Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients

Characterization of metabolism associated with outcomes in severe acute pancreatitis: Insights from serum metabolomic analysis

Severe Acute Pancreatitis (SAP) is characterized by an abrupt onset of pancreatic inflammation, which may induce damage to other organs, and is associated with significant morbidity and mortality. Despite the considerable disease burden, specific treatments to stop progression or prevent occurrence are limited. Currently, there is a paucity of comprehensive studies that thoroughly explore metabolic dysregulation in SAP, particularly those that emphasize changes in outcomes. Nuclear magnetic resonance (NMR) based metabolomics coupled with multivariate analysis was applied to serum samples of 20 survivors and 30 non-survivors of SAP to identify metabolic changes linked to different outcomes. The discriminant analysis of serum samples of SAP survivors and non-survivors revealed isoleucine, leucine, valine, arginine, lactate, and 3-hydroxybutyrate as significant metabolites elevated in the non-survivors. These identified metabolites had shown a significant positive correlation with clinical severity scores in the Pearson correlation analysis. Pathway analysis revealed disruptions in amino acid metabolism, driven by protein catabolism to fulfill the patient's energy requirements. This study highlights the importance of metabolomics in unraveling the molecular and physiological mechanisms underlying SAP. These findings offer valuable insights for clinicians to develop treatment strategies that target metabolic pathways in SAP, potentially for improving patient outcomes.

Exploring the association between computed tomography (CT)-derived skeletal muscle mass and short- and long-term mortality in critically ill patients: a systematic review and meta-analysis

BACKGROUND

Low skeletal mass, often present at hospital admission, has been associated with poor prognoses.

AIM

To explore the association between computed tomography (CT)-derived skeletal muscle mass at the lumbar level and short- and long-term mortality in critically ill patients.

METHODS

Following PRISMA 2020 guidelines, we included studies on critically ill adults (≥ 18 years) hospitalized in intensive care units (ICU) that measured CT-derived skeletal muscle mass at the lumbar vertebral level within ± 7 days of ICU admission. The primary outcome was mortality, categorized as short-term (including ICU, hospital, 28- and 30-day mortality) and long-term (> 30 days) mortality. MEDLINE and Embase databases were searched without date restrictions. Study screening was performed using Rayyan, data extraction was guided by a custom-designed tool, and quality assessment was performed using the JBI Cohort Study Checklist. A meta-analysis was conducted, focusing on studies that reported short- and long-term mortality among patients with preserved and reduced skeletal muscle. A prevalence meta-analysis was also performed for studies that reported the size of subgroups with low muscle mass.

RESULTS

Out of 1248 unique records, 35 studies met the inclusion criteria, involving 9366 participants. The majority were retrospective, single-centre studies conducted on four continents and included heterogeneous populations such as patients with sepsis, COVID-19 and trauma. Sample sizes ranged from 36 to 939, with a wide age range, from 40 to 70 s, and a predominance of male patients (62%). Skeletal mass was most commonly reported as skeletal muscle index at the third lumbar vertebra. Studies reported mainly short-term mortality on day 28 or 30. Long-term mortality, measured at 90 days, 6 months, and 1 year, was evaluated in 11 studies. Meta-analyses revealed that low skeletal muscle mass area and index were significantly associated with increased risks of both short (OR = 2.33, CI 1.90-2.87, I2 = 41.39%)-and long-term mortality (OR = 2.67, CI 1.45-4.92, I2 = 62.24%). The overall prevalence of low muscle mass was 42% (CI 34-49%, I2 = 98.2%).

CONCLUSIONS

CT-assessed skeletal muscle mass at the lumbar level on admission to ICU is associated with both short- and long-term mortality. It may serve as a prognostic marker in critically ill patients. Standardized protocols for measuring and defining low skeletal muscle mass in this population are essential to improve comparability across studies.

Recognizing malnutrition in adults with critical illness: Guidance statements from the Global Leadership Initiative on Malnutrition

BACKGROUND

Patients with critical illness may present with disease-related malnutrition upon intensive care unit (ICU) admission. They are at risk of development and progression of malnutrition over the disease trajectory because of inflammation, dysregulated metabolism, and challenges with feeding.

METHODS

The Global Leadership Initiative on Malnutrition (GLIM) convened a panel of 36 clinical nutrition experts to develop consensus-based guidance statements addressing the diagnosis of malnutrition during critical illness, using a modified Delphi approach with a requirement of ≥75% agreement.

RESULTS

CONCLUSION: Research using consistent etiologic and phenotypic variables offers great potential to assess the efficacy of nutrition interventions for critically ill patients with malnutrition. Assessment of these variables at during and beyond the ICU stay will clarify the trajectory of malnutrition and enable exploration of impactful treatment modalities at each juncture. GLIM offers a diagnostic approach that can be used to identify malnutrition in critically ill patients.

Beyond body mass index: exploring the role of visceral adipose tissue in intensive care unit outcomes

Obesity is a worldwide health crisis and poses significant challenges in critical care. Many studies suggest an 'obesity paradox', in which obesity, defined by body mass index (BMI), is associated with better outcomes. However, the inability of BMI to discriminate between fat and muscle or between visceral adipose tissue and subcutaneous adipose tissue, limits its prediction of metabolic ill health. We suggest that the 'obesity paradox' may be more reflective of the limitations of BMI than the protective effect of obesity. We explore the biological processes leading to visceral fat accumulation, and the evidence linking it to outcomes in critical illness. In the 'spillover' hypothesis of adipose tissue expansion, caloric excess and impaired expansion of storage capacity in the subcutaneous adipose tissue lead to accumulation of visceral adipose tissue. This is associated with a chronic inflammatory state, which is integral to the link between visceral adiposity, type 2 diabetes mellitus, and ischaemic heart disease. We review the current evidence on visceral adiposity and critical illness outcomes. In COVID-19, increased visceral adipose tissue, irrespective of BMI, is associated with more severe disease. This is mirrored in acute pancreatitis, suggesting visceral adiposity is linked to poorer outcomes in some hyperinflammatory conditions. We suggest that visceral adiposity's chronic inflammatory state may potentiate acute inflammation in conditions such as COVID-19 and acute pancreatitis. Further work is required to investigate other critical illnesses, especially sepsis and acute respiratory distress syndrome, in which current evidence is scarce. This may give further insights into pathophysiology and inform tailored treatment and nutrition strategies based on body fat distribution.

Masseter Sarcopenia and Mortality After Type II Odontoid Fractures in the Elderly: A 5-Year Follow-Up Study

BACKGROUND AND OBJECTIVES

Sarcopenia, defined as low muscle mass with reduced strength or function, is associated with poor outcomes in trauma patients. Head computed tomography scans routinely performed in elderly trauma patients allows for masseter sarcopenia measurement. Its association with mortality after Type II odontoid fractures has not been previously investigated. This study examines the relationship between masseter sarcopenia and mortality in elderly patients with Type II odontoid fractures.

METHODS

This retrospective cohort study included patients aged 50 years or older with a Type II odontoid fracture and a head computed tomography scan within 7 days from presentation. Data collected included demographics, Charlson Comorbidity Index, treatment modality, Injury Severity Scores, Modified Frailty Index-5 (mFI-5) scores, fracture characteristics (angulation, displacement, gap, and comminution), and masseter cross-sectional area (MCSA). Sarcopenia was defined as 1 SD below sex-specific means. Multivariate Cox regressions were used to evaluate the association between MCSA and mortality, adjusting for age, sex, body mass index, Charlson Comorbidity Index, Injury Severity Scores, mFI-5, and type of treatment (operative vs conservative). Kaplan-Meier survival curves illustrated cumulative survival.

RESULTS

Among 72 patients (mean age: 80.9 ± 9.5 years, 58.3% females), 14 (19.4%) had masseter sarcopenia. By 1-year postinjury, 16 (22.2%) died, increasing to 22 (30.6%) by 2 years. Masseter sarcopenia significantly predicted 1-year mortality (adjusted hazard ratio [aHR]:5.31 [95% CI: 1.44-19.62], P = .01) whereas mFI-5 predicted 2-year mortality (aHR: 1.96 [95% CI: 1.09-3.52], P = .02). By 5 years, 38 (52.8%) died, including 9 (40.9%, 95% CI: 18.6.0%-63.2%), treated operatively and 29 (58.0%, 95% CI: 43.8%-72.2%) treated conservatively (P = .18). Among sarcopenic, 9 (64.3%, 95% CI: 35.6%-93.0%) died, compared with 29 (50.0%, 95% CI: 36.7%-63.3%) nonsarcopenic (P = .34). Age was consistent predictor of mortality within 3 years to 5 years after injury (aHR: 1.08 [95% CI: 1.03-1.13], P < .01).

CONCLUSION

Masseter sarcopenia is significantly associated with mortality within 1 year after Type II odontoid fractures in elderly patients. In this cohort, 30.6% died by 2 years and 52.8% by 5 years. Early sarcopenia identification using MCSA may aid in prognostication and postinjury management. Level of Evidence: Therapeutic Level III.

Low skeletal muscle and subcutaneous fat at admission are associated with 90-day mortality in intensive care unit patients

BACKGROUND

Low muscle mass assessed by the third lumbar vertebra (L3)-targeted abdominal computed tomography-scan (CT-scan) predicts short-term hospital mortality in the intensive care unit (ICU) patients. However, little is known regarding the relation between the L3 muscle and fat areas at ICU admission and 90-day clinical outcomes.

AIMS

to determine the relation between skeletal muscle, subcutaneous, visceral, intramuscular, and total fat cross-sectional areas at ICU admission and 90-day mortality (main), between skeletal muscle and other clinical outcomes, and between body mass index (BMI) and 90-day mortality (secondary).

