Nutritional Risk Screening 2002 Cut-Off to Identify High-Risk Is a Good Predictor of ICU Mortality in Critically Ill Patients

New application of intestinal obstruction catheter in enterocutaneous fistula: A case report

BACKGROUND

Enterocutaneous fistula (ECF) is an abnormal connection between the gastrointestinal tract and the skin. ECF can lead to massive body fluid loss, hypercatabolism, and malnutrition. Therefore, nutritional support plays a crucial role in managing ECFs and promoting the healing of fistulas. For nutritional support, enteral nutrition (EN) is the preferred method when gastrointestinal function is recovering. Currently, various EN approaches have been applied for different anatomical positions of the ECF. However, the effectiveness of administering EN support for treating lower ECFs still needs further exploration and improvement.

CASE SUMMARY

We present the case of a 46-year-old male who underwent gastrointestinal stromal tumour resection. Six days after the surgery, the patient presented with fever, fatigue, severe upper abdominal pain, and septic shock. Subsequently, lower ECFs were diagnosed through laboratory and imaging examinations. In addition to symptomatic treatment for homeostasis, total parenteral nutrition support was administered in the first 72 h due to dysfunction of the intestine. After that, we gradually provided EN support through the intestinal obstruction catheter in consideration of the specific anatomic position of the fistula instead of using the nasal jejunal tube. Ultimately, the patient could receive optimal EN support via the catheter, and no complications were found during the treatment.

CONCLUSION

Nutritional support is a crucial element in ECF management, and intestinal obstruction catheters could be used for early EN administration.

Assessing the Impact of Nutritional Support Teams on Clinical Outcomes: Compliance and Feasibility of Micronutrient Supplementation

Background: Micronutrient (MN) supplementation has a positive impact on clinical outcomes. However, the evidence for the impact of MN supplementation remains controversial. Therefore, our study aims to assess the impact on nutritional outcomes according to exploring the implementation of MN support with multidisciplinary collaboration. Methods: This retrospective cohort study was conducted at a university hospital in Incheon, Korea. All patients referred to a nutrition support team (NST) between July and November 2022 were included. The NST reviews the MN protocol, which includes multivitamins and trace elements, based on international nutrient guidelines. All patients who were on nothing per oral and did not meet ≥70% of their nutritional requirements within 1 week were recommended MN supplements. Compliance with the MN protocol was evaluated, alterations in nutritional status based on the Nutrition Risk Screening 2002 (NRS 2002) scoring system and clinical outcomes were assessed after 7 day and at discharge. Multiple logistic regression analysis was used to identify factors associated with high nutritional risk in discharged patients. In addition, a sub-analysis was performed on changes in the nutritional of patients on the ward and in the ICU. Results: A total of 255 patients were eligible for analysis, with many patients requiring an MN supply of nothing per oral. The rate of implementation of MN supplementation was 50.2%. The findings indicate a significant decrease in the NRS 2002 score in the good compliance group with MN supplementation. No significant differences in protocol compliance were observed in terms of mortality, hospital stay, or length of stay in the intensive care unit. However, bad compliance with MN supplementation was correlated with risk factors for malnutrition at discharge. In subgroup analysis, nutritional status in the ICU and wards improved, with a significant difference between the two groups. Conclusions: The implementation of a MN supplementation protocol by a multidisciplinary NST is a feasible approach for improving the nutritional status of inpatients. Ensuring high compliance with this protocol is crucial, as poor compliance has been identified as a risk factor for malnutrition at discharge. Active intervention by the NST is essential to achieve optimal nutritional outcomes.

A longitudinal study to determine if all critically ill patients should be considered at nutrition risk or is there a highly accurate screening tool to be adopted?

BACKGROUND

Nutrition risk is prevalent in intensive care unit (ICU) settings and related to poor prognoses. We aimed to evaluate the concurrent and predictive validity of different nutrition risk screening tools in the ICU.

METHODS

Data were collected between 2019 and 2022 in six ICUs (n = 450). Nutrition risk was evaluated by modified Nutrition Risk in Critically ill (mNUTRIC), Nutritional Risk Screening (NRS-2002), Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), and Nutritional Risk in Emergency (NRE-2017). Accuracy and agreement of the tools were assessed; logistic regression was used to verify the association between nutrition risk and prolonged ICU stay; Cox regression was used for mortality in the ICU, both with adjustment for confounders.

