Energy and protein deficits throughout hospitalization in patients admitted with a traumatic brain injury

Cost-effectiveness analysis relies on preference-weighted health outcome measures as they form the basis for quality adjusted life years. Studies of preference-weighted outcomes for children following traumatic brain injury are lacking. This study seeks to describe the preference-weighted health outcomes of children following a traumatic brain injury at 3- and 6-months following pediatric intensive care unit (ICU) discharge. Children aged 5-17 who required ICU admission and endotracheal intubation or mechanical ventilation. The Quality of Well-being (QWB) score was used to describe preference-weighted outcomes. Clinical measures from the intensive care unit stay were used to estimate risk of mortality. Risk of mortality, Glasgow coma scores, patient length of stay in the intensive care unit, and parent-reported items from the Child Health Questionnaire (CHQ) were used to test construct validity. Subject data were obtained from nine pediatric intensive care units with consent procedures approved by representative institutional review boards. Medical records containing clinical information from the ICU stay were abstracted by the study coordinating center. Caregivers of children were contacted by telephone for follow-up interviews at 3- and 6-months following ICU discharge. All interviews were conducted by telephone with the primary caregiver of the injured child. Preference score statistics are presented overall and in relation to characteristics of the patient and their ICU admission. A response rate of 59% was achieved for the 3-month interviews (N = 56) and 67% for the 6-month interviews (N = 65) for caregivers of children aged 5 years and above that consented to participate. Overall, QWB scores averaged 0.508 (95% CI: 0.454-0.562) at the 3-month interview and 0.582 (95% CI: 0.526-0.639) at the 6-month interview. For both interview periods, scores ranged from 0.093 to 1.0 on a 0-1 value scale, where 0 represents death and 1 represents perfect health. Specific acute and chronic health problems from the QWB scale were present more often in patients with higher injury severity. Mortality risk, ICU length of stay, Glasgow Coma Scales, and parental reported summary scores from the CHQ all correlated correctly with the QWB scores. The findings support the use of the QWB score with parental report to measure preference-weighted health outcomes of children following a traumatic brain injury. Information from the study can be used in economic evaluations of interventions to prevent or treat traumatic brain injuries in children.

ObjectiveTo analyse the association between the Glasgow Coma Scale (GCS) score at intensive care unit (ICU) discharge and the 1-year outcome of patients with severe traumatic brain injury (TBI).DesignRetrospective analysis of prospectively collected observational data.PatientsBetween 01/2001 and 12/2005, 13 European centres enrolled 1,172 patients with severe TBI. Data on accident, treatment and outcomes were collected. According to the GCS score at ICU discharge, survivors were classified into four groups: GCS scores 3–6, 7–9, 10–12 and 13–15. Using the Glasgow Outcome Scale (GOS), 1-year outcomes were classified as “favourable” (scores 5, 4) or “unfavourable” (scores <4). Factors that may have contributed to outcomes were compared between groups and for favourable versus unfavourable outcomes within each group.Main resultsOf the 538 patients analysed, 308 (57 %) had GCS scores 13–15, 101 (19 %) had scores 10–12, 46 (9 %) had scores 7–9 and 83 (15 %) had scores 3–6 at ICU discharge. Factors significantly associated with these GCS scores included age, severity of trauma, neurological status (GCS, pupils) at admission and patency of the basal cisterns on the first computed tomography (CT) scan. Favourable outcome was achieved in 74 % of all patients; the rates were significantly different between GCS groups (93, 83, 37 and 10 %, respectively). Within each of the GCS groups, significant differences regarding age and trauma severity were found between patients with favourable versus unfavourable outcomes; neurological status at admission and CT findings were not relevant.ConclusionThe GCS score at ICU discharge is a good predictor of 1-year outcome. Patients with a GCS score <10 at ICU discharge have a poor chance of favourable outcome.

