Quadriceps Muscle Layer Thickness Research Articles

Quadriceps Muscle Layer Thickness and its association with frailty in critically ill patients: A prospective observational study

BackgroundFrailty is a well-recognized clinical entity known to influence the outcomes of critically ill patients. Muscle ultrasound, particularly Quadriceps Muscle Layer Thickness (QMLT), assesses muscle mass, which is a key component determining frailty. However, no studies have assessed the association between frailty and QMLT. This study aimed to determine the association between the QMLT and frailty in critically ill elderly patients. MethodIn this prospective, observational, single-center study conducted in an ICU in India, patients aged >65 years were enrolled. Baseline frailty was assessed using the Clinical Frailty Scale (CFS). Quadriceps muscle thickness was measured via axial cross-section ultrasound at admission. Patients were categorized as non-frail (CFS 1–4) and frail (CFS ≥5), and their characteristics were compared. Multivariate regression analysis was used to identify factors associated with frailty. Results120 patients were included. The median APACHE II and SOFA scores were 19 [IQR 14.25–23] and 4.5 [IQR 3–6], respectively. The median age was 75 years [IQR 70–82]; 62.5 % were male. The most common comorbidities were diabetes mellitus (60 %) and hypertension (59 %). 65 % were mechanically ventilated. 65 % of patients were frail. Frail patients had higher mortality (37.17 % vs. 16.66 %, p = 0.022). QMLT was lesser in frail than non-frail (1.77 cm vs 2.21 cm, p < 0.001). QMLT decreased with an increase in CFS (p < 0.001). Frail and non-frail patients were further divided into four groups based on the median QMLT (1.96 cm). Frail patients with QMLT below the median had a higher 28-day mortality than non-frail and frail patients with QMLT above the median (48.97 % vs. 16.12 % vs. 18.18 % vs. 17.24 %, p = 0.003). Frailty was independently associated with increasing age (OR, 1.14; 95 % CI: 1.055–1.231, p = 0.001), higher APACHE II score (OR, 1.078; 95 % CI: 1.009–1.151, p = 0.025), and lower QMLT (OR, 0.205; 95 % CI: 0.083–0.509, p = 0.001). ConclusionsWe found an independent association between Quadriceps Muscle Layer Thickness (QMLT) and frailty. QMLT decreased progressively with CFS scores. Frail patients with lower QMLT had increased 28-day mortality. These findings highlight the role of incorporating QMLT measurements along with CFS in frailty evaluations to improve decision-making in critically ill elderly patients.

Nutrition intake, muscle thickness, and recovery outcomes for critically ill patients requiring non-invasive forms of respiratory support: A prospective observational study

BackgroundUse of high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV) in the intensive care unit (ICU) is increasing, yet reporting of nutrition intake, muscle thickness, or recovery outcomes in this population is limited. ObjectiveThe objective of this study was to quantify muscle thickness, nutrition intake, and functional recovery outcomes for patients receiving HFNC/NIV within the ICU. MethodsA single-centre, prospective, observational study in adult ICU patients recruited within 48 hrs of commencing HFNC/NIV. Change in quadriceps muscle layer thickness using ultrasound (primary outcome) and 24 hr nutrition intake from study inclusion to day 7 (D7), functional capacity (Barthel Index), and quality of life (EuroQol five-dimension five-level utility index) at D90 were assessed. Data are n (%), mean ± standard deviation or median [interquartile range], are compared using paired sample t-test, and a P value of <0.05 was considered significant. ResultsPrimary outcome data were available for n = 28/42: 64 ± 13 y, 61% male, body mass index: 29.1 ± 9.0 kg/m2, and Acute Physiology and Chronic Health Evaluation II score: 17 ± 5. Quadriceps muscle layer thickness reduced from 2.41 ± 0.87 to 2.12 ± 0.73 cm; mean difference: −0.29 cm (95% confidence interval: -0.44, −0.13). Nutrition intake increased from study inclusion to D7: 1735 ± 1283 to 5448 ± 2858 kJ and 17.4 ± 16.6 to 60.9 ± 36.8g protein. Barthel Index was 87 ± 20 at baseline and 91 ± 15 at D90 (out of 100). Quality of life was impaired at D90: 0.64 ± 0.23 (health = 1.0). ConclusionCritically ill patients receiving HFNC/NIV experienced muscle loss and impaired quality of life.

Effects of early exercise training following severe burn injury: a randomized controlled trial.