RESULTS

NRS-2002 ≥5 showed the best accuracy (0.63 [95% CI, 0.58-0.69]) with mNUTRIC, and MST with NRS-2002 ≥5 (0.76 [95% CI, 0.71-0.80]). All tools had a poor/fair agreement with mNUTRIC (k = 0.019-0.268) and moderate agreement with NRS-2002 ≥5 (k = 0.474-0.503). MUST (2.26 [95% CI 1.40-3.63]) and MST (1.69 [95% CI, 1.09-2.60]) predicted death in the ICU, and the NRS-2002 ≥5 (1.56 [95% CI 1.02-2.40]) and mNUTRIC (1.86 [95% CI, 1.26-2.76]) predicted prolonged ICU stay.

CONCLUSION

No nutrition risk screening tool demonstrated a satisfactory concurrent validity; only the MUST and MST predicted ICU mortality and the NRS-2002 ≥5 and mNUTRIC predicted prolonged ICU stay, suggesting that it could be appropriate to adopt the ESPEN recommendation to assess nutrition status in patients with ≥48 h in the ICU.

Prognostic factors in mobility disability among elderly patients in the emergency department: A single-center retrospective study

Aim

We aimed to evaluate the clinical characteristics and outcomes of elderly critically ill patients and identify prognostic factors for mobility disability at discharge.

Methods

This single-center, retrospective cohort study investigated the period from April 2020 to January 2021. Patients ≥75 years old transferred to our emergency department and admitted to the intensive care unit (ICU) or intermediate unit in our hospital were eligible. Demographics, clinical characteristics, nutritional indicators, and nutritional screening scores were collected from chart reviews and analyzed. The primary outcome was the prevalence of mobility disability, compared to that of no mobility disability.

Results

A total of 124 patients were included in this present study. Median age was 83.0 years (interquartile range [IQR], 79.8-87.0 years) and 48 patients (38.7%) were female. Fifty-two patients (41.9%) could not walk independently at discharge (mobility disability group). The remaining 72 patients were in the no mobility disability group. Multiple logistic regression analyses revealed clinical frailty scale (CFS) score ≥5 (odds ratio [OR] = 6.63, 95% confidence interval [CI] = 2.51-17.52, p < 0.001), SOFA score ≥6 (OR = 6.11, 95% CI = 1.57-23.77, p = 0.009), and neurological disorder as the main cause on admission (OR = 4.48, 95% CI = 1.52-13.20, p = 0.006) were independent and significant prognostic factors for mobility disability at discharge.

Conclusion

Among elderly patients admitted to the emergency department, CFS ≥5, SOFA ≥6, and neurological disorders were associated with mobility disability at hospital discharge.

Prognostic value of different cut-off points of the NRS-2002 tool to identify nutritional risk in critically ill patients: a longitudinal study

The American Society of Parenteral and Enteral Nutrition recommends nutritional risk (NR) screening in critically ill patients with Nutritional Risk Screening - 2002 (NRS-2002) ≥ 3 as NR and ≥ 5 as high NR. The present study evaluated the predictive validity of different NRS-2002 cut-off points in intensive care unit (ICU). A prospective cohort study was conducted with adult patients who were screened using the NRS-2002. Hospital and ICU length of stay (LOS), hospital and ICU mortality, and ICU readmission were evaluated as outcomes. Logistic and Cox regression analyses were performed to evaluate the prognostic value of NRS-2002, and a receiver operating characteristic curve was constructed to determine the best cut-off point for NRS-2002. 374 patients (61·9 ± 14·3 years, 51·1 % males) were included in the study. Of these, 13·1 % were classified as without NR, 48·9 % and 38·0 % were classified as NR and high NR, respectively. An NRS-2002 score of ≥ 5 was associated with prolonged hospital LOS. The best cut-off point for NRS-2002 was a score ≥ 4, which was associated with prolonged hospital LOS (OR = 2·13; 95 % CI: 1·39, 3·28), ICU readmission (OR = 2·44; 95 % CI: 1·14, 5·22), ICU (HR = 2·91; 95 % CI: 1·47, 5·78) and hospital mortality (HR = 2·01; 95 % CI: 1·24, 3·25), but not with ICU prolonged LOS (P = 0·688). NRS-2002 ≥ 4 presented the most satisfactory predictive validity and should be considered in the ICU setting. Future studies should confirm the cut-off point and its validity in predicting nutrition therapy interaction with outcomes.

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.

Modified Nutrition Risk in Critically ill is an effective nutrition risk screening tool in severely burned patients, compared with Nutrition Risk Screening 2002

Objective

The present study aimed to evaluate the value of Modified Nutrition Risk in Critically ill (mNUTRIC) and Nutrition Risk Screening 2002 (NRS2002) in the prognosis of severely burned patients.

