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Im KM, Kim EY. Identification of ICU Patients with High Nutritional Risk after Abdominal Surgery Using Modified NUTRIC Score and the Association of Energy Adequacy with 90-Day Mortality. Nutrients 2022; 14. [PMID: 35267921 DOI: 10.3390/nu14050946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 12/04/2022] Open
Abstract
For patients undergoing abdominal surgery, malnutrition further increases the susceptibility to infection, surgical complications, and mortality. However, there is no standard tool for identifying high-risk groups of malnutrition or exact criteria for the optimal target of nutrition supply. We aimed to identify the nutritional risk in critically ill patients using modified Nutrition Risk in the Critically Ill (mNUTRIC) scores and assessing the relationship with clinical outcomes. Furthermore, we identified the ideal target of energy intake during the acute postoperative period. A prospective observational study was conducted. mNUTRIC scores and the average calories prescribed and given were calculated. To identify the high-risk group of malnutrition, receiver operating characteristic curves were plotted. The ideal target of energy adequacy and predisposing factors of 90-day mortality were assessed using multiple logistic regression analyses. A total of 206 patients were analyzed. The cutoff value for mNUTRIC score predicting 90-day mortality was 5 (Area under the curve = 0.7, 95% confidence interval (Cl) 0.606−0.795, p < 0.001). A total of 75 patients (36.4%) were classified in the high mNUTRIC group (mNUTRIC ≥ 5) and had a significantly higher postoperative complication and longer length of surgical intensive care unit stay. High mNUTRIC scores (odds ratio = 2.548, 95% CI 1.177−5.514, p = 0.018) and energy adequacy less than 50% (odds ratio = 6.427, 95% CI 1.674−24.674, p = 0.007) were associated with 90-day mortality.
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Chada RR, Chidrawar S, Goud BA, Maska A, Medanki R, Nagalla B. Association between nutrition delivery, modified Nutrition Risk in Critically Ill score, and 28-day mortality. Nutr Clin Pract 2021; 36:1020-1033. [PMID: 33964049 DOI: 10.1002/ncp.10673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 03/16/2021] [Accepted: 04/04/2021] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Radha Reddy Chada
- Department of Clinical Nutrition and Dietetics, AIG Hospitals, Gachibowli, Hyderabad, Telangana, India
| | - Sachin Chidrawar
- Department of Intensive Care, Sunshine Hospitals, Secunderabad, Telangana, India.,Bathurst Hospital, NSW, Australia
| | - Bhagyasri A Goud
- Senior dietician, Dept. of Clinical Nutrition & Dietetics, Sunshine Hospitals, Secunderabad, India
| | - Anita Maska
- Senior dietician, Dept. of Clinical Nutrition & Dietetics, Sunshine Hospitals, Secunderabad, India
| | - Rajiv Medanki
- Department of Nephrology, Sunshine Hospitals, Secunderabad, Telangana, India
| | - Balakrishna Nagalla
- Division of Biostatistics, National Institute of Nutrition, Hyderabad, Telangana, India
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De Waele E, Jakubowski JR, Stocker R, Wischmeyer PE. Review of evolution and current status of protein requirements and provision in acute illness and critical care. Clin Nutr 2020; 40:2958-2973. [PMID: 33451860 DOI: 10.1016/j.clnu.2020.12.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 11/20/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022]
Abstract
Nutrition therapy, by enteral, parenteral, or both routes combined, is a key component of the management of critically ill, surgical, burns, and oncology patients. Established evidence indicates overfeeding (provision of excessive calories) results in increased risk of infection, morbidity, and mortality. This has led to the practice of "permissive underfeeding" of calories; however, this can often lead to inadequate provision of guideline-recommended protein intakes. Acutely ill patients requiring nutritional therapy have high protein requirements, and studies demonstrate that provision of adequate protein can result in reduced mortality and improvement in quality of life. However, a significant challenge to adequate protein delivery is the current lack of concentrated protein solutions. Patients often have fluid administration restrictions and existing protein solutions are frequently not sufficiently concentrated to deliver a patient's protein requirements. This has led to the development of new enteral and parenteral nutrition solutions incorporating higher levels of protein in smaller volumes. This review article summarizes current evidence supporting the role of higher protein intakes, especially during the early phases of nutrition therapy in acute illness, methods for assessing protein requirements, as well as, the currently available high-protein enteral and parenteral nutrition solutions. There is sufficient evidence (albeit limited from true randomized, controlled studies) to indicate that earlier provision of guideline-recommended protein intakes may be key to improving patient outcomes and that nutritional therapy that tailors caloric and protein intake to the patients' needs should be considered a desired standard of care.