METHODS

A retrospective observational study was performed in a 10-bed medical ICU. The inclusion criteria were: routine abdominal CT-scan <3 days post-admission, expected length of stay >48 h. CT-scan assessed skeletal muscle, subcutaneous, visceral and intramuscular fat areas (cm2) at the L3 level. Low skeletal muscle index (SMI) was defined as <38.5 (women) and <52.4 cm2/m2 (men). Actuarial survival curves, univariate analyses and multivariable Cox models were performed.

RESULTS

Out of 200 screened patients, 141 were analyzed: age (mean ± standard deviation) 65.2 ± 14.9 years, 59 % of males, Simplified Acute Physiology Score (SAPS) II 61.7 ± 21.5, BMI, 27.9 ± 6.4. Kaplan-Meier analysis indicated worse survival in patients with low skeletal SMI (61 % (n = 39/64) vs. 44 % (n = 34/77), P = 0.04). Cox multivariable analysis indicated that age ≥65 years (hazard ratio (HR) = 1.79 [95 % confidence interval, 1.01 - 3.19], P = 0.047), SAPS II (HR = 1.04 [1.02-1.05], P < 0.001), low SMI (normal vs. low, HR = 0.48 [0.29-0.82], P = 0.007) and subcutaneous fat index log (HR = 0.67 [0.51 - 0.89], P = 0.006), were independently associated with 90-day mortality. Visceral, intramuscular and total fat areas were not associated with 90-day mortality. Higher body mass index was associated with lower 90-day mortality (HR = 0.92 [0.88-0.96, P < 0.001], when the model excluded muscle and fat tissue levels.

CONCLUSIONS

Lower skeletal muscle mass, subcutaneous fat and BMI at ICU admission are associated with higher 90-day mortality. Despite the Global Leadership Initiative on Malnutrition criteria were not used, these results suggest that protein-energy malnutrition at ICU admission is a strong marker of mortality.

Recognizing malnutrition in adults with critical illness: Guidance statements from the Global Leadership Initiative on Malnutrition

BACKGROUND

Patients with critical illness may present with disease-related malnutrition upon intensive care unit (ICU) admission. They are at risk of development and progression of malnutrition over the disease trajectory because of inflammation, dysregulated metabolism, and challenges with feeding.

METHODS

The Global Leadership Initiative on Malnutrition (GLIM) convened a panel of 36 clinical nutrition experts to develop consensus-based guidance statements addressing the diagnosis of malnutrition during critical illness using a modified Delphi approach with a requirement of ≥75% agreement.

RESULTS

(1) To identify pre-existing malnutrition, we suggest evaluation within 48 h of ICU admission when feasible (100% agreement) or within 4 days (94% agreement). (2) To identify the development and progression of malnutrition, we suggest re-evaluation of all patients every 7-10 days (97% agreement). (3) To identify progressive loss of muscle mass, we suggest evaluation of muscle mass as soon as feasible (92% agreement) and again after 7-10 days (89% agreement). (4) To identify the development and progression of malnutrition before and after ICU discharge, we suggest re-evaluating nutrition status before ICU discharge and during clinical visits that follow (100% agreement).

CONCLUSION

Research using consistent etiologic and phenotypic variables offers great potential to assess the efficacy of nutrition interventions for critically ill patients with malnutrition. Assessment of these variables during and beyond the ICU stay will clarify the trajectory of malnutrition and enable exploration of impactful treatment modalities at each juncture. GLIM offers a diagnostic approach that can be used to identify malnutrition in critically ill patients.

Effect of High Protein Normocaloric Nutrition on Skeletal Muscle Wasting in Critically Ill Mechanically Ventilated Patients: A Randomized Double-blind Study

Background and aims

Muscle wasting in critically ill patients is associated with poor outcomes. During intensive care unit (ICU) stay, delivering appropriate nutritional support helps minimize muscle loss. We sought to evaluate the impact of high-dose protein on muscle thickness and cross-sectional area (CSA), as well as to track changes in muscle echogenicity and pennation angle (PA) using bedside ultrasound in this population.

Patients and methods

We conducted a randomized, prospective, double-blind trial in which 30 patients mechanically ventilated for more than 48 hours and receiving enteral feed were enrolled. Patients were divided into two groups, and all patients received enteral feeds with total calories of about 25 kcal/kg/day. In the high-protein feed (HPF) group, patients were targeted to receive 1.5 gm/kg/day of protein, whereas in the standard feed (SF) group, patients received 1 gm/kg/day of protein. After ICU admission, muscle thickness, CSA, echogenicity, and PA were measured in all mechanically ventilated patients on days 1, 3, 5, and 7 using bedside ultrasound. The right lower limb vastus lateralis (VL) and the medial head of the gastrocnemius were investigated.

Results

We found a progressive decrease in muscle mass from day 1 to day 7 in all patients. Our study showed that muscle thickness and CSA were significantly higher in the HPF group than the SF group over 7 days, whereas muscle echogenicity and PA changes were not statistically significant.

Conclusion

High-protein feeds prevent muscle wasting in critically ill patients compared to patients receiving SFs during the first week of ICU stay. The qualitative muscle parameters, like muscle echogenicity and PA changes, were not significant.

How to cite this article

Parasuraman V, Anand RK, Khanna P, Shanmugam R, Ray BK. Effect of High Protein Normocaloric Nutrition on Skeletal Muscle Wasting in Critically Ill Mechanically Ventilated Patients: A Randomized Double-blind Study. Indian J Crit Care Med 2025;29(5):431-440.

Urinary urea, nitrogen balance and mortality in critically ill patients - A prospective cohort study

INTRODUCTION

nitrogen balance (NB) is the difference between nitrogen ingested and excreted, however its value as a prognostic marker in critically ill patients has yet to be determined. This study aimed to evaluate the association between NB, urinary parameters, and adverse outcomes among ICU patients.

METHODS

NB, urinary urea (UUE) and creatinine (UCE) excretion were recorded in the first week of ICU. The primary outcome was ICU mortality, and secondary outcomes were time on mechanical ventilation (MV), ICU and hospital length of stay and hospital mortality.

RESULTS

a total of 127 patients were included (58 ± 16 years, 87.4 % clinical admissions). Negative NB was observed in 77.2 % patients in the first and 47.2 % patients in the second measurement, with a protein intake of 40 (25-58) vs 86 (64-107) g/day. The ICU and hospital mortality rates were 22.0 % and 30.7 %. There was no identified cut-off point for sensibility and specificity in the ROC curves for NB and urinary parameters regarding ICU and hospital mortality.

CONCLUSIONS

NB, UUE, or UCE were not associated with ICU or hospital mortality in our study. Further research is needed to evaluate the practical value of NB as a prognostic marker in ICU patients.

Body Composition Assessment in Critically Ill Adults - Where are We now?

This narrative review provides an overview of body composition methods available for use in critically ill patients. It focuses on the relevance and discussion of the most commonly used techniques. Further, we discuss the validity of these methods with a focus on muscle mass assessment, measuring changes over time and the identification of patients with lower-than-normal muscularity. Current available evidence, as well as future directions is highlighted.

Tackling the small imbalanced horizontal dataset regressions by Stability Selection and SMOGN: a case study of ventilation-free days prediction in the pediatric intensive care unit and the importance of PRISM

OBJECTIVE

The regression of small imbalanced horizontal datasets is an important problem in bioinformatics due to rare but vital data points impacting model performance. Most clinical studies suffer from imbalance in their distribution which impacts the learning ability of regression or classification models. The imbalance once combined with the small number of samples reduces the prediction performance. An improvement in the trainability of small imbalanced datasets hugely improves the potency of current prediction models that rely on a small set of valuable expensive samples.

MATERIALS AND METHODS

A method called Stability Selection has been used to overcome the high dimensionality problem, which arises when the sample sizes are relatively small compared to the number of features. The method was used to improve the performance of the Synthetic Minority Over-Sampling Technique for Regression with Gaussian Noise (SMOGN), an imbalance removal algorithm. To test the new pipeline, a small imbalanced cohort of pediatric ICU patients was used to predict the number of Ventilator-Free Days (VFD) a patient may experience for an admission period of 28 days due to respiratory illnesses.

RESULTS

Our model demonstrated its effectiveness by overcoming label imbalance while predicting almost all the non-surviving patients in the test dataset using Stability Selection before applying SMOGN. Our study also highlighted the importance of Pediatrics Risk of Mortality (PRISM) as a powerful VFD predictor if combined with other clinical features.

CONCLUSION

This paper shows how a hybrid strategy of Stability Selection, SMOGN, and regression can improve the outcome of highly imbalanced datasets and reduce the probability of highly expensive false negative detections in severe acute respiratory disease syndrome cases. The proposed modeling pipeline can reduce the overall VFD regression error but is also expandable to other regressable features. We also showed the importance of PRISM as a strong VFD predictor.

Impact of frailty in elderly patients undergoing decompressive craniectomy after traumatic brain injury

Decompressive craniectomy (DC) is a surgical procedure in which a large portion of the skull is removed and the dura mater is opened to relieve intracranial pressure. The indication in elderly patients is controversial, with prevailing studies indicating an overall poor prognosis. However, some patients recover well despite their advanced age. In this study we aimed to investigate the impact of frailty and muscularity on outcome after DC for TBI. We conducted a retrospective review of clinical notes of patients aged > 60 years, who underwent DC following TBI between January 2010 and December 2021. Temporalis muscle area (TMA) was quantified from head CT-scans upon admission. Frailty was assessed retrospectively from clinical charts using the Clinical Frailty Scale (CFS). Regression analysis were employed to determine their association with postsurgical Glasgow Outcome Scale (GOS). We identified 55 patients with a median age of 72 years (IQR 67-77; range 60-93 years). The 30-day mortality rate was 14.6%. At discharge, 32.7% of patients achieved good recovery or moderate disability (GOS 4-5), while 67.3% experienced severe disability, vegetative state, or death (GOS1-3). Initial GCS and CFS were associated to GOS at discharge in univariate (p = 0.042 and p = 0.009 respectively) and multivariate regression analysis (p = 0.049 and p = 0.013 respectively). TMA showed no association with GOS at discharge (p = 0.773). Age was associated with GOS at discharge in univariate (p = 0.042), but not multivariate linear regression (p = 0.421) when adjusted for GCS and CFS as covariables. Thirty patients (54.6%) were readmitted for cranioplasty, with 17 patients (30.9% of the entire cohort) displaying a GOS of 4-5. Frailty, rather than chronological age, emerges to be a crucial predictor of GOS following decompressive craniectomy for TBI in elderly patients. Incorporation of frailty assessment by CFS into decision-making processes could help to identify elderly patients with a more favorable post-surgical outcome, thereby facilitating treatment decisions.