Methods

The retrospective cohort study used medical data of severely burned patients admitted to the burn center of Shanghai Ruijin Hospital between January 2015 and September 2021. Demographics, clinical characteristics, laboratory nutritional indicators, mNUTRIC score and NRS2002 score were collected and analyzed in evaluation the value of two nutrition risk screening tools. Spearman correlation analysis was carried out to show the correlation between variables. The area under receiver operating characteristic (ROC) curve was used to assess the ability of mNUTRIC and NRS2002 to predict mortality. Kaplan-Meier survival curves and log-rank tests were conducted to compare the overall survival (OS). Multivariate Cox proportional hazard regression model was used to identify risk factors for 28-day mortality of severely burned patients.

Results

A total of 429 adult patients with burn area larger than 30% total body surface area (TBSA) were included in this study. Incidence of nutrition risk was detected in 52.21% by mNUTRIC and 20.51% by NRS2002. However, mNUTRIC was superior to NRS2002 in predicting 28-day mortality (area under ROC curve: 0.795 vs. 0.726). Multivariate Cox regression analysis showed that high mNUTRIC [hazard ratio (HR) = 4.265, 95% CI = 1.469-12.380, P = 0.008] and TBSA (HR = 1.056, 95% CI = 1.033-1.079, P < 0.001) were independent predictors for 28-day mortality. After adjusting for covariates, high NRS2002 was not associated with 28-day mortality (P = 0.367).

Conclusion

The present study illustrated the effectiveness of mNUTRIC as nutrition risk screening tool among severely burned patients. Early identification of nutrition risk may help to maximize benefits of nutritional therapy by providing more aggressive nutritional therapy for patients at nutrition risk.

Construction of a Prediction Model for the Mortality of Elderly Patients with Diabetic Nephropathy

To construct a prediction model for all-cause mortality in elderly diabetic nephropathy (DN) patients, in this cohort study, the data of 511 DN patients aged ≥65 years were collected and the participants were divided into the training set (n = 358) and the testing set (n = 153). The median survival time of all participants was 2 years. The data in the training set were grouped into the survival group (n = 203) or the death group (n = 155). Variables with P ≤ 0.1 between the two groups were selected as preliminary predictors and involved into the multivariable logistic regression model and the covariables were gradually adjusted. The receiver operator characteristic (ROC), Kolmogorov-Smirnov (KS), and calibration curves were plotted for evaluating the predictive performance of the model. Internal validation of the performance of the model was verified in the testing set. The predictive values of the model were also conducted in terms of people with different genders and ages or accompanied with chronic kidney disease (CKD) or cardiovascular diseases (CVD), respectively. In total, 216 (42.27%) elderly DN patients were dead within 2 years. The prediction model for the 2-year mortality of elderly patients with DN was established based on length of stay (LOS), temperature, heart rate, peripheral oxygen saturation (SpO₂), serum creatinine (Scr), red cell distribution width (RDW), the simplified acute physiology score-II (SAPS-II), hyperlipidemia, and the Chronic Kidney Disease Epidemiology Collaboration equation for estimated glomerular filtration rate (eGFR-CKD-EPI). The AUC of the model was 0.78 (95% CI: 0.73–0.83) in the training set and 0.72 (95% CI: 0.63–0.80) in the testing set. The AUC of the model was 0.78 (95% CI: 0.65–0.91) in females and 0.78 (95%CI: 0.68–0.88) in patients ≤75 years. The AUC of the model was 0.74 (95% CI: 0.64–0.84) in patients accompanied with CKD. The model had good predictive value for the mortality of elderly patients with DN within 2 years. In addition, the model showed good predictive values for female DN patients, DN patients ≤75 years, and DN patients accompanied with CKD.

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.

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.

Improving nutritional therapy of persistent critically ill patients by organisational measures: A before and after study

BACKGROUND & AIMS

Critically ill patients requiring prolonged intensive care (ICU) treatment are at high risk of malnutrition, which latter contributes to worsening outcome. Having observed that despite the presence of a nutrition protocol and dieticians, the patients with persistent critical illness (PCI) had been underfed during their ICU stay and particularly during the first 10 days, the aim was to analyse the impact of the organisational changes that were proposed to prevent the observed malnutrition.

METHODS

Before (Period A) and after (Period B) study enrolling critically ill patients consecutively admitted, requiring >10 days of ICU treatment. The intervention consisted in increasing the early morning interactions between dieticians, nurses, and physicians, while modifying the computer visualisation of the dietician proposals. The primary endpoint was a reduction in the cumulative energy balance in period B. The ICU stay was divided in early ICU stay (first 10 days) and late ICU stay (day 11 to day 30). Other variables: protein, glucose, and prealbumin.

