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Journal ArticleDOI

Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool

15 Nov 2011-Critical Care (BioMed Central)-Vol. 15, Iss: 6, pp 1-11
TL;DR: This scoring algorithm may be helpful in identifying critically ill patients most likely to benefit from aggressive nutrition therapy in the intensive care unit (ICU), and based on the statistical significance in the multivariable model, the final score used all candidate variables except BMI.
Abstract: To develop a scoring method for quantifying nutrition risk in the intensive care unit (ICU). A prospective, observational study of patients expected to stay > 24 hours. We collected data for key variables considered for inclusion in the score which included: age, baseline APACHE II, baseline SOFA score, number of comorbidities, days from hospital admission to ICU admission, Body Mass Index (BMI) < 20, estimated % oral intake in the week prior, weight loss in the last 3 months and serum interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) levels. Approximate quintiles of each variable were assigned points based on the strength of their association with 28 day mortality. A total of 597 patients were enrolled in this study. Based on the statistical significance in the multivariable model, the final score used all candidate variables except BMI, CRP, PCT, estimated percentage oral intake and weight loss. As the score increased, so did mortality rate and duration of mechanical ventilation. Logistic regression demonstrated that nutritional adequacy modifies the association between the score and 28 day mortality (p = 0.01). This scoring algorithm may be helpful in identifying critically ill patients most likely to benefit from aggressive nutrition therapy.

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Citations
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Journal ArticleDOI
TL;DR: The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention and there is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake.
Abstract: This document represents the first collaboration between 2 organizations-the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine-to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric critically ill patient (>1 month and 2-3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2032 citations were scanned for relevance. The PubMed/MEDLINE search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1661 citations. In total, the search for clinical trials yielded 1107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline. We used the GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluation) to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery are areas of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

2,947 citations


Cites background from "Identifying critically ill patients..."

  • ...Two prospective nonrandomized studies show that patients at high nutrition risk are more likely to benefit from early EN with improved outcome (reduced nosocomial infection, total complications, and mortality) than patients at low nutrition risk.(13,18) While widespread use and supportive evidence are somewhat lacking to date, improvement in these scoring systems may increase their applicability in the future by providing guidance as to the role of EN and PN in the ICU....

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  • ...Studies suggest that >50%–65% of goal energy may be required to prevent increases in intestinal permeability and systemic infection in burn and bone marrow transplant patients, to promote faster return of cognitive function in head injury patients, and to reduce mortality in high-risk hospitalized patients.(13,46,80,89) In a prospective nonrandomized study, Jie et al showed that high-risk surgery patients (NRS 2002 ≥5) who received sufficient preoperative nutrition therapy (>10 kcal/kg/d for 7 days) had significant reductions in nosocomial infections and overall complications compared with patients who received insufficient therapy....

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Journal ArticleDOI
TL;DR: These guidelines offer basic recommendations that are supported by review and analysis of the current literature, other national and international guidelines, and a blend of expert opinion and clinical practicality that are directed toward generalized patient populations.
Abstract: A.S.P.E.N. and SCCM are both nonprofit organizations composed of multidisciplinary healthcare professionals. The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. The mission of SCCM is to secure the highest quality care for all critically ill and injured patients. Guideline Limitations: These A.S.P.E.N.−SCCM Clinical Guidelines are based on general conclusions of health professionals who, in developing such guidelines, have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy. However, practice guidelines are not intended as absolute requirements. The use of these practice guidelines does not in any way project or guarantee any specific benefit in outcome or survival. The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines. The guidelines offer basic recommendations that are supported by review and analysis of the current literature, other national and international guidelines, and a blend of expert opinion and clinical practicality. The population of critically ill patients in an intensive care unit (ICU) is not homogeneous. Many of the studies on which the guidelines are based are limited by sample size, patient heterogeneity, variability in disease severity, lack of baseline nutritional status, and insufficient statistical power for analysis. Periodic Guideline Review and Update: This particular report is an update and expansion of guidelines published by A.S.P.E.N. and SCCM in 2009 (1). Governing bodies of both A.S.P.E.N. and SCCM have mandated that these guidelines be updated every three to five years. The database of randomized controlled trials (RCTs) that served as the platform for the analysis of the literature was assembled in a joint “harmonization process” with the Canadian Clinical Guidelines group. Once completed, each group operated separately in their interpretation of the studies and derivation of guideline recommendations (2). The current A.S.P.E.N. and SCCM guidelines included in this paper were derived from data obtained via literature searches by the authors through December 31, 2013. Although the committee was aware of landmark studies published after this date, these data were not included in this manuscript. The process by which the literature was evaluated necessitated a common end date for the search review. Adding a last-minute landmark trial would have introduced bias unless a formalized literature search was re-conducted for all sections of the manuscript. Target Patient Population for Guideline: The target of these guidelines is intended to be the adult (≥ 18 years) critically ill patient expected to require a length of stay (LOS) greater than 2 or 3 days in a medical ICU (MICU) or surgical ICU (SICU). The current guidelines were expanded to include a number of additional subsets of patients who met the above criteria, but were not included in the previous 2009 guidelines. Specific patient populations addressed by these expanded and updated guidelines include organ failure (pulmonary, renal, and liver), acute pancreatitis, surgical subsets (trauma, traumatic brain injury [TBI], open abdomen [OA], and burns), sepsis, postoperative major surgery, chronic critically ill, and critically ill obese. These guidelines are directed toward generalized patient populations but, like any other management strategy in the ICU, nutrition therapy should be tailored to the individual patient. Target Audience: The intended use of these guidelines is for all healthcare providers involved in nutrition therapy of the critically ill, primarily physicians, nurses, dietitians, and pharmacists. Methodology: The authors compiled clinical questions reflecting key management issues in nutrition therapy. A committee of multidisciplinary experts in clinical nutrition composed of physicians, nurses, pharmacists, and dietitians was jointly convened by the two societies.

