Malnutrition,Critical Illness Survivors,and Postdischarge Outcomes: A Cohort Study

Background: We hypothesized that preexisting malnutrition in patients who survived critical care would be associated with adverse outcomes following hospital discharge. Methods: We performed an observational cohort study in 1 academic medical center in Boston. We studied 23,575 patients, aged ≥18 years, who received critical care between 2004 and 2011 and survived hospitalization. Results: The exposure of interest was malnutrition determined at intensive care unit (ICU) admission by a registered dietitian using clinical judgment and on data related to unintentional weight loss, inadequate nutrient intake, and wasting of muscle mass and/or subcutaneous fat. The primary outcome was 90‐day postdischarge mortality. Secondary outcome was unplanned 30‐day hospital readmission. Adjusted odds ratios were estimated by logistic regression models adjusted for age, race, sex, Deyo‐Charlson Index, surgical ICU, sepsis, and acute organ failure. In the cohort, the absolute risk of 90‐day postdischarge mortality was 5.9%, 11.7%, 15.8%, and 21.9% in patients without malnutrition, those at risk of malnutrition, nonspecific malnutrition, and protein‐energy malnutrition, respectively. The odds of 90‐day postdischarge mortality in patients at risk of malnutrition, nonspecific malnutrition, and protein‐energy malnutrition fully adjusted were 1.77 (95% confidence interval [CI], 1.23–2.54), 2.51 (95% CI, 1.36–4.62), and 3.72 (95% CI, 2.16–6.39), respectively, relative to patients without malnutrition. Furthermore, the presence of malnutrition is a significant predictor of the odds of unplanned 30‐day hospital readmission. Conclusions: In patients treated with critical care who survive hospitalization, preexisting malnutrition is a robust predictor of subsequent mortality and unplanned hospital readmission.     

Metabolites Associated With Malnutrition in the Intensive Care Unit Are Also Associated With 28‐Day Mortality

Background: We hypothesized that metabolic profiles would differ in critically ill patients with malnutrition relative to those without. Materials and Methods: We performed a prospective cohort study on 85 adult patients with systemic inflammatory response syndrome or sepsis admitted to a 20‐bed medical intensive care unit (ICU) in Boston. We generated metabolomic profiles using gas and liquid chromatography and mass spectroscopy. We followed this by logistic regression and partial least squares discriminant analysis to identify individual metabolites that were significant. We then interrogated the entire metabolomics profile using metabolite set enrichment analysis and network model construction of chemical‐protein target interactions to identify groups of metabolites and pathways that were differentiates in patients with and without malnutrition. Results: Of the cohort, 38% were malnourished at admission to the ICU. Metabolomic profiles differed in critically ill patients with malnutrition relative to those without. Ten metabolites were significantly associated with malnutrition (P < .05). A parsimonious model of 5 metabolites effectively differentiated patients with malnutrition (AUC = 0.76), including pyroglutamine and hypoxanthine. Using pathway enrichment analysis, we identified a critical role of glutathione and purine metabolism in predicting nutrition. Nutrition status was associated with 28‐day mortality, even after adjustment for known phenotypic variables associated with ICU mortality. Importantly, 7 metabolites associated with nutrition status were also associated with 28‐day mortality. Conclusion: Malnutrition is associated with differential metabolic profiles early in critical illness. Common to all of our metabolome analyses, glutathione and purine metabolism, which play principal roles in cellular redox regulation and accelerated tissue adenosine triphosphate degradation, respectively, were significantly altered with malnutrition.     

Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review

Malnutrition is associated with poor clinical outcomes among hospitalized patients. However, studies linking malnutrition with poor clinical outcomes in the intensive care unit (ICU) often have conflicting findings due in part to the inappropriate diagnosis of malnutrition. We primarily aimed to determine whether malnutrition diagnosed by validated nutrition assessment tools such as the Subjective Global Assessment (SGA) or Mini Nutritional Assessment (MNA) is independently associated with poorer clinical outcomes in the ICU and if the use of nutrition screening tools demonstrate a similar association. PubMed, CINAHL, Scopus, and Cochrane Library were systematically searched for eligible studies. Search terms included were synonyms of malnutrition, nutritional status, screening, assessment, and intensive care unit. Eligible studies were case‐control or cohort studies that recruited adults in the ICU; conducted the SGA, MNA, or used nutrition screening tools before or within 48 hours of ICU admission; and reported the prevalence of malnutrition and relevant clinical outcomes including mortality, length of stay (LOS), and incidence of infection (IOI). Twenty of 1168 studies were eligible. The prevalence of malnutrition ranged from 38% to 78%. Malnutrition diagnosed by nutrition assessments was independently associated with increased ICU LOS, ICU readmission, IOI, and the risk of hospital mortality. The SGA clearly had better predictive validity than the MNA. The association between malnutrition risk determined by nutrition screening was less consistent. Malnutrition is independently associated with poorer clinical outcomes in the ICU. Compared with nutrition assessment tools, the predictive validity of nutrition screening tools were less consistent.     