[Recommendations and Innovations in Nutritional Medicine in Critically Ill Patients]

Medical Nutrition Therapy (MNT) is a key component of treatment in intensive care units (ICU) and plays a crucial role in the prognosis of critically ill patients. An individualized nutrition strategy is essential to meet the specific needs of critically ill patients and to minimize potential complications.Recommendations for MNT differ between the guidelines of the German Society for Nutritional Medicine (DGEM), the European Society for Clinical Nutrition and Metabolism (ESPEN), and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), making its implementation in clinical practice challenging. Therefore, the first part of this article provides a pragmatic summary of the current recommendations for everyday clinical practice. The second part focuses on recent data and how these might influence current paradigms of MNT for critically ill patients, with particular emphasis on phase-appropriate macronutrient delivery and combinations of nutrition with other interventions.

Sarcopenia is independently associated with mortality and recovery from dialysis in critically ill patients with sepsis-induced acute kidney injury receiving continuous renal replacement therapy

BACKGROUND

Sarcopenia upon admission to the intensive care unit (ICU) consistently correlates with adverse outcomes, including heightened mortality, in critically ill patients. This study aims to investigate the independent association of sarcopenia with both mortality and recovery from dialysis in critically ill patients with sepsis-induced acute kidney injury (SIAKI) undergoing continuous renal replacement therapy (CRRT).

METHODS

This retrospective study included 618 patients with SIAKI who underwent CRRT in our ICU. All patients had abdominal computed tomography (CT) scans within 3 days preceding ICU admission. The cross-sectional area of skeletal muscles at the third lumbar vertebra was quantified, and the skeletal muscle index (SMI), a normalized measure of skeletal muscle mass, was computed. Using Korean-specific SMI cutoffs, patients were categorized into sarcopenic and non-sarcopenic groups.

RESULTS

Among the 618 patients, 301 expired within 28 days of ICU admission. Multivariable Cox regression analysis revealed that sarcopenia independently predicted 28-day mortality. Among survivors, sarcopenia was independently associated with recovery from dialysis within 28 days after ICU admission. Kaplan-Meier analysis illustrated that sarcopenic patients had a higher mortality rate and a lower rate of recovery from dialysis within 28 days after ICU admission compared to non-sarcopenic patients.

CONCLUSION

This study underscores the independent association of sarcopenia, assessed via CT-derived SMI, with both mortality and recovery from dialysis in critically ill patients with SIAKI undergoing CRRT. The inclusion of sarcopenia assessment could serve as a valuable tool for physicians in effectively stratifying the risk of adverse outcomes in these patients.

Assessment of the Relationship between Pre-Existing Muscle Atrophy, Subcutaneous Fat Volume, and the Prognosis of COVID-19

Background: Coronavirus disease 2019 (COVID-19), with its rapid transmission and emergence, has become a major global public health concern. COVID-19 patients are at an increased risk of acute skeletal muscle loss and complications such as muscular weakness, depression, and anxiety. Furthermore, sarcopenia has been linked to COVID-19 vulnerability, hospitalization rates, and severity. This study aims to investigate the relationship between pre-existing sarcopenia, subcutaneous fat, and the prognosis of COVID-19. Methods: Patients over 18 with positive tests who had chest CT scans without underlying conditions were included in this cohort study. The ratio of muscle volume to the total body surface area was calculated. Patients were divided into four subgroups: outpatients, hospitalized, ICU admitted, and deceased. The initial muscle volume for each group was compared. Results: In total, 127 patients were included in the study, 63 (49%) of whom were male. The mean age of the patients was 51.8 ± 18.16 (from 23 to 87 years). In total, 27 patients (21.3%) were treated as outpatients, 49 patients (38.6%) were hospitalized, and 23 (18.1%) were admitted to the ICU. Twenty-eight patients (22%) died. The total muscle/surface area ratio was significantly associated with disease outcome and prognosis. The ratio was significantly lower in dead individuals (p = 0.017). Conclusions: Sarcopenia was discovered to be significantly associated with the severity of COVID-19 and a poor prognosis. Reducing the risk of severe COVID-19 is possible by identifying and managing sarcopenia-related risk factors.

Assessing Intensive Care Unit Acquired Weakness: An Observational Study Using Quantitative Ultrasound Shear Wave Elastography of the Rectus Femoris and Vastus Intermedius

INTRODUCTION

Intensive care unit-acquired weakness (ICUAW) is associated with unfavorable outcomes. The current diagnostic tools for ICUAW are invasive, yield delayed results, and lack precision. This study explored the potential of shear wave elastography (SWE), an innovative ultrasound technique, to evaluate the quality changes in the lower extremity muscles of ICU patients, potentially aiding the early detection of ICUAW.

MATERIALS AND METHODS

We included adult patients diagnosed with ICUAW (average Medical Research Council score < 48) from December 2020 to October 2021. ICU patients were continuously monitored twice daily. Using ultrasonography, we measured the thickness (TH), cross-sectional area (CSA), pennation angle (PA), and SWE (SWE-values) modulus of the bilateral rectus femoris (RF) and vastus intermedius (VI). The diagnostic performance of each parameter was evaluated using sensitivity, specificity, and area under the receiver operating characteristic curve.

RESULTS

Ultrasound quantification assessments were performed in 47 patients, 24 with ICUAW and 23 without ICUAW. Notably, PA decreased (RF: 11.33%, VI: 10.51%), while muscle rigidity increased (RF: 22.39%, VI: 22.50%) in ICUAW patients compared with non-ICUAW patients. The sensitivity and specificity for PA in the RF were 79.17% and 91.30%, respectively, and those for PA in VI were 79.17% and 78.26%, respectively. The use of both combinations yielded 91.67% and 73.91% sensitivity and specificity, respectively. Employing the PA of RF and SWE-values of RF together, we observed a diagnostic prediction sensitivity of 91.67% and a specificity of 60.87%.

CONCLUSIONS

ICUAW patients exhibited increased rigidity of the lower extremity muscles during their hospital stay. Ultrasonic SWE emerged as a reliable and objective tool, offering significant diagnostic value for ICUAW.

Association Between the Ultrasound Evaluation of Muscle Mass and Adverse Outcomes in Critically Ill Patients: A Prospective Cohort Study

BACKGROUND

Computed tomography (CT)-derived low muscle mass is associated with adverse outcomes in critically ill patients. Muscle ultrasound is a promising strategy for quantitating muscle mass. We evaluated the association between baseline ultrasound rectus femoris cross-sectional area (RF-CSA) and intensive care unit (ICU) mortality. Secondary outcomes were the determinants of RF-CSA, and the diagnostic performance of RF-CSA after adjustment for body size.

METHODS

A prospective, single-center, observational cohort study was conducted in 3 ICUs (general, neuroscience, coronavirus disease-2019 [COVID-19]) of a university-affiliated hospital. Consecutive, mechanically ventilated patients with predicted length of stay >72 hours were included. RF-CSA was assessed at the dominant leg by ultrasound. Association with ICU mortality was tested using multivariable logistic regression. Diagnostic performance of RF-CSA was compared after adjustment by sex (CSA-sex), body surface area (CSA-BSA), and squared height (CSA-H2).

RESULTS

A total of 316 patients were enrolled: age 69 [60-76], 211 men and 183 ICU survivors. Older age (odds ratio, OR [95% confidence interval, CI], 1.03 [1.01-1.05]), the type of ICU (neuroscience: 0.82 [0.38-1.79], COVID-19: 4.1 [2.01-8.38]), a higher modified Nutrition and Rehabilitation Investigators Consortium (NUTRIC) score (1.43 [1.21-1.70]), and a lower RF-CSA (0.41 [0.29-0.58]) were associated with ICU mortality. Baseline RF-CSA was lower in women, with higher nutritional risk, older age, and larger body size. Unadjusted RF-CSA had an area under the receiver operating characteristic (ROC) curve for ICU mortality of 0.720 [0.663-0.776], and this value was not significantly different from that of CSA-sex, CSA-BSA, and CSA-H2 (P = .1487).

CONCLUSIONS

Low baseline RF-CSA was associated with increased ICU mortality. Admission RF-CSA was lower in women, with high nutritional risk, in older subjects and with lower body size. Absolute muscle mass was significantly associated with mortality, with no significant increase in this relationship when adjusting for sex or body size.

Ultrasound assessment of muscle mass in critically ill patients: A correlation with nutritional support and clinical outcomes

BACKGROUND

Critically ill patients are at high risk of Intensive Care Unit (ICU) Acquired weakness, which negatively impacts clinical outcomes. Traditional muscle mass and nutritional status assessments are often impractical in the ICU. Ultrasound offers a promising, non-invasive alternative. This study evaluates the relationship between ultrasound-based muscle assessments, patients' nutritional support, and clinical outcomes in the ICU.