Purpose: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality worldwide. TBIs are increasing in Uganda, but little is known about outcomes and their predictors in post-ICU patients. This study assessed outcomes and their predictors in post-ICU patients admitted with TBI at Mbarara Regional Referral Hospital (MRRH) in south-western Uganda.&#x0D; Methodology: Retrospective study was used to review hospital records of patients admitted to the Intensive Care Unit (ICU) for MRRH with TBI. Data were entered into Excel, cleaned and exported to Stata version for analysis and presented as mean (standard deviation), median (interquartile range) and number (percent), while using the chi-square test and multinomial logistic regression as predictors for Post-ICU outcomes were used&#x0D; Findings: In the study, males dominated at 73%, while 81% were of working age (15-64 years). Road traffic accidents (83%) were the most common injury mechanism, followed by physical injury at 11%. Length of stay in the Intensive Care Unit was 9 (IQR = 4–8) days, mean GCS at ICU admission and discharge was 7.7 (±2.65) and 10 (±3.27), respectively. Fifty-seven patients (63%) were discharged home; with 73% good recovery Glasgow coma Outcome Scale of hospital discharges. Post-ICU outcomes were associated with GCS at ICU discharge ( . Having moderate Glasgow Coma Scale on ICU discharge was 3.59 times higher of being discharged home than dying compared to severe GCS on ICU discharge (OR=3.59; 95%CI, 1.11 to 11.63). This study established GCS as a statistical predictor of patient outcomes at ICU discharge.&#x0D; Unique Contribution to Theory, Practice and Policy: Based on the findings of this study, prevention of TBI is critical in order to reduce incidence of TBI related mortality. Policy makers to put rules that continuously teach and enforce road safety and traffic rules to all road users.

Severe traumatic brain injury (TBI) is associated with a 30%-70% mortality rate. S100B has been proposed as a biomarker for indicating outcome after TBI. Nevertheless, controversy has arisen concerning the predictive value of S100B for severe TBI in the context of multitrauma. Therefore, our aim was to determine whether S100B serum levels correlate with primary outcome following isolated severe TBI or multitrauma in males. Twenty-three consecutive male patients (age 18-65 years), victims of severe TBI [Glasgow Coma Scale (GCS) 3-8] (10 isolated TBI and 13 multitrauma with TBI) and a control group consisting of eight healthy volunteers were enrolled in this prospective study. Clinical outcome variables of severe TBI comprised: survival, time to intensive care unit (ICU) discharge, and neurological assessment [Glasgow Outcome Scale (GOS) at ICU discharge]. Venous blood samples were taken at admission in the ICU (study entry), 24 h later, and 7 days later. Serum S100B concentration was measured by an immunoluminometric assay. At study entry (mean time 10.9 h after injury), mean S100B concentrations were significantly increased in the patient with TBI (1.448 microg/L) compared with the control group (0.037 microg/L) and patients with fatal outcome had higher mean S100B (2.10 microg/L) concentrations when compared with survivors (0.85 microg/L). In fact, there was a significant correlation between higher initial S100B concentrations and fatal outcome (Spearman's =0.485, p=0.019). However, there was no correlation between higher S100B concentrations and the presence of multitrauma. The specificity of S100B in predicting mortality according to the cut-off of 0.79 microg/L was 73% at study entry. Increased serum S100B levels constitute a valid predictor of unfavourable outcome in severe TBI, regardless of the presence of associated multitrauma.

To individualize nutritional interventions for the prevention and treatment of malnutrition and sarcopenia, it is required to understand the nutritional needs of older adults. This study explores the nutritional needs of geriatric outpatients. We hypothesized that inadequate energy and protein intake is common in geriatric outpatients. Data were retrieved from 2 cohort studies encompassing community-dwelling older adults referred to geriatric outpatient mobility clinics in Amsterdam, The Netherlands and Melbourne, Australia. Indirect calorimetry and a food diary, respectively, were used to assess resting metabolic rate (RMR) and energy and protein intake. Total energy expenditure (TEE) was calculated by the RMR multiplied by an activity factor of 1.4. An energy deficit was defined as a relative difference >10% between TEE and energy intake. A protein deficit was defined as protein intake <1.2 g/kg body weight per day. Bland-Altman analysis assessed the agreement between energy and protein requirements versus intake at an individual level. Seventy-four outpatients were included (25 males, median age 78.9 [IQR: 72.8-86.1] years). The mean difference between TEE and energy intake was 292 (SD 481) kcal/d. An energy deficit was present in 46 outpatients. The median protein intake was 1.00 (IQR: 0.87-1.19) g/kg body weight per day and a protein deficit was present in 57 outpatients. There was a low agreement between energy and protein requirements versus intake at an individual level. In conclusion, over half of the outpatients had energy and/or protein deficits. Integrating dietetic services at geriatric outpatient mobility clinics could potentially improve nutrition- and muscle-related outcomes in a multidisciplinary approach.

