In the Iranian ICU population, the m-NUTRIC score may be a valid tool for identifying patients who would benefit from more aggressive nutrition therapy.

Use of Nutrition Risk in Critically Ill (NUTRIC) Scoring System for Nutrition Risk Assessment and Prognosis Prediction in Critically Ill Neurological Patients: A Prospective Observational Study

BACKGROUND

Critically ill patients who are hospitalized in a neurological intensive care unit (NICU) are largely susceptible to nutrition risk. However, only a limited number of studies have investigated the applicable assessment tool in NICUs.

METHODS

This was a prospective observational study conducted at a single-center NICU. A total of 140 adult patients who were hospitalized for >24 hours were enrolled. The Nutritional Risk Screening 2002, Nutrition Risk in the Critically ill (NUTRIC), and modified NUTRIC (mNUTRIC) scores were applied for the assessment of nutrition risk. Analyses of multivariable logistic regression were performed by considering a 28-day mortality as the outcome of interest.

RESULTS

Nutrition risk was commonly identified in NICU patients. Multivariate analysis revealed that age ≥60 years, hospital infection, mechanical ventilation, and high nutrition risk (mNUTRIC score ≥ 5) independently increased 28-day mortality in NICU patients. For subgroups of patients with a prolonged length of stay, high nutrition risk (mNUTRIC score ≥ 5) has always been an independent risk factor of 28-day mortality. Both NUTRIC and mNUTRIC scores were able to predict 28-day mortality, with area under the receiver operating characteristic curves of 0.857 (95% CI, 0.786-0.928) and 0.856 (95% CI, 0.786-0.927), respectively.

CONCLUSION

The mNUTRIC scoring system is not only a useful tool for nutrition risk assessment but also, and more importantly, it is independently related to the risk of 28-day mortality in NICU patients. Therefore, mNUTRIC scoring is an appropriate tool for nutrition risk assessment and prognosis prediction of NICU patients.

Under-Recognizing Malnutrition in Hospitalized Obese Populations: The Real Paradox

PURPOSE OF REVIEW

Obesity and malnutrition are frequently encountered in the hospitalized population. Although malnutrition associated with low or normal body mass index (BMI) is easily identified, malnutrition in obese patients goes frequently unrecognized as their fat mass masks underlying muscle mass deterioration. The purpose of this review is to explore if malnutrition has been studied in the obese hospitalized population and if that may be one of the reasons for the variable results in the obesity outcome data.

RECENT FINDINGS

Various studies have shown a conflicting association between obesity and outcomes in hospitalized patient population. Most prior studies used BMI alone as an indicator of obesity and although some recent studies have included body fat percentage, muscle mass, and functional status, they still showed variable outcomes. Unfortunately, there are not many studies that looked into nutrition status specifically in obese patients to study the outcomes. Studies evaluating clinical outcomes in obese patients showed a wide range of outcomes; some showed a protective effect while others were neutral. We explored recent data about obesity, malnutrition, and outcomes, where researchers more precisely defined malnutrition and obesity to determine health outcomes.

Two variants of the Nutritional Risk in the Critically Ill Score as predictors of mortality in Intensive Care Unit patients at a Brazilian University Hospital

ABSTRACT Objective To evaluate the agreement between the modified version of the Nutritional Risk in the Critically Ill Score (without Interleukin-6) and a variant composed of C-Reactive Protein as well as its capacity to predict mortality. Methods A prospective cohort study was carried out with 315 patients in an Intensive Care Unit of a university hospital from October 2017 to April 2018. The agreement between the instruments was evaluated using the Kappa test. The predictive capacity for estimating mortality was assessed with the Receiver Operating Characteristic curve. Results The critical patients involved in the study had a mean age of 60.8±16.3 years and 53.5% were female. Most patients had C-Reactive Protein levels ?10mg/dL (n=263, 83.5%) and their admission in the Intensive Care Unit was medical (n=219, 69.5%). The prevalence of mortality was observed in 41.0% of the evaluated patients. The proportions at high nutritional risk according to Nutritional Risk in the Critically Ill without Interleukin-6 and with C-Reactive Protein were 57.5% and 55.6%, respectively. The tools showed strong and significant agreement(Kappa=0.935; p=0.020) and satisfactory performances in predicting mortality (area under the curve 0.695 [0.636-0.754] and 0.699 [0.640-0.758]). Conclusion Both versions of the Nutritional Risk in the Critically Ill tool show a satisfactory agreement and performance as predictors of mortality in critically ill patients. Further analysis of this variant and the association between nutrition adequacy and mortality is needed.

