Assessment of Nutritional Status in the Critically Ill

Incorporating ultrasonography to the nutritional assessment process in intensive care settings to improve the prescription of enteral and parenteral nutrition: Benefits, practicality, and challenges

The validity of the traditional nutritional assessment tools in intensive care settings might be compromised when the patient has conditions such as oedema and inflammation. Ultrasound (US) is considered a non-invasive, bedside tool that can be utilized to assess changes in muscle mass. Hence, US could guide healthcare practitioners in identifying the varying degrees of malnutrition and adjusting the nutritional prescription accordingly. This review discusses the currently available data regarding the feasibility and practicality of using US measurements in intensive care settings. Overall, the data suggest that using US as part of the standard anthropometric assessment for critically ill patients is a promising tool to track variations in muscle mass. This has the potential to enhance nutritional prescription and tailor the provision of protein and energy to critically ill patients based on their lean body mass measurements. Therefore, it is recommended to train dietitians on utilizing US for body composition measurements.

Comparison of nutritional risk indices (PNI, GNRI, mNUTRIC) and HALP score in predicting adverse clinical outcomes in older patients staying in an intensive care unit

Malnutrition among critically ill older patients is a frequent problem in intensive care units (ICUs) and is associated with a higher risk of hospital/ICU length of stay (LOS) and mortality. The aim of this study was to evaluate malnutrition in older patients staying in an ICU using the hemoglobin, albumin, lymphocyte, platelet (HALP) score, modified nutrition risk in the critically Ill (mNUTRIC), prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI) and to determine the consistency between these tools and their association with clinical outcomes. This cross-sectional retrospective, observational, hospital-based study included 153 older patients (≥65 years of age), who were admitted to an internal medicine ICU. Sequential organ failure assessment (SOFA) scores and acute physiology and chronic health evaluation (APACHE) II were used to assess disease severity. Nutritional status was evaluated using mNUTRIC, GNRI, PNI, and HALP scores, and their association with ICU LOS and mortality was evaluated using ROC and regression analyses. The mortality rate of the patients was 43.1%. The risk of malnutrition was higher among non-survivors, with mNUTRIC scores showing a significant difference between the groups. The scores for all indices, except HALP, showed significant differences between the groups. APACHE-II, SOFA, and mNUTRIC were the strongest prognostic indices for ICU mortality, with mNUTRIC having the highest sensitivity and negative predictive value. The HALP score was not associated with ICU LOS or a significant prognostic factor for mortality. All indices except HALP were good indicators of clinical outcomes in the study population including older patients. Prospective studies in larger and specific patient populations are needed to draw a strict conclusion in this subject.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

mNUTRIC Score in ICU Mortality Prediction: An Emerging Frontier or Yet Another Transient Trend?

How to cite this article: Arunachala S, Kumar J. mNUTRIC Score in ICU Mortality Prediction: An Emerging Frontier or Yet Another Transient Trend? Indian J Crit Care Med 2024;28(5):422-423.

An Observational Study of Nutritional Assessment, Prescription, Practices, and Its Outcome among Critically Ill Patients Admitted to an Intensive Care Unit

Aim and background

Optimal feeding strategy for critically ill patients of intensive care unit (ICU) is often a matter of debate as patients admitted to ICU are highly catabolic and reduction in muscle mass is very common. We aimed at early achievement of nutritional goals in preventing skeletal muscle breakdown and improving clinical outcomes among critically ill patients with high risk of malnutrition.

Materials and methods

Nutrition risk in the critically ill (mNUTRIC) Score was used to identify the risk of malnutrition within 24 hours of admission. Quadriceps muscle mass index was measured within 24 hours of admission to ICU and repeated on 7th day. Enteral feeding was monitored by the nutrition expert as part of routine patient care and clinical outcomes were monitored.

Results

A total of 287 patients admitted in ICU were screened for malnutrition and 60 (20.9%) of them had high score (>5). There was no statistically significant reduction in the quadriceps muscle mass index (p < 0.05) (t = 0.601) measured within 24 hours of admission and on the 7th day of ICU stay, signifying that the nutritional prescription and monitoring may be useful in preserving the muscle mass. This study did not find statistically significant association between the high mNUTRIC score on admission and the clinical outcomes, such as 28 days mortality, incidence of pressure ulcers, length of ICU stay, and hospital-acquired infection (p > 0.05).

Conclusion

Early initiation and maintenance of enteral nutrition is essential for meeting target calories and protein requirements. It may help to preserve muscle mass in critically ill patients who are otherwise at high risk of malnutrition.