METHODS

A prospective cohort study was conducted in three ICUs of a tertiary center. Daily nutritional intake, ultrasound measurements of the quadriceps muscle (rectus femoris cross-sectional area - RFCSA - and quadriceps muscle layer thickness - QMLT), and clinical data were collected on days 1, 3, and 7 of ICU.

RESULTS

A total of 128 patients were included in the analysis, with a mean age of 65.4 (±18.1) years and a median ICU stay of 6 (4-10) days. QMLT decreased by 5 % and 13 %, and RFCSA decreased by 10 % and 27 % on days 3 and 7, respectively. A significant correlation was found between lower caloric and protein intake and greater muscle mass loss within the initial 3 days of ICU admission. Multivariate logistic regression indicated that QMLT reduction significantly contributed to 28-day mortality (adjusted OR 1.088, 95 % CI: 1.018-1.113, p = 0.015). Lower daily caloric and protein intake was depicted in non-surviving patients (p < 0.001).

CONCLUSIONS

Our study demonstrates that critically ill patients experience significant muscle mass loss within the first 72 h of ICU. QMLT reduction significantly impacts 28-day mortality, with an 8.8 % increase in the odds of death per 0.1 cm reduction.

Sarcopenia in trauma patients: A systematic review and meta-analysis

Sarcopenia is associated with poor prognosis and mortality following injury. This systematic review and meta-analysis aimed to analyze diagnostic criteria for sarcopenia, as well as to assess its prevalence and impact on health outcomes among trauma patients. We conducted a literature search on MEDLINE, EMBASE, and the Cochrane Library from inception to June 2023. A total of 27 studies were included, involving 8692 individuals (55.5 % men) with a mean age ranging from 42.2 to 80.5 years. The pooled prevalence of sarcopenia in trauma patients was 36.0 % [95 % confidence interval (CI): 29.1-43.0 %, I2 = 97.8 %], with a 39.3 % prevalence (95 % CI: 31.0-48.5 %, I2 = 96.8 %) in men and a 39.0 % prevalence (95 % CI: 31.4-46.2 %, I2 = 94.4 %) in women. Trauma patients with sarcopenia were more prone to complications [risk ratio (RR): 1.16, 95 % CI: 1.03-1.31, I2 = 45.8 %] and less able to discharge independently (RR: 0.74, 95 % CI: 0.63-0.86, I2 = 33.3 %). The risk of death in trauma patients with sarcopenia was higher than in non-sarcopenic patients [hazard ratio (HR): 1.64, 95 % CI: 1.31-2.04]. Sarcopenia is commonly present in trauma patients and has a negative impact on prognosis. Early assessment and interventions for sarcopenia should be conducted in trauma patients.

Perioperative Pulmonary Complications in the Older Adults: The Forgotten System

With a rapidly aging population and increasing global surgical volumes, managing the elevated risk of perioperative pulmonary complications has become an expanding focus for quality improvement in health care. In this narrative review, we will analyze the evidence-based literature to provide high-quality and actionable management strategies to better detect, stratify risk, optimize, and manage perioperative pulmonary complications in geriatric populations.

CT-based sarcopenia assessment: Predicting outcomes in acute infection patients

In this retrospective cohort study, we investigated the prognostic value of sarcopenia evaluated by Computed Tomography (CT)-based indices for adverse hospitalization outcomes in patients with acute infections. We analyzed data from 225 patients admitted to the hospital for acute infections between 2019 and 2020. Patients who had undergone an abdominal CT scan either up to 1 month before or within the first 3 days of hospitalization were included. CT image analysis was used to evaluate skeletal muscle mass (by skeletal muscle index (SMI)) and muscle quality (by psoas muscle density, pMD). Low pMD was associated with higher in-hospital mortality (31% vs 11.4% p < 0.001) as well as higher longer-term mortality rates (p = 0.008 for 30 days and <0.001 for 90- and 1-year mortality). Low pMD remained an independent poor prognostic factor after controlling for confounders, with an adjusted odds ratio (aOR) of 2.74, (95% CI 1.33-5.67, p = 0.006) for 1-year mortality, and aOR of 2.61, (95% CI 1.23-5.55) for a prolonged hospital stay. Low SMI was associated with adverse outcomes, although this association was not independent after controlling for confounders. Notably, patients with both low SMI and pMD exhibited the poorest hospitalization outcomes: aOR for 1-year mortality 5.015 (95% CI 1.767-14.23, p = 0.002), and prolonged length of stay aOR 3.197, (95% CI 1.159-8.821, p = 0.025). CT-based muscle indices serve as independent prognostic factors in medical patients admitted with acute infection. Incorporating radiological assessments of sarcopenia into routine care for hospitalized patients with acute infection may enable risk stratification and early intervention in reversible conditions.

Nutritional Challenges in Paediatric Oncology: Screening and Managing Malnutrition and Sarcopenia

Sarcopenia and malnutrition can coexist in pediatric patients with neoplasia, worsening the patient's prognosis. The classification of primary and secondary sarcopenia may be helpful in clinical practice, as it can help with timely initiation of appropriate and tailored dietary treatments to address it. This review summarizes the current state of the art of assessing skeletal muscle function in children and adolescents with cancer and discusses the role of nutritional interventions in the management of children with cancer. It highlights the urgent need for comprehensive nutritional support and interventions to mitigate the impact of malnutritions on both treatment outcomes and patients' well-being.

Skeletal Muscle Mass Loss Leads to Prolonged Mechanical Ventilation and Higher Tracheotomy Rates in Critically Ill Patients

Background: Skeletal muscle mass depletion adversely affects critically ill patient outcomes. Standardized methods for assessing muscle mass in this population are limited, particularly regarding changes during ICU stays and their implications for risk stratification. Methods: In this secondary analysis of our prospective data registry of surgical ICU patients, we used a single slice extracted from a computed tomography scan to determine the patient's direction of absolute change in skeletal muscle mass between two different time points (-14 d to +0 d and +5 d to +21 d) during his or her critical illness. Results: In total, 98 surgical patients were included in the final analysis. A decrease in a patient's skeletal muscle mass is associated with prolonged mechanical ventilation compared to patients whose skeletal muscle mass remained the same or increased (415 vs. 42 h, p = 0.003). Patients losing skeletal muscle mass also needed to be ventilated more frequently (88.3% vs. 60.5%, p = 0.002), had a higher rate of tracheotomy (50.0% vs. 23.7%, p = 0.011), and had an increased ICU length of stay (22 vs. 13 days, p = 0.045). Conclusions: A decreased skeletal muscle index in early critical illness negatively impacts ventilation parameters, highlighting the importance of monitoring and managing muscle mass changes to optimize outcomes in ICU patients.

Body composition parameters in initial CT imaging of mechanically ventilated trauma patients: Single-centre observational study

BACKGROUND

Body composition parameters provide relevant prognostic significance in critical care cohorts and cancer populations. Published results regarding polytrauma patients are inconclusive to date. The goal of this study was to analyse the role of body composition parameters in severely injured trauma patients.

METHODS

All consecutive patients requiring emergency tracheal intubation and mechanical ventilation before initial computed tomography (CT) at a level-1 trauma centre over a 12-year period (2008-2019) were reanalysed. The analysis included CT-derived body composition parameters based upon whole-body trauma CT as prognostic variables for 30-day mortality, intensive care unit length of stay (ICU LOS) and mechanical ventilation duration.

RESULTS

Four hundred seventy-two patients (75% male) with a median age of 49 years, median injury severity score of 26 and 30-day mortality rate of 22% (104 patients) met the inclusion criteria and were analysed. Regarding body composition parameters, 231 patients (49%) had visceral obesity, 75 patients had sarcopenia (16%) and 35 patients had sarcopenic obesity (7.4%). After adjustment for statistically significant univariable predictors age, body mass index, sarcopenic obesity, visceral obesity, American Society of Anesthesiologists classification ≥3, injury severity score and Glasgow Coma Scale ≤ 8 points, the Cox proportional hazard model identified sarcopenia as significant prognostic factor of 30-day mortality (hazard ratio 2.84; 95% confidence interval 1.38-5.85; P = 0.004), which was confirmed in Kaplan-Meier survival analysis (log-rank P = 0.006). In a subanalysis of 363 survivors, linear multivariable regression analysis revealed no significant associations of body composition parameters with ICU LOS and duration of mechanical ventilation.

CONCLUSIONS

In a multivariable analysis of mechanically ventilated trauma patients, CT-defined sarcopenia was significantly associated with 30-day mortality whereas no associations of body composition parameters with ICU LOS and duration of mechanical ventilation were observed.

Dual-Energy CT muscle fat fraction as a new imaging biomarker of body composition and survival predictor in critically ill patients

OBJECTIVE

To analyze changes in the muscular fat fraction (FF) during immobilization at the intensive care unit (ICU) using dual-energy CT (DECT) and evaluate the predictive value of the DECT FF as a new imaging biomarker for morbidity and survival.

METHODS

Immobilized ICU patients (n = 81, 43.2% female, 60.3 ± 12.7 years) were included, who received two dual-source DECT scans (CT1, CT2) within a minimum interval of 10 days between 11/2019 and 09/2022. The DECT FF was quantified for the posterior paraspinal muscle by two radiologists using material decomposition. The skeletal muscle index (SMI), muscle radiodensity attenuation (MRA), subcutaneous-/ visceral adipose tissue area (SAT, VAT), and waist circumference (WC) were assessed. Reasons for ICU admission, clinical scoring systems, therapeutic regimes, and in-hospital mortality were noted. Linear mixed models, Cox regression, and intraclass correlation coefficients were employed.