Assessment of Nutritional Status in the Critically Ill

How to cite this article: Narayan SK, Gudivada KK, Krishna B. Assessment of Nutritional Status in the Critically Ill. Indian J Crit Care Med 2020;24(Suppl 4):S152-S156.

Nutrition Risk Screening in Intensive Care Units: Agreement Between NUTRIC and NRS 2002 Tools

BACKGROUND

The American Society for Parenteral and Enteral Nutrition recommends nutrition screening in patients admitted to the intensive care unit (ICU) and indicates the use of 2 tools: Nutritional Risk Screening 2002 (NRS 2002) or Nutrition Risk in the Critically Ill (NUTRIC). This study aims to compare nutrition risk detected by NRS 2002 and NUTRIC to identify whether both tools are equivalent for clinical practice in the ICU.

METHODS

A retrospective cohort study was conducted in 2 hospital centers in the south of Brazil. Adult patients (≥18 years old) who stayed in the ICU for >24 hours were included. NUTRIC and NRS 2002 were compared with each other for their agreement in screening for nutrition risk.

RESULTS

The study included 208 patients, most of them male (63.5%). The comparison between both nutrition screening tools showed fair agreement (κ = 0.39). Nearly half of the patients were classified at high nutrition risk by NUTRIC (47.6%), whereas only approximately one-third of the sample was classified similarly by NRS 2002 (35.6%).

CONCLUSION

Despite the ability to identify patients with high nutrition risk, NUTRIC and NRS 2002 performed differently and were not concordant, suggesting that are not equivalent for clinical practice in the ICU.

Complementarity of modified NUTRIC score with or without C-reactive protein and subjective global assessment in predicting mortality in critically ill patients

OBJECTIVE

To evaluate the concordance between the modified NUTRIC and NUTRIC with C-reactive protein instruments in identifying nutritional risk patients and predicting mortality in critically ill patients. The risk of death in patient groups was also investigated according to nutritional risk and malnutrition detected by subjective global assessment.

METHODS

A cohort study of patients admitted to an intensive care unit. Nutritional risk was assessed by modified NUTRIC and a version of NUTRIC with C-reactive protein. Subjective global assessment was applied to diagnose malnutrition. Kappa statistics were calculated, and an ROC curve was constructed considering modified NUTRIC as a reference. The predictive validity was assessed considering mortality in 28 days (whether in the intensive care unit or after discharge) as the outcome.

RESULTS

A total of 130 patients were studied (63.05 ± 16.46 years, 53.8% males). According to NUTRIC with C-reactive protein, 34.4% were classified as having a high score, while 28.5% of patients had this classification with modified NUTRIC. According to SGA 48.1% of patients were malnourished. There was excellent agreement between modified NUTRIC and NUTRIC with C-reactive protein (Kappa = 0.88, p < 0.001). The area under the ROC curve was equal to 0.942 (0.881 - 1.000) for NUTRIC with C-reactive protein. The risk of death within 28 days was increased in patients with high modified NUTRIC (HR = 1.827; 95%CI 1.029 - 3.244; p = 0.040) and NUTRIC with C-reactive protein (HR = 2.685; 95%CI 1.423 - 5.064; p = 0.002) scores. A high risk of death was observed in patients with high nutritional risk and malnutrition, independent of the version of the NUTRIC score applied.

CONCLUSION

An excellent agreement between modified NUTRIC and NUTRIC with C-reactive protein was observed. In addition, combining NUTRIC and subjective global assessment may increase the accuracy of predicting mortality in critically ill patients.

Sarcopenia and Psychosocial Variables in Patients in Intensive Care Units: The Role of Nutrition and Rehabilitation in Prevention and Treatment

Critical illness leads to decline in muscle mass that promotes decline in physical function and psychological function and may lead to cognitive decline or dementia. Nurses are key to driving the multidisciplinary interventions that prevent protein loss and promote positive outcomes for critically ill patients.