RESULTS

Altogether, 205 patients (150 and 55 in period A and B respectively) were enrolled in the PCI program. Patient characteristics were similar over both periods except for lower SAPSII score in period B. There was no difference in nutritional pattern in the first 10 days between periods. The cumulate energy balance was less negative from day 11-30 in period B than in A (-884 vs -1566 kcal; p = 0.033). There was a one-day reduction in the median duration of fasting in period B (p < 0.0001). Overall compliance with nutrition protocol improved in period B with an earlier first indirect calorimetry (p = 0.003) and prealbumin measurement (p < 0.001), the latter increasing significantly more during ICU stay.

CONCLUSION

Organizational changes that allowed an early identification of patients at nutritional risk, an increased targeted dieticians intervention and a better inter-disciplinary work was associated with a reduction in undue fasting, and significantly improved energy balances.

Evaluation of the effectiveness of the Nutritional Risk Screening System 2002 (NRS-2002) in COVID-19 patients admitted to the intensive care unit

BACKGROUND

Nutritional status of patients with COVID-19 can affect the recovery process of patients; however, no nutritional scale was introduced to evaluate the nutritional status of the patients. Thus, the main objective of this study was to examine the usefulness of Nutritional status-2002 (NRS-2002) among COVID-19 patients admitted to the intensive care unit (ICU).

MATERIAL AND METHODS

In this cross-sectional study, 73 patients with definitive corona diagnosis admitted to the ICUs of Al-Zahra hospital, Isfahan, Iran in October 2020 to January 2021 were recruited. Dietary intake, NRS-2002, demographic, anthropometric and biochemical indices of patients were recorded.

RESULTS

The majority of patients were at risk for moderate (69.9%) to severe (12.3%) malnutrition. Daily calorie intake (P = .001) and albumin (P = .001) levels in deceased patients were significantly lower than the recovered group. A direct correlation between NRS-2002 and age (P < .001) and an inverse correlation with daily calorie intake (P = .002), albumin (P = .05) and PaO2 (P = .034) was found. Moreover, there is a strong correlation between NRS-2002 score and chance of death among COVID-19 patients (OR=34.5, 95%CI:(5.2 - 228.93), P-value<0.001). Likewise, the levels of bilirubin direct (OR=8, 95%CI:(1.30 - 49.38), P-value=0.025) and creatine-phosphokinase (OR=0.9, 95%CI:(0.99 - 1.00), P-value=0.035) have a significant direct association with chance of death.

CONCLUSION

Results showed patients with COVID-19 admitted to the ICU did not have appropriate nutritional status and mortality was higher among patients with lower amounts of the serum albumin and daily calorie intakes. Furthermore, there is a strong association between the NRS-2002 index and the chance of mortality in these patients.

mNUTRIC tool is capable to predict nutritional needs and mortality early in patients suffering from severe pneumonia

OBJECTIVE

This retrospective observational study aims to evaluate the prognostic accuracy of Modified Nutrition Risk in Critically ill (mNUTRIC) compared to Nutrition Risk Score-2002 (NRS-2002) in patients hospitalized in the intensive care unit due to severe pneumonia during the pandemic period.

METHODS

RT-PCR test and Chest CT was performed in all patients in the emergency department pandemic area. The CURB-65 at the time of admission to the emergency department and Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential organ failure assessment score (SOFA), NRS-2002 and mNUTRIC scores 24 h after hospitalization in the intensive care unit were calculated. The analysis of the data was made in IBM SPSS Statistics Base 22.0 package program.

RESULTS

One hundred and twenty-five patients found to have severe pneumonia based on the chest CT taken in the emergency department pandemic area and hospitalized in the intensive care unit were included in the study. A real-time reverse transcription PCR (RT-PCR) test was positive in 30.4% (n: 38) of the patients. Additional nutrition treatment was initiated in 54.4% of the patients. In the analytical evaluation to predict nutritional treatment needs, mNUTRIC's AUC value (AUC: 0.681, 95% 0.582-0.780, p < 0.001) was higher than NRS-2002. While 64.8% (n: 81) of the patients were discharged, 35.2% (n: 44) died. In the analytical evaluation to predict mortality, the AUC value of mNUTRIC had the highest value (AUC: 0.875, 95% CI 0.814-0.935, p < 0.001).

CONCLUSION

The mNUTRIC score can predict at an early period the nutritional needs and mortality of patients with severe pneumonia during the Covid-19 pandemic.

