A new approach to defining and diagnosing malnutrition in adult critical illness:

Malnutrition is associated with adverse 30-day outcomes after endovascular repair of abdominal aortic aneurysm

BACKGROUND

Malnutrition is particularly pertinent in patients undergoing vascular surgery, who frequently present with a high burden of comorbidities and advanced age that can impede nutrient absorption. While previous studies have established that vascular surgery patients with malnutrition had poorer outcomes, the impact of nutritional status in patients undergoing endovascular aneurysm repair (EVAR) has not yet been investigated. Therefore, this study aimed to assess the effect of malnutrition on 30-day outcomes following non-ruptured EVAR.

METHODS

Patients who had infrarenal EVAR were identified in the ACS-NSQIP targeted database from 2012-2022. Exclusion criteria included age less than 18 years, ruptured aneurysm, and emergency. Malnutrition was defined as patients with preoperative weight loss of greater than 10% decrease in body weight in the 6 months immediately preceding the surgery. A 1:5 propensity-score matching was used to match demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures between patients with and without malnutrition. Thirty-day postoperative outcomes were examined.

RESULTS

There were 154 (0.94%) patients with malnutrition who went under non-ruptured EVAR. Meanwhile, 16,309 patients without malnutrition went under intact EVAR, where 737 of them were matched to all malnutrition patients. Malnourished patients had more comorbidity burdens. After propensity-score matching, patients with malnutrition had elevated but non-significant 30-day mortality (5.92% vs 2.99%, p = .09). However, malnutrition patients had higher risks of renal complications (2.63% vs 0.68%, p = .04), bleeding requiring transfusion (22.37% vs 14.38%, p = .02), and unplanned reoperation (11.18% vs 4.88%, p = .01), as well as longer length of stay (6.11 ± 7.91 vs 4.44 ± 6.22 days, p < .02).

CONCLUSION

Patients with malnutrition experienced higher rates of morbidity after non-ruptured EVAR. Targeting malnutrition could be a strategy for preventing complications after EVAR and proper preoperative malnutritional management could be warranted.

Predictive significance of systemic immune-inflammation index combined with prealbumin for postoperative pneumonia following lung resection surgery

BACKGROUND

We aimed to determine whether systemic immune-inflammation index (SII) combined with prealbumin can provide better predictive power for postoperative pneumonia in patients undergoing lung resection surgery.

METHODS

We identified eligible patients undergoing lung resection surgery at the Affiliated Hospital of Nantong University from March 2021 to March 2022. Demographic characteristics, clinical data, and laboratory information were collected and reviewed from the electronic medical records of the patients. To test the effect of the combined detection of SII and prealbumin, we made an equation using logistic regression analysis. The receiver operating characteristic curve (ROC) was plotted to evaluate the predictive powers, sensitivity, and specificity of prealbumin, SII, and SII combined with prealbumin. Decision curve analysis (DCA) was used to determine the clinical validity and net benefit of different methods of detection.

RESULTS

Totally 386 eligible patients were included with a median age of 62.0 years (IQR: 55.0, 68.0), and 57 (14.8%) patients presented with postoperative pneumonia within 7 days after surgery. The multivariate regression analysis showed that preoperative SII as continuous variable was associated with an increased risk of postoperative pneumonia (OR: 1.38, 95% CI: 1.19-2.83, P = 0.011), whereas the prealbumin as continuous variable remained as an independent protective predictor of postoperative pneumonia in the adjusted analysis (OR: 0.80, 95% CI: 0.37-0.89, P = 0.023). Compared to SII or prealbumin, the combined detection of preoperative SII and prealbumin showed a higher predictive power with area under curve of 0.79 (95% CI: 0.71-0.86, P < 0.05 for all). Additionally, DCA indicated that the combined detection was superior over preoperative SII or prealbumin alone in clinical validity and net benefit.

CONCLUSION

Both preoperative SII and prealbumin are independent influencing factors for postoperative pneumonia after lung resection surgery. The combined detection of preoperative SII and prealbumin can significantly improve prediction capability to identify potential postoperative pneumonia-susceptible patients, facilitating early interventions to improve postoperative quality of life for surgical lung resection patients.

A Prognostic Model Based on Nutritional Indexes for Patients With Pan-Cancer: A Real-World Cohort Study

BACKGROUND

The aim was to identify the nutritional indexes, construct a prognostic model, and develop a nomogram for predicting individual survival probability in pan-cancers.

METHODS

Nutritional indicators, clinicopathological characteristics, and previous major treatment details of the patients were collected. The enrolled patients were randomly divided into training and validation cohorts. Least absolute shrinkage and selection operator (Lasso) regression cross-validation was used to determine the variables to include in the cox regression model. The training cohort was used to build the prediction model, and the validation cohort was used to further verify the discrimination, calibration, and clinical effectiveness of the model.

RESULTS

A total of 2020 patients were included. The median OS was 56.50 months (95% CI, 50.36-62.65 months). In the training cohort of 1425 patients, through Lasso regression cross-validation, 13 characteristics were included in the model. Cox proportional hazards model was developed and visualized as a nomogram. The C-indexes of the model for predicting 1-, 3-, 5-, and 10-year OS were 0.848, 0.826, 0.814, and 0.799 in the training cohort and 0.851, 0.819, 0.814, and 0.801 in the validation cohort. The model showed great calibration in the two cohorts. Patients with a score of less than 274.29 had a better prognosis (training cohort: HR, 6.932; 95% CI, 5.723-8.397; log-rank p < 0.001; validation cohort: HR, 8.429; 95% CI, 6.180-11.497; log-rank p < 0.001).

CONCLUSION

The prognostic model based on the nutritional indexes of pan-cancer can divide patients into different survival risk groups and performed well in the validation cohort.

Relationship between nutritional goals and pressure injuries in critical care patients receiving enteral nutrition

OBJECTIVE

To examine the relationship between pressure injury (PI) development and achievement of nutritional goals (protein and caloric), as well as consider the clinical conditions, hospitalisation factors, and risk assessment for PI development in patients who are critically ill and receiving enteral nutrition (EN) in the intensive care unit (ICU).

METHOD

An observational cohort study was conducted in the ICU of the University Hospital in São Paulo, Brazil. Inclusion criteria were as follows: age ≥18 years; length of ICU stay ≥24 hours; without PI at ICU admission; and receiving EN exclusively during ICU stay. The development of PI was considered the dependent variable. The Chi-squared test was applied to compare categorical variables, and the Mann-Whitney U test was used to compare continuous variables between groups of patients with and without a PI. The analysis of the achievement of nutritional goals was performed using Fisher's exact test. A significance level of 5% (p-value<0.05) and a confidence interval (CI) of 95% was adopted in all statistical tests.

