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Journal Article•DOI•

Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients—A multicenter prospective cohort study

Rosa Mendes, S. Policarpo, Philip Fortuna, Marta Alves, Daniel Virella, Daren K. Heyland1 •
Kingston General Hospital1
01 Feb 2017-Journal of Critical Care (Elsevier)-Vol. 37, pp 45-49
TL;DR: Almost half of the patients in Portuguese ICUs are at high nutritional risk, and NUTRIC score was strongly associated with main clinical outcomes, including mortality from all causes at 28 days after admission.
About: This article is published in Journal of Critical Care.The article was published on 2017-02-01 and is currently open access. It has received 78 citations till now. The article focuses on the topics: Risk assessment & Intensive care unit.

Summary (1 min read)

Jump to: [1. Introduction] – [3. Materials] – [4. Results] – [5. Discussion] and [6. Conclusion]

1. Introduction

  • Malnutrition is common in hospitalized patients and highly prevalent in the population of critically ill patients all around the world [1,2].
  • Data on Portuguese critically ill patients is still, to date, not available.
  • Based on the assumption that the nutritional risk is not the same for all critically ill patients, Heyland et al developed and validated the NUTrition Risk in the Critically ill (NUTRIC score), the first nutritional risk assessment tool developed specifically for the ICU population that could identify patients that requiremore aggressive nutritional support, based on their nutritional risk [14,15].
  • As it has already been demonstrated, the performance of the NUTRIC score varies only slightly when excluding IL-6 levels from the score or when this is replaced by another available inflammatory biomarker.

3. Materials

  • A prospective, observational, multicentric cohort study was conducted in a convenient sample of tertiary polyvalent ICUs across Portugal.
  • Patients consecutively admitted to the participant ICUs were enrolled during a period of 6months, in 2014,with only admission to the ICU being considered.
  • A panel of experts (physicians, nurses and dietitians working in ICU) evaluated the two translations of NUTRIC score, by analyzing the phrasing of each item, and consensually obtaining the proposed version.
  • The back-translated version was reviewed by the developers of the original tool to assess the adequateness of the content (content validity).

4. Results

  • During the 6-month recruitment period, 2061 patients were eligible for enrolment in the 15 participating ICUs and 1143 were included in the analysis.
  • Patients' baseline characteristics are summarized in Table 1.

5. Discussion

  • Most of the critically ill patients admitted to the ICU showmalnutrition criteria [20].
  • The main strengths of this study are the large size of this national sample, the prospective evaluation of the patients using a standardized protocol and the clinical heterogeneity provided by the number of participant ICUs.
  • The absence of data of nutritional support (either enteral or parenteral) during ICU stay, the convenience sample and the potential heterogeneity of therapeutic approaches are other weaknesses.
  • Tudy and in this effectiveness study sample.

6. Conclusion

  • The modified NUTRIC score, the first nutritional risk assessment tool developed and validated specifically for critically ill patients, demonstrated that in ICU Portuguese patients, despite presenting different characteristics from the original validated sample, a good correlation with main clinical outcomes.
  • The modified NUTRIC score can be used widely and systematically, contributing to discriminate ICU patients at high nutritional risk.
  • The cross-cultural adaptation of NUTRIC score demonstrated translation reliability and is acceptable to be used in critically ill patients.
  • Supplementary data to this article can be found online at http://dx.

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Journal Article•DOI•
The modified NUTRIC score can be used for nutritional risk assessment as well as prognosis prediction in critically ill COVID-19 patients.

[...]

Ping Zhang1, Zhigang He1, Gang Yu1, Dan Peng1, Yikuan Feng1, Jianmin Ling1, Ye Wang1, Shusheng Li1, Yi Bian1 •
Huazhong University of Science and Technology1
01 Feb 2021-Clinical Nutrition
TL;DR: A large proportion of critically ill COVID-19 patients had a high nutritional risk, as revealed by their mNUTRIC score, and may be an appropriate tool for nutritional risk assessment and prognosis prediction for critically ill patients.

91 citations

Cites background or result from "Nutritional risk assessment and cul..."

  • ...It is inconsistent with other studies [21,32], as well as ours, reporting significant correlation between 28-day mortality and the NUTRIC score even after adjusting for multivariable analyses....

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  • ...[21] reported that 49% of ICU patients were at high nutritional risk based on their mNUTRIC scores....

    [...]

Journal Article•DOI•
Current Evidence about Nutrition Support in Cardiac Surgery Patients—What Do We Know?

[...]