Despite being a stable component of burn rehabilitation at later stages of recovery, exercise training is not commonly provided during the acute phase of burns. A lack of evidence surrounding its efficacy and safety in severely burned adults has hampered its implementation in acute burn care. The aim of this study was to investigate the capacity of early exercise training to modulate parameters of postburn muscle wasting and quality of life. Adults <65years of age with burns ≥40% total burn surface area (TBSA) were randomly allocated to either receive early exercise (n = 29) in addition to standard care or standard care alone (n = 29). Early exercise involved resistance and aerobic training, which commenced as early as possible and lasted for a duration of 6 to 12 weeks, in line with burn center length of stay. Ultrasound-derived quadriceps muscle layer thickness (QMLT) and rectus femoris cross-sectional area (RF-CSA), lower limb muscle force, Eurocol Quality of Life-5 Dimensions and Burn Specific Health Scale Brief (BSHS-B) were assessed 6 and 12 weeks after baseline. Mixed models were fitted to compare between-group changes over time. A total of 58 adults [42 (95% confidence interval 40-45) years old; 40-94% TBSA range, 86% previously mechanically ventilated] participated in this study. Exercise commenced 7 days [IQR (interquartile range) 5-9] after burn center admission with an attendance rate of 93%. Allocation to the exercise group had a protective effect on the loss of muscle size from baseline to 6 weeks of follow-up (QMLT: β-coefficient: 0.05cm, p = 0.010; RF-CSA: β-coefficient: 0.05 cm2, p = 0.045), and resulted in an improved recovery from 6 to 12 weeks (QMLT: β-coefficient: 0.04cm, p = 0.01; RF-CSA: β-coefficient: 0.06 cm2, p < 0.001). Muscle force increased significantly more in the exercise group than in the control group (β-coefficient: 3.102N, p < 0.001) between 6 and 12 weeks. Besides a marginally significant effect for the BSHS-B domains 'affect' and 'interpersonal relationships' between 6 and 12 weeks, no benefits were observed in the other assessed quality-of-life measures. No serious adverse events were reported in the exercise group. The results of this study support the use of early exercise training as a feasible and efficacious therapeutic strategy to manage burn-related changes in muscle size and strength in adults with acute severe burn injury.

The Impact of Quadriceps Muscle Layer Thickness on Length of Stay of Patients Listed for Renal Transplant

Background: Quadriceps muscle layer thickness (QMLT), which is measured using ultrasound, is an emerging strategy to identify sarcopenia. Purpose: The purpose of the study was to assess whether pre-operative QMLT values are associated with a prolonged length of stay (LOS; defined as &gt;14 days) following a renal transplant. Methods: Between March 2019 and January 2020, we performed a prospective study among patients undergoing renal transplantation. Physical Frailty scores and QMLT measurements were performed pre-operatively. The primary outcome was a greater LOS following transplant. Secondary outcomes included complications and renal function. Statistical analysis: Percentiles divided patients into two categories of QMLT (low and high). Continuous outcomes were compared using a two-sided t-test or Mann–Whitney U test, and Chi-square analysis and Fisher exact testing were used for nominal variables. Results: Of 79 patients, the frailty prevalence was 16%. Among patients with low and higher QMLTs, LOS of &gt;14 days were 21% vs. 3% [p = 0.04], respectively. Demographically, there was a higher percentage of patients with living donors in the high- vs. low-QMLT groups (40 vs. 7%). However, in a subgroup analysis excluding living-donor recipients, the difference between groups was preserved (23% vs. 0%, p = 0.01). No differences in secondary outcomes were seen between groups. Conclusions: Low quadriceps muscle layer thickness may be associated with a prolonged length of stay for renal recipients. Further research is needed to confirm our findings.

Acute muscle wasting is associated with poor prognosis in older adults with severe community-acquired pneumonia.

To investigate the impact of acute muscle wasting on 90-day mortality in older patients with severe pneumonia using ultrasound and chest computed tomography (CT). Quadriceps muscle layer thickness was measured via ultrasound on days 1, 7, and 14, and cross-sectional area of the erector spinae muscle was assessed using chest CT on days 1 and 14 in patients aged ≥ 65years old. The primary outcome was all-cause 90-day mortality. Receiver operating characteristic curves were conducted for muscle loss to predict 90-day mortality. Cox proportional hazard models and Kaplan-Meier survival curves were employed to evaluate the association between muscle loss and 90-day mortality. Sixty-two patients were enrolled with median age of 80.2years, 29 (46.8%) were men and 28 (45.2%) patients died. Muscle mass measured using ultrasound and CT decreased significantly from baseline to day 14 in the non-survivor group. Muscle loss assessed by ultrasound (with minimum and maximum pressure) and CT independently predicted all-cause 90-day mortality (adjusted hazard ratios = 1.497, 1.400 and 1.082; P < 0.001, P = 0.002, and P = 0.004; respectively), and cutoff values of muscle loss were 0.34cm, 0.11cm and 4.92cm2, correspondingly. A higher muscle loss had an increased risk of 90-day mortality. Acute muscle wasting assessed by ultrasound and chest CT persisted for 14days and was an independent predictor of adverse outcomes in older patients with severe pneumonia. A greater decline in muscle mass was associated with a higher 90-day mortality risk.