RESULTS

A total of 181 patients met the inclusion criteria, of whom 102 (56.4%) were male and 79 (43.6%) were female. Mean age was 55.1 years, and mean length of ICU stay was 17.5 days. PI development was associated with not achieving nutritional goals. There was a higher percentage (65.3%) of patients without a PI when both protein and caloric goals were achieved. In contrast, 45.6% of patients developed a PI when the goals were not achieved. The mean days for sedation, vasoactive drugs and mechanical ventilation were all significantly higher in patients who developed a PI (p<0.001).

CONCLUSION

There was a significant association between patients developing a PI and deficits in caloric and protein intake. Patients who did not develop PIs had a greater calorie and protein intake compared with those who developed a PI.

Recommendations for nutritional assessment across clinical practice guidelines: A scoping review

BACKGROUND & AIMS

CPGs propose several methods and criteria to perform nutritional assessment, a key process to determine the type and severity of malnutrition, which generates variability in clinical practice and outcomes. The aim of the study was to describe the criteria considered by clinical practice guidelines (CPGs) for nutritional assessment.

METHODS

We performed a scoping review systematically searching in PubMed, Trip Database, Google Scholar, and Google, until November 5, 2021. We included all CPGs mentioning tools or criteria for nutritional assessment in adults from the general population or with any specific pathology or condition. Two authors independently reviewed and decided on study selection and data extraction.

RESULTS

We included 18 CPGs (12 elaborated in Europe). The CPGs recommended heterogeneous criteria for nutritional assessment: 16/18 CPGs included at least one body composition parameter (e.g., loss of muscle mass, loss of subcutaneous fat), 15/18 included history related to dietary intake, 15/18 included clinical history (e.g., weight loss), 10/18 included anthropometric measurement (e.g., low body mass index [BMI]), 11/18 included biochemical criteria (e.g., albumin, C-reactive protein), 8/18 included physical examination (e.g., fluid retention, sarcopenia, loss of subcutaneous fat), 8/18 included functional test (e.g., decreased handgrip strength), and 1/18 included catabolic state. Also, 9/18 CPGs mentioned a tool for nutritional assessment, the Subjective Global Assessment (SGA) the most common (8/18). None of the CPGs justified the inclusion of any of the tools or criteria they mentioned.

CONCLUSIONS

The CPGs mentioned heterogeneous criteria for nutritional assessment. The most commonly mentioned criteria were decreased food intake, loss of muscle mass, weight loss, and low BMI. The most mentioned tool was the SGA. None of the CPGs provided a clear rationale for using certain criteria or tools for nutritional assessment.

Impact of an interdisciplinary nutrition support team (NST) on the clinical outcome of critically ill patients. A pre/post NST intervention study

BACKGROUND

Intensive care unit (ICU) patients are at particular risk for malnutrition with major impact for outcome and prognosis. Nutrition support teams (NST) have been proposed to improve nutrition care in ICU patients.

OBJECTIVE

To assess the effectiveness of an interdisciplinary NST on anthropometry and clinical outcome of ICU patients.

METHODS

Before NST implementation, we assessed 120 patients (before NST group; SAPS II score 44 ± 16), afterwards 60 patients (after NST group), of whom 29 received NST guidance (after NST + group; SAPS II 65 ± 19) and 31 not (after NST - group; SAPS II, 54 ± 16). The primary outcome parameter was length of stay in the hospital (hospital-LOS). Severity of disease was assessed by the APACHE II score and the nutritional risk (NUTRIC) score.

RESULTS

NST intervention resulted in a more pronounced improvement of disease severity (APACHE II, from 27 ± 8 to 18 ± 6, p < 0.001; NUTRIC, from 7 ± 2 to 4 ± 2, p < 0.001) compared to no NST intervention (APACHE II from 24 ± 7 to 21 ± 7, p < 0.05; NUTRIC from 6 ± 2 to 5 ± 2, p < 0.01). The mean hospital-LOS was not reduced, neither in the NST intervention group nor in the control group without NST intervention. NST intervention failed to improve nutritional status or mortality compared to no NST intervention.

CONCLUSION

In our study the NST intervention had a positive effect on disease severity, but failed to improve mortality, hospital-LOS or nutritional status in ICU patients, likely because of a large patient heterogeneity.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02200874).

Effect of an intensified individual nutrition therapy on serum metabolites in critically ill patients - A targeted metabolomics analysis of the ONCA study

PURPOSE

The effect of medical nutrition on serum metabolomics has been poorly explored. The aim of the study was to investigate the relation between energy supply and metabolic profiles in critically ill patients.

MATERIALS AND METHODS

Twenty mechanically ventilated patients on enteral nutrition (EN) or enteral/parenteral nutrition (EN/PN) were randomized into two groups. One group received an individual energy supply based on indirect calorimetry (IC group, n = 9), the other group received a standard energy supply based on a formula, the standard care group (SC group, n = 11). Targeted metabolomics was performed in early-, late- and post-acute metabolic phase.

RESULTS

Individual versus standard care energy supply resulted in a metabolite class separation between the IC and the SC group (P < 0.001). In the SC group concentrations of four glucogenic amino acids and three biogenic amines increased between the early- and late-acute metabolic phase (P < 0.05). The metabolomics pattern differed between the routes of nutrition administration (P < 0.01).

CONCLUSIONS

The amount of energy supply by EN or PN, besides other factors, seems to modulate serum metabolites. Nutrition therapy based on individualized energy supply is associated with a reduction of metabolites reflecting catabolism. Therefore, metabolomics could be a new tool to determine metabolic phases in critically ill patients.

Comparison of nutritional screening and diagnostic tools in diagnosis of severe malnutrition in critically ill patients

RATIONALE

While various nutritional assessment tools have been proposed, consensus is lacking with respect to the most effective tool to identify severe malnutrition in critically ill patients.

METHODS

We conducted a retrospective study in an adult general intensive care unit (ICU) comparing four nutritional assessment tools: Nutrition Risk Screening (NRS), Nutrition Risk in Critically Ill (NUTRIC), and malnutrition criteria proposed by European Society of Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN). These criteria were tested for their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in diagnosis of severe malnutrition, defined as Subjective Global Assessment (SGA) C.

