Rupinder Dhaliwal, RD

Clinical Evaluation Research Unit

Kingston General Hospital

Outline
incidence of underfeeding in the ICU
nutritional screening tools available for use in ICU
familiar with the novel approach used to assess the
nutritional risk of critically ill patients and implications
of this risk assessment for clinical practice

Does underfeeding in ICUs

exist?

Mean intake 56% International Nutrition Survey, n =211 ICUs

Purpose of Nutrition Screening

Predict the probability of a better or worse
outcome due to nutrition

SCREENING

Malnutrition
goes
undetected

Guidelines ASPEN/SCCM
2009

Screening leads to Nutritional Care

Hospitals & healthcare organizations should have a policy and a
specific set of protocols for identifying patients at nutritional risk.
The following process is suggested:

Screening
Assessment
Monitoring & Outcome
Communication
Audit
Kondrup et al. Clin Nutr 22(4):415-421;2003.

 Underfeeding does occur in ICUs

Malnutrition: 30% ICU patients (SGA)
Existing tools for nutrition screening

Malnutrition Universal Screening Tool (MUST)

Nutritional Risk Screening (NRS 2002)

Mini Nutritional Assessment (MNA)
Short Nutritional Assessment Questionnaire (SNAQ)
Malnutrition Screening Tool (MST)

Subjective Global Assessment (SGA)

Anthony NCP 2008

All ICU patients

treated the same

Subjective Global
Assessment

When training provided in

advance, SGA can produce
reliable estimates of malnutrition
Note rates of missing data
(7-34%)

n = 119, > 65 yrs, mostly medical patients, not all ICU

no difference between well-nourished and malnourished patients with
regard to the serum protein values on admission, LOS, and mortality
rate

n = 124, mostly surgical patients

100% data available for SGA
SGA predicted mortality

Quantify Lean Muscle Mass: CT

Scan

Body composition tools:

BIA, skin fold: low precision , DEXA: not specific, $$

CTs becoming common research tool

Measures tissue mass and changes over time

50 geriatric trauma pts

prevalence of sarcopenia (low
muscularity) on admission
=78%
Despite the majority being
overweight!
M. Mourtzakis et al

ICU patients are not all created equalshould we

expect the impact of nutrition therapy to be the
same across all patients?

Malnutrition should be diagnosed on the

basis of etiology. inflammation acute vs
chronic

In the ICU..
Caloric debt/underfeeding
Malnutrition exists 34% or >
Historical nutrition data n/a
Not all patients equal
Consider
Inflammation
Acute diseases
Chronic diseases

How do we figure out who will

benefit the most from Nutrition
Therapy?

A Conceptual Model for Nutrition Risk

Assessment in the Critically ill
Acute

Chronic

-Reduced po intake
-pre ICU hospital stay

-Recent weight loss

-BMI?

Starvation
Nutrition Status
micronutrient levels - immune markers - muscle mass

Acute
-IL-6
-CRP
-PCT

Inflammation
Chronic
-Comorbid illness

Objective
Develop a score using the variables in the model to
Quantify the risk of ICU pts developing adverse
events that may be modified by nutrition

The Development of the NUTrition Risk

in the Critically ill Score (NUTRIC Score)
When adjusting for age, APACHE II, and SOFA, what effect of
nutritional risk factors on clinical outcomes?
Multi institutional data base of 598 patients (3 ICUs)
Historical po intake and weight loss only available in 171 patients
Outcome: 28 day vent-free days and mortality

What are the nutritional risk factors

associated with mortality?
(validation of our candidate variables)
Age
Baseline APACHE II score
Baseline SOFA
# of days in hospital prior to ICU admission
Baseline Body Mass Index
Body Mass Index

Non-survivors by day 28
(n=138)

Survivors by day 28
(n=460)

p values

71.7 [60.8 to 77.2]

61.7 [49.7 to 71.5]

<.001

26.0 [21.0 to 31.0]

20.0 [15.0 to 25.0]

<.001

9.0 [6.0 to 11.0]

6.0 [4.0 to 8.5]

<.001

0.9 [0.1 to 4.5]

0.3 [0.0 to 2.2]

<.001

26.0 [22.6 to 29.9]

26.8 [23.4 to 31.5]

0.13
0.66

<20
20

6 ( 4.3%)
122 ( 88.4%)
3.0 [2.0 to 4.0]

# of co-morbidities at baseline
Co-morbidity
Patients with 0-1 co-morbidity
20 (14.5%)
Patients with 2 or more co-morbidities
118 (85.5%)

135.0 [73.0 to 214.0]

C-reactive protein
4.1 [1.2 to 21.3]
Procalcitionin
158.4 [39.2 to 1034.4]
Interleukin-6
171 patients had data of recent oral intake and weight loss

% Oral intake (food) in the week prior to enrolment

% of weight loss in the last 3 month

25 ( 5.4%)
414 ( 90.0%)
3.0 [1.0 to 4.0]

<0.001
<0.001

140 (30.5%)
319 (69.5%)
108.0 [59.0 to 192.0]

0.07

1.0 [0.3 to 5.1]

<.001

72.0 [30.2 to 189.9]

<.001

Non-survivors by day 28
(n=32)

