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

Charles Chin Han Lew,Charles Chin Han Lew,Ka Po Cheung,Robert J L Fraser,Ai Ping Chua,Michelle Miller,Mary Foong Fong Chong,Mary Foong Fong Chong,Gabriel Jun Yung Wong

doi:10.1186/s13613-018-0443-1

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.

Highlights

The 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 score
There are four published validation studies [9, 11,12,13] with three showing acceptable external validity for the modified Nutrition Risk in Critically Ill (mNUTRIC) score: high-risk patients who received higher average energy [9, 11, 12] and protein [11] intake were observed to have lower mortality. These results suggested that goal energy and protein intake should be achieved as soon as possible via early aggressive nutrition support including: (1) starting enteral feeding at goal rate [14], (2) using prokinetic agents prophylactically to enhance enteral feeding tolerance [15], and/or (3) using supplemental or total parenteral nutrition support when enteral nutrition cannot meet requirements within the first few days of intensive care unit (ICU) admission [7, 16]
The cut-off intervals that defined “short-term ENS” and “longer-term ENS” were set at ≤ 6-days (n = 106) and ≥ 7-days (n = 146) of ENS, respectively, as clear separation was observed between the per cent goal energy and protein intake of survivors and non-survivors at the univariate level (Fig. 2)

Summary

Introduction

The 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. There are four published validation studies [9, 11,12,13] with three showing acceptable external validity for the mNUTRIC score: high-risk patients who received higher average energy [9, 11, 12] and protein [11] intake were observed to have lower mortality These results suggested that goal energy and protein intake should be achieved as soon as possible via early aggressive (i.e. high dose) nutrition support including: (1) starting enteral feeding at goal rate [14], (2) using prokinetic agents prophylactically to enhance enteral feeding tolerance [15], and/or (3) using supplemental or total parenteral nutrition support when enteral nutrition cannot meet requirements within the first few days of ICU admission [7, 16]

Methods

Results

Discussion

Conclusion