Utility of the Richmond Agitation-Sedation Scale in evaluation of acute neurologic dysfunction in the intensive care unit.

HOW MUCH IS ENOUGH? PROTEIN REQUIREMENTS IN CRITICALLY ILL PATIENTS

Introduction: Enteral nutrition is indicated for critically ill patients who are unable to maintain oral food intake, however, the suboptimal delivery of enteral nutrition is common. Energy and protein deficits are risk factors for hospital malnutrition and negative clinical outcomes, so reducing the occurrence of interruptions is important for adequate nutritional support. The aims of the study were to determine energetic and protein deficits and to identify the main reasons for insufficient enteral feeding. Methods: Retrospective cross-sectional study with data collection from electronic medical records of patients in intensive care units, including patients aged 18 years or more, both sexes and who were fed with enteral nutrition in the nutritional goal. Data on demographic, clinical and nutritional characteristics were collected. Descriptive and inferential analyzes were performed using the statistical software SPSS 23.0, with a p-value &lt;0.05 being considered significant. Results: A total of 161 patients were investigated in 915 days of enteral nutrition. A significant difference was found between the amount of energy and proteins delivered and the nutritional goal (p = 0.000), with a median deficit of 1568 kcal and 88 g of protein during the follow-up period. The main reasons for insufficient enteral feeding were loss of enteral tube (14.6%), extubation/intubation (13.1%), inadequate medical record (11.9%) and procedures (10.4%). Conclusion: Energy and protein deficits demonstrate the need for the implementation of protocols and training for the team, in order to reduce interruptions and improve the delivery of enteral nutrition and the quality of nutritional therapy

Severe traumatic brain injury (TBI) is a leading cause of disability worldwide and cerebral protection (CP) management might determine the outcome of the patient. CP in severe TBI is to protect the brain from further insults, optimise cerebral metabolism and prevent secondary brain injury. This study aimed to analyse the short-term Glasgow Outcome Scale (GOS) at the intensive care unit (ICU) discharge and a month after ICU discharge of patients post CP and factors associated with the favourable outcome. This is a prospective cohort study from January 2021 to January 2022. The short-term outcomes of patients were evaluated upon ICU discharge and 1 month after ICU discharge using GOS. Favourable outcome was defined as GOS 4 and 5. Generalised Estimation Equation (GEE) was adopted to conduct bivariate GEE and subsequently multivariate GEE to evaluate the factors associated with favourable outcome at ICU discharge and 1 month after discharge. A total of 92 patients with severe TBI with GOS of 8 and below admitted to ICU received CP management. Proportion of death is 17% at ICU discharge and 0% after 1 month of ICU discharge. Proportion of favourable outcome is 26.1% at ICU discharge and 61.1% after 1 month of ICU discharge. Among factors evaluated, age (odds ratio [OR] = 0.96; 95% CI: 0.94, 0.99; P = 0.004), duration of CP (OR = 0.41; 95% CI: 0.20, 0.84; P = 0.014) and hyperosmolar therapy (OR = 0.41; CI 95%: 0.21, 0.83; P = 0.013) had significant association. CP in younger age, longer duration of CP and patient not receiving hyperosmolar therapy are associated with favourable outcomes. We recommend further clinical trial to assess long term outcome of CP.

