Refeeding syndrome risk at ICU admission is an independent predictor of ICU readmission but it was not associated with mortality or length of stay in critically ill patients.

OBJECTIVES: This study evaluated the association between refeeding syndrome (RFS) risk and intensive care unit (ICU)/in-hospital mortality and length of stay (LOS) and ICU readmission in critically ill patients. METHODS: This secondary analysis of a cohort study included patients aged ≥ 18 years admitted at ICU 24 h before data collection. We evaluated RFS risk based on the National Institute for Health and Clinical Excellence (NICE), stratifying it into four categories (no, low, high, and very-high risk). SETTING: Five adult ICUs in Brazil. MAIN OUTCOME MEASURES: ICU/in-hospital mortality and LOS and ICU readmission data were obtained from electronic medical records analysis, following patients until discharge (alive or not). RESULTS: The study involved 447 patients, categorized into no (19.2 %), low (28.6 %), high (48.8 %), and very-high (3.4 %) RFS risk groups. No significant differences emerged between the two groups (at RFS risk and no RFS risk) regarding the ICU death ratio (34.3 % versus 23.4 %) and LOS (5 versus 4 days), respectively. In contrast, patients at RFS risk experienced higher in-hospital mortality rates (34.3 % versus 23.4 %) prolonged hospital LOS (21 days versus 17 days), and increased ICU readmission rates (15 % versus 8.4 %) than patients without RFS risk. After adjusting for age and Sequential Organ Failure Assessment (SOFA) Score, we found no association between RFS risk and increased mortality in the ICU or hospital. Also, there was no significant association between RFS risk and prolonged LOS in the ICU or hospital setting. However, patients identified as at risk of RFS showed nearly double the odds of ICU readmission (Odds ratio, 1.90; 95 % CI 1.02-3.43). CONCLUSIONS: This study found no significant association between RFS risk and increased mortality in both the ICU and hospital settings, nor was there a significant association with prolonged LOS in the ICU or hospital among critically ill patients. However, patients at risk of RFS exhibited nearly double the odds of ICU readmission. IMPLICATIONS FOR CLINICAL PRACTICE: Our findings may contribute to understanding risks associated with ICU readmissions, highlighting the complexity of discharge decision-making through comprehensive assessments.

Complementarity of nutrition screening with Global Leadership Initiative on Malnutrition criteria for diagnosing malnutrition in critically ill patients: A comparison study of Nutritional Risk Screening 2002 and modified Nutrition Risk in the Critically Ill Score.

BACKGROUND AND AIM: Critical illness induces hypermetabolism and hypercatabolism, increasing nutrition risk (NR). Early NR identification is crucial for improving outcomes. We assessed four nutrition screening tools (NSTs) complementarity with the Global Leadership Initiative on Malnutrition (GLIM) criteria in critically ill patients. METHODS: We conducted a comparative study using data from a cohort involving five intensive care units (ICUs), screening patients for NR using NRS-2002 and modified-NUTRIC tools, with three cutoffs (≥3, ≥4, ≥5), and malnutrition diagnosed by GLIM criteria. Our outcomes of interest included ICU and in-hospital mortality, ICU and hospital length of stay (LOS), and ICU readmission. We examined accuracy metrics and complementarity between NSTs and GLIM criteria about clinical outcomes through logistic regression and Cox regression. We established a four-category independent variable: NR(-)/GLIM(-) as the reference, NR(-)/GLIM(+), NR(+)/GLIM(-), and NR(+)/GLIM(+). RESULTS: Of the 377 patients analyzed (median age 64 years [interquartile range: 54-71] and 53.8% male), NR prevalence varied from 87% to 40.6%, whereas 64% presented malnutrition (GLIM criteria). NRS-2002 (score ≥4) showed superior accuracy for GLIM-based malnutrition. Multivariate analysis revealed mNUTRIC(+)/GLIM(+) increased >2 times in the likelihood of ICU and in-hospital mortality, ICU and hospital LOS, and ICU readmission compared with the reference group. CONCLUSION: No NST exhibited satisfactory complementarity to the GLIM criteria in our study, emphasizing the necessity for comprehensive nutrition assessment for all patients, irrespective of NR status. We recommend using mNUTRIC if the ICU team opts for nutrition screening, as it demonstrated superior prognostic value compared with NRS-2002, and applying GLIM criteria in all patients.

Derivation of the Screening of Nutritional Risk in Intensive Care risk prediction score: A secondary analysis of a prospective cohort study.

