Malnutrition and pectoralis muscle index in medical intensive care unit patients: A matched cohort study.

BACKGROUND: Muscle assessment is an important component of nutrition assessment. The Global Leadership Initiative on Malnutrition (GLIM) consortium recently underscored the need for more objective muscle assessment methods in clinical settings. Various assessment techniques are available; however, many have limitations in clinical populations. Computed tomography (CT) scans, obtained for diagnostic reasons, could serve multiple purposes, including muscle measurement for nutrition assessment. Although CT scans of the chest are commonly performed clinically, there is little research surrounding the utility of pectoralis muscle measurements in nutrition assessment. The primary aim was to determine whether CT-derived measures of pectoralis major cross-sectional area (PMA) and quality (defined as mean pectoralis major Hounsfield units [PMHU]) could be used to identify malnutrition in patients who are mechanically ventilated in an intensive care unit (ICU). A secondary aim was to evaluate the relationship between these measures and clinical outcomes in this population. METHODS: A retrospective analysis was conducted on 33 pairs of age- and sex-matched adult patients who are being mechanically ventilated in the ICU. Patients were grouped by nutrition status. Analyses were performed to determine differences in PMA and mean PMHU between groups. Associations between muscle and clinical outcomes were also investigated. RESULTS: Compared with nonmalnourished controls, malnourished patients had a significantly lower PMA (P = 0.001) and pectoralis major (PM) index (PMA/height in m2; P = 0.001). No associations were drawn between PM measures and clinical outcomes. CONCLUSION: These findings regarding CT PM measures lay the groundwork for actualizing the GLIM call to action to validate quantitative, objective muscle assessment methods in clinical settings.

Prevalence and characteristics of starvation-related malnutrition in a mid-Atlantic healthcare system: A cohort study.

BACKGROUND: Malnutrition in the hospital negatively impacts outcomes, including readmissions, mortality, and cost. Starvation-related malnutrition (SRM) is a state of chronic undernutrition with little to no inflammation. Research on SRM within the hospital setting is lacking. Our objective was to determine the prevalence and characteristics of malnutrition within the hospital, focusing on characteristics associated with readmissions in those with SRM. METHODS: We conducted a retrospective cohort study analyzing characteristics of adult in patients with acute disease-related malnutrition (ADM) and chronic disease-related malnutrition (CDM) compared with patients with SRM. Prevalence of all malnutrition types was calculated as the total number of malnourished patients divided by the total number of hospital discharges. Analysis of variance with Tukey post hoc analysis was performed to determine differences between characteristics of patients with SRM and other forms of malnutrition. RESULTS: Total prevalence of malnutrition was 2.8%. Of malnourished patients, 17.6%, 79.9%, and 2.5% had ADM, CDM, and SRM, respectively. Patients with SRM had lower body mass index (BMI) (P < .001) and higher rates of readmission (P = 0.046), infectious disease (P < .001), psychiatric disease (P < .001), and substance abuse (P < .001) than patients with ADM or CDM. Readmitted patients with SRM had lower BMI and higher rates of infection and drug abuse than those without readmission. CONCLUSION: The high incidence of comorbid substance abuse and mental illness in patients with SRM provide important targets for treatment that might reduce readmission and improve outcomes.

Nutritional assessment and comparison of nutritional indices in predicting adverse outcomes in patients undergoing left ventricular assist device implantation.

BACKGROUND: Preoperative malnutrition has been correlated to postoperative complications in patients with advanced heart failure undergoing placement of a left ventricular assist device (LVAD). We sought to determine whether nutritional risk scores could identify a subset of patients with an LVAD who were at high risk of adverse events. METHODS: We conducted a retrospective cohort study of all patients undergoing LVAD placement at a single center. The prognostic nutritional index (PNI), nutritional risk index (NRI), and nutrition risk in the critically ill (NUTRIC) score were calculated retrospectively from data abstracted from chart review. The primary endpoint was a composite of mortality and other adverse events associated with LVAD implantation. We used χ2 or Fisher exact tests to compare these three indices against the primary outcome. RESULTS: A total of 41 patients with a mean age of 57.2 ± 13.7 y and a mean body mass index of 29.3 ± 6.3 kg/m2 underwent LVAD placement between 2011 and 2019. The composite outcome at 1 y occurred in 31 (76%) patients. Preoperatively, 3 patients were identified as at high nutritional risk by the PNI score and 39 by the NRI score but none by the NUTRIC score. Most patients received nutritional interventions. The nutritional risk scores did not differ significantly between patients who experienced the composite outcome and those who did not. CONCLUSIONS: The NRI, NUTRIC, and PNI scores did not identify a subset of patients at high risk for the composite outcome. Further studies are needed to determine how to better assess the true nutritional risk of the LVAD population. However, until better risk stratification is available, all patients with an LVAD should be consider at high risk and given appropriate nutritional interventions.