Nutritional status of patients hospitalized in the intensive care unit: A comprehensive report from Iranian hospitals, 2018

INTRODUCTION AND AIM

Malnutrition is a complication of hospitalization in critically ill patients. This event is occurred because of disease and therapeutic processes for curing the patients. Determination of nutritional status helps physicians and clinical nutritionists decide on the best regimen which should be prescribed for a patient. In the current study, we aimed to report the nutritional status ofpatientshospitalizedin the intensive care unit (ICU).

METHOD OF STUDY

We used three standard tolls, including Subjective global assessment (SGA), Nutrition Risk in the Critically Ill (NUTRIC) Score and nutrition risk screening (NRS) questionnaires via a multi-stage sampling for different ICU wards of 32 university hospitals in Iran. Frequencies and rates of nutritional scores, comparative studies, and determined agreement of scoring systems and nutritional status in any ward of hospitals were evaluated.

RESULTS

There were 771 males and 540 female Cancer and trauma patients had the best and worst nutritional scores, respectively. Using NRS and NUTRIC, the low-risk scores were more frequent than thehigh-riskscores among ICU patients. SGA showed that most patients were in grades A (well nutritional status) or B (moderate nutritional status), andfew caseswere in grade C (poor nutritional status).The high-risk nutritional score wasobtained for older patients. NUTRIC and NRS had better agreement for diagnosis and differentiation of malnutrition than NUTRIC-SGA or NRS-SGA pairs. However, there was no strong agreement between the mentioned pairs.

CONCLUSION

Nutritional status of patients hospitalized in ICU wards in Iran wassomewhat better than other countries that this could be due to the highly observed guidelines of patient's care in Iran. Anyway,it is suggested that a more precise tool of nutritional scoresto be validated for patients hospitalized in ICU·In addition, better medical care needs a well evaluation of nutritional insufficiencies and what is necessary for compensation using complementary regimens.

Safety and efficacy of volume-based feeding in critically ill, mechanically ventilated adults using the 'Protein & Energy Requirements Fed for Every Critically ill patient every Time' (PERFECT) protocol: a before-and-after study

BACKGROUND

Underfeeding in critical illness is common and associated with poor outcomes. According to large prospective hospital studies, volume-based feeding (VBF) safely and effectively improves energy and protein delivery to critically ill patients compared to traditional rate-based feeding (RBF) and might improve patient outcomes. A before-and-after study was designed to evaluate the safety, efficacy and clinical outcomes associated with VBF compared to RBF in a single intensive care unit (ICU).

METHODS

The sample included consecutively admitted critically ill adults, mechanically ventilated for at least 72 h and fed enterally for a minimum of 48 h. The first cohort (n = 46) was fed using RBF, the second (n = 46) using VBF, and observed for 7 days, or until extubation or death. Statistical comparison of percentage feed volume, energy and protein delivered, plus indices of feed intolerance, were the primary outcomes of interest. Secondary observations included ventilation period, mortality, and length of ICU stay (LOICUS).

RESULTS

Groups were comparable in baseline clinical and demographic characteristics and nutrition practices. Volume delivered to the VBF group increased significantly by 11.2% (p ≤ 0.001), energy by 13.4% (p ≤ 0.001) and protein by 8.4% (p = 0.02), compared to the RBF group. In the VBF group, patients meeting > 90% of energy requirements increased significantly from 47.8 to 84.8% (p ≤ 0.001); those meeting > 90% of protein requirements changed from 56.5 to 73.9% (p = 0.134). VBF did not increase symptoms of feed intolerance. Adjusted binomial logistic regression found each additional 1% of prescribed feed delivered decreased the odds of vomiting by 0.942 (5.8%), 95% CI [0.900-0.985], p = 0.010. No differences in mortality or LOICUS were identified. Kaplan-Meier found a significantly increased extubation rate in patients receiving > 90% of protein requirements compared to those meeting < 80%, (p = 0.006). Adjusted Cox regression found the daily probability of being extubated tripled in patients receiving > 90% of their protein needs compared to the group receiving < 80%, hazard ratio 3.473, p = 0.021, 95% CI [1.205-10.014].

CONCLUSION

VBF safely and effectively increased the delivery of energy and protein to critically ill patients. Increased protein delivery may improve extubation rate which has positive patient-centred and financial implications, warranting larger confirmatory trials. This investigation adds weight to the ICU literature supporting VBF, and the growing evidence which advocates for enhanced protein delivery to improve patient outcomes.