BACKGROUND: For patients who are critically ill, the recommended nutrition risk screening tools are the Nutrition Risk in the Critically Ill (NUTRIC) and the Nutritional Risk Screening 2002 (NRS-2002) have limitations. OBJECTIVE: To develop a new screening tool, the Screening of Nutritional Risk in Intensive Care (SCREENIC score), and assess its predictive validity. METHODS: A secondary analysis of a prospective cohort study was conducted. Variables from several nutritional screening and assessment tools were considered. The high nutrition risk cutoff point was defined using mNUTRIC as a reference. Predictive validity was evaluated using logistic regression and Cox regression. RESULTS: The study included 450 patients (64 [54-71] years, 52.2% men). The SCREENIC score comprised six questions: (1) does the patient have ≥2 comorbidities (1.3 points); (2) was the patient hospitalized for ≥2 days before intensive care unit (ICU) admission (0.9 points); (3) does the patient have sepsis (1.0 point); (4) was the patient on mechanical ventilation upon ICU admission (1.2 points); (5) is the patient aged >65 years (1.2 points); and (6) does the patient exhibit signs of moderate/severe muscle mass loss according to the physical exam (0.6 points). The high nutrition risk cutoff point was set at 4.0. SCREENIC demonstrated moderate agreement (κ = 0.564) and high accuracy (0.896 [95% CI, 0.867-0.925]) with mNUTRIC. It predicted prolonged ICU (odds ratio [OR] = 1.81 [95% CI, 1.14-2.85]) and hospital stay (OR = 2.15 [95% CI, 1.37-3.38]). CONCLUSION: The SCREENIC score comprises questions with variables that do not require nutrition history. Further evaluation of its applicability, reproducibility, and validity in guiding nutrition therapy is needed using large external cohorts.

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

BACKGROUND: Despite its correlation with skeletal muscle mass and its predictive value for adverse outcomes in clinical settings, calf circumference is a metric underexplored in intensive care. We aimed to determine whether adjusting low calf circumference for adiposity provides prognostic value superior to its unadjusted measurement for intensive care unit (ICU) mortality and other clinical outcomes in critically ill patients. METHODS: In a secondary analysis of a cohort study across five ICUs, we assessed critically ill patients within 24 h of ICU admission. We adjusted calf circumference for body mass index (BMI) (25-29.9, 30-39.9, and ≥40) by subtracting 3, 7, or 12 cm from it, respectively. Values ≤34 cm for men and ≤33 cm for women identified low calf circumference. RESULTS: We analyzed 325 patients. In the primary risk-adjusted analysis, the ICU death risk was similar between the low and preserved calf circumference (BMI-adjusted) groups (hazard ratio, 0.90; 95% CI, 0.47-1.73). Low calf circumference (unadjusted) increased the odds of ICU readmission 2.91 times (95% CI, 1.40-6.05). Every 1-cm increase in calf circumference as a continuous variable reduced ICU readmission odds by 12%. Calf circumference showed no significant association with other clinical outcomes. CONCLUSION: BMI-adjusted calf circumference did not exhibit independent associations with ICU and in-hospital death, nor with ICU and in-hospital length of stay, compared with its unadjusted measurement. However, low calf circumference (unadjusted and BMI-adjusted) was independently associated with ICU readmission, mainly when analyzed as a continuous variable.

Feasibility and criterion validity of the GLIM criteria in the critically ill: A prospective cohort study.

BACKGROUND: This study aimed to evaluate the feasibility and validity of the Global Leadership Initiative on Malnutrition (GLIM) criteria in the intensive care unit (ICU). METHODS: This was a cohort study involving critically ill patients. Diagnoses of malnutrition by the Subjective Global Assessment (SGA) and GLIM criteria within 24 h after ICU admission were prospectively performed. Patients were followed up until hospital discharge to assess the hospital/ICU length of stay (LOS), mechanical ventilation duration, ICU readmission, and hospital/ICU mortality. Three months after discharge, the patients were contacted to record outcomes (readmission and death). Agreement and accuracy tests and regression analyses were performed. RESULTS: GLIM criteria could be applied to 377 (83.7%) of 450 patients (64 [54-71] years old, 52.2% men). Malnutrition prevalence was 47.8% (n = 180) by SGA and 65.5% (n = 247) by GLIM criteria, presenting an area under the curve equal to 0.835 (95% confidence interval [CI], 0.790-0.880), sensitivity of 96.6%, and specificity of 70.3%. Malnutrition by GLIM criteria increased the odds of prolonged ICU LOS by 1.75 times (95% CI, 1.08-2.82) and ICU readmission by 2.66 times (95% CI, 1.15-6.14). Malnutrition by SGA also increased the odds of ICU readmission and the risk of ICU and hospital death more than twice. CONCLUSION: The GLIM criteria were highly feasible and presented high sensitivity, moderate specificity, and substantial agreement with the SGA in critically ill patients. It was an independent predictor of prolonged ICU LOS and ICU readmission, but it was not associated with death such as malnutrition diagnosed by SGA.

Prognostic value of different cut-off points of the NRS-2002 tool to identify nutritional risk in critically ill patients: a longitudinal study.