Aileen Hill1, Ekaterina Nesterova, Vladimir V. Lomivorotov, Sergey M. Efremov, Andreas Goetzenich1, Carina Benstoem1, Mikhail Zamyatin, Michael Chourdakis2, Daren K. Heyland3, Christian Stoppe1 •
RWTH Aachen University1, RMIT University2, Kingston General Hospital3
11 May 2018-Nutrients
TL;DR: The understanding of the metabolic response to the inflammatory burst induced by cardiac surgery is reviewed and the potential role of pharmaconutrition in cardiac surgery patients is discussed.
Abstract: Nutrition support is increasingly recognized as a clinically relevant aspect of the intensive care treatment of cardiac surgery patients. However, evidence from adequate large-scale studies evaluating its clinical significance for patients’ mid- to long-term outcome remains sparse. Considering nutrition support as a key component in the perioperative treatment of these critically ill patients led us to review and discuss our understanding of the metabolic response to the inflammatory burst induced by cardiac surgery. In addition, we discuss how to identify patients who may benefit from nutrition therapy, when to start nutritional interventions, present evidence about the use of enteral and parenteral nutrition and the potential role of pharmaconutrition in cardiac surgery patients. Although the clinical setting of cardiac surgery provides advantages due to its scheduled insult and predictable inflammatory response, researchers and clinicians face lack of evidence and several limitations in the clinical routine, which are critically considered and discussed in this paper.

72 citations

Journal Article•DOI•
Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study.

[...]

M S Kalaiselvan1, M. K. Renuka1, A. S. Arunkumar1•
Sri Ramachandra University1
01 May 2017-Indian Journal of Critical Care Medicine
TL;DR: Nearly 42.5% of MV patients admitted to ICU were at nutritional risk, and high mNUTRIC score was associated with increased ICU length of stay and higher mortality.
Abstract: Context: Nutritional risk assessment must be done on all critically ill patients Malnutrition in intensive care unit (ICU) patients is associated with adverse clinical outcomes Traditional scoring systems cannot be used for screening in mechanically ventilated (MV) patients because these patients are unable to provide information on their history of food intake and weight loss The Nutrition Risk in Critically ill (NUTRIC) score is the appropriate nutritional assessment tool in MV patients Aims: This prospective observational study was conducted to identify the nutritional risk in MV patients using modified NUTRIC (mNUTRIC) score (with the exception of interleukin-6) Patients and Methods: All adult patients admitted to the ICU and required MV for more than 48 h were included in the study Data were collected on variables required to calculate mNUTRIC score Patients with mNUTRIC score ≥5 are considered at nutritional risk Outcome data were collected on ICU length of stay, ventilator-free days, and mortality Results: A total of 678 MV patients fit into the inclusion criteria Majority of the patients were male (67%) Mean age of the patients was 55 years About 288 (425%) patients were at high nutritional risk (mNUTRIC score ≥5) Patients with high mNUTRIC score ≥5 had longer mean ICU average length of stay of 90 (±42) versus 78 (±58) mean (± standard deviation) days ( P P Conclusions: Nearly 425% of MV patients admitted to ICU were at nutritional risk, and high mNUTRIC score was associated with increased ICU length of stay and higher mortality

62 citations

Journal Article•DOI•
Protein Delivery in the Intensive Care Unit: Optimal or Suboptimal?

[...]

Daren K. Heyland1, Daren K. Heyland2, Peter J.M. Weijs, Jorge A. Coss-Bu3, Jorge A. Coss-Bu4, Beth Taylor5, Arnold S. Kristof6, Grant E. O'Keefe7, Robert G. Martindale •
Queen's University1, Kingston General Hospital2, Baylor College of Medicine3, Boston Children's Hospital4, Barnes-Jewish Hospital5, McGill University Health Centre6, University of Washington7
01 Mar 2017-Nutrition in Clinical Practice
TL;DR: Investigating the effect of combining adequate protein delivery with early mobility and/or resistance exercise in the ICU setting has the greatest potential for improving the functional outcomes of survivors of critical illness and warrants further study.
Abstract: Emerging evidence suggests that exogenous protein/amino acid supplementation has the potential to improve the recovery of critically ill patients. After a careful review of the published evidence, experts have concluded that critically ill patients should receive up to 2.0-2.5 g/kg/d of protein. Despite this, however, recent review of current International Nutrition Survey data suggests that protein in critically ill patients is underprescribed and grossly underdelivered. Furthermore, the survey suggests that most of protein administration comes from enteral nutrition (EN) despite the availability of products and protocols that enhance the delivery of protein/amino acids in the intensive care unit (ICU) setting. While future research clarifies the dose, timing, and composition for exogenous protein administration, as well as identification of patients who will benefit the most, ongoing process improvement initiatives should target a concerted effort to increase protein intake in the critically ill. This assertion follows from the notion that current patients are possibly being harmed while we wait for confirmatory evidence. Further research should also develop better tools to enable bedside practitioners to monitor optimal or adequate protein intake for individual patients. Finally, exploring the effect of combining adequate protein delivery with early mobility and/or resistance exercise in the ICU setting has the greatest potential for improving the functional outcomes of survivors of critical illness and warrants further study.