RESULTS

Hospitalization records for 120 critically ill patients were analyzed. 60 (50%), 17 (14.2%) and 43 (35.8%) patients were classified as SGA A, B, and C, respectively. The sensitivity in diagnosis of severe malnutrition was 79.1%, 58.1%, 65.1%, and 65.1%, and specificity was 94.8%, 74.0%, 94.8%, and 98.7% for NRS, NUTRIC, ESPEN, and ASPEN, respectively. NRS, ESPEN, and ASPEN had higher PPV (89.5%, 87.5%, and 87.5%, respectively) and NPV (89%, 83%, and 83.5%, respectively) than NUTRIC (PPV 55.6% and NPV 76%). NUTRIC showed the highest correlation with mortality, but none of the tools retained their correlation with mortality after adjustment for potential confounding factors.

CONCLUSIONS

NRS showed the highest sensitivity and high specificity, PPV, and NPV. NUTRIC had least effective overall performance in diagnosis of severe malnutrition in an ICU setting. A larger population may be required to explore the association between mortality and these nutritional assessment tools.

Malnutrition at Admission Predicts In-Hospital Falls in Hospitalized Older Adults

Malnutrition leads to poor prognoses, including a predisposition to falls. Few studies have investigated the relationship between malnutrition and falls during hospitalization. This study aimed to determine malnutrition’s association with falls during hospitalization. A retrospective observational study was conducted. Patients aged ≥65 years that were admitted to and discharged from a university hospital between April 2018 and March 2019 were examined. Patients with independent basic activities of daily living were included. Diagnosis of malnutrition was based on the European Society for Clinical Nutrition and Metabolism (ESPEN) criteria at admission. Disease information such as the Charlson Comorbidity Index (CCI) and reasons for hospitalization were reviewed. Kaplan–Meier curve and multivariate Cox regression analyses were performed. Data from 6081 patients (mean age: 74.4 ± 6.1 years; males: 58.1%) were analyzed. The mean CCI was 2.3 ± 2.8 points. Malnutrition was detected in 668 (11.0%) and falls occurred in 55 (0.9%) patients. Malnourished patients experienced a higher fall rate than those without malnutrition (2.4% vs. 0.7%, log-rank test p < 0.001). In multivariate analysis, malnutrition had the highest hazard ratio for falls among covariates (hazard ratio 2.78, 95% confidence interval 1.51–5.00, p = 0.001). In conclusion, malnutrition at the time of admission to hospital predicts in-hospital falls.

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.

Role of nutritional indices in predicting outcomes of vascular surgery

BACKGROUND

Malnutrition is frequent among vascular surgery patients, given their age, chronic comorbidities, and poor functional status, and it is believed to increase their operative risk. We aimed to assess the combined use of recent significant weight loss (>10% body mass) and serum albumin levels as a nutritional status index to predict outcomes.

METHODS

We analyzed vascular surgery data from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2012; N = 238,082) to compare operative death (in-hospital and 30-day operative death) across eight nutritional status groups based on weight loss (yes/no) and albumin category: very low albumin level (VL-Alb; <2.50 g/dL), low albumin level (L-Alb; 2.50-3.39 g/dL), normal albumin level (N-Alb; 3.40-4.39 g/dL), and high albumin level (H-Alb; 4.40-5.40 g/dL). Risk-adjusted odds ratios (AOR) with 95% confidence intervals were estimated by multivariable logistic regression (N-Alb [no weight loss], reference).

RESULTS

The study population included 113,936 patients for whom albumin level was available (age, 67 ± 13 years; 60.2% male). Operative death was documented in 5160 (4.53%) patients. The eight-category nutritional status was more predictive of operative death than age alone (C statistic, 0.74 vs 0.63). A high discrimination multivariable model for operative death was derived (C statistic, 0.851). Low albumin level was associated with increased death that worsened in case of weight loss: VL-Alb + WL, AOR = 3.83 (3.03-4.83); VL-Alb, AOR = 3.36 (3.06-3.69); L-Alb + WL, AOR = 2.46 (1.98-3.05); and L-Alb, AOR = 1.99 (1.84-2.15). Weight loss was associated with increased death even if albumin level was normal: N-Alb + WL, AOR = 1.77 (1.34-2.35); and H-Alb + WL, AOR = 1.91 (0.69-5.31). H-Alb was protective (AOR = 0.65 [0.55-0.76]).

CONCLUSIONS

Nutritional status predicts outcomes of vascular surgery. Serum albumin level and weight loss should be incorporated in patients' risk stratification.

Immunonutrition in Critical Illness: What Is the Role?

Acute illness-associated malnutrition leads to muscle wasting, delayed wound healing, failure to wean from ventilator support, and possibly higher rates of infection and longer hospital stays unless appropriate metabolic support is provided in the form of nutrition therapy. Agreement is still lacking about the value of individual immune-modulating substrates for specific patient populations. However, it has long been agreed that there are 3 primary targets for these substrates: 1) mucosal barrier function, 2) cellular defense function, and 3) local and systemic inflammation. These targets guide the multitude of interventions necessary to stabilize and treat the hypercatabolic intensive care unit patient, including specialized nutrition therapy. The paradigm shift that occurred 30 years ago created a unique role for nutrition as an agent to support host defense mechanisms and prevent infectious complications in the critically ill patient. This overview of immunonutrition will discuss the evidence for its role in critical illness today.

Complementarity of NUTRIC score and Subjective Global Assessment for predicting 28-day mortality in critically ill patients

AIMS

To compare the prognostic power of nutritional screening (NUTRIC score) and Subjective Global Assessment (SGA), executed alone or their complementarity, for predicting 28-day mortality risk in ICU patients. We also aimed to identify the cut-off point obtained in the NUTRIC that presented the best validity parameters for predicting mortality in this population.

METHODS

A sample of 159 patients was evaluated in the first 24 hours of ICU admission. Modified NUTRIC score was performed (without interleucina-6). ROC curve and Youden criterion were used to identify the best cut-off point. Poisson regression and the number needed to screen (NNS) were used to test the complementarity between the tools and their ability to predict 28-day mortality.