A Comprehensive Nutrition‐Focused Quality Improvement Program Reduces 30‐Day Readmissions and Length of Stay in Hospitalized Patients

Background: Although screening patients for malnutrition risk on hospital admission is standard of care, nutrition shortfalls are undertreated. Nutrition interventions can improve outcomes. We tested effects of a nutrition‐focused quality improvement program (QIP) on hospital readmission and length of stay (LOS). Materials and Methods: QIP included malnutrition risk screening at admission, prompt initiation of oral nutrition supplements (ONS) for at‐risk patients, and nutrition support. A 2‐group, pre‐post design of malnourished adults with any diagnosis was conducted at 4 hospitals: QIP‐basic (QIPb) and QIP‐enhanced (QIPe). Comparator patients had a malnutrition diagnosis and ONS orders. For QIPb, nurses screened all patients on admission using an electronic medical record (EMR)–cued Malnutrition Screening Tool (MST); ONS was provided to patients with MST scores ≥2 within 24–48 hours. QIPe had ONS within 24 hours, postdischarge nutrition instructions, telephone calls, and ONS coupons. Primary outcome was 30‐day unplanned readmission. We used baseline (January 1–December 31, 2013) and validation cohorts (October 13, 2013–April 2, 2014) for comparison. Results: Patients (n = 1269) were enrolled in QIPb (n = 769) and QIPe (n = 500). Analysis included baseline (n = 4611) and validation (n = 1319) comparator patients. Compared with a 20% baseline readmission rate, post‐QIP relative reductions were 19.5% for all QIP, 18% for QIPb, and 22% for QIPe, respectively. Compared with a 22.1% validation readmission rate, relative reductions were 27.1%, 25.8%, and 29.4%, respectively. Similar reductions were noted for LOS. Conclusions: Thirty‐day readmissions and LOS were significantly lowered for malnourished inpatients by use of an EMR‐cued MST, prompt provision of ONS, patient/caregiver education, and sustained nutrition support.     

Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone

Background: This study aimed to determine the agreement between the modified Nutrition Risk in Critically ill Score (mNUTRIC) and the Subjective Global Assessment (SGA) and compare their ability in discriminating and quantifying mortality risk independently and in combination. Methods: Between August 2015 and October 2016, all patients in a Singaporean hospital received the SGA within 48 hours of intensive care unit admission. Nutrition status was dichotomized into presence or absence of malnutrition. The mNUTRIC of patients was retrospectively calculated at the end of the study, and high mNUTRIC was defined as scores ≥5. Results: There were 439 patients and 67.9% had high mNUTRIC, whereas only 28% were malnourished. Hospital mortality was 29.6%, and none was lost to follow‐up. Although both tools had poor agreement (κ statistics: 0.13, P < .001), they had similar discriminative value for hospital mortality (C‐statistics [95% confidence interval (CI)], 0.66 [0.62–0.70] for high mNUTRIC and 0.61 [0.56–0.66] for malnutrition, P = .12). However, a high mNUTRIC was associated with higher adjusted odds for hospital mortality compared with malnutrition (adjusted odds ratio [95% CI], 5.32 [2.15–13.17], P < .001, and 4.27 [1.03–17.71], P = .046, respectively). Combination of both tools showed malnutrition and high mNUTRIC were associated with the highest adjusted odds for hospital mortality (14.43 [5.38–38.78], P < .001). Conclusion: The mNUTRIC and SGA had poor agreement. Although they individually provided a fair discriminative value for hospital mortality, the combination of these approaches is a better discriminator to quantify mortality risk.     

