Higher Energy and Protein Intake from Enteral Nutrition May Reduce Hospital Mortality in Mechanically Ventilated Critically Ill Elderly Patients

Prognostic utility of adequate nutritional support in critically ill surgical patients as revealed by the modified nutrition risk in critically ill score

BACKGROUND

The modified Nutrition Risk in the Critically Ill (mNUTRIC) score was developed to identify patients most likely to benefit from nutritional therapies and to stratify or select subjects for clinical trials. However, the validity of the score and the association between that score and the prognosis of patients in surgical intensive care units (SICUs) remain unclear. This study explored whether the score was a useful prognostic indicator for SICU patients, and whether survival could be improved via nutritional interventions based on mNUTRIC status.

METHODS

This retrospective observational study enrolled 123 patients admitted to our SICU for critical care from January 2018 to December 2019. Among these, mNUTRIC medical data were available for 116. In-hospital mortality rates were compared based on both mNUTRIC status and the adequacy of nutritional supplementation.

RESULTS

mNUTRIC-high status (5 points or more) was apparent in 16 ​% of all critically ill surgical patients. In-hospital mortality was significantly higher in those with mNUTRIC-high scores (42.1 ​% vs. 15.5 ​%, P ​= ​0.023). Both groups exhibited less mortality when nutrition was adequate vs. inadequate (5.0 ​% vs. 40.9 ​% and 26.7 ​% vs. 100 ​%, respectively). In multivariate analysis, mNUTRIC-high scores and inadequate nutritional support were significant risk factors for in-hospital mortality (hazard ratios 7.336 and 13.636, P ​= ​0.027 and 0.002, respectively).

CONCLUSION

In critically ill surgical patients, those identified as nutritionally high-risk using the mNUTRIC classification had poor in-hospital survival. Moreover, patients who received adequate nutritional support had a better prognosis than those who did not.

Impact of a multidisciplinary collaborative nutritional treatment model in patients who are critically ill with neurological disorders: A randomized controlled trial

BACKGROUND

Malnutrition is a widespread problem in critically ill patients with neurological disorders.

OBJECTIVE

The purpose of this study is to investigate the effect of a multidisciplinary collaborative nutritional treatment mode based on a standardized unit for nutritional support on the outcome metrics in patients with neurological disorders who are critically ill.

METHODS

We enrolled 84 participants who were hospitalized in the intensive care unit (ICU) of Yancheng No. 1 People's Hospital for neurological disorders between June 2018 and December 2021. The participants were randomly assigned to the control group and the test group. The control group received traditional nutritional support, while the test group was treated with a multidisciplinary collaborative nutritional treatment mode based on a standardized unit for nutritional support. We collected the general information, feeding tolerance (FT), nutritional risk score, and laboratory indicators before intervention, after intervention for one week, and after intervention for 2 weeks, and other data of the participants.

RESULTS

After the intervention, the test group scored significantly lower than the control group in the incidence of gastroparesis and diarrhea, as well as the NUTRIC score, with statistically significant differences (P< 0.001). The prealbumin levels in the test group increased progressively prior to intervention, after intervention for one week, and after intervention for two weeks. Compared to the control group, the test group had higher prealbumin levels prior to intervention, after intervention for one week, and after intervention for two weeks, with statistically significant differences (P< 0.001).

CONCLUSION

We developed a multidisciplinary collaborative nutritional treatment model based on a standard unit for nutritional support. This model can improve neural function, FT, and pertinent outcome indicators and is generally applicable.

Nutrition therapy in the older critically ill patients: A scoping review

Introduction: There is a lack of guidelines or formal systematic synthesis of evidence for nutrition therapy in older critically ill patients. This study is a scoping review to explore the state of evidence in this population. Method: MEDLINE and Embase were searched from inception until 9 February 2022 for studies that enrolled critically ill patients aged ≥60 years and investigated any area of nutrition therapy. No language or study design restrictions were applied. Results: Thirty-two studies (5 randomised controlled trials) with 6 topics were identified: (1) nutrition screening and assessments, (2) muscle mass assessment, (3) route or timing of nutrition therapy, (4) determination of energy and protein requirements, (5) energy and protein intake, and (6) pharmaconutrition. Topics (1), (3) and (6) had similar findings among general adult intensive care unit (ICU) patients. Skeletal muscle mass at ICU admission was significantly lower in older versus young patients. Among older ICU patients, low muscularity at ICU admission increased the risk of adverse outcomes. Predicted energy requirements using weight-based equations significantly deviated from indirect calorimetry measurements in older vs younger patients. Older ICU patients required higher protein intake (>1.5g/kg/day) than younger patients to achieve nitrogen balance. However, at similar protein intake, older patients had a higher risk of azotaemia. Conclusion: Based on limited evidence, assessment of muscle mass, indirect calorimetry and careful monitoring of urea level may be important to guide nutrition therapy in older ICU patients. Other nutrition recommendations for general ICU patients may be used for older patients with sound clinical discretion. Keywords: Critical care nutrition, geriatric patients, intensive care medicine, older adults, scoping review