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Affiliation(s)
- Elisabeth De Waele
- Department of Intensive Care Medicine and Department of Nutrition, UZ Brussel, Vrije Unversiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Julie Roth Jakubowski
- Medical Affairs, Baxter Healthcare Corporation, One Baxter Parkway, Deerfield, IL 60015, USA.
| | - Reto Stocker
- Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, 8032, Zurich, Switzerland.
| | - Paul E Wischmeyer
- Department of Anesthesiology and Surgery Duke University School of Medicine, 200 Morris Street, #7600-H, P.O. Box 17969, Durham, NC 27701, USA.
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Swiatlo T, Berta JW, Mauldin K. A Quality Improvement Study: Comparison of Volume-Based and Rate-Based Tube Feeding Efficacy and Clinical Outcomes in Critically Ill Patients. Nutr Clin Pract 2019; 35:578-583. [PMID: 31549467 DOI: 10.1002/ncp.10412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Adequate nutrition (receiving ≥80% of estimated energy requirements [EER]) is important in preventing and treating malnutrition and improving clinical outcomes. In conventional rate-based tube feeding (RBTF), patients are prescribed a constant infusion rate. Per volume-based tube feeding (VBTF), the hourly infusion rate can be increased (max 150 mL/h) to make up for feeding deficits, ensuring patients receive the targeted 24-hour volume. This study compared clinical outcomes between patients on VBTF vs RBTF. METHODS Data were collected from medical charts of patients within a 5-month period. Inclusion criteria included patients ≥18 years of age who were admitted to an intensive care unit and receiving enteral nutrition for at least 24 hours. RESULTS More patients on VBTF (n = 77; 55.8% females, age 59.9 ± 18.1 years, body mass index [BMI] 29.7 ± 17.7 kg/m2 ) received adequate nutrition (VBTF: 88.3%, 93.1 ± 11.3% EER; RBTF: 36.4%, 71.3 ± 35.8% EER) than those on RBTF (n = 206; 35.9% females, age 61 ± 15 years, BMI 28.3 ± 6.5 kg/m2 ) during the first crucial 7 days of nutrition support. No significant differences in adverse outcomes (hyperglycemia P = 0.052, hypoglycemia P = 0.168, emesis P = 0.084, diarrhea P = 0.470, and high gastric output P = 0.096) were found between the groups. CONCLUSION VBTF can help promote nutrition adequacy. This study provides evidence for clinicians to be more proactive and aggressive in providing tube feeding in the critical care setting when patients are deemed appropriate for VBTF.
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Affiliation(s)
- Travis Swiatlo
- Nutrition, Food Science, and Packaging, San José State University, California, USA
| | - Janine W Berta
- Clinical Nutrition, Stanford Health Care, Palo Alto, California, USA
| | - Kasuen Mauldin
- Nutrition, Food Science, and Packaging, San José State University, California, USA.,Clinical Nutrition, Stanford Health Care, Palo Alto, California, USA
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Yeh DD, Ortiz LA, Lee JM, Chan J, McKenzie K, Young B, Chetelat L, Collier B, Benson A, Heyland DK. PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol) in Surgical Patients-A Multicenter Pilot Randomized Controlled Trial. JPEN J Parenter Enteral Nutr 2019; 44:197-204. [PMID: 30741439 DOI: 10.1002/jpen.1521] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 12/20/2018] [Accepted: 01/24/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP) has been shown to be feasible, safe, and effective in delivering significantly more energy/protein, though it has not been well studied in surgical/trauma patients. We hypothesized that PEP uP will effectively increase energy/protein delivery to critically ill surgical/trauma patients. METHODS This multicenter, prospective, randomized pilot study included adult patients admitted to surgical service who were expected to require mechanical ventilation for >24 hours and intensive care unit (ICU) care for >72 hours. Subjects were randomized to PEP uP or standard care. The PEP uP protocol includes initiation at goal rate, semi-elemental formula, prophylactic prokinetic agents, 24-hour volume-based goals, and modular protein supplementation. The primary outcome was nutrition adequacy over the first 12 ICU days. RESULTS Thirty-six subjects were enrolled. Slow recruitment resulted in early trial termination by the sponsor. There were no baseline differences between groups. PEP uP patients received more protein (106.8 ± 37.0 vs 78.5 ± 30.3 g/d, P = 0.02). Energy delivery was not significantly different (1400.0 ± 409.5 vs 1237.9 ± 459.1 kcal, P = 0.25). Vomiting was more common in the PEP uP patients (32% vs 12%, P = 0.03). PEP uP protocol violations included 2 patients (15.4%) not receiving pro-motility medications, 3 (23.1%) not receiving volume-based feeds as ordered, and 4 (30.8%) not receiving supplemental protein. CONCLUSIONS In surgical/trauma patients, PEPuP seemed to improve protein delivery but was difficult to implement successfully and may increase vomiting rates.