Relationship of Vitamin D Deficiency to Clinical Outcomes in Critically Ill Patients

Background: Despite the numerous disease conditions associated with vitamin D deficiency in the general population, the relationship of this deficiency to outcome in critically ill patients remains unclear. The objective of this study is to determine the burden of vitamin D deficiency in intensive care unit (ICU) patients and determine if it is associated with poor patient outcomes. Methods: The authors conducted an analysis of samples collected from a prospective study of 196 patients admitted to a medical/surgical ICU in a tertiary care hospital. They measured serum 25‐hydroxyvitamin D at admission and up to 10 days following admission and followed patients prospectively for 28‐day outcomes. Results: Of analyzable patients, 50 (26%) were deficient (≤30 nmol/L) and 109 (56%) were insufficient (>30 and ≤60 nmol/L). Baseline 25(OH)D levels decreased significantly in all patients after 3 days in the ICU and remained significantly lower through 10 days (P < .001). 25(OH)D status was not significantly associated with 28‐day all‐cause mortality (hazard ratio [HR], 0.89; 95% confidence interval, [CI] 0.37–2.24). Higher levels of 25(OH)D were associated with a shorter time‐to‐alive ICU discharge (HR, 2.11; 95% CI, 1.27–3.51). 25(OH)D‐deficient patients showed a nonstatistically significant trend toward a higher infection rate (odds ratio [OR], 3.20; 95% CI, 0.784–13.07; P = .11) compared with patients with sufficient levels of 25(OH)D. Conclusions: This study demonstrates significant decreases in vitamin D status over the duration of the patient's ICU stay. Low levels of vitamin D are associated with longer time to ICU discharge alive and a trend toward increased risk of ICU‐acquired infection.     

Greater Nutrient Intake Is Associated With Lower Mortality in Western and Eastern Critically Ill Patients With Low BMI: A Multicenter,Multinational Observational Study

Background: Little is known about the impact of feeding adequacy by NUTrition Risk in the Critically Ill (NUTRIC) groups in critically ill patients with body mass index (BMI) <20. Our purpose was to assess whether adequacy of protein/energy intake impacts mortality in patients with BMI <20 in Western/Eastern intensive care units (ICUs) and high/low NUTRIC groups. Methods: Data from the International Nutrition Survey 2013–2014 were dichotomized into Western/Eastern ICU settings; BMI <20 or ≥20; and high (≥5)/low (<5) NUTRIC groups. Association of BMI <20 with 60‐day mortality was compared in unadjusted and adjusted (Western/Eastern, age, medical/surgical admission, high/low NUTRIC group) logistic regression models. The impact of adequacy of protein/energy on 60‐day mortality relationship was tested using general estimating equations in high/low NUTRIC groups, in unadjusted and adjusted models. Results: Western (n = 4274) patients had higher mean BMI (27.9 ± 7.7 versus (vs) 23.4 ± 4.9, P < 0.0001) than Eastern (n = 1375), respectively. BMI <20 was associated with greater mortality (adjusted odds ratio [OR] 1.30, 95% confidence interval [CI] 1.07–1.57), with no interaction between BMI group and Western/Eastern ICU site. Among patients with BMI <20 and high NUTRIC score, 10% greater protein and energy adequacy was associated with 5.7% and 5.5% reduction in 60‐day mortality, respectively. Results were not significantly different between Western and Eastern ICUs. Conclusions: The benefit of greater protein/energy intake in high‐NUTRIC patients was observed regardless of geographic origin or low BMI, suggesting a consistent response to nutrition support in this group. Clinical guidelines and research projects focused on improving care in high‐risk critically ill patients can be applied across geographic boundaries.     

Nutrition therapy for the critically ill surgical patient: we need to do better!