Effects of exercise training on muscle wasting, muscle strength and quality of life in adults with acute burn injury

ObjectivesExercise training during the acute phase of burns is difficult to implement but offers potential benefits. This multicenter trial explored the effects of an exercise program on muscular changes and quality of life during burn center stay. MethodsFifty-seven adults with burns ranging between 10% and 70% TBSA were allocated to receive either standard of care (n = 29), or additionally exercise (n = 28), consisting of resistance and aerobic training, commenced as early as possible according to safety criteria. Muscle wasting (primary outcome), quantified by ultrasound-derived quadriceps muscle layer thickness (QMLT) and rectus femoris cross-sectional area (RF-CSA), muscle strength and quality of life (Burn Specific Health Scale-Brief (BSHS-B) and EQ-5D-5L) were assessed at baseline, four and eight weeks later, or hospital discharge. Mixed models were used to analyze between-group changes over time with covariates of interest added in stepwise forward modeling. ResultsThe addition of exercise training to standard of care induced significant improvements in QMLT, RF-CSA, muscle strength and the BSHS-B subscale hand function (ß-coefficient. 0.055 cm/week of QMLT, p = 0.005). No added benefit was observed for other quality-of-life measures. ConclusionsExercise training, administered during the acute phase of burns, reduced muscle wasting, and improved muscle strength throughout burn center stay.

Muscle size, strength, and physical function in response to augmented calorie delivery: A TARGET sub-study

PurposeAugmented calories may attenuate muscle loss experienced in critical illness. This exploratory sub-study assessed the effect of augmented calorie delivery on muscle mass, strength, and function. Materials and methodsPatients in The Augmented versus Routine approach to Giving Energy Trial (TARGET) randomised to 1.5 kcal/ml or 1.0 kcal/ml enteral formulae at a single-centre were included. Ultrasound-derived muscle layer thickness (MLT) at quadriceps, forearm and mid-upper arm, and handgrip strength, were measured weekly from baseline to hospital discharge, and 3- and 6-months. Physical function was assessed at 3- and 6-months using the ‘get up and go’ and 6-min walk tests. Data are mean ± SD. ResultsEighty patients were recruited (1.5 kcal: n = 38, 58 ± 14y, 60%M, APACHE II 20 ± 7; 1.0 kcal: n = 42, 54 ± 18y, 66%M, APACHE II 22 ± 10). The 1.5 kcal/ml group received more calories with no difference in quadriceps MLT at any timepoint including ICU discharge (primary outcome) (2.90 ± 1.27 vs 2.39 ± 1.06 cm; P = 0.141). Relationships were similar for all MLT measures, handgrip strength, and 6-min walk test. Patients in the 1.5 kcal/ml group had improved ‘get up and go’ test at 3-months (6.66 ± 1.33 vs. 9.11 ± 2.94 s; P = 0.014). ConclusionAugmented calorie delivery may not attenuate muscle loss or recovery of strength or function 6-months post-ICU, but this requires exploration in a larger trial.

Reliability and feasibility of skeletal muscle ultrasound in the acute burn setting

ObjectivesDespite the impact of muscle wasting after burn, tools to quantify muscle wasting are lacking. This multi-centre study examined the utility of ultrasound to measure muscle mass in acute burn patients comparing different methodologies. MethodsB-mode ultrasound was used by two raters to determine feasibility and inter-rater reliability in twenty burned adults following admission. Quadriceps muscle layer thickness (QMLT) and rectus femoris cross-sectional area (RF-CSA) were measured, comparing the use of i) a single versus average measurements, ii) a proximal versus distal location for QMLT, and iii) a maximum- versus no-compression technique for QMLT. ResultsAnalysis of twenty burned adults (50 years [95%CI 42–57], 32%TBSA [95%CI 23–40]) yielded ICCs of> 0.97 for QMLT (for either location and compression technique) and> 0.95 for RF-CSA, using average measurements. Relative minimal detectable changes were smaller using no-compression than maximum-compression (6.5% vs. 15%). Using no-compression to measure QMLT was deemed feasible for both proximal and distal locations (94% and 96% of attempted measurements). In 9.5% of cases maximum-compression was not feasible. 95% of RF-CSA measurements were successfully completed. ConclusionUltrasound provides feasible and reliable values of quadriceps muscle architecture that can be adapted to clinical scenarios commonly encountered in acute burn settings.

