Determination of the most effective nutritional risk screening tool to predict clinical outcomes in intensive care unit patients

Blanckenberg, Christa (2012-12)

Thesis (MNutr)--Stellenbosch University, 2012.

Thesis

ENGLISH ABSTRACT: Introduction: Malnutrition, as defined by the Malnutrition Universal Screening Tool (MUST), Mini-Nutritional Assessment-Short Form (MNA-SF), Subjective Global Assessment (SGA), Nutritional Risk Screening Tool-2002 (NRS-2002), Short Nutritional Assessment Questionnaire (SNAQ), Nutritional Risk Indicator (NRI) and Malnutrition Screening Tool (MST), has been associated with adverse outcomes in hospitalised patients. Therefore nutritional risk screening is recommended for all hospitalised patients to improve the recognition and treatment of malnutrition. However, little is known about the use of screening tools in an intensive care unit (ICU) setting. The aim of this study was to assess which of these screening tools could best predict clinical outcomes in ICU patients and to comment on their feasibility, in order to make suggestions on their applicability for this patient population. Methods: Over an eight month study period all patients (>18years) with a surgical ICU stay of >48 hours were included. Patients were screened within 48 hours of admission using each of the seven screening tools. Clinical outcomes (mortality, APACHE II score, length of stay (LOS), length of ventilation (LOV), complications, serum-albumin, white cell count (WCC) and C-reactive protein) were recorded until discharge or death. Feasibility and applicability of the screening tools were also assessed. Results: A total of 206 patients (62.6% males) were included. The average age was 49.5 ±17.4 years and average LOS was 5.7 ± 5.5 days. Screening was not feasible in 18.3% of patients. The MUST classified 18.9% of patients as at risk of malnutrition and 30.1% as malnourished, but was not predictive of any clinical outcomes. According to the MNA-SF, 52.2% of patients were at risk of malnutrition and 16.5% were malnourished. This was associated with progressively decreasing serum-albumin levels (p<0.01) and WCC (p=0.01). The SGA classified 30.6% of patients as moderately and 18.4% of patients as severely malnourished and was significantly associated with LOS (p=0.03), LOV (p=0.01), mild complications (p=0.04) and serum-albumin (p=0.01). However, except for serum-albumin which progressively declined with a poorer nutritional status, the moderately malnourished patients showed the worst outcomes and the severely malnourished patients the best. According to the NRS-2002, 72.8% of patients were malnourished; and this correlated significantly with LOV (p=0.02) and the development of moderate (p=0.04) and total (p=0.01) complications. A non-significant but consistent trend for worse results in the malnourished group was also seen for the other outcomes studied. The SNAQ classified 35.9% of patients as malnourished or at risk thereof. This was associated with lower serum-albumin levels (p=0.04), but also with decreased LOV (p<0.01). The NRI classified 2.3% of patients as mildly malnourished, 21.0% as moderately malnourished and 75.0% as severely malnourished and only effectively predicted serum-albumin (p<0.01). The MST classified 78.2% of patients as malnourished and this was predictive of developing more complications (p<0.01). Almost all of the other variables also showed worse outcomes for the malnourished group, but this was not significant. Conclusion: Screening in an ICU seems to have only moderate feasibility and applicability and limited value. Only the NRS-2002 and MST showed potential for predicting clinical outcomes in ICU patients.

