Solunum yetmezliği nedeniyle yoğun bakım ünitesine kabul edilen hastalarda mortalite tahmini; beslenme tarama araçları mNUTRIC ve NRS-2002'nin kullanımı

Abstract

Amaç: Bu çalışmanın amacı, Kritik Hastalarda Modifiye Beslenme Riski (mNUTRIC) ve Beslenme Riski Taraması-2002 (NRS-2002) beslenme tarama araçlarının solunum yetmezliği (SY) ile yoğun bakım ünitesine (YBÜ) kabul edilen hastalarda mortaliteyi tahmin etmedeki etkinliğini ve bu etkinliğin SY tipine göre değişip değişmediğini incelemektir. Yöntemler: Bu prospektif, kohort, tanımlayıcı çalışma etik kurul onayından sonra başlatıldı. Altı aylık bir süre boyunca, üçüncü basamak YBÜ'lere akut SY ile kabul edilen, tip 1 ve tip 2 SY olan ve 48 saatten fazla kalan tüm yetişkin hastalar (≥18 yaş) dahil edildi. Hastalar hayatta kalanlar ve hayatta kalmayanlar olmak üzere iki gruba ayrıldı. Beslenme taraması mNUTRIC ve NRS-2002 ile yapıldı. Beslenme araçlarından herhangi birinden alınan 5 puan veya üzeri skorlar yüksek beslenme riski göstergesi olarak kabul edildi. Çoklu lojistik regresyon analizi, 1 aylık (30 günlük) ve 3 aylık (90 günlük) mortaliteyi öngören verileri test etmek için kullanıldı. Beslenme araçlarının mortalite üzerindeki rölatif risk (RR) değerleri hesaplandı. Sonuçlar: Çalışma popülasyonu akut SY ile başvuran 525 hastadan oluşmaktaydı ve bunların %35,4'ünde tip 1 SY ve %64,6'sında tip 2 SY vardı. Mortalite oranları bir ayda %44,2 ve üç ayda %62,5 olup her iki dönemde de tip 1 SY'de daha yüksek mortalite gözlendi. mNUTRIC skoru, inotropik destek varlığı, tip 1 SY ve servisten kabul, 1. ve 3. aylarda mortalite ile anlamlı ilişkisi olan bağımsız değişkenler olarak tanımlandı. mNUTRIC skoru her iki dönemde de mortalite ile en güçlü şekilde ilişkili değişken olarak saptandı. mNUTRIC skoru tek başına değerlendirildiğinde, optimum kesme değeri 6 olarak belirlendi. mNUTRIC tarafından tanımlanan beslenme riski olan hastalarda, bir ay ve üç ay içinde dört kat daha yüksek mortalite riski saptandı. Sonuç: SY'li hastalarda, mNUTRIC skoru yüksek riskli grubu tanımlamak için en güçlü parametredir. Tip 1 SY'li hastalarda prognoz tip 2'ye kıyasla daha kötüdür. Özellikle mNUTRIC skoru yüksek, inotropik desteğe ihtiyaç duyan, tip 1 SY bulguları olan ve servis yatışı sırasında YBÜ ihtiyacı doğan hasta grubunda beslenme açısından erken müdahale ve yönetim, yoğun bakımda kalış süresini ve mortalite oranlarını iyileştirmek için önemlidir.

Keywords

• akut solunum yetmezliği
• yoğun bakım ünitesi
• mortalite
• mNUTRIC
• NRS-2002

Prediction of mortality in patients admitted to the intensive care unit due to respiratory failure; use of nutritional screening tools mNUTRIC and NRS-2002

Abstract

Aims: The objective of this study was to examine the effectiveness of the nutritional screening tools modified nutrition risk in the critically ill (mNUTRIC) and nutrition risk screening-2002 (NRS-2002) in predicting mortality among patients admitted to the intensive care unit (ICU) with acute respiratory failure (ARF) and to determine if their effectiveness varies by respiratory failure (RF) type. Methods: This prospective, cohort, descriptive study was initiated after ethics committee approval. During a 6-month period, all adult patients (aged ≥18 years) admitted to the tertiary ICUs with acute RF, with type 1 and type 2 RF, who stayed for more than 48 hours were included. Patients were divided into two groups: survivors and non-survivors. Nutritional screening was performed with mNUTRIC and NRS-2002. Scores of 5 points or more on any of the nutritional tools were considered to indicate high nutritional risk. Multiple logistic regression analysis was used to test data predicting 1-month (30-day) and 3-month (90-day) mortality. Relative risk (RR) values of the nutritional tools on mortality were calculated. Results: Among 525 patients, 35.4% had type 1 RF, and 64.6% had type 2 RF. The mortality rates were 44.2% at one month and 62.5% at three months, with higher mortality observed in type 1 RF in both periods. The mNUTRIC score, the presence of inotropic support, type 1 RF, and admission from the ward were identified as independent variables with a significant association with mortality at 1 and 3 months. The mNUTRIC score emerged as the variable most strongly associated with mortality in both periods. When the mNUTRIC score was evaluated in isolation, the optimal cut-off value was determined to be 6 (1-month mortality AUC: 0.77, 3-month mortality AUC: 0.82). Patients with nutritional risk, as identified by mNUTRIC, exhibited a fourfold elevated risk of mortality within one month (RR=4.2; 95% CI: 2.56–6.95; p<.001) and three months (RR=4.6; 95% CI: 3.04–7.15; p<.001). Combining mNUTRIC and NRS-2002 scores did not significantly enhance predictive accuracy compared to mNUTRIC alone. Conclusion: In patients with RF, the mNUTRIC score is the most powerful parameter for identifying the high-risk group. The prognosis is worse in patients with type 1 RF compared to type 2. Especially in the group of patients with high mNUTRIC score, in need of inotropic support, type 1 RF findings, and the need for ICU during hospitalization, early intervention and management in terms of nutrition is important to improve the duration of intensive care stay and mortality rates.