RESULTS

Between CT1 and CT2 (median 21 days), the DECT FF increased (from 20.9% ± 12.0 to 27.0% ± 12.0, p = 0.001). The SMI decreased (35.7 cm2/m2 ± 8.8 to 31.1 cm2/m2 ± 7.6, p < 0.001) as did the MRA (29 HU ±  10 to 26 HU ± 11, p = 0.009). WC, SAT, and VAT did not change. In-hospital mortality was 61.5%. In multivariable analyses, only the change in DECT FF was associated with in-hospital mortality (hazard ratio (HR) 9.20 [1.78-47.71], p = 0.008), renal replacement therapy (HR 48.67 [9.18-258.09], p < 0.001), and tracheotomy at ICU (HR 37.22 [5.66-245.02], p < 0.001). Inter-observer reproducibility of DECT FF measurements was excellent (CT1: 0.98 [0.97; 0.99], CT2: 0.99 [0.96-0.99]).

CONCLUSION

The DECT FF appears to be suitable for detecting increasing myosteatosis. It seems to have predictive value as a new imaging biomarker for ICU patients.

CLINICAL RELEVANCE STATEMENT

The dual-energy CT muscular fat fraction appears to be a robust imaging biomarker to detect and monitor myosteatosis. It has potential for prognosticating, risk stratifying, and thereby guiding therapeutic nutritional regimes and physiotherapy in critically ill patients.

KEY POINTS

The dual-energy CT muscular fat fraction detects increasing myosteatosis caused by immobilization. Change in dual-energy CT muscular fat fraction was a predictor of  in-hospital morbidity and mortality. Dual-energy CT muscular fat fraction had a predictive value superior to established CT body composition parameters.

Creatinine clearance/eGFR ratio: a simple index for muscle mass related to mortality in ICU patients

INTRODUCTION

In patients admitted to the intensive care unit (ICU), muscle mass is inversely associated with mortality. Although muscle mass can be estimated with 24-h urinary creatinine excretion (UCE), its use for risk prediction in individual patients is limited because age-, sex-, weight- and length-specific reference values for UCE are lacking. The ratio between measured creatinine clearance (mCC) and estimated glomerular filtration rate (eGFR) might circumvent this constraint. The main goal was to assess the association of the mCC/eGFR ratio in ICU patients with all-cause hospital and long-term mortality.

METHODS

The mCC/eGFR ratio was determined in patients admitted to our ICU between 2005 and 2021 with KDIGO acute kidney injury (AKI) stage 0-2 and an ICU stay ≥ 24 h. mCC was calculated from UCE and plasma creatinine and indexed to 1.73 m2. mCC/eGFR was analyzed by categorizing patients in mCC/eGFR quartiles and as continuous variable.

RESULTS

Seven thousand five hundred nine patients (mean age 61 ± 15 years; 38% female) were included. In-hospital mortality was 27% in the lowest mCC/eGFR quartile compared to 11% in the highest quartile (P < 0.001). Five-year post-hospital discharge actuarial mortality was 37% in the lowest mCC/eGFR quartile compared to 19% in the highest quartile (P < 0.001). mCC/eGFR ratio as continuous variable was independently associated with in-hospital mortality in multivariable logistic regression (odds ratio: 0.578 (95% CI: 0.465-0.719); P < 0.001). mCC/eGFR ratio as continuous variable was also significantly associated with 5-year post-hospital discharge mortality in Cox regression (hazard ratio: 0.27 (95% CI: 0.22-0.32); P < 0.001).

CONCLUSIONS

The mCC/eGFR ratio is associated with both in-hospital and long-term mortality and may be an easily available index of muscle mass in ICU patients.

Meeting complex multidimensional needs in older patients and their families during and beyond critical illness

PURPOSE OF REVIEW

To highlight the emerging crisis of critically ill elderly patients and review the unique burden of multidimensional morbidity faced by these patients and caregivers and potential interventions.

RECENT FINDINGS

Physical, psychological, and cognitive sequelae after critical illness are frequent, durable, and robust across the international ICU outcome literature. Elderly patients are more vulnerable to the multisystem sequelae of critical illness and its treatment and the resultant multidimensional morbidity may be profound, chronic, and significantly affect functional independence, transition to the community, and quality of life for patients and families. Recent data reinforce the importance of baseline functional status, health trajectory, and chronic illness as key determinants of long-term functional disability after ICU. These risks are even more pronounced in older patients.

SUMMARY

The current article is an overview of the outcomes of older survivors of critical illness, putative interventions to mitigate the long-term morbidity of patients, and the consequences for families and caregivers. A multimodal longitudinal approach designed to follow patients for one or more years may foster a better understanding of multidimensional morbidity faced by vulnerable older patients and families and provides a detailed understanding of recovery trajectories in this unique population to optimize outcome, goals of care directives, and ongoing informed consent to ICU treatment.

Disparity in guideline adherence for prehospital care according to patient age in emergency medical service transport for moderate to severe trauma

OBJECTIVES

The aim of this study was to investigate the association between patient age and guideline adherence for prehospital care in emergency medical services (EMS) for moderate to severe trauma.

METHODS

This was a retrospective observational study that used a nationwide EMS-based trauma database from 2016 to 2019. Adult trauma patients whose injury severity score was greater than or equal to nine were screened, and those with cardiac arrest or without outcome data were excluded. The enrolled patients were categorized into four groups according to patient age: young (<45 years), middle-aged (45-64 years), old (65-84 years), and very old (>84 years). The primary outcome was guideline adherence, which was defined as following all prehospital care components: airway management for level of consciousness below verbal response, oxygen supply for pulse oximetry under 94 %, intravenous fluid administration for systolic blood pressure under 90 mmHg, scene resuscitation time within 10 min, and transport to the trauma center or level 1 emergency department. Multivariable logistic regression was conducted to calculate the adjusted odds ratios (aORs) and 95 % confidence intervals (95 % CIs).

RESULTS

Among the 430,365 EMS-treated trauma patients, 38,580 patients were analyzed-9,573 (24.8 %) in the young group, 15,296 (39.7 %) in the middle-aged group, 9,562 (24.8 %) in the old group, and 4,149 (10.8 %) in the very old group. The main analysis revealed a lower probability of guideline adherence in the old group (aOR 95 % CI = 0.84 (0.76-0.94)) and very old group (aOR 95 % CI = 0.68 (0.58-0.81)) than in the young group.

CONCLUSION

We found disparities in guideline adherence for prehospital care according to patient age at the time of EMS assessment of moderate to severe trauma. Considering this disparity, the prehospital trauma triage and management for older patients needs to be improved and educated to EMS providers.

Association of baseline muscle mass with functional outcomes in intensive care unit survivors: A single-center retrospective cohort study in Korea

In critical care settings, ultrasound (US) of the quadriceps muscle and Bioelectrical Impedance Analysis (BIA) are noninvasive and widely available tools to evaluate muscle mass. We studied whether baseline muscle mass affects physical function in intensive care unit (ICU) survivors after discharge. This retrospective review of a prospective cohort enrolled 30 patients admitted to the medical ICU between April 2016 and June 2018. On ICU admission, quadriceps muscle thickness and skeletal muscle mass were measured using US and BIA, respectively. Muscle strength and physical function were measured using handgrip dynamometry, the 6-min walk test, and the Barthel index questionnaire survey during every clinic visit at 1, 3, 6, and 12 months after hospital discharge. Skeletal muscle mass at ICU admission was statistically correlated with the 6-min walk distance (6MWD) and Barthel index score. The segmental lean mass of the right arm was also positively correlated with handgrip muscle strength at 6 months after discharge. Likewise, the correlation between quadriceps muscle thickness at ICU admission and 6MWD at 6 months after discharge was positive and statistically significant. Multivariate regression analysis showed that skeletal muscle mass was associated with a reduced 6MWD, but the length of ICU stay was not. The segmental lean mass of the right arm also showed a significant association with handgrip strength after discharge. Low muscle mass on ICU admission is associated with reduced muscle strength, causing impaired physical function after hospital discharge in ICU survivors.

Epicardial adipose tissue defined by initial polytrauma CT of mechanically ventilated trauma patients: retrospective single-center cohort study to predict short-term outcomes

PURPOSE

Epicardial adipose tissue (EAT) detected by computed tomography (CT) is associated with morbidity and mortality in patients with COVID-19 and other critical care patient cohorts, whereas their prognostic relevance in trauma patients remains unclear. The present study explored associations with four potential short-term outcomes in trauma patients.

METHODS

All consecutive trauma patients requiring emergency tracheal intubation and mechanical ventilation before initial whole-body CT imaging at a level-1 trauma center over a 12-year period (2008-2019) were reanalyzed for this study. EAT was measured semiquantitatively in initial CT and analyzed regarding associations with 24-hour and 30-day mortality using Cox proportional hazard models. In survivors, associations of EAT with intensive care unit length of stay (ICU LOS) and mechanical ventilation duration were analyzed using linear regression analyses.

RESULTS

Four hundred fifty-five patients (74.7% male) with a median age of 49 years, and a median injury severity score (ISS) of 26 points were analyzed. In univariable analysis, EAT index was significantly associated with 24-hour and 30-day mortality (p = 0.007, and p = 0.013, respectively). After adjustment for significant predictors age, body mass index, and ISS, no significant associations were confirmed (p = 0.622, and p = 0.903, respectively). In a subanalysis of 353 survivors, EAT index was significantly associated with ICU LOS and mechanical ventilation duration in univariable analyses (p = 0.031, and p = 0.014, respectively), but not in multivariable analyses (p = 0.81 and p = 0.46, respectively).

CONCLUSION

EAT index was associated with short-term outcomes in severely injured trauma patients, which not remained significant in multivariable analysis, suggesting that its prognostic capability is limited.

Risk Factors and Electromyographic Characteristics of Acquired Weakness in Critically Ill Patients: A Retrospective Study

Objective

This retrospective study examines risk factors and electromyographic (EMG) characteristics associated with acquired weakness in critically ill patients and assesses their impact on patient prognosis.

