Original articleIdentifying critically-ill patients who will benefit most from nutritional therapy: Further validation of the “modified NUTRIC” nutritional risk assessment tool
Introduction
Heyland et al. previously proposed a novel scoring tool, the Nutrition Risk in Critically ill (NUTRIC) score, which is the first nutritional risk assessment tool developed and validated specifically for intensive care unit (ICU) patients [1]. Many other risk scores and assessment tools exist to quantify nutrition risk [2], [3], [4], [5], [6], [7] but none have been specifically designed for ICU patients [7]. Indeed, they generally consider all critically ill patients to be at high nutritional risk [2], [8]. However, the recognition that not all ICU patients will respond the same to nutritional interventions was the critical concept behind the NUTRIC score [1], [8], [9]. The conceptual model incorporated candidate predictor markers of acute starvation, chronic starvation, acute inflammation and chronic inflammation [1], [9]. All candidate predictors incorporated into our final model predictors were significantly associated with 28-day mortality [1]. Measure of under-nutrition, such as history or reduced oral intake or recent weight loss, did not factor into the final model because of significant amounts of missing data. The final composite score accurately identified those patients who had higher mortality rates or survivors with longer lengths of stay. In addition, there was an interaction between mortality, nutritional intake and NUTRIC score suggesting that those with higher NUTRIC scores (6 or more) benefited the most from increasing nutritional intake. However, the inferences about the validity of the NUTRIC score are limited because they are derived and validated in the same database.
Many methods of nutritional screening in hospitalized patients are cumbersome and time-consuming and hence are not routinely done [10]. The NUTRIC score is easy to calculate as it contains variables that are mostly easy to obtain in the critical care setting, with the exception of IL-6 levels which is not commonly measured. In practice, many units are using the NUTRIC score without the IL-6 level and the question remains as to the validity of the validity of the NUTRIC score without IL-6 level (modified NUTRIC score). The second stage in development of a clinical ICU prediction model is external validation [11]. The aim of this study is to externally validate [11] this modified NUTRIC score in a second, population of critically ill patients. We hypothesize that the modified NUTRIC score will retain its validity in this new database by omitting the IL-6 levels, and we can increase the clinical utility of the tool.
Section snippets
Methods
This study was a post hoc analysis of an existing database derived from a randomized control trial conducted in 40 tertiary ICU's in Europe and North America, after ethics approval was obtained. The purpose of the trial was to evaluate the effectiveness of glutamine and antioxidant supplementation in critically ill patients [12]. All patients were attempted to be fed according to the Canadian Critical Care Nutrition practice guidelines, independent of study supplements [12]. The trial
Results
Five patients withdrew consent prior to treatment and were not evaluable for 28-day mortality, and the amount of calories received was not known for an additional 19 patients. Thus, the current analysis included 1199 patients.
The overall 28-day mortality rate in this validation sample is 29.0% compared to 23.1% in the NUTRIC development sample. The distribution of the items included in the NUTRIC risk score are presented for both this validation sample and the previous development sample in
Discussion
We set out to provide a second validation of the NUTRIC score in a second database and this time, without IL-6 levels. We report that a logistic model with NUTRIC score, excluding IL-6, as the sole continuous independent variable predicted mortality with odds of mortality multiplied by 1.4 (95% CI, 1.3–1.5) for every point increase on the NUTRIC score. We demonstrate that increased nutritional adequacy is associated with increased survival in patients with higher NUTRIC scores (≥6) but not in
Conclusion
We have demonstrated independent validation of the NUTRIC score without IL-6 levels to help discriminate which ICU patients will benefit more (or less) from early adapted protein-energy provision. This scoring tool represents the first nutritional risk assessment tool developed and validated specifically for ICU patients. The NUTRIC score is a practical, easy-to-use tool based on variables that are easy to obtain in the critical care setting. We assert that not all ICU patients are the same,
Conflict of interest
None declared.
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