Nutritional risk in critically ill patients: how it is assessed, its prevalence and prognostic value: a systematic review

CONTEXT

Nutritional risk (NR) screening is the first step of nutrition care process. Few data are available in literature about its prevalence, nor, to our knowledge, is a universally accepted reference method for the intensive care unit (ICU).

OBJECTIVE

The aim for this systematic review was to summarize evidence regarding the prevalence of NR and the predictive validity of different tools applied for NR screening of critically ill patients.

DATA SOURCES

The PubMed, Embase, and Scopus databases were searched up to December 2019 using the subject headings related to critically ill patients and NR screening. The current systematic review is registered with PROSPERO (identifier: CRD42019129668).

DATA EXTRACTION

Data on NR prevalence, predictive validity of nutritional screening tools, and interaction between caloric-protein balance and NR in outcome prediction were collected.

DATA ANALYSIS

Results were summarized qualitatively in text and tables, considering the outcomes of interest.

RESULTS

From 15 669 articles initially identified, 36 fulfilled the inclusion criteria, providing data from 8 nutritional screening tools: modified Nutrition Risk in the Critically Ill (mNUTRIC; n = 26 studies) and Nutritional Risk Screening-2002 (NRS-2002; n = 7 studies) were the most frequent; the NR prevalence was 55.9% (range, 16.0% to 99.5%). Nutritional risk was a predictor of 28-day and ICU mortality in 8 studies. Interactions between caloric-protein balance and NR on outcome prediction presented were scarcely tested and presented heterogeneous results (n = 8).

CONCLUSIONS

Prevalence of NR in patients in the ICU varies widely; a satisfactory predictive validity was observed, especially when mNUTRIC or NRS-2002 were applied.

Nutritional Risk Screening 2002 was associated with acute kidney injury and mortality in patients with acute coronary syndrome: Insight from the REACP study

BACKGROUND AND AIMS

Acute kidney injury (AKI) is a common complication of acute coronary syndrome (ACS), and is associated with increased risk of morbidity and mortality. We aimed to evaluate the impact of malnutrition risk at admission assessed using Nutritional Risk Screening 2002 (NRS-2002) on AKI and mortality in patients with ACS.

METHODS AND RESULTS

We enrolled 3185 ACS patients from the retrospective multi-centre study. AKI was defined as criteria of the 2012 Kidney Disease Improving Global Outcomes. Risk of malnutrition was defined as NRS-2002 score ≥3. The end points were AKI and all-cause mortality. There were 926 (29.1%) patients with risk of malnutrition and 481 (15.1%) patients complicated with AKI during hospitalisation, and 378 (12.0%) patients died during the 13.1 (8.5-20.4) months of follow-up. Patients with NRS-2002 score ≥3 had a higher incidence of AKI and all-cause mortality (P < 0.001). Multivariate logistic and Cox regression analysis showed that the adjusted odd ratios and hazard ratios of categorised NRS-2002 (<3 vs. ≥3) for AKI and mortality were 1.643 (95% confidence interval: 1.242-2.172, P < 0.001) and 2.026 (95% confidence interval: 1.491-2.753, P < 0.001), respectively. In structural equation modelling, the indirect effects of NRS-2002 on mortality via AKI were 54.1% (P < 0.001).

CONCLUSION

The risk of malnutrition assessed using NRS-2002 was useful in identifying high-risk patients with AKI and mortality, and patients with ACS may benefit from further nutritional intervention and prevention of AKI.

REGISTRATION NUMBER

ChiCTR1900024657.

Association between disease-related malnutrition and innate immunity gene expression in critically ill patients at intensive care unit admission

The aim of the study was to analyse the relationship between nutritional disorders and the expression of innate antibacterial response genes in patients admitted to the intensive care unit (ICU). In 46 patients with severe malnutrition and life-threatening surgical complications, nutritional status tests were performed on the basis of the NRS 2002 (Nutritional Risk Screening) scale, cytokine, albumin, C-reactive protein concentrations, anthropometric tests, and body composition analysis. Concurrently, the expression of Toll-like receptor 2, NOD1, TRAF6, and HMGB1 genes was determined in peripheral blood leukocytes at the mRNA level using real-time polymerase chain reaction. It was found that both the nutritional status and the gene expression changed depending on the group of patients studied (including the group of survivors vs. non-survivors). Significant correlations were found between the results of routine tests used in the diagnostics of malnutrition (including NRS 2002, resistance, reactance, phase angle, excess of extracellular water) and the expression of the studied genes. Moreover, the expression of TRAF6 and HMGB1 genes correlated with the Acute Physiology and Chronic Health Evaluation II scale and the age of the patients. The results of the research suggest that the expression of innate antibacterial response genes may be a new diagnostic tool complementing the assessment of nutritional disorders in surgical patients admitted to the ICU. These tests may be helpful in providing more accurate diagnostics of the genetic effects of malnutrition and in the monitoring of patients for whom nutritional treatment is planned to support the functions of the immune system, thereby increasing the effectiveness of this type of treatment in the ICU.