Methods

Ninety-seven critically ill patients, ventilated for over 48 hours, were included. Patient data, encompassing general condition, medical history, Medical Research Council (MRC) scores, serum markers (c-reactive protein, calcitonin gene, albumin, brain natriuretic peptide, urea nitrogen, creatinine), EMG characteristics, respiratory treatment modalities, and parameters, were recorded. Mechanical ventilation duration, ICU stay duration, hospitalization duration, and patient prognosis were documented. Based on MRC scores, patients were categorized into the ICU-acquired weakness (ICU-AW) group (MRC <48 points) and the non-ICU-AW group (MRC ≥48 points).

Results

The study comprised 47 ICU-AW and 50 non-ICU-AW patients. Significant differences (p <0.05) were observed in age, MRC scores, albumin levels, c-reactive protein, calcitonin gene, brain natriuretic peptide, urea nitrogen, creatinine, mechanical ventilation duration, ICU stay duration, and hospitalization duration between groups. In the ICU-AW group, nerve conduction examinations revealed slow conduction velocity, reduced wave amplitude, and in severe cases, a complete loss of motor and sensory potentials. Multivariate logistic analysis identified low serum albumin levels and MRC scores as potential ICU-AW risk factors.

Conclusion

This study suggests that low serum albumin levels and MRC scores may contribute to ICU-AW risk. The ICU-AW group exhibited varied peripheral nerve damage and slow conduction velocities on EMG. Additionally, severe systemic inflammatory responses, renal function, brain natriuretic peptide levels, prolonged mechanical ventilation, and peripheral nerve damage may be associated with ICU-AW. Follow-up studies are essential for further understanding these complex interactions.

Author Response: Emphasizing Patient-centered Outcomes and Improved Exclusion Criteria in Randomized Control Trials for Clinical Nutrition in ICU

How to cite this article: Govil D, Chandrasekaran A, Pachisia AV, Harne R, Patel SJ, Pal D. Author Response: Emphasizing Patient-centered Outcomes and Improved Exclusion Criteria in Randomized Control Trials for Clinical Nutrition in ICU. Indian J Crit Care Med 2024;28(8):806-807.

Skeletal muscle estimation: A review of techniques and their applications

Quantifying skeletal muscle size is necessary to identify those at risk for conditions that increase frailty, morbidity, and mortality, as well as decrease quality of life. Although muscle strength, muscle quality, and physical performance have been suggested as important assessments in the screening, prevention, and management of sarcopenic and cachexic individuals, skeletal muscle size is still a critical objective marker. Several techniques exist for estimating skeletal muscle size; however, each technique presents with unique characteristics regarding simplicity/complexity, cost, radiation dose, accessibility, and portability that are important factors for assessors to consider before applying these modalities in practice. This narrative review presents a discussion centred on the theory and applications of current non-invasive techniques for estimating skeletal muscle size in diverse populations. Common instruments for skeletal muscle assessment include imaging techniques such as computed tomography, magnetic resonance imaging, peripheral quantitative computed tomography, dual-energy X-ray absorptiometry, and Brightness-mode ultrasound, and non-imaging techniques like bioelectrical impedance analysis and anthropometry. Skeletal muscle size can be acquired from these methods using whole-body and/or regional assessments, as well as prediction equations. Notable concerns when conducting assessments include the absence of standardised image acquisition/processing protocols and the variation in cut-off thresholds used to define low skeletal muscle size by clinicians and researchers, which could affect the accuracy and prevalence of diagnoses. Given the importance of evaluating skeletal muscle size, it is imperative practitioners are informed of each technique and their respective strengths and weaknesses.

Thigh muscle mass evaluated by point-of-care ultrasound is associated with short-term mortality in patients with sepsis in the emergency department

Muscle mass depletion is associated with mortality and morbidity in various conditions including sepsis. However, few studies have evaluated muscle mass using point-of-care ultrasound in patients with sepsis. This study aimed to evaluate the association between thigh muscle mass, evaluated using point-of-care ultrasound with panoramic view in patients with sepsis in the emergency department, and mortality. From March 2021 to October 2022, this prospective observational study used sepsis registry. Adult patients who were diagnosed with sepsis at the emergency department and who underwent point-of-care ultrasounds for lower extremities were included. The thigh muscle mass was evaluated by the cross-sectional area of the quadriceps femoris (CSA-QF) on point-of-care ultrasound using panoramic view. The primary outcome was 28 day mortality. Multivariable Cox proportional hazard model was performed. Of 112 included patients with sepsis, mean CSA-QF was significantly lower in the non-surviving group than surviving group (49.6 [34.3-56.5] vs. 63.2 [46.9-79.6] cm2, p = 0.002). Each cm2 increase of mean CSA-QF was independently associated with decreased 28 day mortality (adjusted hazard ratio 0.961, 95% CI 0.928-0.995, p = 0.026) after adjustment for potential confounders. The result of other measurements of CSA-QF were similar. The muscle mass of the quadriceps femoris evaluated using point-of-care ultrasound with panoramic view was associated with mortality in patients with sepsis. It might be a promising tool for determining risk factors for mortality in sepsis patients in the early stages of emergency department.

Comparison between Effect of Indirect Calorimetry vs Weight-based Equation (25 kcal/kg/day)-guided Nutrition on Quadriceps Muscle Thickness as Assessed by Bedside Ultrasonography in Medical Intensive Care Unit Patients: A Randomized Clinical Trial

Aim and background

Sarcopenia is a substantial contributor to intensive care unit (ICU)-acquired weakness and is associated with significant short- and long-term outcomes. It can, however, be mitigated by providing appropriate nutrition. Indirect calorimetry (IC) is believed to be the gold standard in determining caloric targets in the dynamic environment of critical illness. We conducted this study to compare the effect of IC vs weight-based (25 kcal/kg/day) feeding on quadriceps muscle thickness (QMT) by ultrasound in critically ill patients.

Materials and methods

A prospective study was conducted on 60 mechanically ventilated patients randomized to two groups [weight-based equation (WBE) group or the IC group] in medical ICU after obtaining institutional ethics committee approval, and fed accordingly. The right QMT measurement using ultrasound and caloric targets were documented on day 1, 3 and 7 and analyzed statistically. The IC readings were obtained from the metabolic cart E-COVX ModuleTM.

Results

The baseline demographics, APACHE-II, NUTRIC score, and SOFA scores on day 1, 3, and 7 were comparable between the two groups. The resting energy expenditure (REE) obtained in the IC group was significantly less than the WBE energy targets and the former were fed with significantly less calories. A significantly less percent reduction of QMT in the IC group compared with the WBE group was observed from day 1 to day 3, day 3 to day 7, and day 1 to day 7.

Conclusion

From our study, we conclude that IC-REE-based nutrition is associated with lesser reduction in QMT and lesser calories fed in critically ill mechanically ventilated patients compared from WBE. CTRI registration-CTRI/2023/01/049119.

How to cite this article

Chandrasekaran A, Pal D, Harne R, Patel SJ, Jagadeesh KN, Pachisia AV, et al. Comparison between Effect of Indirect Calorimetry vs Weight-based Equation (25 kcal/kg/day)-guided Nutrition on Quadriceps Muscle Thickness as Assessed by Bedside Ultrasonography in Medical Intensive Care Unit Patients: A Randomized Clinical Trial. Indian J Crit Care Med 2024;28(6):587-594.

Relationship among low baseline muscle mass, skeletal muscle quality, and mortality in critically ill children

BACKGROUND

Studies in adults have shown that low baseline muscle mass at intensive care unit (ICU) admission was associated with poor clinical outcomes. However, no information on the relationship between baseline muscle quality or mass and clinical outcomes in critically ill children was found.

METHODS

3775 children were admitted to the pediatric ICU (PICU), 262 were eligible for inclusion. Abdominal computed tomography was performed to assess baseline skeletal muscle mass and quality. Patients were categorized to normal or low group based on the cutoff value for predicting hospital mortality of the skeletal muscle index (SMI; 30.96 cm2/m2) and skeletal muscle density (SMD; 41.21 Hounsfield units).

RESULTS

Body mass index (BMI) (18.07 ± 4.44 vs 15.99 ± 4.51) and BMI-for-age z score (0.46 [-0.66 to 1.74] vs -0.87 [-1.69 to 0.05]) were greater in the normal-SMI group, the length of PICU stay was longer in the low-SMI group (16.00 days [8.50-32.50] vs 13.00 days [7.50-20.00]), and the in-PICU mortality rate in the normal-SMI group (10.00%) was lower than the low-SMI group (22.6%). Children with low SMD had a higher in-PICU mortality rate (25.6% vs 7.7%), were younger (36.00 months [12.00-120.00] vs 84.00 months [47.50-147.50]) and weighed less (16.40 kg [10.93-37.25] vs 23.00 kg [16.00-45.00]). Mortality was greater in patients with lower SMD and prolonged hospital stay (log-rank, P = 0.007). SMD was an independent predictor for length of PICU stay and in-PICU mortality.

CONCLUSIONS

Low baseline skeletal muscle quality in critically ill children is closely tied with a higher in-PICU mortality and longer PICU stay and is an independent risk factor for unfavorable clinical outcomes.

Association of Psoas Muscle Mass at Intensive Care Unit Admission With Physical Function and Post-discharge Destination in Survivors of Critical Illness

OBJECTIVE

Survivors of critical illness may have physical impairments, known as post-intensive care syndrome (PICS). Early screening for the risk of PICS is recommended to prevent PICS. Skeletal muscle mass is a clinically important indicator associated with various outcomes. This study aimed to examine the association of psoas muscle mass at intensive care unit (ICU) admission with the destination and physical function at hospital discharge.