How to cite this article

Sharon T, Nayak SG, Shanbhag V, Hebbar S. An Observational Study of Nutritional Assessment, Prescription, Practices, and Its Outcome among Critically Ill Patients Admitted to an Intensive Care Unit. Indian J Crit Care Med 2024;28(4):364-368.

Intramedullary Kirschner Wire Fixation for Metatarsal Fractures: A Comprehensive Review of Treatment Outcomes

Metatarsal fractures pose significant challenges in orthopedic practice, necessitating effective treatment methods to ensure optimal patient outcomes. This comprehensive review focuses on intramedullary Kirschner wire fixation as a promising intervention for metatarsal fractures. Beginning with an overview of metatarsal fractures and the imperative for effective treatments, the review delves into intramedullary fixation's definition, historical background, advantages, and disadvantages. Indications for its use in metatarsal fractures are discussed, providing a foundation for understanding its application. The surgical technique section outlines critical aspects, including patient selection criteria and preoperative planning. Before presenting a detailed step-by-step procedure for intramedullary Kirschner wire fixation, anesthesia considerations are explored. Emphasizing precision, fluoroscopic guidance, and meticulous postoperative care, this section provides insights for surgeons and healthcare practitioners. Considerations for rehabilitation follow, addressing postoperative care, expected recovery timelines, and physical therapy recommendations. Early mobilization, weight-bearing guidelines, and a structured rehabilitation program play pivotal roles in recovery. In the conclusion, key findings are summarized, highlighting the efficacy of intramedullary Kirschner wire fixation, its advantages, and recommendations for clinical practice. Additionally, areas for future research are identified, guiding further exploration and refinement of this surgical approach. This review is valuable for clinicians, researchers, and healthcare practitioners involved in metatarsal fracture management, contributing to the evolution of treatment strategies and improving patient care.

Utility of Lean Body Mass Equations and Body Mass Index for Predicting Outcomes in Critically Ill Adults with Sepsis: A Retrospective Study

Lean body mass is a significant component of survival from sepsis. Several equations can be used for calculating lean body mass based on age, sex, body weight, and height. We hypothesized that lean body mass is a better predictor of outcomes than the body mass index (BMI). This study used a multicenter cohort study database. The inclusion criteria were age ≥18 years and a diagnosis of sepsis or septic shock. BMI was classified into four categories: underweight (<18.5 kg/m2), normal (≥18.5-<25 kg/m2), overweight (≥25-<30 kg/m2), and obese (≥30 kg/m2). Four lean body mass equations were used and categorized on the basis of quartiles. The outcome was in-hospital mortality among different BMI and lean body mass groups. Among 85,558 patients, 3916 with sepsis were included in the analysis. Regarding BMI, in-hospital mortality was 36.9%, 29.8%, 26.7%, and 27.9% in patients who were underweight, normal weight, overweight, and obese, respectively (p < 0.01). High lean body mass did not show decreased mortality in all four equations. In critically ill patients with sepsis, BMI was a better predictor of in-hospital mortality than the lean body mass equation at intensive care unit (ICU) admission. To precisely predict in-hospital mortality, ICU-specific lean body mass equations are needed.

The prevalence of malnutrition among critically ill children: a systematic review and meta-analysis

BACKGROUND

Critically ill children have a lower nutritional reserve, compounding the restricted food intake during intensive care unit (ICU) and hospital stays, and scarce data are available to point out the problem. Therefore, this review aimed to assess the pooled prevalence of malnutrition among critically ill children.

METHODOLOGY

This systematic review was conducted in accordance with the JBI methodology for systematic reviews of prevalence and incidence. Databases including, PubMed/MEDLINE, CINAHL/EBSCO, HINARI, Google Scholar, and gray literatures were used to find relevant articles. Eligible studies were critically appraised by two independent reviewers. Systematic review and meta-analysis was conducted using STATA 17 software. Funnel plot and at the 5% significance level, Egger's test were used to check for publication bias.

RESULT

From a total of 15 studies with 4331 study participants, the pooled prevalence of malnutrition in critically ill children was 37.19% (95% CI; 35.89-38.49) with a significant statistical heterogeneity (I2 = 98.6, P = < 0.0001). High income countries reported the lower pooled prevalence of malnutrition among critically ill children (30.14%, 95% CI; 28.41, 31.88). No publication bias was reported and sensitivity analysis suggested that no significance difference was shown in the prevalence of malnutrition among critically ill children with the pooled prevalence.