49 citations

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

[...]

Zheng-Yii Lee1, Zheng-Yii Lee2, Daren K. Heyland3•
University of Malaya1, Universiti Putra Malaysia2, Kingston General Hospital3
01 Feb 2019-Nutrition in Clinical Practice
TL;DR: The (modified) Nutrition Risk in the Critically Ill (mNUTRIC) is suggested for nutrition risk screening and the subjective global assessment (SGA) together with other criteria relevant to the critically ill patients, such as gastrointestinal function, risk of aspiration, determination of sarcopenia and frailty, and risk of refeeding syndrome for nutrition assessment.
Abstract: The stress catabolism state predisposes critically ill patients to a high risk of malnutrition. This, coupled with inadequate or delayed nutrition provision, will lead to further deterioration of nutrition status. Preexisting malnutrition and iatrogenic underfeeding are associated with increased risk of adverse complications. Therefore, accurate detection of patients who are malnourished and/or with high nutrition risk is important for timely and optimal nutrition intervention. Various tools have been developed for nutrition screening and assessment for hospitalized patients, but not all are studied or validated in critically ill populations. In this review article, we consider the pathophysiology of malnutrition in critical illness and the currently available literature to develop recommendations for nutrition screening and assessment. We suggest the use of the (modified) Nutrition Risk in the Critically Ill (mNUTRIC) for nutrition risk screening and the subjective global assessment (SGA) together with other criteria relevant to the critically ill patients, such as gastrointestinal function, risk of aspiration, determination of sarcopenia and frailty, and risk of refeeding syndrome for nutrition assessment. Further research is needed to identify suitable nutrition monitoring indicators to determine the response to the provision of nutrition.

44 citations

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William A. Knaus, Elizabeth A. Draper, Douglas P. Wagner, Jack E. Zimmerman
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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.
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TL;DR: The guidelines described in this document are based on a review of cross-cultural adaptation in the medical, sociological, and psychological literature and led to the description of a thorough adaptation process designed to maximize the attainment of semantic, idiomatic, experiential, and conceptual equivalence between the source and target questionnaires.
Abstract: With the increase in the number of multinational and multicultural research projects, the need to adapt health status measures for use in other than the source language has also grown rapidly. 1,4,27 Most questionnaires were developed in English-speaking countries, 11 but even within these countries, researchers must consider immigrant populations in studies of health, especially when their exclusion could lead to a systematic bias in studies of health care utilization or quality of life. 9,11 The cross-cultural adaptation of a health status selfadministered questionnaire for use in a new country, culture, and/or language necessitates use of a unique method, to reach equivalence between the original source and target versions of the questionnaire. It is now recognized that if measures are to be used across cultures, the items must not only be translated well linguistically, but also must be adapted culturally to maintain the content validity of the instrument at a conceptual level across different cultures. 6,11‐13,15,24 Attention to this level of detail allows increased confidence that the impact of a disease or its treatment is described in a similar manner in multinational trials or outcome evaluations. The term “cross-cultural adaptation” is used to encompass a process that looks at both language (translation) and cultural adaptation issues in the process of preparing a questionnaire for use in another setting. Cross-cultural adaptations should be considered for several different scenarios. In some cases, this is more obvious than in others. Guillemin et al 11 suggest five different examples of when attention should be paid to this adaptation by comparing the target (where it is going to be used) and source (where it was developed) language and culture. The first scenario is that it is to be used in the same language and culture in which it was developed. No adaptation is necessary. The last scenario is the opposite extreme, the application of a questionnaire in a different culture, language and country—moving the Short Form 36-item questionnaire from the United States (source) to Japan (target) 7 which would necessitate translation and cultural adaptation. The other scenarios are summarized in Table 1 and reflect situations when some translation and/or adaptation is needed. The guidelines described in this document are based on a review of cross-cultural adaptation in the medical, sociological, and psychological literature. This review led to the description of a thorough adaptation process designed to maximize the attainment of semantic, idiomatic, experiential, and conceptual equivalence between the source and target questionnaires. 13 . Further experience in cross-cultural adaptation of generic and diseasespecific instruments and alternative strategies driven by different research groups 18 have led to some refinements

8,523 citations

"Nutritional risk assessment and cul..." refers methods in this paper

  • ...The process of cross-cultural adaptation followed the multistep approach, according to the international guidelines [19]....