METHODS

In this single-center retrospective cohort study, we reviewed the medical records of adult patients who had required emergency ICU admission and who had been intubated and mechanically ventilated. Psoas major muscle was measured as an indicator of skeletal muscle mass from abdominal computed tomography images at ICU admission. Physical function was assessed using the functional status score for the ICU and ICU mobility scale at hospital discharge. Multinomial logistic and multivariable linear regression were used to analyze the associations of the psoas muscle mass with the discharge destination and physical function at discharge.

RESULTS

We enrolled 124 patients (79 men and 45 women) with a median (interquartile range) age of 72.0 (62.0-80.0) years; 39 (31.5%) were discharged to home, 50 (40.3%) were transferred to rehabilitation wards, and 35 (28.2%) were transferred to long-term care settings. The psoas muscle area and volume were 16.9 (11.3-20.6) cm2 and 228.3 (180.2-282.0) cm3 in home discharge patients, 17.5 (11.5-21.5) cm2 and 248.4 (162.0-311.4) cm3 in rehabilitation ward patients, and 15.9 (10.3-19.5) cm2 and 184.0 (137.0-251.1) cm3 in long-term care patients. The areas and volumes of the psoas muscle were not significantly different in the three groups. Furthermore, psoas muscle mass was not significantly associated with the discharge destination and physical function.

CONCLUSIONS

Discharge destination and physical function at hospital discharge were not significantly associated with psoas muscle mass at ICU admission.

Absence of association between low calf circumference, adjusted or not for adiposity, and ICU mortality in critically ill adults: A secondary analysis of a cohort study

BACKGROUND

Despite its correlation with skeletal muscle mass and its predictive value for adverse outcomes in clinical settings, calf circumference is a metric underexplored in intensive care. We aimed to determine whether adjusting low calf circumference for adiposity provides prognostic value superior to its unadjusted measurement for intensive care unit (ICU) mortality and other clinical outcomes in critically ill patients.

METHODS

In a secondary analysis of a cohort study across five ICUs, we assessed critically ill patients within 24 h of ICU admission. We adjusted calf circumference for body mass index (BMI) (25-29.9, 30-39.9, and ≥40) by subtracting 3, 7, or 12 cm from it, respectively. Values ≤34 cm for men and ≤33 cm for women identified low calf circumference.

RESULTS

We analyzed 325 patients. In the primary risk-adjusted analysis, the ICU death risk was similar between the low and preserved calf circumference (BMI-adjusted) groups (hazard ratio, 0.90; 95% CI, 0.47-1.73). Low calf circumference (unadjusted) increased the odds of ICU readmission 2.91 times (95% CI, 1.40-6.05). Every 1-cm increase in calf circumference as a continuous variable reduced ICU readmission odds by 12%. Calf circumference showed no significant association with other clinical outcomes.

CONCLUSION

BMI-adjusted calf circumference did not exhibit independent associations with ICU and in-hospital death, nor with ICU and in-hospital length of stay, compared with its unadjusted measurement. However, low calf circumference (unadjusted and BMI-adjusted) was independently associated with ICU readmission, mainly when analyzed as a continuous variable.

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

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

Association between body composition and mortality in patients requiring extracorporeal membrane oxygenation support

AIM

To ascertain the association between body composition, including muscle mass and adiposity, and patient mortality in those requiring extracorporeal membrane oxygenation (ECMO) for acute respiratory failure.

MATERIALS AND METHODS

A retrospective study was undertaken of all patients with acute respiratory failure requiring veno-venous (VV) ECMO between January 2015 and December 2019. Automated image segmentation software was used to quantify the cross-sectional area and average radiodensity (in Hounsfield units) of different muscle and fat compartments at the L3 level of whole-body computed tomography (CT) images taken within 48 h of initiation of ECMO support. The primary endpoint was 30-day post-ECMO initiation all-cause mortality. Logistic regression was used to analyse the correlation between CT measurements, co-morbidities, and 30-day survival.

RESULTS

The study included 189 patients (age = 43.8 ± 14.6, sex = 42.3% female). There was no significant association between 30-day survival status and cross-sectional area of muscle or fat. Muscle attenuation (psoas, long spine, and abdominal muscles respectively) at the L3 level were significantly lower in those who died within 30 days of ECMO cannulation (p<0.05). On multivariable analysis including age, sex, and pre-existing respiratory comorbidities, psoas muscle attenuation was an independent predictor of survival at 30 days (OR 0.97; 95% CI 0.94 to 1.00; p=0.047).

CONCLUSIONS

Reduced psoas muscle attenuation is associated with poorer survival outcomes at 30 days post-ECMO cannulation in patients who received VV ECMO support for respiratory failure. Cross-sectional areas of muscle and fat compartments did not correlate with survival outcomes at 30 days even when corrected for height and sex.

Muscularity of older trauma patients at intensive care unit admission, association with functional outcomes, and relationship with frailty: A retrospective observational study

BACKGROUND

Older individuals are at an increased risk of delayed recovery following a traumatic injury. Measurement of muscularity and frailty at hospital admission may aid with prognostication and risk stratification.

OBJECTIVE

This study aimed to describe muscularity at intensive care unit (ICU) admission in patients admitted following trauma and assess the relationship between muscularity and clinical, long-term functional outcomes and frailty at ICU admission.

METHODS

This retrospective study utilised data from a prospective observational study investigating frailty in patients aged ≥50 years, admitted to the ICU following trauma. Patients were eligible if they had a Computed Tomography (CT) scan including the third lumbar vertebra at ICU admission. Specialist software was used to quantify CT-derived skeletal muscle cross-sectional area. Muscularity status was classified as normal or low using published sex-specific cut-points. Demographic data, frailty, clinical, and long-term functional outcomes (Glasgow Outcome Scale-Extended and EQ-5DL-5L Visual analogue scale and utility score) were extracted from the original study.

RESULTS

One hundred patients were screened; 71 patients had a CT scan on admission with 66 scans suitable for muscle assessment. Patients with low muscularity (n = 25, 38%) were older and had a higher Acute Physiology and Chronic Health Evaluation II score and lower body mass index than patients with normal muscularity. Low muscularity was associated with frailty at admission (32% vs 5%, p = 0.005) but not with long term outcomes at 6 or 12 months. As a continuous variable, lower muscle cross-sectional area was associated with a poorer outcome on the Glasgow Outcome Scale-Extended at 6 months (mean [standard deviation]: 150 [43] and 180 [44], respectively; p = 0.014), no association was observed after adjustment for age p = 0.43).

CONCLUSION

In a population of older adults hospitalised following trauma, low muscularity at ICU admission was prevalent. Low muscularity was associated with frailty but not long-term functional outcomes. Larger studies are warranted to better understand the relationship between muscularity and long-term functional outcomes.

Effects of Cervical Paravertebral Extensors in Patients with Cervical Ossification of the Posterior Longitudinal Ligament Grouped According to mK-Line

OBJECTIVES

The objective of this study was to quantify the morphology, composition, and asymmetry of the paravertebral extensor muscles (PSEMs) in patients with cervical ossification of the posterior longitudinal ligament (OPLL) who had different modified K-line (mK-line) and the minimum interval between the mK-line and OPLL (INTmin ) values and to investigate the relationship between PSEMs and symptoms and outcomes following laminoplasty. These original findings elucidated that the atrophy of PSEMs could predict decompression outcomes and provided a theoretical basis for paraspinal muscle rehabilitation.

METHODS

A total of 94 consecutive patients who underwent laminoplasty for OPLL between January 2020 and January 2022 were enrolled in this retrospective study. The relative cross-sectional areas (rCSA), functional cross-sectional areas (rFCSA), and FCSA/CSA ratio of the multifidus (MF), semispinalis cervicalis (SSCe), semispinalis capitis (SSCa), and splenius capitis (SpCa) were measured at the C3-C7 segments on cervical magnetic resonance imaging (MRI). This study compared the differences between the mK-line (+) group and the mK-line (-) group, as well as between the INTmin  <4 mm group and the INTmin  ≥4 mm group, using the independent t-test or Mann-Whitney test for continuous variables and the χ2 -test for categorical variables. The correlations between the PSEMs and symptoms were analyzed using either the Pearson or Spearman correlation coefficient.

RESULTS

The relative total CSA (rTCSA) of the PSEMs, especially the MF, was significantly smaller in the mK-line (-) group. However, the FCSA/CSA of the right deep extensor muscle (DEM) was larger. The asymmetry of the MF TFCSA/TCSA showed a significant difference between the mK-line groups. In the INTmin  <4 mm group, the PSEMs rCSA and rFCSA were significantly smaller, while the bilateral MF TFCSA/TCSA and right SSCe TFCSA/TCSA were larger. The asymmetry of the superficial extensor muscle rCSA was significantly lower in the group with INTmin  <4 mm. The postoperative modified Japanese Orthopedic Association score (mJOA) and mJOA recovery rate were positively correlated with the INTmin and DEM rCSA and negatively correlated with the asymmetry of MF FCSA/CSA.

CONCLUSIONS

In patients with mK-line (-) or INTmin  <4 mm, the PSEMs were smaller, and the DEM atrophy and composition changes were predominant. The MF asymmetry was higher in patients with mK-lines (-), whereas the SEM atrophy and asymmetry were more prevalent in patients with INTmin  <4 mm. The DEM was related to the preoperative and postoperative mJOA scores. DEM-preserving surgery or DEM-specific rehabilitation exercises can improve the recovery of patients with OPLL during the perioperative period. In addition, attention should be paid to the evaluation of the SEM, especially the SpCa at the C3 and C5 levels.

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

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

Ultrasound for measurement of skeletal muscle mass quantity and muscle composition/architecture in critically ill patients: A scoping review on studies' aims, methods, and findings

AIMS

This scoping review aimed to identify, explore, and map the objectives, methodological aspects, and results of studies that used ultrasound (US) to assess skeletal muscle (SM) in critically ill patients.