Is the amino acid pattern in medical nutrition therapy crucial for successfully attenuating muscle mass loss in adult ICU patients? Secondary analysis of a RCT.

We hypothesized that in long-term immobilized intensive care unit (ICU) patients, both the quantity and quality of protein nutrition are vital in supporting muscle mass maintenance. Hence, the aim of this secondary analysis of our recently performed RCT was to calculate the intake of individual amino acids and to evaluate the potential associations of amino acid patterns with muscle mass loss during the ICU stay. Clinical and nutritional data were collected from a recent RCT conducted in long-term immobilized, critically ill patients receiving medical nutrition therapy with either 1.8g (interventional group) or 1.2g (standard group) of protein/amino acids per kg body weight per day over 4 weeks. Intake of the individual amino acids as well as the sum scores of the indispensable, conditionally indispensable, and dispensable amino acids were calculated for all patients, both group specific (n=21 in each group) and in total (n=42), based on the detailed nutrition protocols; inter-group differences were analyzed by t-tests. Linear regression models were used to test the effects of individual amino acids and the sum scores on the extent of skeletal muscle loss by measuring the quadriceps muscle layer thickness during the study period. The significance level was adjusted for multiple testing according to the Bonferroni procedure (α=0.002). In both groups, the proportion of indispensable amino acids was approximately 41% of the total exogenous protein supply, with the proportion of enteral administration slightly over 50%. The intake of conditionally indispensable amino acids (glutamine, tyrosine, cysteine, histidine, and arginine) accounted for 17% and 18% of the total amino acids in the interventional and standard groups, respectively; glutamine (5% of total amino acids) was exclusively administered enterally. The intake of dispensable amino acid varied widely, with glutamic acid, proline, and asparagine/aspartic acid representing the highest proportions (10%, 8%, and 8% of total amino acids, respectively). For all amino acids, no statistically significant association was observed between the quantitative intake and the skeletal muscle changes after terminating the intervention phase. This secondary analysis of the RCT conducted in routine clinical practice did not support our working hypothesis that the amino acid patterns of medical nutrition therapy have a statistically significant impact on the skeletal muscle loss in long-term immobilized ICU patients. Due to the limited variety of enteral/parenteral products used in this single-center study, the calculated amino acid patterns showed only small differences. Larger multi-center trials with adequate power are needed to evaluate the potential effects of the individual amino acids or defined amino acid patterns on the muscle protein metabolism in further detail. German Clinical Trials Register (http://www.drks.de); DRKS-ID: DRKS00013594.

Ultrasound assessment of muscle mass has potential to identify patients with low muscularity at intensive care unit admission: A retrospective study.

Muscle mass is an important biomarker of survival from a critical illness; however, there is no widely accepted method for routine assessment of low muscularity at intensive care unit (ICU) admission. We hypothesize that ultrasound-based partial muscle mass assessments can reflect the trunk muscle mass. Therefore, we aimed to investigate whether ultrasound muscle mass measurements could reflect trunk muscle mass and identify patients with low muscularity. We performed a retrospective analysis of prospectively obtained ultrasound data at ICU admission. We included patients who underwent computed tomography (CT) imaging at the third lumbar vertebra (L3) within 2 days before and 2 days after ICU admission. Primary outcomes included the correlation between the femoral muscle mass measurements using ultrasound and the cross-sectional area (CSA) at L3 obtained by CT. Low muscularity was defined as a skeletal muscle index of 36.0cm2/m2 for males and 29.0cm2/m2 for females. Secondary outcomes included the correlation with the ultrasound measurements of the biceps brachii muscle mass and diaphragm thickness. Among 133 patients, 89 underwent CT imaging, which included the L3. The patient mean age was 72±13 years, and 60 patients (67%) were male. The correlation between the femoral muscle ultrasound and CT was ρ=0.57 (p<0.01, n=89) and ρ=0.48 (p<0.01, n=89) for quadriceps muscle layer thickness and rectus femoris muscle CSA, and these had the discriminative power to assess low muscularity, with the areas under the curve of 0.84 and 0.76, respectively. The ultrasound measurements of the biceps brachii muscle mass and diaphragm thickness were correlated with CT imaging [ρ=0.57-0.60 (p<0.01, n=52) and ρ=0.35 (p<0.01, n=79)]. Ultrasound measurements of muscle mass were correlated with CT measurements, and the measurements of femoral muscle mass were useful to assess low muscularity at ICU admission. UMIN000044032 (retrospectively registered on April 25, 2021).