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Journal Article•DOI•
A note on a general definition of the coefficient of determination

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N. J. D. Nagelkerke1•
International Statistical Institute1
01 Sep 1991-Biometrika
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.
Abstract: SUMMARY A generalization of the coefficient of determination R2 to general regression models is discussed. A modification of an earlier definition to allow for discrete models is proposed.

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What is subjective global assessment of nutritional status

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Allan S. Detsky, McLaughlin, Jeffrey P. Baker, Johnston N, S Whittaker, Rena A. Mendelson, K.N. Jeejeebhoy 
01 Jan 1987-Journal of Parenteral and Enteral Nutrition
TL;DR: It is concluded that SGA can easily be taught to a variety of clinicians (residents, nurses), and that this technique is reproducible.
Abstract: Presented and described in detail is a clinical technique called subjective global assessment (SGA), which assesses nutritional status based on features of the history and physical examination. Illustrative cases are presented. To clarify further the nature of the SGA, the method was applied before gastrointestinal surgery to 202 hospitalized patients. The primary aim of the study was to determine the extent to which our clinician's SGA ratings were influenced by the individual clinical variables on which the clinicians were taught to base their assessments. Virtually all of these variables were significantly related to SGA class. Multivariate analysis showed that ratings were most affected by loss of subcutaneous tissue, muscle wasting, and weight loss. A high degree of interobserver agreement was found (kappa = 0.78, 95% confidence interval 0.624 to 0.944, p less than 0.001). We conclude that SGA can easily be taught to a variety of clinicians (residents, nurses), and that this technique is reproducible.

2,826 citations

"Nutritional risk assessment and cul..." refers background in this paper

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Frequently Asked Questions (14)
Q1. What contributions have the authors mentioned in the paper "Nutritional risk assessment and cultural validation of the modified nutric score in critically ill patients—a multicenter prospective cohort study" ?

Serrano et al. this paper developed and validated the NUTrition Risk in the Critically ill ( NUTRIC score ), the first nutritional risk assessment tool developed specifically for the ICU population that could identify patients that require more aggressive nutritional support, based on their nutritional risk. 

More prospective studies investigating witch nutritional interventions could positively modify the patients prognosis based on the NUTRIC score should be done in the near future. 

The nutrition therapy is thought to help to attenuate themetabolic response to stress, prevent oxidative cellular injury andmodulate immune responses. 

During the 6-month recruitment period, 2061 patients were eligible for enrolment in the 15 participating ICUs and 1143 were included in the analysis. 

Changes in weight can be influenced by fluid status, given the large volumes necessary tomaintain hemodynamic stability, and consequentlymuscle and fat wasting evaluation becomemore difficult. 

Primary admission diagnoses were respiratory (n = 262, 23.0%), sepsis (n = 230, 20.2%) and trauma (n = 167, 14.6%); 2 or more co-morbidities were present in 393 (34.4%) patients. 

The conceptual model links patient predictor markers of acute and chronic starvation, acute and chronic inflammation and outcome. 

Logistic regression analysis was used to further characterize the association between the NUTRIC score and the three main outcomes, using odds ratio (OR) with 95% CI of the estimates; linear regression was performed but discarded due to rejection of the normality of the residuals. 

nutritional risk, such as food/nutritional intake, physical examination, severity of illness, anthropometric data and functional assessment. 

The main strengths of this study are the large size of this national sample, the prospective evaluation of the patients using a standardized protocol and the clinical heterogeneity provided by the number of participant ICUs. 

Patients consecutively admitted to the participant ICUs were enrolled during a period of 6months, in 2014,with only admission to the ICU being considered. 

The cross-cultural adaptation of NUTRIC score demonstrated translation reliability and is acceptable to be used in critically ill patients. 

The modified NUTRIC score can be used widely and systematically, contributing to discriminate ICU patients at high nutritional risk. 

A pilot study was conducted with 46 critically ill patients admitted in one of the ICU's from the study, to assess the understanding and applicability of the translated version of the modified NUTRIC Score.