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

Clinical practice guidelines for nutritional assessment and monitoring of adult ICU patients in China

The Chinese Society of Critical Care Medicine (CSCCM) has developed clinical practice guidelines for nutrition assessment and monitoring for patients in adult intensive care units (ICUs) in China. This guideline focuses on nutrition evaluation and metabolic monitoring to achieve optimal and personalized nutrition therapy for critically ill patients. This guideline was developed by experts in critical care medicine and evidence-based medicine methodology and was developed after a thorough review of the system and a summary of relevant trials or studies published from 2000 to July 2023. A total of 18 recommendations were formed and consensus was reached through discussions and reviews by expert groups in critical care medicine, parenteral and enteral nutrition, and surgery. The recommendations are based on currently available evidence and cover several key fields, including screening and assessment, evaluation and assessment of enteral feeding intolerance, metabolic and nutritional measurement and monitoring during nutrition therapy, and organ function evaluation related to nutrition supply. Each question was analyzed according to the Population, Intervention, Comparison, and Outcome (PICO) principle. In addition, interpretations were provided for four questions that did not reach a consensus but may have potential clinical and research value. The plan is to update this nutrition assessment and monitoring guideline using the international guideline update method within 3-5 years.

[High nutritional risk by three variants of NUTRIC score in critically ventilated patients]

Introduction

Introduction: variants of the NUTRIC score with or without inflammatory biomarkers, modified without interleukin 6 (IL-6) (NUTRICm), with C-reactive protein (CRP) instead of IL-6, dichotomous (NUTRICpcr1) or in tertiles (NUTRICpcr2), were proposed to assess nutritional risk (NR) in critical patients. However, the assessment of the high NR might not be uniform between these scores. Objectives: to compare the assessment of the high NR by NUTRICm and the two variants of the NUTRICpcr. Material and methods: analysis of a prospective cohort of patients ventilated prior to COVID-19. Agreement was analyzed using the Kappa test and mortality discrimination by logistic regression. The proportion of patients with high NR was compared with the Chi-square test. Results: five hundred and fifty patients were analyzed. Median (IQR) age and APACHE II: 44 (28-58) years and 17 (12-22) points, predominant traumatic pathology (38.2 %) and Intensive Care Unit (ICU) mortality of 32.5 %. The concordance was high between NUTRICm and NUTRICpcr1 (Kappa = 0.81) and lower between NUTRICm and NUTRICpcr2 (Kappa = 0.60). The AUCROC (95 % CI) of NUTRICm, NUTRICpcr1 and NUTRICpcr2 to discriminate mortality was 0.695 (0.495-0.591), 0.693 (0.495-0.591) and 0.685 (0.495-0.591), respectively. The tall NB showed significant differences between NUTRICm and NUTRICpcr1 (19.8 % vs 14.4 %, p 0.0243), being greater between NUTRICm and NUTRICpcr2 (19.8 vs 9.8 %, p < 0.0001). Conclusion: the three NUTRIC variants studied discriminate mortality in a similar way. However, the NUTRICm, without an inflammatory biomarker, classifies more patients as high nutritional risk.

Survey on Nutrition in Neurological Intensive Care Units (SONNIC)-A Cross-Sectional Survey among German-Speaking Neurointensivists on Medical Nutritional Therapy