METHODS

A scoping review was conducted according to the Joanna Briggs Institute's methodology. All studies that evaluated SM parameters from the US in patients admitted to the intensive care unit (ICU) were considered eligible. We categorized muscle thickness and cross-sectional area as parameters for assessing SM quantity, while echogenicity, fascicle length, and pennation angle analysis were used to evaluate muscle "quality" (composition/architecture). A literature search was conducted using four databases for articles published until December 2022. Independent reviewers selected the studies and extracted data. Descriptive statistics were calculated to present the results.

RESULTS

A total of 107 studies were included, the majority of which were prospective cohort studies (59.8 %) conducted in general ICUs (49.5 %). The most frequent objective of the studies was to evaluate SM quantity depletion during the ICU stay (25.2 %), followed by determining whether a specific intervention would modify SM (21.5 %). Most studies performed serial SM evaluations (76.1 %). The rectus femoris muscle thickness was evaluated in most studies (67.9 %), followed by the rectus femoris cross-sectional area (54.3 %) and the vastus intermedius muscle thickness (40.2 %). The studies demonstrated the feasibility and reproducibility of US for SM evaluation, especially related to quantitative parameters. Most studies (70.3 %) reported significant SM quantity depletion during hospitalization. However, the accuracy of the US in measuring SM varied across the studies.

CONCLUSIONS

The lack of detailed description and standardization in the protocols adopted by the studies included in this scoping review precludes the translation of the evidence related to US for SM assessment into clinical practice.

Skeletal muscle index impacts the treatment outcome of elderly patients with diffuse large B cell lymphoma

Sarcopenia is a crucial factor in the physical fitness of elderly individuals. This study investigated the prognostic values of multiple parameters of sarcopenia in association with established prognostic factors in elderly Japanese patients with diffuse large B cell lymphoma (DLBCL). As candidate indicators for sarcopenia, the skeletal muscle index (SMI) (cm2 /m2 ), the psoas muscle index, the erector spinae muscle index, the visceral fat index, the subcutaneous fat index, and the visceral to subcutaneous fat area ratio at the third lumbar level were assessed by computed tomography at their initial diagnosis in 102 patients with DLBCL over 75 years old those were diagnosed and treated in our institute from 2007 to 2020. The primary endpoint was overall survival (OS), and the secondary endpoint was progression-free survival (PFS). The median age of patients analyzed was 80 years at diagnosis. The sex-specific cut-offs for the indices adopted two approaches: (i) the historical cut-off values established in the previous study for healthy Japanese individuals (Hamaguchi Y. J Cachexia Sarcopenia Muscle. 2018), and (ii) each sex-specific lowest quartile in our cohort. As the results, SMI evaluated by the historical cut-off and sex-specific lowest quartile was identified as the most influential independent prognostic factor for both OS and PFS among various parameters for sarcopenia. Furthermore, we developed an elderly sarcopenia prognostic index (ESPI). ESPI, which combines SMI evaluated by the historical cut-off and LDH > ULN, demonstrated statistically significant prognostic impacts on OS and PFS. Moreover, compared to the R-IPI, ESPI showed the ability to identify intermediate-risk groups and indicated a trend toward improved predictive accuracy. Our study revealed that SMI is the most appropriate assessment method for evaluating sarcopenia and the critical prognostic factor in OS and PFS of elderly patients with DLBCL.

Sarcopenia and Mortality in Critically Ill COVID-19 Patients

COVID-19 can manifest as either asymptomatic or progressing to a severe phase in some patients, which may require hospitalization. These patients may experience dyspnea and hypoxia, leading to the development of acute respiratory distress syndrome. Studies have reported an increased risk of severe sarcopenia in COVID-19 patients during and after recovery. This narrative review aimed to summarize and synthesize available studies on the association between sarcopenia and mortality in critically ill COVID-19 patients. A total of 22 studies conducted on hospitalized COVID-19 patients were included in this review. Of those, 17 studies reported a direct association, while 5 studies showed no association between sarcopenia and mortality in severe COVID-19 patients. It is important to maintain muscle quality and quantity in defense against COVID-19. The measurement of lean muscle mass should be included in the risk assessment of severely ill COVID-19 patients as part of the therapy plan.

The impact of muscle mass and myosteatosis on mortality in critically ill patients with Sars-Cov2-related pneumonia

BACKGROUND & AIMS

Sars-Cov-2 pneumonia can lead to severe complications, requiring invasive mechanical ventilation and admission to the intensive care unit (ICU). Low muscle quantity and quality (the latter evaluated by the amount of ectopic fat infiltration in the muscle [myosteatosis]) at ICU admission are associated with worse outcomes in critically ill patients. The purpose of the present study is to assess muscle mass and myosteatosis of paravertebral skeletal muscle, in critically ill patients with Sars-Cov2 pneumonia and its association with mortality.

METHODS

We conducted a retrospective observational study in 110 critically ill patients with severe Sars-Cov-2 pneumonia that had a high - resolution chest Computerized Tomography (HR-CT) at ICU admission. We acquired CT images at the level of the thoracic 12 (T12) vertebral body and measured skeletal muscle area (SMA), intermuscular adipose tissue (IMAT), and low attenuation muscle area (LAMA). Patients were followed until ICU mortality or discharge.

RESULTS

Patients were 59.8 ± 8.1 years old, 77% were male. Seventy-nine percent of patients were considered at nutritional risk, and 22% were obese. Average Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 17 ± 5.4, and the overall ICU mortality was 48,2% (53/110). At ICU admission, both parameters of myosteatosis were associated with higher mortality (IMAT [per 10% increase] HR: 2.01 (95% Confidence Interval [CI] 1.27 to 3.17), P = 0.003; LAMA HR [per 10% increase]: 1.53 (95% CI 1.10 to 2.13), P = 0.012).

CONCLUSION

Myosteatosis as assessed by CT scans plays a relevant role as a prognostic marker in critically ill patients with Sars-Cov2 severe pneumonia.

The bioelectrical impedance analysis (BIA) international database: aims, scope, and call for data

BACKGROUND

Bioelectrical impedance analysis (BIA) is a technique widely used for estimating body composition and health-related parameters. The technology is relatively simple, quick, and non-invasive, and is currently used globally in diverse settings, including private clinicians' offices, sports and health clubs, and hospitals, and across a spectrum of age, body weight, and disease states. BIA parameters can be used to estimate body composition (fat, fat-free mass, total-body water and its compartments). Moreover, raw measurements including resistance, reactance, phase angle, and impedance vector length can also be used to track health-related markers, including hydration and malnutrition, and disease-prognostic, athletic and general health status. Body composition shows profound variability in association with age, sex, race and ethnicity, geographic ancestry, lifestyle, and health status. To advance understanding of this variability, we propose to develop a large and diverse multi-country dataset of BIA raw measures and derived body components. The aim of this paper is to describe the 'BIA International Database' project and encourage researchers to join the consortium.

METHODS

The Exercise and Health Laboratory of the Faculty of Human Kinetics, University of Lisbon has agreed to host the database using an online portal. At present, the database contains 277,922 measures from individuals ranging from 11 months to 102 years, along with additional data on these participants.

CONCLUSION

The BIA International Database represents a key resource for research on body composition.

Effects of exercise training on muscle wasting, muscle strength and quality of life in adults with acute burn injury

OBJECTIVES

Exercise training during the acute phase of burns is difficult to implement but offers potential benefits. This multicenter trial explored the effects of an exercise program on muscular changes and quality of life during burn center stay.

METHODS

Fifty-seven adults with burns ranging between 10% and 70% TBSA were allocated to receive either standard of care (n = 29), or additionally exercise (n = 28), consisting of resistance and aerobic training, commenced as early as possible according to safety criteria. Muscle wasting (primary outcome), quantified by ultrasound-derived quadriceps muscle layer thickness (QMLT) and rectus femoris cross-sectional area (RF-CSA), muscle strength and quality of life (Burn Specific Health Scale-Brief (BSHS-B) and EQ-5D-5L) were assessed at baseline, four and eight weeks later, or hospital discharge. Mixed models were used to analyze between-group changes over time with covariates of interest added in stepwise forward modeling.

RESULTS

The addition of exercise training to standard of care induced significant improvements in QMLT, RF-CSA, muscle strength and the BSHS-B subscale hand function (ß-coefficient. 0.055 cm/week of QMLT, p = 0.005). No added benefit was observed for other quality-of-life measures.

CONCLUSIONS

Exercise training, administered during the acute phase of burns, reduced muscle wasting, and improved muscle strength throughout burn center stay.

Sarcopenia as an important determinant for adverse outcomes in patients with pyogenic liver abscess

Background

Low muscle mass/sarcopenia has been associated with poor prognosis in many diseases, but its clinical significance in pyogenic liver abscess (PLA) remains unclear. The purpose of this study is to investigate the relationship between muscle mass and prognosis of patients with PLA.

Methods

A total of 154 adult patients with PLA hospitalized at Tongji Hospital (Wuhan, Hubei, China) between October 2011 and June 2021 were included in this retrospective analysis. Muscle-fat related indicators were measured by computed tomography (CT) images at the third lumbar vertebra (L3) level. The data of patients between the sarcopenia group and non-sarcopenia group were compared. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were performed.

Results

The skeletal muscle index (SMI) was independently associated with adverse outcomes (95% CI [0.649-0.954], P = 0.015) of PLA in multivariate logistic regression analysis. This conclusion held true in sex-specific subgroup analysis. ROC analysis indicated that SMI may predict adverse outcomes in both male (area under the ROC curve [AUC], 0.718; cut-off, 52.59; P < 0.001) and female (AUC, 0.714; cut-off, 38.39; P = 0.017) patient populations.

Conclusions

Sarcopenia serves as an independent risk factor for poor prognosis in PLA and patients with sarcopenia may be more prone to adverse outcomes.