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.

Evaluation of Nutrition Risk in Patients Over 65 Years of Age With Nontraumatic Acute Abdominal Syndrome

BACKGROUND

The objective of this study is to investigate the power of CRP/Albumin ratio, NRS-2002, mNUTRIC scores to predict nutritional needs and mortality in patients over 65 years of age diagnosed with acute abdominal syndrome in the emergency department and then transferred to the surgical intensive care unit.

MATERIAL AND METHOD

CRP/Albumin ratio, APACHE II, SOFA, NRS-2002 and mNUTRIC scores were calculated. The analysis of the data was conducted in IBM SPSS Statistics Base 22.0 package program.

RESULTS

In the analytical evaluation made for nutritional needs, AUC value for mNUTRIC was found to be: 0,683, 95% CI 0,611-0,755, p < 0.001. It was found out that mortality of patients had a statistically significant and moderate correlation with mNUTRIC score (r = 0.537; p < 0.001). In the analytical evaluation made for mortality, mNUTRIC's AUC value (AUC: 0.808, 95% CI 0.736-0.880, p < 0.001) was found to be the highest. When the cut-off value determined to predict mortality was taken as 3.5 for mNUTRIC score, sensitivity was 75.9% and specificity was 69.4%.

CONCLUSION

The evaluation of the risk of malnutrition through nutritional risk tools in intensive care patients over 65 years of age with acute abdominal syndrome can also predict nutritional needs in the early period besides mortality. Based on our data, the fact that mNUTRIC score cut-off value in older patients hospitalized in intensive care is 3.5 and higher may be a predictor for ICU mortality.

Association between ultrasound quadriceps muscle status with premorbid functional status and 60-day mortality in mechanically ventilated critically ill patient: A single-center prospective observational study

BACKGROUND & AIMS

In critically ill patients, direct measurement of skeletal muscle using bedside ultrasound (US) may identify a patient population that might benefit more from optimal nutrition practices. When US is not available, survey measures of nutrition risk and functional status that are associated with muscle status may be used to identify patients with low muscularity. This study aims to determine the association between baseline and changing ultrasound quadriceps muscle status with premorbid functional status and 60-day mortality.

METHODS

This single-center prospective observational study was conducted in a general ICU. Mechanically ventilated critically ill adult patients (age ≥18 years) without pre-existing systemic neuromuscular diseases and expected to stay for ≥96 h in the ICU were included. US measurements were performed within 48 h of ICU admission (baseline), at day 7, day 14 of ICU stay and at ICU discharge (if stay >14 days). Quadriceps muscle layer thickness (QMLT), rectus femoris cross sectional area (RFCSA), vastus intermedius pennation angle (PA) and fascicle length (FL), and rectus femoris echogenicity (mean and standard deviation [SD]) were measured. Patients' next-of-kin were interviewed by using established questionnaires for their pre-hospitalization nutritional risk (nutrition risk screening-2002) and functional status (SARC-F, clinical frailty scale [CFS], Katz activities of daily living [ADL] and Lawton Instrumental ADL).

RESULTS

Ninety patients were recruited. A total of 86, 53, 24 and 10 US measures were analyzed, which were performed at a median of 1, 7, 14 and 22 days from ICU admission, respectively. QMLT, RFCSA and PA reduced significantly over time. The overall trend of change of FL was not significant. The only independent predictor of 60-day mortality was the change of QMLT from baseline to day 7 (adjusted odds ratio 0.95 for every 1% less QMLT loss, 95% confidence interval 0.91-0.99; p = 0.02). Baseline measures of high nutrition risk (modified nutrition risk in critically ill ≥5), sarcopenia (SARC-F ≥4) and frailty (CFS ≥5) were associated with lower baseline QMLT, RFCSA and PA and higher 60-day mortality.

CONCLUSIONS

Every 1% loss of QMLT over the first week of critical illness was associated with 5% higher odds of 60-day mortality. SARC-F, CFS and mNUTRIC are associated with quadriceps muscle status and 60-day mortality and may serve as a potential simple and indirect measures of premorbid muscle status at ICU admission.