RESULTS

A sample of 159 patients was evaluated (51% male, 56.6 ± 20 years) and the APACHE II, SOFA and NUTRIC score medians were 22 (IQR:15;26), 6 (IQR:2;9) and 3 (IQR: 2;5), respectively. Almost 60% of the patients were malnourished (SGA B or C) and 32.7% died during 28-day follow-up. The area under ROC curve for NUTRIC score was 0.79. Using a new cutoff (NUTRIC score ≥ 4), patients with nutritional risk have a 28-day mortality risk almost 6 times higher than subjects without nutritional risk. Patients classified as SGA C showed a 28-day mortality risk 2.19 times higher compared to nourished ones. Evaluating the complementarity of the tools, patients classified as nutritional risk (NUTRIC score ≥ 4) and SGA C showed a 28-day mortality risk 7 times higher and a lower NNS when compared to those patients with a NUTRIC < 4 and any SGA category.

CONCLUSIONS

A new cutoff value was identified for this population. Simultaneous SGA assessment in patients with nutritional risk may enhance the predictive power of 28-day mortality, providing better identification of higher risk patients who may benefit from a more aggressive nutritional therapy.

Determination of Nutrition Risk and Status in Critically Ill Patients: What Are Our Considerations?

The stress catabolism state predisposes critically ill patients to a high risk of malnutrition. This, coupled with inadequate or delayed nutrition provision, will lead to further deterioration of nutrition status. Preexisting malnutrition and iatrogenic underfeeding are associated with increased risk of adverse complications. Therefore, accurate detection of patients who are malnourished and/or with high nutrition risk is important for timely and optimal nutrition intervention. Various tools have been developed for nutrition screening and assessment for hospitalized patients, but not all are studied or validated in critically ill populations. In this review article, we consider the pathophysiology of malnutrition in critical illness and the currently available literature to develop recommendations for nutrition screening and assessment. We suggest the use of the (modified) Nutrition Risk in the Critically Ill (mNUTRIC) for nutrition risk screening and the subjective global assessment (SGA) together with other criteria relevant to the critically ill patients, such as gastrointestinal function, risk of aspiration, determination of sarcopenia and frailty, and risk of refeeding syndrome for nutrition assessment. Further research is needed to identify suitable nutrition monitoring indicators to determine the response to the provision of nutrition.

Optimization of Nutrition Therapy with the Use of Calorimetry to Determine and Control Energy Needs in Mechanically Ventilated Critically Ill Patients: The ONCA Study, a Randomized, Prospective Pilot Study

BACKGROUND

Adequate nutrition therapy in critically ill patients poses a challenge because of the variable energy and substrate needs. The objective was to investigate whether nutrition therapy involving indirect calorimetry (IC), instead of equations for assessment of energy needs, could improve the nutrition status of critically ill patients.

METHODS

Forty mechanically ventilated patients were randomized into a group in which energy needs were controlled by calorimetry (IC group) and a group treated with a formula-based approach reflecting standard care (SC group). The primary outcome was change in the phase angle (PhA), a bioelectrical impedance parameter related to nutrition status and prognosis.

RESULTS

The mean IC-based energy requirement was lower than the formula-based estimate (21.1 ± 6.4 versus [vs] 25 kcal/kg/d, P < .01). The IC group reached 98% ± 8% of the energy goal, whereas the SC group reached only 79% ± 29% (P < 0.05), although mean intake was similar in both groups. The protein intake goal was better met in the IC group (91% ± 24%) than the SC group (73% ± 33%). The PhA of the IC group did not change during treatment, whereas that of the SC group tended to decrease by 0.36° ± 0.86° (P = .077). A shorter length of stay in intensive care was observed in the IC than in the SC group (13 ± 8 vs 24 ± 20 days, P < .05).

CONCLUSION

Intensified individual nutrition therapy involving IC appears to be useful for improving nutrition status in critically ill patients.

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

BACKGROUND

The Nutritional Risk Screening 2002 (NRS-2002) is a widely recommended nutrition risk indicator. Two cut-offs have been proposed for intensive care unit (ICU) patients to classify nutrition risk: ≥3-<5, at risk and ≥5, high risk. To date, no study has directly compared these cut-offs. The aim of this study is to compare the NRS-2002 ICU nutrition risk cut-offs as predictors of clinical outcomes including infections, ICU and hospital mortality, length of stay (LOS), duration of mechanical ventilation (MVd), weaning failure, tracheotomy for prolonged MVd, and chronic critical illness (CCI).

METHODS

Adult patients were screened and stratified according to NRS-2002 ICU criteria. Clinical, epidemiologic, and nutrition data were extracted from medical records. Statistical analysis for independent samples and Poisson regression were performed.

RESULTS

A total of 185 patients were screened: 1 (0.54%) no risk; 96 (51.89%) at risk, and 88 (47.56%) high risk. High-risk patients were older, had higher Simplified Acute Physiology Score 3 (62.0 ± 14.1 vs 53.0 ± 12.9, respectively; P < .001) and Sequential Organ Failure Assessment (6.9 ± 3.7 vs 5.1 ± 3.1, respectively; P < .001), and developed more infections (42 [47.8%] vs 27 [28.1%]; P = .010). No differences were found for ICU and hospital LOS, MVd days, weaning failure, tracheotomy, and CCI. ICU and hospital mortality were higher in high-risk patients. The high-risk cut-off was predictor of ICU mortality (relative risk 2.10, 95% confidence interval 1.07-4.14; P = .032).

CONCLUSION

Our data suggest that the NRS-2002 high-risk cut-off is associated with worse clinical outcomes and is a predictor for ICU mortality.

Nutrition Screening vs Nutrition Assessment: What's the Difference?

Screening and assessment imply different processes, with the former indicating risk factors for a deprived nutrition condition and the latter providing the nutrition diagnosis. Both should be routinely performed at hospital admission according to recommended guidelines; however, this is not the reality worldwide, and undernutrition remains highly prevalent in the hospital setting. Therefore, the objective of the current review is to delve into the principles leading to nutrition status deficiencies and how they should be addressed by screening and assessment. A critical appraisal for the reasons associated with the misunderstanding between screening and assessing is proposed without further discussing the many available screening tools while approaching some of the assessment instruments.