The American Society of Parenteral and Enteral Nutrition recommends nutritional risk (NR) screening in critically ill patients with Nutritional Risk Screening - 2002 (NRS-2002) ≥ 3 as NR and ≥ 5 as high NR. The present study evaluated the predictive validity of different NRS-2002 cut-off points in intensive care unit (ICU). A prospective cohort study was conducted with adult patients who were screened using the NRS-2002. Hospital and ICU length of stay (LOS), hospital and ICU mortality, and ICU readmission were evaluated as outcomes. Logistic and Cox regression analyses were performed to evaluate the prognostic value of NRS-2002, and a receiver operating characteristic curve was constructed to determine the best cut-off point for NRS-2002. 374 patients (61·9 ± 14·3 years, 51·1 % males) were included in the study. Of these, 13·1 % were classified as without NR, 48·9 % and 38·0 % were classified as NR and high NR, respectively. An NRS-2002 score of ≥ 5 was associated with prolonged hospital LOS. The best cut-off point for NRS-2002 was a score ≥ 4, which was associated with prolonged hospital LOS (OR = 2·13; 95 % CI: 1·39, 3·28), ICU readmission (OR = 2·44; 95 % CI: 1·14, 5·22), ICU (HR = 2·91; 95 % CI: 1·47, 5·78) and hospital mortality (HR = 2·01; 95 % CI: 1·24, 3·25), but not with ICU prolonged LOS (P = 0·688). NRS-2002 ≥ 4 presented the most satisfactory predictive validity and should be considered in the ICU setting. Future studies should confirm the cut-off point and its validity in predicting nutrition therapy interaction with outcomes.

A scoping review on the GLIM criteria for malnutrition diagnosis: Understanding how and for which purpose it has been applied in studies on hospital settings.

AIMS: This scoping review aimed to identify and map the literature on malnutrition diagnosis made using the GLIM criteria in hospitalized patients. METHODS: The scoping review was conducted using the Joanna Briggs Institute's methodology. We searched PubMed, Embase, Scopus, and Web of Science (until 16 April 2022) to identify studies based on the 'population' (adults or elderly patients), 'concept' (malnutrition diagnosis by the GLIM criteria), and 'context' (hospital settings) framework. Titles/abstracts were screened, and two independent reviewers extracted data from eligible studies. RESULTS: Ninety-six studies were eligible (35.4% from China, 30.2% involving oncological patients, and 30.5% with prospective data collection), 32 followed the two-step GLIM approach, and 50 applied all the criteria. All the studies evaluated body mass index (BMI), while 92.7% evaluated weight loss; 77.1%, muscle mass; 93.8%, inflammation; and 70.8%, energy intake. A lack of details on the methods adopted for criterion evaluation was observed in five (muscle mass evaluation) to 40 studies (energy intake evaluation). The frequency of the use of the GLIM criteria ranged from 22.2% (frequency of low BMI) to 84.7% (frequency of inflammation), and the malnutrition prevalence ranged from 0.96% to 87.9%. Less than 30% of studies aimed to assess the GLIM criterion validity, eight studies cited the guidance on validation of the GLIM criteria, and a minority implemented it. CONCLUSIONS: This map of studies on the GLIM criteria in hospital settings demonstrated that they are applied in a heterogeneous manner, with a wide range of malnutrition prevalence. Almost 50% of the studies applied all the criteria, while one-third followed the straightforward two-step approach. The recommendations of the guidance on validation of the criteria were scarcely adhered to. The gaps that need to be explored in future studies have been highlighted.

Parameters of Bioelectrical Impedance Are Good Predictors of Nutrition Risk, Length of Stay, and Mortality in Critically Ill Patients: A Prospective Cohort Study.

BACKGROUND: Assessment of nutrition risk in the intensive care unit (ICU) is limited by characteristics of critically ill patients, and new methods have been investigated for their applicability and predictive validity. The aim of the present study was to evaluate the validity of bioelectrical impedance analysis (BIA) parameters as predictors of nutrition risk and clinical outcomes in critically ill patients. METHODS: This was a prospective cohort study of patients admitted to an ICU. The modified Nutrition Risk in the Critically Ill score was used for assessment of nutrition risk, and BIA was performed in the first 72 hours of admission. Phase angle (PA) measurements were obtained, and bioelectrical impedance vector analysis (BIVA) was used to classify patients by hydration status (BIVA >70%). Patients were followed until hospital discharge and evaluated for hospital mortality, ICU length of stay, length of hospitalization, and duration of mechanical ventilation. RESULTS: Eighty-nine patients were included (62.5 ± 14.1 years, 50.6% female). A PA <5.5o showed an accuracy of 79% (95% CI 0.59-0.83) in identifying patients at high nutrition risk and was associated with nearly 2 times greater risk for an ICU length of stay longer than 5 days (relative risk = 2.18 [95% CI 1.39-3.40]). Hyperhydration was a significant predictor of mortality (hazard ratio = 2.24 [95% CI 1.07-4.68]). Higher resistance and reactance values, adjusted for height, were found in survivors compared with nonsurvivors. CONCLUSION: The predictive validity of BIA was satisfactory for the assessment of nutrition risk, ICU length of stay, and mortality in critically ill patients.