Keywords

• Acute respiratory failure
• intensive care unit
• mortality
• mNUTRIC
• NRS-2002

References

1. Bellani G, Laffey JG, Pham T, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. Jama. 2016;315(8):788-800. doi:10. 1001/jama.2016.0291
2. Linko R, Okkonen M, Pettilä V, et al. Acute respiratory failure in intensive care units. FINNALI: a prospective cohort study. Intensive Care Med. 2009;35(8):1352-1361. doi:10.1007/s00134-009-1519-z
3. Roupie E, Lepage E, Wysocki M, et al. Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients. SRLF Collaborative group on mechanical ventilation. Société de Réanimation de Langue Française. Intensive Care Med. 1999;25(9):920-929. doi:10.1007/s001340050983
4. Mirabile VS, Shebl E, Sankari A, Burns B. Respiratory failure in adults. StatPearls (serial online) 2023 June 11 (cited 2024 December 20). Available from: https://www.ncbi.nlm.nih.gov/books/NBK526127.
5. Lagina M, Valley TS. Diagnosis and management of acute respiratory failure. Crit Care Clin. 2024;40(2):235-253. doi:10.1016/j.ccc.2024.01.002
6. Taylor BE, McClave SA, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: society of critical care medicine (SCCM) and American society for parenteral and enteral nutrition (A.S.P.E.N.). Crit Care Med. 2016;44(2):390-438. doi:10.1097/CCM.0000000000001525
7. Singer P, Doig GS, Pichard C. The truth about nutrition in the ICU. Intensive Care Med. 2014;40(2):252-255. doi:10.1007/s00134-013-3162-y
8. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr. 2003;22(3):321-36. doi:10.1016/s0261-5614(02) 00214-5

9. Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care. 2011; 15(6):1-11. doi:10.1186/cc10546
10. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79. doi:10. 1016/j.clnu.2018.08.037
11. Rahman A, Hasan RM, Agarwala R, Martin C, Day AG, Heyland DK. Identifying critically-ill patients who will benefit most from nutritional therapy: Further validation of the "modified NUTRIC" nutritional risk assessment tool. Clin Nutr. 2016;35(1):158-162. doi:10.1016/j.clnu.2015. 01.015
12. Machado Dos Reis A, Marchetti J, Forte Dos Santos A, Franzosi OS, Steemburgo T. NUTRIC score: isolated and combined use with the NRS-2002 to predict hospital mortality in critically ill patients. JPEN J Parenter Enteral Nutr. 2020;44(7):1250-1256. doi:10.1002/jpen.1804
13. Halpin DMG, Criner GJ, Papi A, et al. Global initiative for the diagnosis, management, and prevention of chronic obstructive lung disease. The 2020 GOLD science committee report on COVID-19 and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021;203(1): 24-36. doi:10.1164/rccm.202009-3533SO
14. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: society of critical care medicine (SCCM) and American society for parenteral and enteral nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211. doi:10.1177/0148607115621863
15. Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38(1):65-71. doi:10.1097/CCM.0b013e 3181b090d0
16. Vincent JL, Akça S, De Mendonça A, et al. The epidemiology of acute respiratory failure in critically ill patients(*). Chest. 2002;121(5):1602-1609. doi:10.1378/chest.121.5.1602
17. Villgran VD, Lyons C, Nasrullah A, Clarisse Abalos C, Bihler E, Alhajhusain A. Acute respiratory failure. Crit Care Nurs Q. 2022;45(3): 233-247. doi:10.1097/CNQ.0000000000000408
18. Sbaih N, Hawthorne K, Lutes J, Cavallazzi R. Nutrition therapy in non-intubated patients with acute respiratory failure. Curr Nutr Rep. 2021; 10(4):307-316. doi:10.1007/s13668-021-00367-z
19. Grant JP. Nutrition care of patients with acute and chronic respiratory failure. Nutr Clin Pract. 1994;9(1):11-17. doi:10.1177/011542659400900111
20. Canales C, Elsayes A, Yeh DD, et al. Nutrition risk in critically ill versus the nutritional risk screening 2002: are they comparable for assessing risk of malnutrition in critically ill patients? JPEN J Parenter Enteral Nutr. 2019;43(1):81-87. doi:10.1002/jpen.1181
21. Raslan M, Gonzalez MC, Torrinhas RS, Ravacci GR, Pereira JC, Waitzberg DL. Complementarity of Subjective Global Assessment (SGA) and Nutritional risk screening 2002 (NRS 2002) for predicting poor clinical outcomes in hospitalized patients. Clin Nutr. 2011;30(1):49-53. doi:10.1016/j.clnu.2010.07.002
22. Gonzalez MC, Bielemann RM, Kruschardt PP, Orlandi SP. Complementarity of NUTRIC score and Subjective Global Assessment for predicting 28-day mortality in critically ill patients. Clin Nutr. 2019; 38(6):2846-2850. doi:10.1016/j.clnu.2018.12.017
23. Auiwattanakul S, Chittawatanarat K, Chaiwat O, et al. Effects of nutrition factors on mortality and sepsis occurrence in a multicenter university-based surgical intensive care unit in Thailand (THAI-SICU study). Nutrition. 2019;58:94-99. doi:10.1016/j.nut.2018.06.021
24. Maciel L, Franzosi OS, Nunes DSL, et al. Nutritional risk screening 2002 cut-off to identify high-risk is a good predictor of ICU mortality in critically ill patients. Nutr Clin Pract. 2019;34(1):137-141. doi:10.1002/ncp.10185