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Nutritional adequacy in critically ill patients: Result of PNSI study

BACKGROUND & AIMS

Critically ill patients are provided with the intensive care medicine to prevent further complications, including malnutrition, disease progression, and even death. This study was intended to assess nutritional support and its' efficacy in the Intensive Care Units (ICUs) of Iran.

METHODS

This cross-sectional study assessed 50 ICU's patients out of 25 hospitals in the 10 major regions of Iran's health system and was performed using the multistage cluster sampling design. The data were collected from patient's medical records, ICU nursing sheets, patients or their relatives from 2017 to 2018. Nutritional status was investigated by modified NUTRIC score and food frequency checklist.

RESULTS

This study included 1321 ICU patients with the mean age of 54.8 ± 19.97 years, mean mNUTRIC score of 3.4 ± 2.14, and malnutrition rate of 32.6%. The mean time of first feeding was the second day and most of patients (66%) received nutrition support, mainly through enteral (57.2%) or oral (37%) route during ICU stay. The patients received 59.2 ± 37.78 percent of required calorie and 55.5 ± 30.04 percent of required protein. Adequate intake of energy and protein was provided for 16.2% and 10.7% of the patients, respectively. The result of regression analysis showed that the odds ratio of mNUTRIC score was 0.85 (95% confidence interval [CI] = 0.74-0.98) and APACHE II was 0.92 (95%CI = 0.89-0.95) for the prediction of energy deficiency. Nutrition intake was significantly different from patient's nutritional requirements both in terms of energy (p < 0.001) and protein (p < 0.001). Also, mean mNUTRIC score varied notably (p = 0.011) with changing in energy intake, defined as underfeeding, adequate feeding, and overfeeding.

CONCLUSION

The present findings shown that, provided nutritional care for ICU patients is not adequate for their requirements and nutritional status.

The diagnosis and NUTRIC score of critically ill patients in enteral nutrition are risk factors for the survival time in an intensive care unit?

Introduction

Objective: to investigate whether the caloric and protein deficits, the diagnosis and the NUTRIC score, behaved as risk factors associated to the survival time. Methods: prospective study with 82 critically ill patients in intensive care unit (ICU), with exclusive enteral nutritional therapy (EENT). We investigated the calorie and protein deficiencies of EENT, the NUTRIC score, and the inflammatory-nutritional index by the C-reactive protein-CRP/albumin. The data were analyzed using the Chi-square, Fisher, Mann-Whitney, Kruskal-Wallis, univariate and multiple Cox regressions and the Kaplan-Meyer method. Results: in the univariate Cox regression, one-year increase in age increased the risk of death by 4.1% (p=0.0009; HR=1.041) and one-day increase with intercurrent events, by 1.8% (p = 0.0485; HR = 1.018). In the multiple Cox regression, the clinical diagnosis (p = 0.0462, HR = 2.091) and the NUTRIC score ≥ 5 (p < 0.0001; HR = 5.740) were the variables that together were associated with the survival time. The critical caloric and protein deficits did not behave as death risk factors in this population. Kaplan-Meier curves showed that the probability of survival in 40 days was 28.1% with clinical diagnosis and 40.2% with surgical diagnosis. The mean survival time with NUTRIC score ≥ 5 was 17.4 days. The probability of survival at 40 days was 72.8% with NUTRIC score < 5 and 6.4% with NUTRIC score ≥ 5. Conclusion: caloric and protein deficits are not risk factors for mortality. Only the diagnosis and the NUTRIC score were considered risk factors associated with the survival time.