Peripheral muscular ultrasound as outcome assessment tool in critically ill patients on mechanical ventilation: An observational cohort study.

Survivors of critical illness experience significant skeletal muscle wasting that may predict clinical outcome. Ultrasound (US) is a noninvasive method that can measure muscle quadriceps muscle layer thickness (QMLT) at the bedside. The aim of this study was to determine the muscle loss assessed by ultrasonography (US) of the quadriceps femoris muscle in critically ill patients on mechanical ventilation and its relationship with hospital outcomes. This study involved patients ≥18 years admitted to the intensive care unit who needed mechanical ventilation for at least 48h. The quadriceps muscle layer thickness (QMLT) in the two-thirds of the thigh was quantified using bedside US. The QMLT of the left and right legs on the first (D1), third (D3), and seventh (D7) days were measured. US quadriceps thickness measurements were performed in 74 critically ill patients. The mean age was 62.3±19.5 years, 54.1% of the patients were men, with a BMI of 25.5±4.6kg/m2, SAPS 3 of 55.2±17.2, and NRS of 3.2±1.0. The percentage muscle thickness declined at the right leg in 15% (95%CI, 10.5%-19.4%), and 12.7% (95%CI, 9.1%-16.3%) at the left leg from the first to the seventh day. Receiver operating characteristic showed cutoff value in muscle thickness of ≤1.64cm on day 7 could predict survival (area under then curve=0.7; 95% CI, 0.582-0.801). In Cox regression after adjusting, the probability of patients remaining on mechanical ventilation was higher with ≤1.64cm loss of thigh muscle thickness on day 7; HR=2.1 (95% CI 1.1-3.8, P=0.017). The same occurred about ICU survival probability; HR=3.7 (95% CI 1.2 to 11.5) and hospital survival probability; HR=4.5 (95% CI 1.5 to 13.7). The measurement of QMLT using US showed that critically ill patients on mechanical ventilation presented with muscle wasting and greater loss of muscle thickness was associated with worse outcomes.

Medical high-protein nutrition therapy and loss of muscle mass in adult ICU patients: A randomized controlled trial

BACKGROUND & AIMS The degradation of muscle mass and loss of functional proteins due to catabolism are associated with adverse outcomes in critically ill patients. While an adequate supply of protein within a medical nutrition concept is suggested to minimize proteolysis, the specificities on appropriate dosage and timing are still under debate. The current study aimed to evaluate the effect of two different quantities of protein as part of a standardized energetically controlled nutrition therapy for the preservation of muscle mass in the later phase of critical illness. METHODS A randomized controlled trial was conducted in 42 critically ill patients (age 65 ± 15; 12 females; SAPS 45 ± 11; TISS 20 ± 7; SOFA-score 7 ± 3). The subjects were randomly assigned to either the intervention (1.8 g protein/kg body weight [BW]/d) or standard (1.2 g protein/kg BW/d) group. Nutrient supply via enteral and/or parenteral nutrition was calculated based on the individual energy expenditure measured by indirect calorimetry and target protein content. Quadriceps muscle layer thickness (QMLT) was observed through sonography at inclusion, and during the follow-up period, two and four weeks after inclusion. The measurement points were fixed on two sides at the midpoint and two-thirds between the anterior superior iliac spine and top of the patella. The data were analyzed descriptively wherein chi-squared tests or unpaired two-samle t-tests checked group differences. Daily changes in muscle mass were estimated using a linear mixed model. All data are shown as the mean ± standard deviation (SD). RESULTS Actual protein intake reached 1.5 ± 0.5 g and 1.0 ± 0.5 g/kg BW/d in the intervention and standard group, respectively. Mean values of all measurements of QMLT at inclusion (day 13 ± 2 after ICU admission) were 13.5 ± 7.4 mm and 13.4 ± 7.1 mm in the intervention and standard group, respectively (P = 0.967). In both the groups, QMLT decreased over time (P < 0.001), while the estimated mean values of daily QMLT changes were -0.15 ± 0.08 mm (intervention) and -0.28 ± 0.08 mm (standard) without significant between-group differences (intervention effect, P = 0.368; time x intervention effect, P = 0.242). Illness scores and clinical outcomes showed no group differences. CONCLUSION In this single-center trial the increased amounts of protein (1.5 g vs. 1.0 g/kg BW/d) provided through medical nutrition therapy in the late phase of critical illness did not achieve a statistically significant impact on the loss of muscle mass in long-term immobilized ICU patients. Larger multi-center trials are needed to evaluate whether observed numerical differences in muscle mass could be a true finding, and will translate into improved clinical outcomes. TRIAL REGISTRATION German Clinical Trials Register (http://www.drks.de/), DRKS-ID: DRKS00013594.