Survivors by day 28
(n=139)

p values

4.0[ 1.0 to 70.0]

50.0[ 1.0 to 100.0]

0.10

0.0[ 0.0 to 2.5]

0.0[ 0.0 to

0.0]

0.06

What are the nutritional risk factors

associated with Vent Free days?
(validation of our candidate variables)
Spearman
correlation with
VFD within 28
days

p values

Number of
observations

Age
Baseline APACHE II score
Baseline SOFA

-0.1891
-0.3914
-0.3857

<.0001
<.0001
<.0001

598
598
594

% Oral intake (food) in the week prior to enrollment

0.1676

0.0234

183

number of days in hospital prior to ICU admission

-0.1387

0.0007

598

% of weight loss in the last 3 month

Baseline BMI
# of co-morbidities at baseline
Baseline CRP
Baseline Procalcitionin
Baseline IL-6

-0.1828
0.0581
-0.0832
-0.1539
-0.3189
-0.2908

0.0130
0.1671
0.0420
0.0002
<.0001
<.0001

184
567
598
589
582
581

Variable

BMI: no effect on Vent free days

The Development of the NUTrition Risk

in the Critically ill Score (NUTRIC Score)
% oral intake in the week prior dichotomized into
patients who reported less than 100%
all other patients
Weight loss was dichotomized as
patients who reported any weight loss
all other patients
BMI was dichotomized as
<20
all others
Comorbidities was left as integer values range 0-5

The Development of the NUTrition Risk

in the Critically ill Score (NUTRIC Score)
All other variables (Age, APACHE 2, SOFA, Comorbidities, LOS pre ICU, IL 6)
were categorized into five equal sized groups (quintiles)
Exact quintiles and logistic parameters for age

Exact Quintile

Parameter

Points

19.3-48.8

referent

48.9-59.7

0.780

59.7-67.4

0.949

67.5-75.3

1.272

75.4-89.4

1.907

Logistic regression analyses

Each quintile compared to lowest risk
category
Rounded off to the nearest whole # to
provide points for the scoring system

The Development of the NUTrition Risk

in the Critically ill Score (NUTRIC Score)
Variable
Age

APACHE II

SOFA

# Comorbidities

Range
<50
50-<75
>=75
<15
15-<20
20-28
>=28
<6
6-<10
>=10
0-1
2+

Points
0
1
2
0
1
2
3
0
1
2
0
1

Days from hospital to ICU admit

0-<1
1+

0
1

IL6

0-<400
400+

0
1

AUC
Gen R-Squared
Gen Max-rescaled R-Squared

0.783
0.169
0.256

BMI, CRP, PCT, weight loss, and oral intake were excluded because they were not significantly
associated with mortality or their inclusion did not improve the fit of the final model.

Observed
Model-based

20

40

Statistical
modeling

n=12

n=33

n=55

n=75

n=90

n=114

n=82

n=72

n=46

n=17

n=2

Mortality Rate (%)

60

80

The Validation of the NUTrition Risk in

the Critically ill Score (NUTRIC Score)

Nutrition Risk Score

10

higher
score =
higher
mortality

Observed
Model-based

10
8
2

high score
= longer
ventilation

n=12

n=33

n=55

n=75

n=90

n=114

n=82

n=72

n=46

n=17

n=2

10

Days on Mechanical Ventilator

12

14

The Validation of the NUTrition Risk in

the Critically ill Score (NUTRIC Score)

Nutrition Risk Score

The Validation of the NUTrition Risk in

the Critically ill Score (NUTRIC Score)

1.0

Can NUTRIC score modify the association between nutritional adequacy

and mortality? (n=211)

0.6

P value for the

P value
for the
interaction=0.01
interaction=0.01

Highest score pts,

low nutrition is
associated with
higher mortality!!

0.2

0.4

Lowest score pts,

more nutrition may
be associated with
higher mortality ?

0.0

28 Day Mortality

0.8

NUTRIC 0-3
NUTRIC 4-6
NUTRIC 7-8
NUTRIC 9-10

50

100
Nutrition Adequacy Levles (%)

150

Summarize: NUTRIC Score

NUTRIC Score (0-10) based on

Age
APACHE II
SOFA
# comorbidities
Days in hospital pre ICU
IL 6

High NUTRIC Score associated worse outcomes

(mortality, ventilation)
High NUTRIC Score benefit the most from nutrition
Low NUTRIC Score : harmful?

Applications of NUTRIC
Score
Help determine which patients will benefit more from
nutrition
Supplemental PN
Aggressive feeding
Small bowel feeding

Design & interpretation of future studies

Negative studies, non high risk, heterogenous patients

Limitations

Applies only to macronutrients

Does not apply to pharmaconutrients
Nutritional history is suboptimal
Requires IL-6

Conclusion

Iatrogenic underfeeding in ICUs exist

Nutrition Screening/audits* detect underfeeding
Existing Screening tools not helpful in ICU
Not all ICU patients are the same in terms of risk
NUTRIC Score is one way to quantify that risk and can
be used in your ICU
Further refinement of this tool will ensure that the right
patient gets nutrition

Bedside nutrition tool

Thanks
Dr. Daren Heyland
Xuran Jiang
Andrew Day