Protein intake and outcome in critically ill patients

PURPOSE OF REVIEW

The objective of this review is to describe the impact of protein intake on the outcomes of critically ill patients in the literature published in the preceding 2 years.

RECENT FINDINGS

Observational studies showed inconsistent results regarding the association of higher protein intake and outcomes of critically ill patients. Randomized controlled trials that directly compared higher versus lower protein intake in ICU patients are scarce, varied considerably in their designs and primary outcomes, and generally had relatively small differences in the amount of delivered protein between the study arms. Systematic reviews of existing studies showed no difference in mortality with higher protein intake. In addition, there is uncertainty regarding high protein provision in the early phase of critical illness.

SUMMARY

The optimal amount of protein intake in critically ill patients remains largely unclear and is considered a high priority for research. Ongoing clinical trials are likely to provide additional evidence on several important questions including the dose, timing, type of protein and the interaction with caloric intake and exercise.

Nutritional therapy in hospital care of in-patients with Covid-19: evidence, consensus and practice guidelines

ABSTRACT Objective The objective of this work was to review papers that deal with nutritional therapy of inpatients with Covid-19 from the beginning of the pandemic. The survey covered the period until the month of September 2020. Methods This is a review of the indexed literature (Scopus, Pubmed and Lilacs), including area consensus. Results The review showed that the initial recommendations were based on generic assumptions and, as specific knowledge was being produced, the recommendations became more targeted. Conclusion In the health crisis generated by Covid-19, in the context of uncertainties related to nutritional care procedures, knowledge and action strategies were generated, coordinated by researchers and health professionals.

Manufacturing Process, In Vivo and In Vitro Digestibility Assessment of an Enteral Feeding Product Hydrolyzed from Locally Available Ingredients Using Commercial Enzymes

A ready-for-use enteral feeding product was manufactured based on energy standard mixing using hydrolyzed products from local foods (i.e., loin pork, carrot, pumpkin, soybean, rice, and potato). When compared to enteral foods based on defined ingredients, the manufactured product is more cost-effective, appropriately functional and has similar physicochemical properties. Relative protein digestibility for in vitro value was tested by using enzyme pepsin, pH-drop and pH-stat method with three different enzymes. The product was shown to be easily digested with an in vivo digestibility value of 89.7%. Molecule sizes of components in the product ranged from 3.5 to 8.5 kDa, determined by SDS-PAGE, and the average molecular weight was 1.52 kDa, determined by Gel Permeation Chromatography (GPC) method. In terms of nutritional value, the product achieved a caloric density of 1 kcal/mL, dietary fibers of 1.48 g per 100 mL and provided both oligomeric and monomeric forms of protein. In addition, the product has the leucine: isoleucine: valine ratio of 2:1:1, thus facilitating the absorption of the protein. In conclusion, the manufactured enteral feeding product has been shown to be appropriate for providing nutritional support for patients.

Effect of Registered Dietitian Nutritionist Order-Writing Privileges on Enteral Nutrition Administration in Selected Intensive Care Units

BACKGROUND

Adequate nutrition is linked to improved patient outcomes during critical illness. Nutrition care is further enhanced by registered dietitian nutritionist (RDN) order-writing privileges, which improve the implementation of nutrition interventions. The purpose of this performance improvement project was to evaluate the effect of RDN order-writing privileges on enteral nutrition (EN) order compliance and nutrition delivery in selected intensive care units (ICUs) at a university-affiliated teaching hospital.

METHODS

Patients admitted to selected ICUs from January 23, 2018, to January 25, 2018, were screened for eligibility. Demographic and nutrition data were collected retrospectively from the electronic health record. Percent of energy and protein needs met were calculated. Data were compared with historical internal controls identified prior to RDN order-writing privileges.

RESULTS

Fifty adult patients (150 EN days) were included in data analysis, with 93 patients (279 EN days) included in historical data. Compared with historical data, cumulative EN order compliance increased by 17% and tube feed infusion rate compliance by 15% post-RDN order-writing privileges. Mean (± SD) protein needs delivered significantly increased from 72.1 ± 28.6% to 89.1 ± 24.8% after RDN order-writing implementation (P < 0.001).

CONCLUSIONS

RDN order-writing privileges improved EN order compliance and significantly improved protein delivery in selected ICUs. Future studies are recommended to confirm these results and determine if other variables besides protein delivery are statistically significant with a larger sample size.