Nutritional status plays a crucial role in the mortality of critically ill patients with acute renal failure

We aimed to clarify associations between nutritional status and mortality in patients with acute renal failure. De-identified data were obtained from the Medical Information Mart for Intensive Care III database comprising more than 40,000 critical care patients treated at Beth Israel Deaconess Medical Centerbetween 2001 and 2012. Weight loss and body mass index criteria were used to define malnutrition. Data of 193 critically ill patients with acute renal failure were analyzed, including demographics, nutrition intervention, laboratory results, and disease severity. Main outcomes were in-hospital and 1-year mortality. The 1-year mortality was significantly higher in those with malnutrition than in those without malnutrition (50.0% vs 29.3%, p=0.010), but differences in in-hospital survival were not significant (p=0.255). Significant differences in mortality were found between those with malnutrition and without starting at the 52nd day after intensive care unit (ICU) discharge (p=0.036). No significant differences were found between men and women with malnutrition in in-hospital mortality (p=0.949) and 1-year mortality (p=0.051). Male patients requiring intervention with blood products/colloid supplements had greater risk of 1-year mortality, but without statistical significance. Nutritional status is a predictive factor for mortality among critically ill patients with acute renal failure, particularly 1-year mortality after ICU discharge.

Differentiating a Pressure Ulcer from Acute Skin Failure in the Adult Critical Care Patient

PURPOSE

The purpose of this learning activity is to provide information regarding the differentiation between pressure ulcers and acute skin failure (ASF) in critically ill patients.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES

After participating in this educational activity, the participant should be better able to:1. Describe the purpose, methodology and impact of this research.2. Differentiate the pathophysiology of pressure ulcers and ASF.3. Identify risk factors and diagnostic criteria for ASF.

ABSTRACT

To develop a statistical model to predict the development of acute skin failure in patients admitted to the intensive care unit (ICU) and to validate this model.Retrospective case-control, logistic regression modeling552 ICU patientsIntensive care unit patients with and without pressure ulcers (PrUs) were studied and compared on key variables sorted into the following categories: (1) disease status, (2) physical conditions, and (3) conditions of hospitalization.The variables, peripheral arterial disease (odds ratio [OR], 3.8; P = .002), mechanical ventilation greater than 72 hours (OR, 3.0; P < .001), respiratory failure (OR, 3.2; P < .001), liver failure (OR, 2.9; P = .04), and severe sepsis/septic shock (OR, 1.9; P = .02), were found to be statistically significant and independent predictors of acute skin failure in ICU patients. These variables created a predictor model for acute skin failure in the ICU.Lack of objective criteria to define acute skin failure presents a clinical conundrum for practitioners-the acknowledgment that skin failure exists, but no clear-cut diagnostic criteria in which to support its existence as a result of a paucity of empirical evidence. In certain populations, such as the critically ill patient, the phenomenon of acute skin failure may be occurring, and with the current level of evidence, these ulcers may be incorrectly identified as PrUs. Accurately distinguishing risk factors that lead to a PrU from factors that result in a lesion due to acute skin failure is crucial in the quest to provide evidence-based practice to patients.

OBESITY AND CRITICAL ILLNESS: INSIGHTS FROM ANIMAL MODELS

Critical illness is a major cause of morbidity and mortality around the world. While obesity is often detrimental in the context of trauma, it is paradoxically associated with improved outcomes in some septic patients. The reasons for these disparate outcomes are not well understood. A number of animal models have been used to study the obese response to various forms of critical illness. Just as there have been many animal models that have attempted to mimic clinical conditions, there are many clinical scenarios that can occur in the highly heterogeneous critically ill patient population that occupies hospitals and intensive care units. This poses a formidable challenge for clinicians and researchers attempting to understand the mechanisms of disease and develop appropriate therapies and treatment algorithms for specific subsets of patients, including the obese. The development of new, and the modification of existing animal models, is important in order to bring effective treatments to a wide range of patients. Not only do experimental variables need to be matched as closely as possible to clinical scenarios, but animal models with pre-existing comorbid conditions need to be studied. This review briefly summarizes animal models of hemorrhage, blunt trauma, traumatic brain injury, and sepsis. It also discusses what has been learned through the use of obese models to study the pathophysiology of critical illness in light of what has been demonstrated in the clinical literature.

Inadequação calórica e proteica e fatores associados em pacientes graves

RESUMO Objetivo: Investigar a adequação calórico-proteica de pacientes em terapia nutricional enteral exclusiva internados nas Unidades de Terapia Intensiva de um hospital universitário. Métodos: Estudo longitudinal realizado entre abril e novembro de 2014 nas Unidades de Terapia Intensiva de um hospital universitário. Foram avaliados no período de 14 dias: percentual de adequação calórico-proteica, calculada pelas médias dos valores prescritos e administrados; condições clínicas (unidade e diagnóstico de internação, escore prognóstico Acute Physiology and Chronic Health Evaluation II, estado nutricional, tempo de internação); complicações gastrointestinais; e motivo de interrupção da dieta. Valores inferiores a 80% de adequação calórica e proteica foram considerados inadequados. Realizou-se análise multivariada por Regressão de Poisson com nível de significância de 5%. Resultados: O estudo contou com uma amostra de 38 pacientes, sendo 52,63% desnutridos. As médias de adequação calórica e proteica foram de 76,47% e 69,11%, respectivamente. A prevalência de inadequação calórica foi de 55,26% e de proteica, 68,42%. O jejum para procedimentos foi a causa mais frequente de interrupção da dieta. O volume residual gástrico e a diarreia foram as complicações gastrointestinais mais comuns. A inadequação calórica associou-se ao tempo de permanência ≤14 dias e ao volume residual elevado. A inadequação proteica associou-se ao tempo de permanência ≤14 dias, ao volume residual gástrico elevado e à saída ou obstrução da sonda. Conclusão: A prevalência de inadequação calórica e proteica ocorreu em mais da metade dos pacientes avaliados. Estratégias como a elaboração de protocolos por equipe multiprofissional devem ser implantadas para minimizar interrupções da dieta administrada, estabelecer medidas de controle para complicações gastrointestinais e, assim, garantir um aporte nutricional adequado durante o período de internação.

Existing equations to estimate lean body mass are not accurate in the critically ill: Results of a multicenter observational study

BACKGROUND & AIMS

Lean body mass (LBM), quantified using computed tomography (CT), is a significant predictor of clinical outcomes in the critically ill. While CT analysis is precise and accurate in measuring body composition, it may not be practical or readily accessible to all patients in the intensive care unit (ICU). Here, we assessed the agreement between LBM measured by CT and four previously developed equations that predict LBM using variables (i.e. age, sex, weight, height) commonly recorded in the ICU.

METHODS

LBM was calculated in 327 critically ill adults using CT scans, taken at ICU admission, and 4 predictive equations (E1-4) that were derived from non-critically adults since there are no ICU-specific equations. Agreement was assessed using paired t-tests, Pearson's correlation coefficients and Bland-Altman plots.