Assessment of muscle mass using ultrasound with minimal versus maximal pressure compared with computed tomography in critically ill adult patients

BackgroundPreserved skeletal muscle mass identified using computed tomography (CT) predicts improved outcomes from critical illness; however, CT imaging have few limitations such that it involves a radiation dose and transferring patients out of the intensive care unit. This study aimed to assess in critically ill patients the relationship between muscle mass estimates obtained using minimally invasive ultrasound techniques with both minimal and maximal pressure compared with CT images at the third lumber vertebra level. MethodsAll patients were treated in a single Australian intensive care unit. Eligible patients had paired assessments, within a 72-h window, of muscle mass by ultrasound (quadriceps muscle layer thickness in centimetres, with maximal and minimal pressure) and CT axial cross-sectional area (cm2). Data are presented as mean (standard deviation), median (interquartile range), and frequencies [n (%)]. ResultsThirty-five patients [mean (standard deviation) age = 55 (16) years, median (interquartile range) body mass index = 27 (25–32) kg/m2, and 26 (74%) men] contributed 41 paired measurements. Quadriceps muscle thickness measured using the maximal pressure technique was a strong independent predictor of lumbar muscle cross-sectional area. Within a multivariate mixed linear regression model and adjusting for sex, age, and body mass index, for every 1 cm increase in quadriceps muscle layer thickness, the lumbar muscle cross-sectional area increased by 35 cm2 (95% confidence interval = 11–59 cm2). Similar univariate associations were observed using minimal pressure; however, as per multivariate analysis, there was no strength in this relationship [8 cm2 (95% confidence interval = –5 to 22 cm2)]. ConclusionUltrasound assessment of the quadriceps muscle using maximal pressure reasonably predicts the skeletal muscle at the third lumbar vertebra level of critically ill patients. However, there is substantial uncertainty within these regression estimates, and this may reduce the current utility of this technique as a minimally invasive surrogate for CT assessment of skeletal muscle mass.

Assessment of nutritional status by monitoring quadriceps muscle layer thickness with ultrasonography in intensive care unit: an observational study

Rationale: The reliability of quadriceps muscle layer thickness (QMLT) measurements with ultrasonography (US) remains uncertain for assessing the nutritional status of the critically ill patients in routine clinical practice.

Association between ultrasound quadriceps muscle status with premorbid functional status and 60-day mortality in mechanically ventilated critically ill patient: A single-center prospective observational study

In critically ill patients, direct measurement of skeletal muscle using bedside ultrasound (US) may identify a patient population that might benefit more from optimal nutrition practices. When US is not available, survey measures of nutrition risk and functional status that are associated with muscle status may be used to identify patients with low muscularity. This study aims to determine the association between baseline and changing ultrasound quadriceps muscle status with premorbid functional status and 60-day mortality. This single-center prospective observational study was conducted in a general ICU. Mechanically ventilated critically ill adult patients (age≥18 years) without pre-existing systemic neuromuscular diseases and expected to stay for ≥96h in the ICU were included. US measurements were performed within 48h of ICU admission (baseline), at day 7, day 14 of ICU stay and at ICU discharge (if stay >14 days). Quadriceps muscle layer thickness (QMLT), rectus femoris cross sectional area (RFCSA), vastus intermedius pennation angle (PA) and fascicle length (FL), and rectus femoris echogenicity (mean and standard deviation [SD]) were measured. Patients' next-of-kin were interviewed by using established questionnaires for their pre-hospitalization nutritional risk (nutrition risk screening-2002) and functional status (SARC-F, clinical frailty scale [CFS], Katz activities of daily living [ADL] and Lawton Instrumental ADL). Ninety patients were recruited. A total of 86, 53, 24 and 10 US measures were analyzed, which were performed at a median of 1, 7, 14 and 22 days from ICU admission, respectively. QMLT, RFCSA and PA reduced significantly over time. The overall trend of change of FL was not significant. The only independent predictor of 60-day mortality was the change of QMLT from baseline to day 7 (adjusted odds ratio 0.95 for every 1% less QMLT loss, 95% confidence interval 0.91-0.99; p=0.02). Baseline measures of high nutrition risk (modified nutrition risk in critically ill ≥5), sarcopenia (SARC-F≥4) and frailty (CFS≥5) were associated with lower baseline QMLT, RFCSA and PA and higher 60-day mortality. Every 1% loss of QMLT over the first week of critical illness was associated with 5% higher odds of 60-day mortality. SARC-F, CFS and mNUTRIC are associated with quadriceps muscle status and 60-day mortality and may serve as a potential simple and indirect measures of premorbid muscle status at ICU admission.