CLINICAL NUTRITION WEEK 2015: Long Beach, CA February 14–17, 2015

Background: Traumatic brain injury (TBI) is a major public health concern. Creatinine (Cr) has been well studied as a marker of renal function, specifically the development of acute kidney injury (AKI) in TBI patients. We aimed to evaluate the effect of Cr on various clinical outcomes in patients with severe TBI. Methods: We investigated the relationship between Cr levels at various time points and a range of clinical variables, using parametric and non-parametric statistical testing. Results: 1000 patients were included in our study. We found a significant association between sex and Cr level at intensive care unit (ICU) admission and ICU discharge. Cr was positively correlated with ISS at hospital admission, ICU admission, ICU discharge, and at death. Conversely, Cr was negatively correlated with GCS at hospital admission, ICU admission, ICU discharge, and at death. Larger decreases in Cr from Hospital to ICU admission were significantly correlated with increased vent days. Larger decreases in Cr from ICU admission to ICU discharge were significantly correlated with increased hospital length of stay (LOS), ICU LOS, and vent days, likely reflecting the degree of initial hypercreatinemia. For all patients, there were significant positive correlations between Cr at admission and ICU LOS, Cr at ICU admission and ICU LOS, and Cr at ICU admission and vent days. Conclusions: Our findings support existing literature that demonstrates a positive relationship between Cr levels, ICU LOS, and vent days amongst patients with severe TBI. These data suggest renal injury is predictive of TBI outcomes. Future research should investigate the role of renal therapeutic interventions in TBI recovery.

Nutrition is often thought to influence outcomes in critically ill patients. However, the relationship between macronutrient delivery and functional status is not well characterized. Our goal was to investigate whether caloric or protein deficit over the course of critical illness is associated with functional status at the time of intensive care unit (ICU) discharge. We performed a retrospective analysis of surgical ICU patients at a teaching hospital in Boston, MA. To investigate the association of caloric or protein deficit with Functional Status Score for the ICU (FSS-ICU), we constructed linear regression models, controlling for age, sex, race, body mass index, Nutritional Risk in the Critically Ill score, and ICU length of stay. We then dichotomized caloric as well as protein deficit, and performed logistic regressions to investigate their association with functional status, controlling for the same variables. Linear regression models (n = 976) demonstrated a caloric deficit of 238 kcal (237.88; 95%CI 75.13-400.63) or a protein deficit of 14 g (14.23; 95%CI 4.46-24.00) was associated with each unit decrement in FSS-ICU. Logistic regression models demonstrated a 6% likelihood (1.06; 95%CI 1.01-1.14) of caloric deficit ≥6000 vs. <6000 kcal and an 8% likelihood (1.08; 95%CI 1.01-1.15) of protein deficit ≥300 vs. <300 g with each unit decrement in FSS-ICU. In our cohort of patients, macronutrient deficit over the course of critical illness was associated with worse functional status at discharge. Future studies are needed to determine whether optimized macronutrient delivery can improve outcomes in ICU survivors.

Mortality in COVID-19 patients in the ICU is reported to be higher than non-ICU. Early parenteral nutrition is avoided considering the complications, but COVID-19 patients in the ICU require parenteral nutrition because enteral intake is inadequate or contraindicated. This study aims to identify early parenteral nutrition and other risk factors that cause mortality of COVID-19 patients in the ICU of Dr. Kariadi Hospital. Observational analytic study using a retrospective cohort approach using secondary data involving COVID-19 patients treated in the ICU of RSUP dr. Kariadi in March – September 2020. The sampling technique used total sampling with the following criteria: inclusion: confirmed COVID-19, age &gt;18 years and given PN and EN therapy or a combination thereof. Statistical analysis using Chi Square test and Logistic Regression. Total of 188 subjects met the inclusion criteria. There was no difference in the mortality of patients who were given early or late PN p:0.92 RR 0.90 (95% CI 0.43-1.84). The risk factors for mortality were the presence of comorbidities p=0.023 RR 2.13 (95% CI 1.15-3.95), use of VM p=&lt;0.0001 RR 43.68 (95% CI 18.52 – 102.99) , energy deficit p=0.002 RR 3.09 (95% CI 1.52-5.99) and protein deficit p=0.039 RR 1.93 (95% CI 1.07-3.49). In the multivariate analysis of controlled VM usage with ARDS status p=0.022 RR 6.20 (95% CI 1.29 – 29.72) and energy deficit p=0.045 RR 2.15 (1.01 – 4.57) together -the same as a risk factor for mortality in COVID-19 patients in the ICU of Dr. Kariadi Hospital. Early PN is not a risk factor for mortality in COVID-19 patients while the use of VM is controlled by ARDS status and energy deficit together are risk factors for mortality in COVID-19 patients in the ICU of RSUP dr. Kariadi.