What factors predict length of stay in the intensive care unit? Systematic review and meta-analysis

PURPOSE

Studies have shown that a small percentage of ICU patients have prolonged length of stay (LoS) and account for a large proportion of resource use. Therefore, the identification of prolonged stay patients can improve unit efficiency. In this study, we performed a systematic review and meta-analysis to understand the risk factors of ICU LoS.

MATERIALS AND METHODS

We searched MEDLINE, Embase and Scopus databases from inception to November 2018. The searching process focused on papers presenting risk factors of ICU LoS. A meta-analysis was performed for studies reporting appropriate statistics.

RESULTS

From 6906 citations, 113 met the eligibility criteria and were reviewed. A meta-analysis was performed for six factors from 28 papers and concluded that patients with mechanical ventilation, hypomagnesemia, delirium, and malnutrition tend to have longer stay, and that age and gender were not significant factors.

CONCLUSIONS

This work suggested a list of risk factors that should be considered in prediction models for ICU LoS, as follows: severity scores, mechanical ventilation, hypomagnesemia, delirium, malnutrition, infection, trauma, red blood cells, and PaO2:FiO2. Our findings can be used by prediction models to improve their predictive capacity of prolonged stay patients, assisting in resource allocation, quality improvement actions, and benchmarking analysis.

A pragmatic approach and treatment of coronavirus disease 2019 (COVID-19) in intensive care unit

There is a new global pandemic that emerged in China in 2019 that is threatening different populations with severe acute respiratory failure. The disease has enormous potential for transmissibility and requires drastic governmental measures, guided by social distancing and the use of protective devices (gloves, masks, and facial shields). Once the need for admission to the ICU is characterized, a set of essentially supportive therapies are adopted in order to offer multi-organic support and allow time for healing. Typically, patients who require ventilatory support have bilateral infiltrates in the chest X-ray and chest computed tomography showing ground-glass pulmonary opacities and subsegmental consolidations. Invasive ventilatory support should not be postponed in a scenario of intense ventilatory distress. The treatment is, in essence, supportive.

Caloric Adequacy in the First Week of Mechanically Ventilated Patients has No Impact on Long-term Daily Life Activities

Aim and objective

The aim and objective of this study is to test the effect of an optimized caloric supply in the first week of intensive care unit (ICU) stay in mechanically ventilated patients on the ability to perform their activities of daily living (ADL) in the long-term.

Materials and methods

A prospective observational study comparing patients who achieved an adequate caloric target (≥80%) vs those whose target was inadequate (<80%). The primary outcome under study is the instrumental ADL (IADL) scale after 6 months of discharge.

Results

Ninety-two patients were evaluated in the ICU and 50 were alive at 6 months. Follow-up was lost for 3 patients and 47 patients were evaluated at ICU and after 6 months. Thirty-four patients reached the energetic target and 13 did not reach it. There was no significant variation in IADL.

Conclusion

The energy adequacy in the first week of hospitalization was achieved by most survivors; however, this conduct does not seem to have influenced the ability to perform ADL after 6 months of discharge.

How to cite this article

Dariano AP, Couto CFL, Rubin BA, Viana MV, Friedman G. Caloric Adequacy in the First Week of Mechanically Ventilated Patients has No Impact on Long-term Daily Life Activities. Indian J Crit Care Med 2020;24(12):1206–1212.

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.

Pulsed Electromagnetic Field Therapy Improves Osseous Consolidation after High Tibial Osteotomy in Elderly Patients-A Randomized, Placebo-Controlled, Double-Blind Trial

Extremely low-frequency pulsed electromagnetic field (ELF-PEMF) therapy is proposed to support bone healing after injuries and surgical procedures, being of special interest for elderly patients. This study aimed at investigating the effect of a specific ELF-PEMF, recently identified to support osteoblast function in vitro, on bone healing after high tibial osteotomy (HTO). Patients who underwent HTO were randomized to ELF-PEMF or placebo treatment, both applied by optically identical external devices 7 min per day for 30 days following surgery. Osseous consolidation was evaluated by post-surgical X-rays (7 and 14 weeks). Serum markers were quantified by ELISA. Data were compared by a two-sided t-test (α = 0.05). Device readouts showed excellent therapy compliance. Baseline parameters, including age, sex, body mass index, wedge height and blood cell count, were comparable between both groups. X-rays revealed faster osseous consolidation for ELF-PEMF compared to placebo treatment, which was significant in patients ≥50 years (∆_mean = 0.68%/week; p = 0.003). Findings are supported by post-surgically increased bone-specific alkaline phosphatase serum levels following ELF-PEMF, compared to placebo (∆_mean = 2.2 µg/L; p = 0.029) treatment. Adverse device effects were not reported. ELF-PEMF treatment showed a tendency to accelerate osseous consolidation after HTO. This effect was stronger and more significant for patients ≥50 years. This ELF-PEMF treatment might represent a promising adjunct to conventional therapy supporting osseous consolidation in elderly patients. Level of Evidence: I.