Use of Bedside Ultrasound to Assess Muscle Changes in the Critically Ill Surgical Patient.

Critical illness causes hypercatabolism, loss of lean body mass (LBM), and poor outcomes. Evaluating LBM in the critically ill is challenging, and it is uncertain whether nutrition support (NS) impacts LBM. This study measured quadriceps muscle layer thickness (QMLT) by bedside ultrasound (US) to estimate LBM changes in surgical intensive care unit (SICU) patients and healthy controls (HCs). Trained RDNs measured QMLT via US at the midpoint and one-third distance between the superior margin of the patella and the anterior superior iliac spine. QMLT measurements were taken upon enrollment and repeated 1-2 times over 10 days. Fifty-two SICU patients and 15 HCs were enrolled. Average SICU percent QMLT loss per day at the midpoint and one-third landmarks was 3.2 ± 3.8 (P < 0.001) and 2.9 ± 5.7 (P = 0.001); and QMLT loss was higher between the second and third measurements (4.0 ± 8.0, P = 0.005 and 4.3 ± 9.8, P = 0.017 at the midpoint and one-third landmarks) compared with that at the first and second measurements (1.7 ± 9.2, P = 0.20 & 1.7 ± 9.4, P = 0.22). Changes were not associated with NS received. No significant QMLT change was found in HCs. SICU patients significantly lost QMLT over 10 days, with greater losses occurring after 5 days. These results support RDNs performing USs to detect QMLT changes and suggest this technique could be valuable to evaluate LBM changes in critically ill patients.

Nutrition-related outcomes and dietary intake in non–mechanically ventilated critically ill adult patients: A pilot observational descriptive study

BackgroundCritically ill patients who do not receive invasive mechanical ventilation (IMV) are a growing population, experiencing complex interventions that may impair dietary intake and nutrition-related outcomes. ObjectivesThe objectives of this study were to quantify intake and nutrition-related outcomes of non-IMV critically ill patients and to establish feasibility of methods to measure nutrition-related outcomes in this population. MethodsNon-IMV adult patients expected to remain in the intensive care unit (ICU) for ≥24 h were eligible. Nutrition-related outcomes were assessed at baseline by subjective global assessment (SGA); on alternate study days by mid-upper arm circumference (MUAC), calf circumference (CC), and ultrasound of quadriceps muscle layer thickness (QMLT); and daily by body weight and bioelectrical impedance analysis (BIA). Data were censored at day 5 or ICU discharge. Dietary intake from all sources, including oral intake via investigator-led weighed food records, was quantified on days 1–3. Feasibility was defined as data completion rate ≥70%. Data are expressed as mean (standard deviation) or median [interquartile range (IQR)]. ResultsTwenty-three patients consented (50% male; 53 [42–64] y; ICU stay: 2.8 [1.9–4.0] d). Nutrition-related outcomes at baseline and ICU discharge were as follows: MUAC: 33.2 (8.6) cm (n = 18) and 29.3 (5.4) cm (n = 6); CC: 39.5 (7.4) cm (n = 16) and 37.5 (6.2) cm (n = 6); body weight: 95.3 (34.8) kg (n = 19) and 95.6 (41.0) kg (n = 10); and QMLT: 2.6 (0.8) cm (n = 15) and 2.5 (0.3) cm (n = 5), respectively. Oral intake provided 3155 [1942–5580] kJ and 32 [20–53] g protein, with poor appetite identified as a major barrier. MUAC, CC, QMLT, and SGA were feasible, while BIA and body weight were not. ConclusionsOral intake in critically ill patients not requiring IMV is below estimated requirements, largely because of poor appetite. The small sample and short study duration were not sufficient to quantify changes in nutrition-related outcomes. MUAC, CC, QMLT, and SGA are feasible methods to assess nutrition-related outcomes at a single time point in this population.