Background: To identify opportunities for quality improvement, the nutrition adequacy of critically ill surgical patients, in contrast to medical patients, is described. Methods: International, prospective, and observational studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) were combined for purposes of this analysis. Sites provided institutional and patient characteristics and nutrition data from ICU admission to ICU discharge for maximum of 12 days. Medical and surgical patients staying in ICU at least 3 days were compared. Results: A total of 5497 mechanically ventilated adult patients were enrolled; 37.7% had surgical ICU admission diagnosis. Surgical patients were less likely to receive enteral nutrition (EN) (54.6% vs 77.8%) and more likely to receive parenteral nutrition (PN) (13.9% vs 4.4%) (P < .0001). Among patients initiating EN in ICU, surgical patients started EN 21.0 hours later on average (57.8 vs 36.8 hours, P < .0001). Consequently, surgical patients received less of their prescribed calories from EN (33.4% vs 49.6%, P < .0001) or from all nutrition sources (45.8% vs 56.1%, P < .0001). These differences remained after adjustment for patient and site characteristics. Patients undergoing cardiovascular and gastrointestinal surgery were more likely to use PN, were less likely to use EN, started EN later, and had lower total nutrition and EN adequacy rates compared with other surgical patients. Use of feeding and/or glycemic control protocols was associated with increased nutrition adequacy. Conclusions: Surgical patients receive less nutrition than medical patients. Cardiovascular and gastrointestinal surgery patients are at highest risk of iatrogenic malnutrition. Strategies to improve nutrition performance, including use of protocols, are needed.     

Difference in Composite End Point of Readmission and Death Between Malnourished and Nonmalnourished Veterans Assessed Using Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Clinical Characteristics

Background: Previous studies have demonstrated an association between malnutrition and poor outcomes. The primary objective of this study was to explore the difference in the composite end point of readmission rate or mortality rate between hospitalized veterans with and without malnutrition. Materials and Methods: This was a retrospective chart review comparing veterans with malnutrition based on a modified version of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition consensus characteristics that used 5 of the 6 clinical characteristics to a matched control group of nonmalnourished veterans based on age, admitting service, and date of admission who were admitted between August 1, 2012, and December 1, 2014. Data were extracted from the medical record. Multivariate analysis was used to identify predictors of outcomes. Results: In total, 404 patients were included in the final analysis. All end points were found to be statistically significant. The malnourished group was more likely to meet the composite end point (odds ratio [OR], 5.3), more likely to be readmitted within 30 days (OR, 3.4), more likely to die within 90 days of discharge (OR, 5.5), and more likely to have a length of stay >7 days (OR, 4.3) compared with the nonmalnourished group. Length of stay was significantly longer in the malnourished group, 9.80 (11.5) vs 4.38 (4.5) days. Conclusion: Malnutrition was an independent risk factor for readmission within 30 days or death within 90 days of discharge. Malnourished patients had higher rates of readmission, higher mortality rates, and longer lengths of stay and were more likely to be discharged to nursing homes.     

Factors associated with inpatient readmission among managed care enrollees with COPD

Objective. To assess factors associated with inpatient readmission among a US managed care population with chronic obstructive pulmonary disease (COPD). Background. COPD is often accompanied by intermittent acute exacerbations, which may result in hospitalizations. These exacerbations are often associated with an increased frequency of subsequent exacerbations, which may lead to inpatient readmissions. Methods. We assessed US managed care claims data for enrollees ≥ 40 years old with an inpatient admission with a primary diagnosis of COPD (ICD-9-CM codes 491.xx, 492.xx or 496.xx) between 1 January 2010 and 31 December 2013 (discharge date of first observed inpatient admission defined the “index date”). Patients were required to be continuously enrolled for ≥ 12 months before the index date. Two non-mutually exclusive cohorts were analyzed: (1) patients with ≥ 30 days of post-index date continuous enrollment (to evaluate 30-day readmission) and (2) patients with ≥ 90 days of post-index date continuous enrollment (to evaluate 90-day readmission). Logistic regression evaluated the association between patient characteristics and risk of 30- and 90-day COPD-related and all-cause readmission. Results. After applying selection criteria, 140,981 patients had ≥ 30 days of enrollment post-index date, and 123,545 patients had ≥ 90 days of enrollment post-index date. Within 30 days, nearly 20% of patients had an all-cause readmission and 7% had a COPD-related readmission. Within 90 days, 28% had an all-cause readmission and 12% had a COPD-related readmission. Logistic regression indicated that longer length of stay, older age, greater comorbidity burden, specific comorbidities and COPD complexity were associated with significantly greater odds of COPD-related 30- and 90-day readmission. Results for all-cause readmission were generally similar. Conclusions. Many of the factors associated with inpatient readmission documented here can be ascertained at discharge and may be used to inform discharge plans, with the end goal of improving patient outcomes, including reducing the risk of readmission.     