Medical nutritional therapy (MNT) in neurointensive care units (NICUs) is both particularly relevant and challenging due to prolonged analgosedation, immobilization, disorders of consciousness, and the high prevalence of dysphagia. Moreover, current guideline recommendations predominantly address the general intensive care unit (ICU) population, overlooking specific characteristics of neurological patients. We, therefore, conducted a web-based, cross-sectional survey for German-speaking neurointensivists mapping the clinical practices of MNT on NICUs to identify research gaps and common grounds for future clinical trials. A total of 25.9% (56/216) NICU representatives responded to our questionnaire. A total of 78.2% (43/55) were neurologist and 63% (34/54) held a leadership role. Overall, 80.4% (41/51) had established a standard operating procedure (SOP), largely based on the DGEM-Guideline (53.7%; 22/41), followed by the ESPEN-Guideline (14.6%; 6/41). Upon admission, 36% (18/50) conducted a risk stratification, with 83.3% primarily relying on past medical history (15/18) and clinical gestalt (15/18). Energy expenditure (EE) was measured or calculated by 75% (36/48), with 72.2% (26/36) using pragmatic weight-based equations. Indirect calorimetry was used by 19.4% (7/36). A total of 83.3% (30/36) used the patient's serum glucose level as the primary biomarker to monitor metabolic tolerance. SOPs regarding ICU-Acquired Weakness (ICUAW) were found in 8.9% (4/45) of respondents. Overall, guideline adherence was 47%. In summary, this is, to the best of our knowledge, the first study systematically describing the currently applied concepts of MNT on NICUs. The data reveal great variations in the implementation of guideline recommendations, indicating the need for further research and tailored approaches to optimize nutritional therapy in neurointensive care settings.

Reducing In-Hospital and 60-Day Mortality in Critically Ill Patients after Surgery with Strict Nutritional Supplementation: A Prospective, Single-Labeled, Randomized Controlled Trial

Malnutrition in critically ill patients is a global concern, especially those who undergo abdominal surgery, as it is associated to higher infectious complications, prolonged hospital stays, and increased morbidity. Despite the importance of proper nutrition, guidelines remain broad, and practical implementation is often inadequate. We aimed to assess the effects of strict nutritional provision and investigate the appropriate target for nutrition support. A prospective, randomized controlled trial was conducted in critically ill patients admitted to intensive care units following abdominal surgery. The intervention group received targeted protein and calories, with consultation from a nutritional support team upon admission. In total, 181 patients in the intervention and 144 in the control group were analyzed. The intervention group demonstrated improved nutrition provision and subsequently better clinical outcomes, including a reduced 60-day mortality (4.4 versus 15.3, p = 0.001), postoperative complications (24.9 versus 47.2, p < 0.001), and in-hospital mortality (5 versus 17.4, p < 0.001). High modified nutrition risk in the critically ill scores [odds ratio (OR) = 2.658, 95% CI = 1.498-4.716] were associated with increased 60-day mortality, while active nutritional intervention (OR = 0.312, 95% CI = 0.111-0.873) was associated with lower mortality rates. Notably, the provision of targeted energy and protein alone did not exhibit a significant association with mortality outcomes.

Modified Nutrition Risk in the Critically ill score and mortality in critically ill patients with traumatic brain injury

BACKGROUND

Understanding the relationship between nutrition risk at admission to the intensive care unit (ICU) and the prognosis of patients with traumatic brain injury (TBI) may aid early recognition of high-risk patients.

METHODS

We extracted data from the Medical Information Mart for Intensive Care III and the electronic ICU Collaborative Research Databases. Using modified Nutrition Risk in the Critically ill score (mNUTRIC) within the first 24 h of ICU admission, 5153 patients were divided into three groups: low (≤1, n = 1765), moderate (2-4, n = 2574), and high (≥5, n = 814). The primary outcome was 28-day in-hospital mortality, and the secondary outcomes were 7-day in-hospital mortality, length of ICU stay, and duration of mechanical ventilation.

RESULTS

During the median follow-up time of 6.69 days, 647 deaths occurred in total. After adjustment for potential confounding factors, setting the low mNUTRIC group as a reference, the risk of 28-day mortality was increased in the high and moderate mNUTRIC groups (hazard ratio [HR]high vs low [95% CI]: 4.21 [2.70-6.58] and 2.84 [1.95-4.14], respectively). Similarly, high and moderate mNUTRIC scores are linked to a higher risk of 7-day mortality (PTrend  < 0.001) and a longer duration of mechanical ventilation (PTrend  < 0.001). The effect of mNUTRIC on mortality varied by serum glucose level (PInteraction  = 0.01). Lastly, those whose mNUTRIC scores deteriorated within the first 3 days have a 1.46 times greater risk of dying compared with patients with improved mNUTRIC scores.

CONCLUSIONS

Nutrition risk screening by mNUTRIC score at the time of admission to the ICU may improve mortality prediction.