Measuring nutrition‐related outcomes in a cohort of multi‐trauma patients following intensive care unit discharge

Functional recovery is an important outcome for those who survive critical illness. The present study aimed to assess nutrition provision and nutrition-related outcomes in a multi-trauma cohort following intensive care unit (ICU) discharge. The present study investigated a prospective cohort of patients discharged from an ICU, who had been admitted because of major trauma and required mechanical ventilation for at least 48h. Nutrition-related outcomes, including body weight, quadriceps muscle layer thickness (QMLT), handgrip strength and subjective global assessment, were recorded on ICU discharge, days 5-7 post-ICU discharge and then weekly until hospital discharge. Nutrition intake was recorded for 5days post-ICU discharge. Unless otherwise stated, data are presented as the mean (SD). Twenty-eight patients [75% males, 55 (22.5)years] were included. Intake met 64% (28%) of estimated energy and 72% (32%) of protein requirements over the 5days post-ICU discharge, which was similar to over the ICU admission. From ICU admission to hospital discharge, the mean reduction in weight was 4.2kg (95% confidence interval=2.2-6.3, P<0.001) and after ICU discharge, the mean reduction in weight and QMLT was 2.6kg (95% confidence interval=1.0-4.2, P=0.004) and 0.23cm (95% confidence interval=0.06-0.4, P=0.01), respectively. Patients received less energy and protein than estimated requirements after ICU discharge. Weight loss and reduction in QMLT also occurred during this period.

Ultrasonography to measure quadriceps muscle in critically ill patients: A literature review of reported methodologies.

Muscle wasting in the intensive care unit (ICU) is common and may impair functional recovery. Ultrasonography (US) presents a modern solution to quantify skeletal muscle size and monitor muscle wasting. However, no standardised methodology for the conduct of ultrasound-derived quadriceps muscle layer thickness or cross-sectional area in this population exists. The aim of this study was to compare methodologies reported for the measurement of quadriceps muscle layer thickness (MLT) and cross-sectional area (CSA) using US in critically ill patients. Databases PubMed, Ovid, Embase, and CINAHL were searched for original research publications that reported US-derived quadriceps MLT and/or CSA conducted in critically ill adult patients. Data were extracted from eligible studies on parameters relating to US measurement including anatomical location, patient positioning, operator technique and image analysis. It was identified that there was a clear lack of reported detail and substantial differences in the reported methodology used for all parameters. A standardised protocol and minimum reporting standards for US-derived measurement of quadriceps muscle size in ICU is required to allow for consistent measurement techniques and hence interpretation of results.

Targeted Full Energy and Protein Delivery in Critically Ill Patients: A Pilot Randomized Controlled Trial (FEED Trial).

International guidelines recommend greater protein delivery to critically ill patients than they currently receive. This pilot randomized clinical trial aimed to determine whether a volume-target enteral protocol with supplemental protein delivered greater amounts of protein and energy to critically ill patients compared with standard care. Sixty participants received either the intervention (volume-based protocol, with protein supplementation) or standard nutrition care (hourly-rate-based protocol, without protein supplementation) in the intensive care unit (ICU). Coprimary outcomes were average daily protein and energy delivery. Secondary outcomes included change in quadriceps muscle layer thickness (QMLT, ultrasound) and malnutrition (subjective global assessment) at ICU discharge. Mean (SD) protein and energy delivery per day from nutrition therapy for the intervention were 1.2 (0.30) g/kg and 21 (5.2) kcal/kg compared with 0.75 (0.11) g/kg and 18 (2.7) kcal/kg for standard care. The mean difference between groups in protein and energy delivery per day was 0.45 g/kg (95% CI, 0.33-0.56; P < .001) and 2.8 kcal/kg (95% CI, 0.67-4.9, P = .01). Muscle loss (QMLT) at discharge was attenuated by 0.22 cm (95% CI, 0.06-0.38, P = .01) in patients receiving the intervention compared with standard care. The number of malnourished patients was fewer in the intervention [2 (7%) vs 8 (28%); P = .04]. Mortality and duration of admission were similar between groups. A high-protein volume-based protocol with protein supplementation delivered greater amounts of protein and energy. This intervention was associated with attenuation of QMLT loss and reduced prevalence of malnutrition at ICU discharge.