Energy balance in obese, mechanically ventilated intensive care unit patients.

OBJECTIVES: The aims of this study were, first, to compare the predicted (calculated) energy requirements based on standard equations with target energy requirement based on indirect calorimetry (IC) in critically ill, obese mechanically ventilated patients; and second, to compare actual energy intake to target energy requirements. METHODS: We conducted a prospective cohort study of mechanically ventilated critically ill patients with body mass index ≥30.0 kg/m2 for whom enteral feeding was planned. Clinical and demographic data were prospectively collected. Resting energy expenditure was measured by open-circuit IC. American Society of Parenteral and Enteral Nutrition (APSPEN)/Society of Critical Care Medicine (SCCM) 2016 equations were used to determine predicted (calculated) energy requirements. Target energy requirements were set at 65% to 70% of measured resting energy expenditure as recommended by ASPEN/SCCM. Nitrogen balance was determined via simultaneous measurement of 24-h urinary nitrogen concentration and protein intake. RESULTS: Twenty-five patients (mean age: 64.5 ± 11.8 y, mean body mass index: 35.2 ± 3.6 kg/m2) underwent IC. The mean predicted energy requirement was 1227 kcal/d compared with mean measured target energy requirement of 1691 kcal/d. Predicted (calculated) energy requirements derived from ASPEN/SCCM equations were less than the target energy requirements in most cases. Actual energy intake from enteral nutrition met 57% of target energy requirements. Protein intake met 25% of target protein requirement and the mean nitrogen balance was -2.3 ± 5.1 g/d. CONCLUSIONS: Predictive equations underestimated target energy needs in this population. Further, we found that feeding to goal was often delayed resulting in failure to meet both protein and energy intake goals.

Association Between Enteral Feeding, Weight Status, and Mortality in a Medical Intensive Care Unit.

BACKGROUND: Clinical practice guidelines recommend enteral nutrition for most patients receiving mechanical ventilation. However, recently published evidence on the effect of enteral nutrition on mortality, particularly for patients who are well nourished, is conflicting. OBJECTIVES: To examine the association between enteral feeding and hospital mortality in critically ill patients receiving mechanical ventilation and to determine if body mass index mediates this relationship. METHODS: A retrospective cohort study of patients receiving mechanical ventilation admitted to a medical intensive care unit in 2013. Demographic and clinical variables were collected. Cox proportional hazards regression was used to examine the relationship between an enteral feeding order and hospital mortality and to determine if the relationship was mediated by body mass index. RESULTS: Of 777 patients who had 811 hospitalizations requiring mechanical ventilation, 182 (23.4%) died in the hospital. A total of 478 patients (61.5%) received an order for enteral tube feeding, which was associated with a lower risk of death (hazard ratio, 0.41; 95% CI, 0.29-0.59). Body mass index did not mediate the relationship between mortality and receipt of an order for enteral feeding. Median stay in the unit was 3.6 days. Most deaths (72.0%) occurred more than 48 hours after admission. CONCLUSION: The finding of a positive association between an order for enteral feeding and survival supports enteral feeding of patients in medical intensive care units. Furthermore, the beneficial effect of enteral feeding appears to apply to patients regardless of body mass index.

Characteristics and Outcomes of Adult Inpatients With Malnutrition.

BACKGROUND: The diagnosis of malnutrition remains controversial. Furthermore, it is unknown if physician diagnosis of malnutrition impacts outcomes. We sought to compare outcomes of patients with physician diagnosed malnutrition to patients recognized as malnourished by registered dietitians (RDs), but not physicians, and to describe the impact of each of 6 criteria on the diagnosis of malnutrition. METHODS: We conducted a retrospective cohort study of adult patients identified as meeting criteria for malnutrition. Pediatric, psychiatric, maternity, and rehabilitation patients were excluded. Patient demographics, clinical data, malnutrition type and criteria, nutrition interventions, and outcomes were abstracted from the electronic medical record. RESULTS: RDs identified malnutrition for 291 admissions during our study period. This represents 4.1% of hospital discharges. Physicians only diagnosed malnutrition on 93 (32%) of these cases. Physicians diagnosed malnutrition in 43% of patients with a body mass index <18.5 but only 26% of patients with body mass index higher than 18.5. Patients with a physician diagnosis had a longer length of stay (mean 14.9 days vs 7.1 days) and were more likely to receive parenteral nutrition (PN) (20.4% vs 4.6%). Of the patients, 62% had malnutrition due to chronic illness. Of the 6 criteria used to identify malnourished patients, weight loss and reduced energy intake were the most common. CONCLUSIONS: Malnutrition is underrecognized by physicians. However, further research is needed to determine if physician recognition and treatment of malnutrition can improve outcomes. The most important criteria for identifying malnourished patients in our cohort were weight loss and reduced energy intake.