1,734 citations


Cites background from "Identifying critically ill patients..."

  • ...Two prospective nonrandomized studies show that patients at high nutrition risk are more likely to benefit from early EN with improved outcome (reduced nosocomial infection, total complications, and mortality) than patients at low nutrition risk.(13,18) While widespread use and supportive evidence are somewhat lacking to date, improvement in these scoring systems may increase their applicability in the future by providing guidance as to the role of EN and PN in the ICU....

    [...]

  • ...Studies suggest that >50%–65% of goal energy may be required to prevent increases in intestinal permeability and systemic infection in burn and bone marrow transplant patients, to promote faster return of cognitive function in head injury patients, and to reduce mortality in high-risk hospitalized patients.(13,46,80,89) In a prospective nonrandomized study, Jie et al showed that high-risk surgery patients (NRS 2002 ≥5) who received sufficient preoperative nutrition therapy (>10 kcal/kg/d for 7 days) had significant reductions in nosocomial infections and overall complications compared with patients who received insufficient therapy....

    [...]

Journal ArticleDOI
TL;DR: Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy.

1,474 citations


Cites methods from "Identifying critically ill patients..."

  • ...The final composite NUTRIC score was correlated with mortality and the expected advantage of the score was to be able to show interaction between the score and nutritional intervention regarding outcome, hypothesizing that nutritional support might decreasemortality in patients with a high NUTRIC score (>5)....

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  • ...Since there is no “gold standard” to define the "at risk patient" and the malnourished ICU patient, we disagree with the recent American Society for Parenteral and Enteral Nutrition (ASPEN)/ Society for Critical Care Medicine (SCCM) guidelines [41] that categorize patients according to NRS 2002 [42] or nutritional risk in critically ill (NUTRIC) [43] to define their nutritional regimen...

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  • ...Recently, NUTRIC, a novel risk assessment tool [43] was proposed, based on age, severity of disease reflected by the APACHE II and Sequential Organ Failure (SOFA) scores, co-morbidities, days from hospital to ICU admission, and including or not inflammation assessed by the level of interleukin 6....

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  • ...Abbreviations ALI acute lung injury ARDS adult respiratory distress syndrome ASPEN American Society for Parenteral and Enteral Nutrition BMI body mass index CI confidence interval CRP C reactive protein CT computerized tomography CVVH continuous veno-venous hemo-dia-filtration DHA docosahexaenoic acid DRI Dietary reference intakes EE energy expenditure EN enteral nutrition EPA eicosapentaenoic acid ESICM European Society of Intensive Care Medicine ESPEN European Society for Clinical Nutrition and Metabolism FA fatty acid FFMI Fat free mass index GLA gamma-linolenic acid GLN glutamine GPP good practice point HDL High density lipoprotein ICU intensive care unit IU international units K potassium LCT long chain triglyceride Mg Magnesium MCT medium chain triglyceride MNA mini-nutrition assessment MNA-SF MNA-short form MUST malnutrition universal screening tool NRS nutritional risk screening NUTRIC nutritional risk in critically ill P Phosphorus PDMS Patient data management system PICO Patient Intervention Control Outcome PN parenteral nutrition RCT randomized controlled trial REE resting energy expenditure RR relative risk SCCM Society for Critical Care Medicine SGA subjective global assessment SIGN Scottish Intercollegiate Guidelines Network SOFA Sequential Organ Failure Assessment VO2 oxygen consumption VCO2 Carbon dioxide production patient on an individual basis [5]....