Thirty‐Day Readmission Rate Is High for Hospitalized Patients Discharged With Home Parenteral Nutrition or Intravenous Fluids

Background: Reducing hospital readmissions decreases healthcare costs and improves quality of care. There are no published studies examining the rate of, and risk factors for, 30‐day readmissions for patients discharged with home parenteral support (HPS). Objective: Determine the rate of 30‐day readmissions for patients discharged with HPS and whether malnutrition and other demographic or clinical factors increase the risk. Materials and Methods: Retrospective review of patients discharged with HPS from the Cleveland Clinic between July 1, 2013, and June 30, 2014, and followed by the Cleveland Clinic Home Nutrition Support Service. Results: Of the 224 patients studied, 31.6% (n = 71) had unplanned readmissions within 30 days of hospital discharge. Of these, 21.1% (n = 15) were HPS related, with catheter‐related bloodstream infection (n = 5) and dehydration (n = 5) the most common. The majority of patients (84.4%) were diagnosed with malnutrition, but the presence or degree did not influence the readmission rate (P = .41). According to univariable analysis, patients with an ostomy (P = .037), a small bowel resection (P = .002), a higher HPS volume at discharge (P < .001), and a shorter period between HPS consult and hospital discharge (P < .026) had a lower risk of 30‐day readmission than their counterparts. On multivariable analysis, patients had a higher risk of 30‐day readmission if they had a history of heart disease (P = .048) and for every 1‐unit increase in white blood cells (P = .026). Conclusions: Patients discharged with HPS have a high 30‐day readmission rate, although most readmissions were not related to the HPS itself. The presence and degree of malnutrition were not associated with 30‐day readmissions.     

Clinical Outcomes in Critically Ill Patients Associated With the Use of Complex vs Weight‐Only Predictive Energy Equations

Background: The energy intake goal is important to achieving energy intake in critically ill patients, yet clinical outcomes associated with energy goals have not been reported. Methods: This secondary analysis used the Improving Nutrition Practices in the Critically III International Nutrition Surveys database from 2007–2009 to evaluate whether mortality or time to discharge alive is related to use of complex energy prediction equations vs weight only. The sample size was 5672 patients in the intensive care unit (ICU) ≥4 days and a subset of 3356 in the ICU ≥12 days. Mortality and time to discharge alive were compared between groups by regression, controlling for age, sex, admission type, Acute Physiology and Chronic Health Evaluation II score, ICU geographic region, actual energy intake, and obesity. Results: There was no difference in mortality between the use of complex and weight‐only equations (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.86–1.15), but obesity (OR, 0.83; 95% CI, 0.71–0.96) and higher energy intake (OR, 0.65; 95% CI, 0.56–0.76) had lower odds of mortality. Time to discharge alive was shorter in patients fed using weight‐only equations (hazard ratio [HR], 1.11; 95% CI, 1.01–1.23) in patients staying ≥4 days and with greater energy intake (HR, 1.19; 95% CI, 1.06–1.34) in patients in the ICU ≥12 days. Conclusion: These data suggest that higher energy intake is important to survival and time to discharge alive. However, the analysis was limited by actual energy intake <70% of goal. Delivery of full goal intake will be needed to determine the relationship between the method of determining energy goal and clinical outcomes.     

Nutritional status in intensive care unit patients: a prospective clinical cohort pilot study

Previous researches have shown that the nutritional status of patients in the intensive care unit (ICU) was poor on admission and appears to decline during their stay in the ICU. Critically ill patients are prone to malnutrition because their hypermetabolic disorders lead to an increase in nutritional requirements that are not often met with the nutrition supplied. The aim of this study was to assess the nutritional status and hs-CRP of ICU patients on admission and discharge from the hospital. Twenty-nine neurological ICU patients (20–87 years old) underwent fasting blood sample collections, anthropometric measurements and impedance analysis on admission and discharge at Ghaem Teaching Hospital. NRS 2002 was used to determine malnutrition in ICU patients. Markers of nutritional status changed from admission into the ICU until discharge as follows: weight, BMI and triceps skinfold thickness decreased (p < 0.001, p < 0.001 and p < 0.005, respectively). hs-CRP was decreased over the stay in the hospital (admission = 19.4 ± 16.3, discharge = 13.8 ± 14.5, p value = 0.11). The percent of patients at risk of malnutrition decreased during stay in ICU (not significant). Prevalence of malnutrition was as high as 47.6% on admission. The nutritional status of patients was slightly improved over the period of their stay in hospital using NRS 2002 method.     