RESULTS

Median LBM calculated by CT was 45 kg (IQR 37-53 kg) and was significantly different (p < 0.001) from E1 (52.5 kg; IQR: 42-61 kg), E2 (55 kg; IQR 45-64 kg), E3 (55 kg; IQR 44-64 kg), and E4 (54 kg; IQR 49-61 kg). Pearson correlation coefficients suggested moderate correlation (r = 0.739, 0.756, 0.732, and 0.680, p < 0.001, respectively). Each of the equations overestimated LBM (error ranged from 7.5 to 9.9 kg), compared with LBM calculated by CT, suggesting insufficient agreement.

CONCLUSIONS

Our data indicates a large bias is present between the calculation of LBM by CT imaging and the predictive equations that have been compared here. This underscores the need for future research toward the development of ICU-specific equations that reliably estimate LBM in a practical and cost-effective manner.

The Indigenous Australian Malnutrition Project: the burden and impact of malnutrition in Aboriginal Australian and Torres Strait Islander hospital inpatients, and validation of a malnutrition screening tool for use in hospitals-study rationale and protocol

BACKGROUND

Malnutrition is associated with adverse outcomes for hospital inpatients and is a significant economic burden on hospitals. Malnutrition is frequently under-recognised in this setting and valid screening and early diagnosis are important for timely nutritional management. Aboriginal Australian and/or Torres Strait Islander peoples (Indigenous Australians) are likely to be at increased risk of malnutrition due to their disproportionate burden, pattern and age-distribution of chronic diseases. Despite this increased risk, the burden and impact of malnutrition in Indigenous Australians is poorly understood. Furthermore, a suitable screening tool has not been validated for this vulnerable patient group. The aim of this study is to determine the burden of malnutrition, understand its impact, and validate a malnutrition screening tool for Indigenous Australian inpatients.

METHODS

This project involves cross-sectional, prospective cohort and diagnostic validation methodologies to assess the burden and impact of malnutrition and to validate a malnutrition screening tool. A target of 752 adult Indigenous and non-Indigenous Australian inpatients will be recruited across three different public hospitals in the Northern Territory and far north Queensland of Australia. Cross-sectional data collection will be used to determine the prevalence of malnutrition using the Subjective Global Assessment and to stratify participants based on the International Consensus Guideline Committee malnutrition aetiology-diagnostic framework. Subjects will then be followed prospectively to measure short and long-term health outcomes such as length of hospital stay, in-hospital mortality, 30-day and 6-month readmission rates. Finally, the utility of a new screening tool, the Australian Nutrition Tool, will be assessed against an existing screening tool, the malnutrition screening tool, used in these settings and the malnutrition reference standard, the Subjective Global Assessment.

DISCUSSION

Indigenous Australians continue to experience poorer levels of health than non-Indigenous Australians and issues such as food insecurity, poor diet, and a disproportionate burden of chronic disease play a key contributing role for malnutrition in Indigenous Australians. To improve the health and hospital outcomes of Indigenous and non-Indigenous Australians, it is important that patients are routinely screened using a validated screening tool. It is also imperative that the burden and impact of malnutrition is properly understood, and fully appreciated, so that early and appropriate nutritional management can be provided to this group of hospital patients.

Tryptophan depletion in context of the inflammatory and general nutritional status of a low-income South African HIV-infected population

BACKGROUND

The essential amino acid tryptophan cannot be synthesised in the body and must be acquired through dietary intake. Oxidation of tryptophan, due to immune induction of the enzyme indoleamine 2,3-dioxygenase (IDO), is considered to be the main cause of tryptophan depletion in HIV infection and AIDS. We examined plasma tryptophan levels in a low-income sub-Saharan HIV-infected population and compared it to that of developed countries. Tryptophan levels were further examined in context of the general nutritional and inflammatory status.

METHODS

This cross-sectional study included 105 HIV-positive patients recruited from the Kalafong Hospital in Pretoria, South Africa, and 60 HIV-negative controls.

RESULTS

Patient tryptophan levels were in general markedly lower than those reported for developed countries. In contrast to reports from developed countries that showed tryptophan levels on average to be 18.8 % lower than their control values, tryptophan levels in our study were 44.1 % lower than our controls (24.4 ± 4.1 vs. 43.6 ± 11.9 μmol/l; p < 0.001). Tryptophan levels correlated with both CD4 counts (r = 0.341; p = 0.004) and with pro-inflammatory activity as indicated by neopterin levels (r = -0.399; p = 0.0001). Nutritional indicators such as albumin and haemoglobin correlated positively with tryptophan and negatively with the pro-inflammatory indicators neopterin, interleukin 6 and C-reactive protein. The most probable causes of the lower tryptophan levels seen in our population are food insecurity and higher levels of inflammatory activity.

CONCLUSIONS

We contend that inflammation-induced tryptophan depletion forms part of a much wider effect of pro-inflammatory activity on the nutritional profile of HIV-infected patients.

Simplifications of the mini nutritional assessment short-form are predictive of mortality among hospitalized young and middle-aged adults

OBJECTIVE

Measuring malnutrition in hospitalized patients is difficult in all settings. I evaluated associations of items in the mini nutritional assessment short-form (MNA-sf), a nutritional-risk screening tool previously validated in the elderly, with malnutrition among hospitalized patients in Uganda. I used results to construct two simplifications of this tool that may be applicable to young and middle-aged adults.

METHODS

I assessed the association of each MNA-sf item with the mid-upper arm circumference (MUAC), a specific measure of malnutrition at appropriate cut-offs. I incorporated only malnutrition-specific items into the proposed simplifications scoring each item according to its association with malnutrition. I assessed numbers classified to different score-levels by the simplifications and, via proportional hazards regression, how the simplifications predicted in-hospital mortality.

RESULTS

I analyzed 318 patients (median age 37, interquartile range 27 to 56). Variables making it into the simplifications were: reduced food intake, weight loss, mobility, and either BMI in kg/m(2) (categorized as <16, 16 to 16.9, and ≥17) or MUAC in centimeters (categorized as <16 or <17, 16 to 18.9 or 17 to 19.9, and ≥19 or ≥20 for females and males respectively). Compared to the traditional MNA-sf, the simplifications classified fewer patients as malnourished, yet remained strongly predictive of in-hospital mortality. In the MUAC-incorporating simplification, malnourished patients had 3.8-fold (95% CI 1.9 to 7.8) higher risk of in-hospital death than those not malnourished; adjusting for age, sex, and HIV status.