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  • ...Since there is no “gold standard” to define the "at risk patient" and the malnourished ICU patient, we disagree with the recent American Society for Parenteral and Enteral Nutrition (ASPEN)/ Society for Critical Care Medicine (SCCM) guidelines [41] that categorize patients according to NRS 2002 [42] or nutritional risk in critically ill (NUTRIC) [43] to define their nutritional regimen (discussed further)....

    [...]

Journal ArticleDOI
TL;DR: The NUTRIC scoring system is externally validated and may be useful in identifying critically ill patients most likely to benefit from optimal amounts of macronutrients when considering mortality as an outcome.

308 citations


Cites background or methods from "Identifying critically ill patients..."

  • ...Based on our observations, studies that include heterogeneous ICU patients, are more likely to be negative than those that focus on high risk patients [1,15]....

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  • ...However, the recognition that not all ICU patients will respond the same to nutritional interventions was the critical concept behind the NUTRIC score [1,8,9]....

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  • ...The absence of IL-6 may makes assessment of the performance of the NUTRIC score more conservative, although it is not expected that the absence of this one item will have a strong impact on the score [1]....

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  • ...previously proposed a novel scoring tool, the Nutrition Risk in Critically ill (NUTRIC) score, which is the first nutritional risk assessment tool developed and validated specifically for intensive care unit (ICU) patients [1]....

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  • ...All candidate predictors incorporated into our final model predictors were significantly associated with 28day mortality [1]....

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Journal ArticleDOI
TL;DR: In this paper, the authors focused on determining 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.
Abstract: 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 ...

248 citations

References
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TL;DR: Hosmer and Lemeshow as discussed by the authors provide an accessible introduction to the logistic regression model while incorporating advances of the last decade, including a variety of software packages for the analysis of data sets.
Abstract: From the reviews of the First Edition. "An interesting, useful, and well-written book on logistic regression models... Hosmer and Lemeshow have used very little mathematics, have presented difficult concepts heuristically and through illustrative examples, and have included references."- Choice "Well written, clearly organized, and comprehensive... the authors carefully walk the reader through the estimation of interpretation of coefficients from a wide variety of logistic regression models . . . their careful explication of the quantitative re-expression of coefficients from these various models is excellent." - Contemporary Sociology "An extremely well-written book that will certainly prove an invaluable acquisition to the practicing statistician who finds other literature on analysis of discrete data hard to follow or heavily theoretical."-The Statistician In this revised and updated edition of their popular book, David Hosmer and Stanley Lemeshow continue to provide an amazingly accessible introduction to the logistic regression model while incorporating advances of the last decade, including a variety of software packages for the analysis of data sets. Hosmer and Lemeshow extend the discussion from biostatistics and epidemiology to cutting-edge applications in data mining and machine learning, guiding readers step-by-step through the use of modeling techniques for dichotomous data in diverse fields. Ample new topics and expanded discussions of existing material are accompanied by a wealth of real-world examples-with extensive data sets available over the Internet.

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TL;DR: Applied Logistic Regression, Third Edition provides an easily accessible introduction to the logistic regression model and highlights the power of this model by examining the relationship between a dichotomous outcome and a set of covariables.
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TL;DR: The form and validation results of APACHE II, a severity of disease classification system that uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status, are presented.
Abstract: This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.

14,583 citations


"Identifying critically ill patients..." refers methods in this paper

  • ...Acute Physiology and Chronic Health Evaluation Scores (APACHE II) [15] and Sequential Organ Failure Assessment (SOFA) scores [16] variables were recorded on admission to ICU....

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BookDOI
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TL;DR: In this article, the authors present a case study in least squares fitting and interpretation of a linear model, where they use nonparametric transformations of X and Y to fit a linear regression model.
Abstract: Introduction * General Aspects of Fitting Regression Models * Missing Data * Multivariable Modeling Strategies * Resampling, Validating, Describing, and Simplifying the Model * S-PLUS Software * Case Study in Least Squares Fitting and Interpretation of a Linear Model * Case Study in Imputation and Data Reduction * Overview of Maximum Likelihood Estimation * Binary Logistic Regression * Logistic Model Case Study 1: Predicting Cause of Death * Logistic Model Case Study 2: Survival of Titanic Passengers * Ordinal Logistic Regression * Case Study in Ordinal Regrssion, Data Reduction, and Penalization * Models Using Nonparametic Transformations of X and Y * Introduction to Survival Analysis * Parametric Survival Models * Case Study in Parametric Survival Modeling and Model Approximation * Cox Proportional Hazards Regression Model * Case Study in Cox Regression

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TL;DR: In this article, a generalization of the coefficient of determination R2 to general regression models is discussed, and a modification of an earlier definition to allow for discrete models is proposed.
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