Association of obesity with illness severity in hospitalized patients with COVID-19: A retrospective cohort study

BackgroundAlthough recent studies have shown an association between obesity and adverse coronavirus disease 2019 (COVID-19) patient outcomes, there is a paucity in large studies focusing on hospitalized patients. We aimed to analyze outcomes associated with obesity in a large cohort of hospitalized COVID-19 patients.MethodsWe performed a retrospective study at a tertiary care health system of adult patients with COVID-19 who were admitted between March 1 and April 30, 2020. Patients were stratified by body mass index (BMI) into obese (BMI ≥ 30 kg/m 2) and non-obese (BMI < 30 kg/m 2) cohorts. Primary outcomes were mortality, intensive care unit (ICU) admission, intubation, and 30-day readmission.ResultsA total of 1983 patients were included of whom 1031 (51.9%) had obesity and 952 (48.9%) did not have obesity. Patients with obesity were younger (P < 0.001), more likely to be female (P < 0.001) and African American (P < 0.001) compared to patients without obesity. Multivariable logistic models adjusting for differences in age, sex, race, medical comorbidities, and treatment modalities revealed no difference in 60-day mortality and 30-day readmission between obese and non-obese groups. In these models, patients with obesity had increased odds of ICU admission (adjusted OR, 1.37; 95% CI, 1.07?1.76; P = 0.012) and intubation (adjusted OR, 1.37; 95% CI, 1.04?1.80; P = 0.026).ConclusionsObesity in patients with COVID-19 is independently associated with increased risk for ICU admission and intubation. Recognizing that obesity impacts morbidity in this manner is crucial for appropriate management of COVID-19 patients.     

A Cohort Study of Nutrition Practices in the Intensive Care Unit Following Abdominal Aortic Aneurysm Repair

Introduction: Enteral nutrition within 48 hours of intensive care unit (ICU) admission is recommended for the ICU population. Major vascular surgery patients have a higher incidence of pre‐ and postoperative malnutrition compared with the general surgical population. Our objectives were to determine if early feeding (within 48 hours of admission) is achievable and well tolerated, identify factors that predict early feeding, and determine if there is an association between early feeding and in‐hospital mortality among abdominal aortic aneurysm (AAA) repair patients. Methods: A retrospective cohort study was conducted among 145 postsurgical AAA repair patients admitted to the ICU within 48 hours of surgery. Kaplan‐Meier methods and Cox proportional hazard multiple regression were used to analyze the data. Results: Only 35 (24%) patients received early feeding. Patients were more likely to be fed early if they were male (adjusted hazard ratio [aHR] = 2.3; 95% confidence interval [CI], 0.8–6.7; P = .13), had endovascular AAA repair (aHR = 2.9; 95% CI, 1.4–6.2; P = .006), had less blood loss (<4 L) during surgery (aHR = 2.3; 95% CI, 0.7–7.2; P = .14), and had shorter length of ventilation (<48 hours) (aHR = 2.2; 95% CI, 1.1–4.8; P = .048). Of 44 patients fed via enteral nutrition (EN), 27 (61%) achieved nutrition adequacy (>80% EN goal) during ICU admission. After controlling for other factors, 14‐day mortality was not related to feeding time (aHR = 1.1; P = .88). Conclusion: Early feeding was achieved in a minority of patients following AAA repair, was related to type of surgery and duration of mechanical ventilation, and was tolerated as well as later introduced feedings. Randomized trials are needed to determine safety and benefits of early feeding in this patient group.     