CONCLUSION

The MNA-sf simplifications described may provide an improved measure of malnutrition in hospitalized young and middle-aged adults.

Association of body mass index with disease severity and prognosis in patients with non-cystic fibrosis bronchiectasis

The objective of this observational, multicenter study was to evaluate the association of body mass index (BMI) with disease severity and prognosis in patients with non-cystic fibrosis bronchiectasis. A total of 339 patients (197 females, 142 males) diagnosed with non-cystic fibrosis bronchiectasis by high-resolution computed tomography were classified into four groups: underweight (BMI<18.5 kg/m²), normal weight (18.5≤BMI<25.0 kg/m²), overweight (25.0≤BMI<30.0 kg/m²), and obese (BMI≥30.0 kg/m²). Clinical variables expressing disease severity were recorded, and acute exacerbations, hospitalizations, and survival rates were estimated during the follow-up period. The mean BMI was 21.90 kg/m². The underweight group comprised 28.61% of all patients. BMI was negatively correlated with acute exacerbations, C-reactive protein, erythrocyte sedimentation rate, radiographic extent of bronchiectasis, and chronic colonization by P. aeruginosa and positively correlated with pulmonary function indices. BMI was a significant predictor of hospitalization risk independent of relevant covariates. The 1-, 2-, 3-, and 4-year cumulative survival rates were 94%, 86%, 81%, and 73%, respectively. Survival rates decreased with decreasing BMI (χ²=35.16, P<0.001). The arterial carbon dioxide partial pressure, inspiratory capacity, age, BMI, and predicted percentage of forced expiratory volume in 1 s independently predicted survival in the Cox proportional hazard model. In conclusion, an underweight status was highly prevalent among patients with non-cystic fibrosis bronchiectasis. Patients with a lower BMI were prone to developing more acute exacerbations, worse pulmonary function, amplified systemic inflammation, and chronic colonization by P. aeruginosa. BMI was a major determinant of hospitalization and death risks. BMI should be considered in the routine assessment of patients with non-cystic fibrosis bronchiectasis.

Quick Fix for Hospital-Acquired Malnutrition?

Hospital-acquired malnutrition is universally present across the globe. Little progress has been made on overcoming hospital-acquired malnutrition despite known presence for at least 40 years. Technologies and methods to deliver the recommended calories and protein are available in most healthcare settings. Despite this, inadequate nutrient delivery continues to be a problem. Correia and colleagues propose a simplified algorithm that assists clinicians in becoming aware of poor nutrient intake and suggest nutrition interventions.

Nutrition therapy in critically ill patients- a review of current evidence for clinicians

The provision of nutrition to critically ill patients is internationally accepted as standard of care in intensive care units (ICU). Nutrition has the potential to positively impact patient outcomes, is relatively inexpensive compared to other commonly used treatments, and is increasingly identified as a marker of quality ICU care. Furthermore, we are beginning to understand its true potential, with positive and deleterious consequences when it is delivered inappropriately. As with many areas of medicine the evidence is rapidly changing and often conflicting, making interpretation and application difficult for the individual clinician. This narrative review aims to provide an overview of the major evidence base on nutrition therapy in critically ill patients and provide practical suggestions.

Bedside measures of malnutrition and association with mortality in hospitalized adults

BACKGROUND & AIMS

The impact of malnutrition on the outcomes of hospitalized adults in resource-limited settings such as sub-Saharan Africa (SSA) is not fully described. We aimed to determine the association between malnutrition and mortality in adults admitted to hospital in the resource-limited setting of Southwestern Uganda.

METHODS

We performed a cohort study of adults admitted to the medical ward of Mbarara Regional Referral Hospital. Measures of nutritional status included: 1) body mass index (BMI), 2) the mini-nutritional assessment short form (MNA-sf), and 3) mid-upper arm circumference (MUAC). Subjects were followed until death or 30 days from admission. We used proportional hazards regression to assess associations between malnutrition and in-hospital and 30-day mortality.

RESULTS

We enrolled 318 subjects. The prevalence of malnutrition was 25-59% depending on the measure used. In-hospital and 30-day mortality were 18% and 37% respectively. In the adjusted analysis, subjects with MNA-sf score 0-7 had a 2.7-fold higher risk of in-hospital mortality (95% CI: 1.3-5.9, p = 0.011) than those with a score of 8-14, and subjects with malnutrition determined by MUAC (<20 cm for males, and <19 cm for females) had a 1.8-fold higher risk of in-hospital mortality (95% CI: 0.98-3.4, p = 0.06) than those normally nourished. MNA-sf (HR 1.6, 95% CI: 1.02-2.6, p = 0.039) and MUAC (HR 1.6, 95% CI: 1.0-2.3, p = 0.048) were independently predictive of 30-day mortality. BMI <18.5 was not associated with in-hospital or 30-day mortality.

CONCLUSIONS

Malnutrition was common and simple measures of nutritional status predicted in-hospital and 30-day mortality. Further research is needed to understand the pathophysiology of malnutrition during acute illness and mitigate its effects.

Prognostic indices of poor nutritional status and their impact on prolonged hospital stay in a Greek university hospital

Background. To ascertain the potential contributors to nutritional risk manifestation and to disclose the factors exerting a negative impact on hospital length of stay (LOS), by means of poor nutritional status, in a nonselected hospitalized population. Materials and Methods. NutritionDay project questionnaires were applied to 295 adult patients. Study parameters included anthropometric data, demographics, medical history, dietary-related factors, and self-perception of health status. Body Mass Index (BMI) and Malnutrition Universal Screening Tool (MUST) were calculated for each participant. MUST score was applied for malnutrition assessment, while hospital LOS constituted the outcome of interest. Results. Of the total cohort, 42.3% were at nutritional risk and 21.4% malnourished. Age, gender, BMI, MUST score, autonomy, health quality, appetite, quantity of food intake, weight loss, arm or calf perimeter (P < 0.001, for all), and dietary type (P < 0.01) affected nutritional status. Poor nutrition status (P = 0.000), deteriorated appetite (P = 0.000) or food intake (P = 0.025), limited autonomy (P = 0.013), artificial nutrition (P = 0.012), weight loss (P = 0.010), and arm circumference <21 cm (P = 0.007) were the most powerful predictors of hospital LOS >7 days. Conclusion. Nutritional status and nutrition-related parameters such as weight loss, quantity of food intake, appetite, arm circumference, dietary type, and extent of dependence confer considerable prognostic value regarding hospital LOS in acute care setting.