AFRIKAANSE OPSOMMING: Inleiding: Wanvoeding, soos gedefinineer deur die “Malnutrition Universal Screening Tool” (MUST), “Mini-Nutritional Assessment-Short Form” (MNA-SF), “Subjective Global Assessment” (SGA), “Nutritional Risk Screening Tool-2002” (NRS-2002), “Short Nutritional Assessment Questionnaire” (SNAQ), “Nutritional Risk Indicator” (NRI) en die “Malnutrition Screening Tool” (MST), is al met nadelige uitkomste in hospitaal pasiënte geassosieer. Daarom word voedings-risiko-sifting vir alle gehospitaliseerde pasiënte aanbeveel om die herkenning en behandeling van wanvoeding te verbeter. Daar is egter min bekend oor die gebruik van siftingshulpmiddele in ‘n intensiewe sorg eenheid (ISE) omgewing. Die doel van die studie was om te assesseer watter van hierdie siftingshulpmiddele kliniese uitkomste in ISE pasiënte die beste kon voorspel en om kommentaar te lewer op die uitvoerbaarheid daarvan, om sodoende voorstelle te maak oor die toepaslikheid daarvan vir hierdie pasiënt populasie. Metodes: Alle pasiënte (>18 jaar) met ‘n chirurgiese ISE verblyf van >48 uur gedurende ‘n ag maande studieperiode is ingesluit. Pasiënte is binne 48 uur na toelating gesif m.b.v. al sewe siftingshulpmiddele. Kliniese uitkomste (mortaliteit, APACHE II telling, lengte van verblyf (LVVer), lengte van ventilasie (LVVen), komplikasies, serum-albumien, witseltelling (WST) en C-reaktiewe proteïen) is genoteer tot en met ontslag of dood. Uitvoerbaarheid en toepaslikheid van die siftingshulpmiddele is ook geassesseer. Resultate: ‘n Totaal van 206 pasiënte (62.6% manlik) is ingesluit. Die gemiddelde ouderdom was 49.5 ±17.4 jare en die gemiddelde LVVer was 5.7 ± 5.5 dae. Siftings was onuitvoerbaar in 18.3% van die pasiënte. Die MUST het 18.9% van die pasiënte as wanvoeding-risikogevalle geklassifiseer en 30.1% as wangevoed, maar kon nie enige kliniese uitkomste voorspel nie. Volgens die MNA-SF was 52.2% van die pasiënte wanvoeding-risikogevalle en 16.5% was wangevoed. Dit was geassosieer met progressief dalende serum-albumienvlakke (p<0.01) sowel as WST (p=0.01). Die SGA het 30.6% van pasiënte as matig en 18.4% as erg wangevoed geklassifiseer en het ‘n beduidende assosiasie met LVVer (p=0.03), LVVen (p=0.01), ligte komplikasies (p=0.04) en serum-albumien (p=0.01) getoon. Behalwe vir serum-albumien wat progressief verlaag het met ‘n swakker voedingstatus, het die matig wangevoede pasiënte egter die swakste uitkomste getoon en die erg wangevoede pasiënte die beste. Volgens die NRS-2002 was 72.8% van die pasiënte wangevoed en dit het ‘n beduidende korrelasie met LVVen (p=0.02) en die ontwikkeling van matige (p=0.04) en totale (p=0.01) komplikasies gehad. ‘n Nie-beduidende, maar konsekwente neiging vir swakker resultate in die wangevoede groep is ook vir die ander studie-uitkomste gesien. Die SNAQ het 35.9% van pasiënte as wangevoed of as risikogevalle daarvoor geklassifiseer. Dit was geassosieer met laer serum-albumienvlakke (p=0.04), maar ook met ‘n korter LVVen (p<0.01). Die NRI het 2.3% van pasiënte as lig, 21.0% as matig en 75.0% as erg wangevoed geklassifiseer en het slegs serum-albumien effektief voorspel (p<0.01). Die MST het 78.2% van pasiënte as wangevoed geklassifiseer en dit het die ontwikkeling van meer komplikasies (p<0.01) voorspel. Amper al die ander veranderlikes het ook swakker uitkomste getoon in die wangevoede groep, maar dit was nie-beduidend. Gevolgtrekking: Dit blyk of sifting in ‘n ISE slegs matige uitvoerbaarheid en toepaslikheid en beperkte waarde het. Slegs die NRS-2002 en die MST het potensiaal gewys om kliniese uitkomste in ISE pasiënte te voorspel.

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