Identification of ICU Patients with High Nutritional Risk after Abdominal Surgery Using Modified NUTRIC Score and the Association of Energy Adequacy with 90-Day Mortality

For patients undergoing abdominal surgery, malnutrition further increases the susceptibility to infection, surgical complications, and mortality. However, there is no standard tool for identifying high-risk groups of malnutrition or exact criteria for the optimal target of nutrition supply. We aimed to identify the nutritional risk in critically ill patients using modified Nutrition Risk in the Critically Ill (mNUTRIC) scores and assessing the relationship with clinical outcomes. Furthermore, we identified the ideal target of energy intake during the acute postoperative period. A prospective observational study was conducted. mNUTRIC scores and the average calories prescribed and given were calculated. To identify the high-risk group of malnutrition, receiver operating characteristic curves were plotted. The ideal target of energy adequacy and predisposing factors of 90-day mortality were assessed using multiple logistic regression analyses. A total of 206 patients were analyzed. The cutoff value for mNUTRIC score predicting 90-day mortality was 5 (Area under the curve = 0.7, 95% confidence interval (Cl) 0.606–0.795, p < 0.001). A total of 75 patients (36.4%) were classified in the high mNUTRIC group (mNUTRIC ≥ 5) and had a significantly higher postoperative complication and longer length of surgical intensive care unit stay. High mNUTRIC scores (odds ratio = 2.548, 95% CI 1.177–5.514, p = 0.018) and energy adequacy less than 50% (odds ratio = 6.427, 95% CI 1.674–24.674, p = 0.007) were associated with 90-day mortality.     

Malnutrition May Worsen the Prognosis of Critically Ill Children With Hyperglycemia and Hypoglycemia

Objectives: To determine whether hyperglycemia and hypoglycemia are associated with higher mortality, longer length of intensive care unit (ICU) stay, and fewer ventilator‐free days in critically ill children while taking into account the clinical severity and nutrition status. Patients and Methods: A prospective observational cohort study was conducted on 221 children admitted to the ICU. Blood glucose levels were analyzed in the first 72 hours. Potential exposure variables for adverse prognosis included hyperglycemia (blood glucose >150 mg/dL), hypoglycemia (blood glucose ≤60 mg/dL), age <1 year, sex, nutrition status, the revised Pediatric Index of Mortality (PIM 2), and the Pediatric Logistic Organ Dysfunction (PELOD). Results: Of the patients, 47.1% were malnourished. Controlling for nutrition status, both hyperglycemia and hypoglycemia increased the risk of mortality in the malnourished patients compared with the well‐nourished ones. Adjusting for clinical severity, the odds ratio of mortality was higher in malnourished patients with hyperglycemia (odds ratio [OR], 3.98; 95% confidence interval [CI], 1.14–13.94; P = .03), whereas no significant associations were detected in the well‐nourished patients. After controlling for nutrition status, hypoglycemia was associated with longer length of ICU stay (OR, 6.5; 95% CI, 1.30–32.57; P < .01) and fewer ventilator‐free days (OR, 4.11; 95% CI, 1.26–13.40; P < .01) only in the malnourished group of patients. Conclusions: Compared with the well nourished, malnourished patients with hyperglycemia are at a greater risk of mortality, independent of clinical severity. Hypoglycemia was shown to be associated with mortality, longer length of ICU stay, and fewer ventilator‐free days only in malnourished patients.     

Clinical Outcomes Related to Protein Delivery in a Critically Ill Population

Objective: Optimal intake of energy and protein is associated with improved outcomes, although outcomes relative to protein intake are very limited. Our purpose was to evaluate the impact of prescribed protein delivery on mortality and time to discharge alive (TDA) using data from the International Nutrition Survey 2013. We hypothesized that greater protein delivery would be associated with lower mortality and shorter TDA. Methods: The sample included patients in the intensive care unit (ICU) ≥4 days (n = 2828) and a subsample in the ICU ≥12 days (n = 1584). Models were adjusted for evaluable nutrition days, age, body mass index, sex, admission type, acuity scores, and geographic region. Percentages of prescribed protein and energy intake were compared with mortality outcomes using logistic regression and with Cox proportional hazards for TDA. Results: Mean intake for the 4‐day sample was protein 51 g (60.5% of prescribed) and 1100 kcal (64.1% of prescribed); for the 12‐day sample, mean intake was protein 57 g (66.7% of prescribed) and 1200 kcal (70.7% of prescribed). Achieving ≥80% of prescribed protein intake was associated with reduced mortality (4‐day sample: odds ratio [OR], 0.68; 95% confidence interval [CI], 0.50–0.91; 12‐day sample: OR, 0.60; 95% CI, 0.39–0.93), but ≥80% of prescribed energy intake was not. TDA was shorter with ≥80% prescribed protein (hazard ratio [HR], 1.25; 95% CI, 1.04–1.49) in the 12‐day sample but longer with ≥80% prescribed energy in the 4‐day sample (HR, 0.82; 95% CI, 0.69–0.96). Conclusion: Achieving at least 80% of prescribed protein intake may be important to survival and shorter TDA in ICU patients. Efforts to achieve prescribed protein intake should be maximized.     