Early Detection of Coagulation Abnormalities in Patients at Nutritional Risk: The Novel Role of Thromboelastography

It is believed that malnutrition is common among hospitalized patients and associated with increased risk of morbidity and mortality. It is unclear if it is more likely to cause coagulation disorders in patients with malnutrition. We, therefore, investigate the feasibility of using thromboelastography (TEG) in early detection of coagulation abnormalities in patients at nutritional risk. Fifty successive adult patients with gastrointestinal disease were prospectively divided into one of two groups according to nutritional risk score (less than 3 and 3 or greater). Blood samples were collected at admission for analysis of standard biochemical parameters, routine coagulation tests, and TEG parameters. A total of 62 per cent of patients (n = 31) were at nutritional risk. Serum concentrations of prealbumin, transferrin, total protein, low-density lipoprotein, high-density lipoprotein, and cholesterol were much lower in the nutritional risk group than in the no-risk group ( P ≤ 0.05). There was no significant difference in routine coagulation tests, whereas most of the TEG parameters showed significant differences between the two groups. The overall coagulation function was worse in patients at nutritional risk than in patients with good nutritional status ( P ≤ 0.01). TEG appears to be more sensitive for the detection of coagulation abnormalities compared with routine coagulation tests in patients at nutritional risk. The phenomenon described in this article should be useful in further studies of patients with malnutrition.

Nutrition and hydration in older adults in critical care

Nutrition and hydration are vital components of critical care nursing. However, meeting the nutrition and hydration needs of the critically ill older adult is often complex, because of preexisting risk factors (malnutrition, unintentional weight loss, frailty, and dehydration); as well as intensive care unit-related challenges (catabolism, eating and feeding, end-of-life care). This article highlights the challenges of managing nutrition and hydration in the critically ill older adult, reviews assessment principles, and offers strategies for optimizing nutrition and hydration.

Recognizing malnutrition in adults: definitions and characteristics, screening, assessment, and team approach

Appropriate recognition of malnutrition in adults requires knowledge of screening and assessment methodologies. An appreciation for the contributions of inflammation has resulted in a new etiology-based approach to defining malnutrition syndromes. The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) have published a consensus document that extends this approach to describe characteristics for the identification and documentation of malnutrition in adults. Nutrition screening tools are used to identify patients at nutrition risk and those who are likely to benefit from further assessment and intervention. Nutrition assessment serves to guide appropriate intervention. A systematic approach to nutrition assessment that supports the new diagnostic scheme and criteria from the Academy and A.S.P.E.N. has recently been presented. Since screening delays and failures in the diagnosis and management of malnutrition are all too common, a multidisciplinary team approach is recommended to promote improved communication and quality of care.

Why critically ill patients are protein deprived

Critical illness dramatically increases muscle proteolysis and more than doubles the dietary protein requirement. Yet surprisingly, most critically ill patients receive less than half the recommended amount of protein during their stay in a modern intensive care unit. What could explain the wide gap between the recommendations in clinical care guidelines and actual clinical practice? We suggest that an important aspect of the problem is the failure of guidelines to explain the pathophysiology of protein-energy malnutrition and the ways critical illness modifies protein metabolism. The difficulty created by the lack of a framework for reasoning about appropriate protein provision in critical illness is compounded by the many ambiguous and often contradictory ways the word malnutrition is used in the critical care literature. Failing to elucidate these matters, the recommendations for protein provision in the guidelines are incoherent, unconvincing, and easy to ignore.

Nutrient intake, peripheral edema, and weight change in elderly recuperative care patients

BACKGROUND

It is unclear whether serial measures of body weight are valid indicators of nutritional status in older patients recovering from illness. Objectives. Investigate the relative influence of nutrient intake and changes in peripheral edema on weight change.

METHODS

A prospective cohort study of 404 older men (mean age = 78.7±7.5 years) admitted to a transitional care unit of a Department of Veterans Affairs nursing home. Body weight and several indicators of lower extremity edema were measured at both unit admission and discharge. Complete nutrient intake assessments were performed daily.

RESULTS

Over a median length of stay of 23 days (interquartile range: 15-41 days), 216 (53%) participants gained or lost more than or equal to 2.5% of their body weight. Two hundred eighty-two (70%) participants had recognizable lower extremity pitting edema at admission and/or discharge. The amount of weight change was strongly and positively correlated with multiple indicators of both nutrient intake and the change in the amount of peripheral edema. By multivariable analysis, the strongest predictor of weight change was maximal calf circumference change (partial R (2) = .35, p < .0001), followed by average daily energy intake (partial R (2) = .14, p < .0001), and the interaction of energy intake by time (partial R (2) = .02, p < .0001).

CONCLUSIONS

Many older patients either gain or lose a significant amount of weight after admission to a transitional care unit. Because of the apparent high prevalence of co-occurring changes in total body water, the weight changes do not necessarily represent changes in nutritional status. Although repeat calf circumference measurements may provide some indication as to how much of the weight change is due to changes in body water, there is currently no viable alternative to monitoring the nutrient intake of older recuperative care patients in order to ensure that their nutrient needs are being met.

Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition)

The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend that a standardized set of diagnostic characteristics be used to identify and document adult malnutrition in routine clinical practice. An etiologically based diagnostic nomenclature that incorporates a current understanding of the role of the inflammatory response on malnutrition's incidence, progression, and resolution is proposed. Universal use of a single set of diagnostic characteristics will facilitate malnutrition's recognition, contribute to more valid estimates of its prevalence and incidence, guide interventions, and influence expected outcomes. This standardized approach will also help to more accurately predict the human and financial burdens and costs associated with malnutrition's prevention and treatment and further ensure the provision of high-quality, cost-effective nutrition care.

Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition)

The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend that a standardized set of diagnostic characteristics be used to identify and document adult malnutrition in routine clinical practice. An etiologically based diagnostic nomenclature that incorporates a current understanding of the role of the inflammatory response on malnutrition's incidence, progression, and resolution is proposed. Universal use of a single set of diagnostic characteristics will facilitate malnutrition's recognition, contribute to more valid estimates of its prevalence and incidence, guide interventions, and influence expected outcomes. This standardized approach will also help to more accurately predict the human and financial burdens and costs associated with malnutrition's prevention and treatment, and further ensure the provision of high quality, cost effective nutritional care.