Introduction: Neurocritical patients may suffer functional limitations due to various factors, ranging from primary brain injury to cultural and structural barriers. Objective: To compare the functional mobility of adult neurocritical patients on invasive mechanical ventilation (IMV) undergoing an early mobilization protocol between intensive care unit (ICU) admission and discharge and to evaluate ventilatory and clinical outcomes. Methods: A retrospective study conducted in the neurological ICU of a teaching hospital from January to December 2022. Data were collected from electronic medical records, including sex, age, diagnosis, comorbidities, length of IMV and ICU stay, discharge or death outcomes, and functionality scores from the ICU Mobility Scale and the Johns Hopkins Scale. Results: Seventy-five patients were included in the study, with a mean age of 52.1 ± 19.5 years, predominantly female (52%). The most prevalent diagnosis and comorbidity were traumatic brain injury (24%) and hypertension (40%). The mean duration of IMV was 4.7 ± 3.3 days, with an average ICU stay of 11.9 ± 6.9 days. The study showed an 85% success rate in IMV weaning and 95% of ICU discharge rate. There was a significant improvement in functionality (p &lt; 0.0001) from admission to discharge, with a notable reduction (p &lt; 0.0001) in the total restriction score and a significant increase (p &lt; 0.0001) in the moderate and mild reduction in mobility scores. Conclusion: The functional mobility of neurocritical patients improved from total complete bed restriction to the ability to perform orthostatic activities, transfer out of bed, and walk with assistance between ICU admission and discharge. Among the outcomes analyzed, there were high rates of ventilatory weaning and ICU discharges.

Patients who survive critical illness frequently develop muscle weakness that can impact on quality of life; nutrition is potentially a modifiable risk factor. The present study aimed to explore the associations between cumulative energy deficits (using indirect calorimetry and estimated requirements), nutritional and functional outcomes. A prospective single-centre observational study of 60 intensive care unit (ICU) patients, who were mechanically ventilated for at least 48h, was conducted. Cumulative energy deficit was determined from artificial nutrition delivery compared to targets. Measurements included: (i) at recruitment and ICU discharge, weight, fat-free mass (bioimpedance spectroscopy) and malnutrition (Subjective Global Assessment score B/C); (ii) at awakening and ICU discharge, physical function (Physical Function in Intensive Care Test-scored) and muscle strength (Medical Research Council sum-score (MRC-SS). ICU-acquired weakness was defined as a MRC-SSscore of less than 48/60. The median (interquartile range) cumulative energy deficit compared to the estimated targets up to ICU day 12 was 3648 (2514-5650)kcal. Adjusting for body mass index, age and severity of illness, cumulative energy deficit (per 1000kcal) was independently associated with greater odds of ICU-acquired weakness [odds ratio (OR)=2.1, 95% confidence interval (CI)=1.4-3.3, P=0.001] and malnutrition (OR=1.9, 95% CI=1.1-3.2, P=0.02). In similar multivariable linear models, cumulative energy deficit was associated with reductions in fat-free mass (-1.3kg; 95% CI=-2.4 to -0.2, P=0.02) and physical function scores (-0.6 points; 95% CI=-0.9 to -0.3, P=0.001). Cumulative energy deficit from artificial nutrition support was associated with reduced functional outcomes and greater loss of fat-free mass in ventilated ICU patients.