Sample size requirements are not being considered in studies developing prediction models for binary outcomes: a systematic review

BACKGROUND

Having an appropriate sample size is important when developing a clinical prediction model. We aimed to review how sample size is considered in studies developing a prediction model for a binary outcome.

METHODS

We searched PubMed for studies published between 01/07/2020 and 30/07/2020 and reviewed the sample size calculations used to develop the prediction models. Using the available information, we calculated the minimum sample size that would be needed to estimate overall risk and minimise overfitting in each study and summarised the difference between the calculated and used sample size.

RESULTS

A total of 119 studies were included, of which nine studies provided sample size justification (8%). The recommended minimum sample size could be calculated for 94 studies: 73% (95% CI: 63-82%) used sample sizes lower than required to estimate overall risk and minimise overfitting including 26% studies that used sample sizes lower than required to estimate overall risk only. A similar number of studies did not meet the ≥ 10EPV criteria (75%, 95% CI: 66-84%). The median deficit of the number of events used to develop a model was 75 [IQR: 234 lower to 7 higher]) which reduced to 63 if the total available data (before any data splitting) was used [IQR:225 lower to 7 higher]. Studies that met the minimum required sample size had a median c-statistic of 0.84 (IQR:0.80 to 0.9) and studies where the minimum sample size was not met had a median c-statistic of 0.83 (IQR: 0.75 to 0.9). Studies that met the ≥ 10 EPP criteria had a median c-statistic of 0.80 (IQR: 0.73 to 0.84).

CONCLUSIONS

Prediction models are often developed with no sample size calculation, as a consequence many are too small to precisely estimate the overall risk. We encourage researchers to justify, perform and report sample size calculations when developing a prediction model.

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.

The emerging roles of next-generation metabolomics in critical care nutrition

Critical illness leads to millions of deaths worldwide each year, with a significant surge due to the COVID-19 pandemic. Patients with critical illness are frequently associated with systemic metabolic disorders and malnutrition. The idea of intervention for critically ill patients through enteral and parenteral nutrition has been paid more and more attention gradually. However, current nutritional therapies focus on evidence-based practice, and there have been lacking holistic approaches for nutritional support assessment. Metabolomics is a well-established omics technique in system biology that enables comprehensive profiling of metabolites in a biological system and thus provides the underlying information expressed and modulated by all other omics layers. In recent years, with the development of high-resolution and accurate mass spectrometry, metabolomics entered a new "generation", promoting its broader applications in critical care nutrition. In this review, we first described the technological development and milestones of next-generation metabolomics in the past 20 years. We then discussed the emerging roles of next-generation metabolomics in advancing our understanding of critical care nutrition, such as nutritional deficiency risk evaluation, metabolic mechanisms of nutritional therapies, and novel nutrition target identification.

Nutritional assessment of patients with aneurysmal subarachnoid hemorrhage using the modified "Nutrition Risk in the Critically Ill" score, and its association with outcomes

Introduction

Introduction: subarachnoid hemorrhage (SAH) is a rare and life-threatening cerebrovascular disease. Mitigating the factors that compromise patient recovery during neurocritical care due to SAH is of clinical benefit. Objectives: to evaluate the nutritional risk of patients with aneurysmal subarachnoid hemorrhage using "The Modified Nutrition Risk in the Critically Ill" (mNUTRIC) score, and examine its association with outcomes such as mortality, time of mechanical ventilation, and functional status among survivors. Methods: we designed a cross-sectional study. Patients with SAH admitted to the neurointensive critical care unit (neuroICU) in a tertiary care public hospital were eligible. The inclusion criteria were a minimum stay in the intensive care unit (ICU) of 24 hrs for subarachnoid hemorrhage from a nontraumatic, spontaneously ruptured cerebral aneurysm, and hospital admission within 24 hrs after the onset of symptoms. Results: high nutritional risk as stratified by the mNUTRIC score was associated with discharge type (OR = 0.346; 95 % CI = 0.182-0.650; p = 0.001), acute hypertensive hydrocephalus (OR = 4.371; 95 % CI = 2.283-8.549; p < 0.001), and functional outcome (OR = 0.106; 95 % CI = 0.025-0.0388; p < 0.001). The mNUTRIC score was significantly different among median age (p < 0.001), length of stay in the neuroICU (p = 0.005), SOFA score (p < 0.001), and APACHE II score (p < 0.001) categories. Conclusions: this study demonstrated an association between nutritional risk assessment and outcomes such as length of stay in the neuroICU, type of discharge, functional status, and mortality prediction accuracy.