Use of subjective global assessment and clinical outcomes in critically ill geriatric patients receiving nutrition support

The objective of this study is to examine the prevalence of malnutrition and evaluate the nutrition status and clinical outcome in hospitalized patients aged 65 years and older receiving enteral‐parenteral nutrition. This retrospective study was carried out at Ba?kent University Hospital, Adana, Turkey. A total of 119 patients older than 65 years were recruited. Patients were classified into 3 groups: protein‐energy malnutrition (PEM), moderate PEM, and well nourished according to subjective global assessment (SGA) at admission. All patients were fed by enteral or parenteral route. Acute physiological and chronic health evaluation (APACHE‐2) and simplified acute physiology (SAPS 2) scores were recorded in patients followed in the intensive care unit (ICU). Nutrition status was assessed with biochemical (serum albumin, serum prealbumin) parameters. These results were compared with mortality rate and length of hospital stay (LOS). The subjects' mean (±SD) age was 73.1 ± 5.4 years. Using SGA, 5.9% (n = 7) of the patients were classified as severely PEM, 27.7% (n = 33) were classified as moderately PEM, and 66.4% (n = 79) were classified as well nourished. Some 73.1% (n = 87) of the patients were followed in the ICU. Among all patients, 42.9% (n = 51) were fed by a combined enteral‐parenteral route, 31.1% (n = 37) by an enteral route, 18.5% (n = 22) by a parenteral route, and 7.6% (n = 9) by an oral route. The average length of stay for the patients was 18.9 ± 13.7 days. The mortality rate was 44.5% (n = 53). The mortality rate was 43% (n = 34) in well‐nourished patients (n = 79), 48.5% (n = 16) in moderately PEM patients (n = 33), and 42.9% (n = 3) in severely PEM patients (n = 7) (P = .86). The authors observed no difference between well‐nourished and malnourished patients with regard to the serum protein values on admission, LOS, and mortality rate. In this study, malnutrition as defined by SGA did not influence the mortality rate of critically ill geriatric patients receiving enteral or parenteral nutrition. Furthermore, no factor was found to be a good predictor of survival.     

Causes and Consequences of Interrupted Enteral Nutrition

Background: Malnutrition and underfeeding are major challenges in caring for critically ill patients. Our goal was to characterize interruptions in enteral nutrition (EN) delivery and their impact on caloric debt in the surgical intensive care unit (ICU). Materials and Methods: We performed a prospective, observational study of adults admitted to surgical ICUs at a Boston teaching hospital (March–December 2012). We categorized EN interruptions as “unavoidable” vs “avoidable” and compared caloric deficit between patients with ≥1 EN interruption (group 1) vs those without interruptions (group 2). Multivariable logistic regression was used to investigate the association of EN interruption with the risk of underfeeding. Poisson regression was used to investigate the association of EN interruption with length of stay (LOS) and mortality. Results: Ninety‐four patients comprised the analytic cohort. Twenty‐six percent of interruptions were deemed “avoidable.” Group 1 (n = 64) had a significantly higher mean daily and cumulative caloric deficit vs group 2 (n = 30). Patients in group 1 were at a 3‐fold increased risk of being underfed (adjusted odds ratio, 2.89; 95% confidence interval [CI], 1.03–8.11), had a 30% higher risk of prolonged ICU LOS (adjusted incident risk ratio [IRR], 1.27; 95% CI, 1.14–1.42), and had a 50% higher risk of prolonged hospital LOS (adjusted IRR, 1.53; 95% CI, 1.41–1.67) vs group 2. Conclusions: In our cohort of critically ill surgical patients, EN interruption was frequent, largely “unavoidable,” and associated with undesirable outcomes. Future efforts to optimize nutrition in the surgical ICU may benefit from considering strategies that maximize nutrient delivery before and after clinically appropriate EN interruptions.