Seven Deadly Sins of Nutrition Therapy in Critically Ill Patients

This article presents 7 nutrition steps that, if not followed by the clinical staff, may be metaphorically considered as "7 deadly sins" of nutrition therapy. In this review, we suggest approaches that must be avoided or accomplished to increase compliance with the "Ten Commandments" of good nutrition practice in the intensive care setting. Multiple aggressive and simultaneous sets of therapies are implemented in the intensive care setting, which include nutrition and metabolic support as important components in these therapies. "Sins" should be remembered as a mnemonic device for nutrition standard care in the intensive care unit; this incorporates nutrition adequacy and protocol adherence.

High nutritional risk is associated with unfavorable outcomes in patients admitted to an intensive care unit

OBJECTIVE

To evaluate possible associations between nutritional risk and the clinical outcomes of critical patients admitted to an intensive care unit.

METHODS

A prospective study was carried out with a cohort comprising 200 patients admitted to a university hospital intensive care unit. Nutritional risk was assessed with the NRS-2002 and NUTRIC scores. Patients with scores ≥ 5 were considered at high nutritional risk. Clinical data and outcome measures were obtained from patients' medical records. Multiple logistic regression analysis was used to calculate odds ratios and their respective 95% confidence intervals (for clinical outcomes).

RESULTS

This sample of critical patients had a mean age of 59.4 ± 16.5 years and 53.5% were female. The proportions at high nutritional risk according to NRS-2002 and NUTRIC were 55% and 36.5%, respectively. Multiple logistic regression models adjusted for gender and type of admission indicated that high nutritional risk assessed by the NRS-2002 was positively associated with use of mechanical ventilation (OR = 2.34; 95%CI 1.31 - 4.19; p = 0.004); presence of infection (OR = 2.21; 95%CI 1.24 - 3.94; p = 0.007), and death (OR = 1.86; 95%CI 1.01 - 3.41; p = 0.045). When evaluated by NUTRIC, nutritional risk was associated with renal replacement therapy (OR = 2.10; 95%CI 1.02 - 4.15; p = 0.040) and death (OR = 3.48; 95%CI 1.88 - 6.44; p < 0.001).

CONCLUSION

In critically ill patients, high nutritional risk was positively associated with an increased risk of clinical outcomes including hospital death.

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.

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.

Metabolic and Nutritional Characteristics of Long-Stay Critically Ill Patients

Background: insufficient feeding is frequent in the intensive care unit (ICU), which results in poor outcomes. Little is known about the nutrition pattern of patients requiring prolonged ICU stays. The aims of our study are to describe the demographic, metabolic, and nutritional specificities of chronically critically ill (CCI) patients defined by an ICU stay >2 weeks, and to identify an early risk factor. Methods: analysis of consecutive patients prospectively admitted to the CCI program, with the following variables: demographic characteristics, Nutrition Risk Screening (NRS-2002) score, total daily energy from nutritional and non-nutritional sources, protein and glucose intakes, all arterial blood glucose values, length of ICU and hospital stay, and outcome (ICU and 90-day survival). Two phases were considered for the analysis: the first 10 days, and the next 20 days of the ICU stay. Statistics: parametric and non-parametric tests. Results: 150 patients, aged 60 ± 15 years were prospectively included. Median (Q1, Q3) length of ICU stay was 31 (26, 46) days. The mortality was 18% at ICU discharge and 35.3% at 90 days. Non-survivors were older (p = 0.024), tended to have a higher SAPSII score (p = 0.072), with a significantly higher NRS score (p = 0.033). Enteral nutrition predominated, while combined feeding was minimally used. All patients received energy and protein below the ICU’s protocol recommendation. The proportion of days with fasting was 10.8%, being significantly higher in non-survivors (2 versus 3 days; p = 0.038). Higher protein delivery was associated with an increase in prealbumin over time (r² = 0.19, p = 0.027). Conclusions: High NRS scores may identify patients at highest risk of poor outcome when exposed to underfeeding. Further studies are required to evaluate a nutrition strategy for patients with high NRS, addressing combined parenteral nutrition and protein delivery.