CONCLUSION

The current systematic review and meta-analysis showed that more than one in three critically ill children was malnourished. Serious medical conditions in children that deserve admission to the intensive care unit could be a complication of malnutrition that may end up in deaths unless the undernutrition is addressed together with critical care intervention. Hence, specific strategies to prevent malnutrition among this neglected segment should be integrated with the existing healthcare systems and nutritional programs.

The global leadership initiative on malnutrition criteria for the diagnosis of malnutrition in patients admitted to the intensive care unit: A systematic review and meta-analysis

BACKGROUND

Malnutrition is associated with a high risk of morbidity and mortality in patients with critical illness. The nutrition status of patients in the intensive care unit (ICU) is challenging to assess. The Global Leadership Initiative on Malnutrition (GLIM) is a novel framework used for the diagnosis of malnutrition. However, its efficacy in patients with critical illness in the ICU has not been validated.

AIM

To investigate the use and validity of the GLIM criteria in adult patients admitted to the ICU.

METHODS

A systematic review and meta-analysis were performed, and seven databases were searched for relevant studies. The selection criteria included studies that used the GLIM in adult patients admitted to the ICU. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

RESULTS

Five studies were included in the analysis. Approximately 15%-68% of patients were diagnosed with malnutrition using the GLIM criteria. Meanwhile, 48%-75% of patients with malnutrition were identified with the Subjective Global Assessment (SGA). The inflammation criterion was easily adjudicated due to critical status, and three studies compared the GLIM and the SGA. According to the QUADAS-2 tool, the nutritional assessment process was not explicit in the studies. The meta-analysis had an overall sensitivity of 65.3% (95% CI: 34.9%-86.9%) and an overall specificity of 88.8% (95% CI: 58.1%-97.8%). In the prospective validation, malnutrition assessed by the GLIM criteria, and the SGA was associated with mortality. However, the association between length of hospital stay and mechanical ventilation was unclear.

CONCLUSIONS

The use and validity of the GLIM criteria among patients admitted to the ICU is still limited. Moreover, some concurrent and predictive validation studies have methodological limitations. Further studies must be performed to validate the use of the GLIM criteria in the ICU.

Modified Nutrition Risk in Critically Ill Score, A Prognostic Marker of Morbidity and Mortality in Mechanically Ventilated Patients: A Prospective Observational Study

BACKGROUND

Critically ill (CI) patients, especially those requiring mechanical ventilation (MV) are at a higher risk of malnutrition, which in turn is associated with increased hospitalization and excess mortality. The modified Nutrition Risk in Critically Ill (mNUTRIC) score, a predictor of mortality, has not been validated adequately in CI Indian patients. Thus, this study evaluated the mNUTRIC score as a prognostic marker of morbidity and mortality in CI patients requiring MV.

MATERIALS AND METHODS

This prospective observational study was performed, between January 2018 and June 2019, in the intensive critical care unit (ICCU) of the medicine department of a tertiary care hospital. A total of 250 patients aged above 12 years, admitted in ICCU, and requiring MV for &gt;48 hours were included. Based on the data collected, mNUTRIC score was calculated and patients were classified as at low (0-4) and high (5-9) nutritional risk. Mortality was the outcome variable.

RESULTS

More than a quarter of patients had a high mNUTRIC score (28.4%) and the overall mortality was 35.6%. A significantly greater proportion of non-survivors had a high mNUTRIC score (p-value&lt;0.0001). Likewise, the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, and mNUTRIC score (all p-values&lt;0.0001) were significantly higher among the non-survivors than the survivors. On receiver operator characteristic (ROC) curve analysis, a cutoff value of &gt;2 predicted mortality [area under the curve (AUC): 0.83; 95% confidence interval: 0.778-0.874] with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 80.9, 76.4, 65.5, and 87.9%, respectively.

CONCLUSION

At a cutoff of &gt;2, mNUTRIC score had high sensitivity and specificity in the prediction of mortality.

Subclinical Kwashiorkor in Adults: A New Age Paradigm

Childhood protein-energy undernutrition (PEU) is a well-recognized problem and therefore a lot of work has been done to identify and manage paediatric PEU. Though there have been several reports of low protein consumption in adults from developing countries, PEU and its subtle forms (subclinical PEU) are not yet recognized as adult disorders. Physicians and public perception do not favour easy recognition and action. In this review, the authors provide a scoping review of the existing literature on this entity providing insights into its recognition, pathogenesis and management. Adult subclinical PEU is an enormous under-recognized challenge that can have detrimental consequences if not recognized and corrected in time. PEU has grave health and economic impact on the patient and society. Therefore, it is important to recognize subclinical PEU and prevent its progression to full-blown form.