When timing and dose of nutrition support were examined, the modified Nutrition Risk in Critically Ill (mNUTRIC) score did not differentiate high-risk patients who would derive the most benefit from nutrition support: a prospective cohort study

Abstract

BackgroundThe timing and dose of exclusive nutrition support (ENS) have not been investigated in previous studies aimed at validating the modified Nutrition Risk in Critically Ill (mNUTRIC) score. We therefore evaluated the mNUTRIC score by determining the association between dose of nutrition support and 28-day mortality in high-risk patients who received short- and longer-term ENS (≤ 6 days vs. ≥ 7 days).MethodsA prospective cohort study included data from 252 adult patients with > 48 h of mechanical ventilation in a tertiary care institution in Singapore. The dose of nutrition support (amount received ÷ goal: expressed in percentage) was calculated for a maximum of 14 days. Associations between the dose of energy (and protein) intake and 28-day mortality were evaluated with multivariable Cox regressions. Since patients have different durations of ENS, only the first 6 days of ENS in patients with short- and longer-term ENS were assessed in the Cox regressions to ensure a valid comparison of the associations between energy (and protein) intake and 28-day mortality.ResultsIn high-risk patients with short-term ENS (n = 106), each 10% increase in goal energy intake was associated with an increased hazard of 28-day mortality [adj-HR 1.37 (95% CI 1.17, 1.61)], and this was also observed for protein intake [adj-HR 1.31 (95% CI 1.10, 1.56)]. In contrast, each 10% increase in goal protein intake in high-risk patients with longer-term ENS (n = 146) was associated with a lower hazard of 28-day mortality [adj-HR 0.78 (95% CI 0.66, 0.93)]. The mean mNUTRIC scores in these two groups of patients were similar.ConclusionWhen timing and dose of nutrition support were examined, the mNUTRIC did not differentiate high-risk patients who would derive the most benefit from nutrition support.Electronic supplementary materialThe online version of this article (10.1186/s13613-018-0443-1) contains supplementary material, which is available to authorized users.

Full versus Trophic Feeds in Critically Ill Adults with High and Low Nutritional Risk Scores: A Randomized Controlled Trial

“…Because IL-6 is not routinely measured in most ICUs, a modified NUTRIC score (mNUTRIC) without IL-6 level was applied for practical purposes [ 23 ]. Critically ill patients with high nutrition risk (mNUTRIC score ≥5) could benefit from higher energy delivery in order to decrease hospital mortality, as shown in our previous study and in various other investigations [ 23 , 24 , 25 , 26 ], although the opposite finding was reported in one study [ 27 ]. A post-hoc analysis in the PermiT trial by Arabi et al [ 28 ] found no significant difference in 90-day mortality between the permissive underfeeding and standard feeding group regardless of nutritional risk (high vs. low).…”

“…In agreement with previous results [ 23 , 25 , 26 ], the findings of our previous study, which retrospectively assessed patients’ nutritional status using the mNUTRIC score, showed high energy intake was significantly associated with lower mortality in patients with high nutrition risk [ 24 ]. Lew et al indicated that higher energy intake at the early phase of nutrition support (≤6 days) was associated with higher 28-day mortality in critically ill patients with high nutrition risk, but the significant association between energy intakes and 28-day mortality disappeared in high nutrition risk patients with longer-term nutrition support (≥7 days) [ 27 ]. However, Arabi et al indicated that the NUTRIC score could not differentiate the risk association between moderate and full energy intake and outcomes in a large post-hoc analysis study [ 28 ].…”

The association between nutritional adequacy and 28-day mortality in the critically ill is not modified by their baseline nutritional status and disease severity

“…Since mNUTRIC was not part of routine care, it was calculated at the end of the study. Details of the collection of energy and protein intakes via ENS have been previously published [10]. Briefly, adequacy of nutritional support was calculated by dividing the total enteral and/or parenteral nutrition (energy and protein) intake as well as energy provided by propofol and intravenous dextrose by a number of days on ENS and expressed as a percentage of the goals established at ICU admission.…”

“…However, several recent studies have reported conflicting results [8, 9]. Lew et al [10] recently validated the mNUTRIC score and observed that the association between mNUTRIC score and 28-day mortality was modified by the timing and dose of nutritional support [10]. Specifically, the study suggested that early high energy and protein intakes were associated with a higher risk of 28-day mortality in high-mNUTRIC patients with short-term nutritional support (≤ 6 days), whereas the inverse was observed in those with longer-term nutritional support (≥ 7 days) [10].…”

“…Lew et al [10] recently validated the mNUTRIC score and observed that the association between mNUTRIC score and 28-day mortality was modified by the timing and dose of nutritional support [10]. Specifically, the study suggested that early high energy and protein intakes were associated with a higher risk of 28-day mortality in high-mNUTRIC patients with short-term nutritional support (≤ 6 days), whereas the inverse was observed in those with longer-term nutritional support (≥ 7 days) [10]. However, the median mNUTRIC scores of these two groups of patients (receiving ≤ 6 days vs. ≥ 7 days of nutritional support) at ICU admission were similar, which suggested that the associations between early high energy and protein intakes and 28-day mortality were not modified by baseline disease severity measured by the mNUTRIC score.…”