Association between the modified Nutrition Risk in Critically Ill (mNUTRIC) score and clinical outcomes in the intensive care unit: a secondary analysis of a large prospective observational study

Background

Malnutrition in intensive care unit (ICU) patients is associated with adverse clinical outcomes. The modified nutrition risk in the critically ill score (mNUTRIC) was proposed as an appropriate nutritional assessment tool in critically ill patients, but it has not been fully demonstrated and widely used. Our study was conducted to identify the nutritional risk in ICU patients using the mNUTRIC score and explore the relationship between 28-day mortality and high mNUTRIC scores.

Methods

This study is a secondary analysis, the data were extracted from The Beijing Acute Kidney Injury Trial (BAKIT). In total, 9049 patients were admitted consecutively, and 3107 patients with complete clinical data were included in this study. We divided the study population into high nutritional risk (mNUTRIC score ≥ 5 points) and low nutritional risk (mNUTRIC score < 5 points) groups. The predictive capacity of the mNUTRIC score was studied by receiver operating characteristic (ROC) curve analysis, appropriate cut-off was identified by highest combined sensitivity and specificity using Youden’s index. The significance level was set at 5%.

Results

Among the 3107 patients, the 28-day mortality rate was 17.4% (540 patients died). Nearly 28.2% of patients admitted to the ICU were at risk of malnutrition, high nutritional risk patients were older (P < 0.001), with higher illness severity scores than low nutritional risk patients. Multivariate analysis revealed that the mNUTRIC score was an independent risk factor for 28-day mortality and mortality increased with increasing scores (p = 0.000). The calculated area under curve (AUC) for the mNUTRIC score was 0.763 (CI 0.740–0.786). According to Youden’s index, we found a suitable cut-off > 4 for the mNUTRIC score to predict the 28-day mortality.

Conclusions

Patients admitted to the ICU were at high risk of malnutrition, and a high mNUTRIC score was associated with increased ICU length of stay and higher mortality. More large prospective studies are needed to demonstrate the validity of this score.

Trial registration

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

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01439-x.

The prognostic value of modified NUTRIC score for patients in cardiothoracic surgery recovery unit: A retrospective cohort study

BACKGROUND

Malnutrition is highly prevalent in critically ill patients. The modified Nutrition Risk in the Critically ill (mNUTRIC) score has been introduced to evaluate the nutritional risk of patients in an intensive care unit (ICU). The mNUTRIC score is a predictive factor of mortality for patients in a medical or mixed ICU, whereas the relationship between mNUTRIC and prognosis of patients in a cardiothoracic surgery recovery unit (CSRU) is unclear and related researches are limited.

METHODS

We conducted this retrospective cohort study to explore the value of mNUTRIC score in CSRU patients. We identified totally 4059 patients from the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC III) database.

RESULTS

The optimal cut-off value of mNUTRIC score was 4 and a total of 1498 (36.9%) patients were considered to be at high nutritional risk (mNUTRIC ≥ 4). A multivariate logistic regression model indicated that patients at high nutritional risk have higher hospital mortality compared to those at low nutritional risk (odds ratio = 2.49, 95% confidence interval (CI) = 1.32-4.70, p = 0.005]. Furthermore, a Cox regression model was established adjusted for age, white blood cell and body mass index. The Kaplan-Meier curve indicated that patients at high nutritional risk have poorer 365-days [hazard ratio (HR) = 1.76, 95% CI = 1.30-2.37, p < 0.001] and 1000-days (HR = 2.30, 95% CI = 1.87-2.83, p < 0.001) overall survival.

CONCLUSIONS

The mNUTRIC score could not only predict hospital mortality, but also be an independent prognostic factor for long-term survival in CSRU patients. More well-designed clinical trials are needed to verify and update our findings.

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.