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Affiliation(s)
- D Dante Yeh
- Ryder Trauma Center/University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Luis Alfonso Ortiz
- Clinical Evaluation Research Unit, Kingston General Hospital, Department of Critical Care, Queen's University, Kingston, Ontario, Canada
| | - Jae Moo Lee
- Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Jeffrey Chan
- Jamaica Hospital Medical Center, New York City, New York, USA
| | | | - Brian Young
- Jamaica Hospital Medical Center, New York City, New York, USA
| | | | - Bryan Collier
- Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Andrew Benson
- Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Department of Critical Care, Queen's University, Kingston, Ontario, Canada
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Canales C, Elsayes A, Yeh DD, Belcher D, Nakayama A, McCarthy CM, Chokengarmwong N, Quraishi SA. Nutrition Risk in Critically Ill Versus the Nutritional Risk Screening 2002: Are They Comparable for Assessing Risk of Malnutrition in Critically Ill Patients? JPEN J Parenter Enteral Nutr 2018; 43:81-87. [PMID: 29846011 DOI: 10.1002/jpen.1181] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 03/22/2018] [Accepted: 03/30/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Malnutrition influences clinical outcomes. Although various screening tools are available to assess nutrition status, their use in the intensive care unit (ICU) has not been rigorously studied. Our goal was to compare the Nutrition Risk in Critically Ill (NUTRIC) to the Nutritional Risk Screening (NRS) 2002 in terms of their associations with macronutrient deficit in ICU patients. METHODS We performed a retrospective analysis to investigate the relationship between NUTRIC vs NRS 2002 and macronutrient deficit (protein and calories) in critically ill patients. We performed linear regression analyses, controlling for age, sex, race, body mass index, and ICU length of stay. We then dichotomized our primary exposures and outcomes to perform logistic regression analyses, controlling for the same covariates. RESULTS The analytic cohort included 312 adults. Mean NUTRIC and NRS 2002 scores were 4 ± 2 and 4 ± 1, respectively. Linear regression demonstrated that each increment in NUTRIC score was associated with a 49 g higher protein deficit (β = 48.70: 95% confidence interval [CI] 29.23-68.17) and a 752 kcal higher caloric deficit (β = 751.95; 95% CI 447.80-1056.09). Logistic regression demonstrated that NUTRIC scores >4 had over twice the odds of protein deficits ≥300 g (odds ratio [OR] 2.35; 95% CI 1.43-3.85) and caloric deficits ≥6000 kcal (OR 2.73; 95% CI 1.66-4.50) compared with NUTRIC scores ≤4. We did not observe an association of NRS 2002 scores with macronutrient deficit. CONCLUSION Our data suggest that NUTRIC is superior to NRS 2002 for assessing malnutrition risk in ICU patients. Randomized, controlled studies are needed to determine whether nutrition interventions, stratified by NUTRIC score, can improve patient outcomes.
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Affiliation(s)
- Cecilia Canales
- University of California School of Medicine, Irvine, California, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ali Elsayes
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - D Dante Yeh
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Donna Belcher
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna Nakayama
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Caitlin M McCarthy
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Nalin Chokengarmwong
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sadeq A Quraishi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Arenas Moya D, Plascencia Gaitán A, Ornelas Camacho D, Arenas Márquez H. Hospital Malnutrition Related to Fasting and Underfeeding: Is It an Ethical Issue? Nutr Clin Pract 2017; 31:316-24. [PMID: 27208012 DOI: 10.1177/0884533616644182] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hospital malnutrition is a relevant clinical issue present in about 50% of patients that is associated with increased morbidity, mortality, and cost of care. Because of the relation of malnutrition with chronic and acute inflammatory processes secondary to disease, nutrition therapy is considered an important medical treatment. However, there is little discussion about the impact of another critical issue related to hospital malnutrition, that is, lack of appropriate food or nutrition therapy given to the patients. Unnecessary fasting practices and the use of inappropriate nutrition prescriptions result in underfeeding that can be a related or direct cause of hospital malnutrition, independent of disease or inflammatory state. Suboptimal prescription of oral, enteral, and parenteral nutrition should be analyzed and discussed from an ethical perspective since this practice has the potential to harm patients. In addition, absence or inadequate provision of nutrition may present barriers for improved patient outcomes and could be prevented by simply recognizing lack of knowledge, skills, or experience in nutrition and entrusting nutrition prescription to interdisciplinary teams with clinicians well prepared in nutrition sciences. This article reviews potential barriers to the prevention or treatment of hospital malnutrition and proposes specific actions that can help clinicians to overcome and implement optimal nutrition not just as medical therapy but also as a basic comfort care that may help patients nutritionally, clinically, physically, and emotionally.
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