Comparison of Nutric Score, Nutritional Risk Screening (NRS) 2002 and Subjective Global Assessment (SGA) in the ICU: a Cohort Study

Abstract

Nutritional screening for malnutrition is the first step in the nutrition care plan process.There is multiple tools that have been utilized for nutritional screening. Many patients admitted to the intensive care units are known to have a very high risk for malnutrition. Various countries and also various intensive care units in different intensive care units in the same country also have different tools to screen out patients at risk for malnutrition. Among the most frequently used are the Nutric score, the SGA (subjective global assessment) and the NRS (nutrition risk screening) 2002. We compared the level of agreement between the Nutric score, Nutritional Risk Screening (NRS) 2002 and Subjective Global Assessment (SGA) for nutritional risk assessment and for predicting length of ICU stay (LOS-ICU), length of hospital stay (LOS-HOSP) and in-hospital mortality. Received: 01 October, 2019; Accepted: 03 December, 2019; Published: 10 December, 2019 *Corresponding author: Sanjith Saseedharan, University: s l raheja hospital, Address: dept of critical care, s l raheja hospital, raheja rugnalaya marg mahim, mumbai400016, Tel: 00919004479549, E-mail: [email protected] Introduction Patients admitted to the intensive care unit (ICU) are usually at high risk of malnutrition [1, 2]. Critical illness is associated with a very high energy expenditure and an uncontrolled cachexia at times which leads to high amount of protein loss associated with weight loss. This resetting of the homeostasis leads to various other problems like electrolytes abnormality, increased length of hospital and ICU stay, increase duration on mechanical ventilator, reduction in muscle power, failure to thrive etc. These patents if not picked up early go onto a phase of prolonged acute critical illness followed by a phase of chronic critical illness. This causes marked reduction of quality of life. Hence identifying these patients early might help in tackling the issue by helping to reduce iatrogenic underfeeding or overfeeding. This demand for some form of screening tool to identify at-risk patients early. There are many tools, subjective and objective, but unfortunately there is no single standard tool used to assess nutritional status. The commonly used scores which have been validated include the Nutric score, the NRS 2002 and the SGA (subjective global assessment). The purpose of our study was to compare the accuracy of Nutric score, NRS 2002 and SGA in predicting LOSICU, LOS-HOSP and in-hospital mortality. Materials and Methods A total of 348 consecutive patients admitted between March to June 2016 in a mixed (medical/surgical) ICU were assessed on day of admission using the three screening tools separately to classify them into high-risk and low-risk of malnutrition. A trained intensive care doctor and a dietitian were involved in the data collection. Day 1 APACHE 2 scores and demographic data (weight, height, age, sex) were recorded. LOS-ICU (length of Stay in the ICU), LOS-HOSP (length of stay in the hospital) and inhospital mortality and secondary outcomes were studied, need for supplemental nutritional support (enteral/parenteral), need for ventilation (non-invasive/invasive) and need for dialysis in high-risk and low-risk patients by each nutrition assessment tool were studied. These data were all compiled using the “inutrimon” software which is a data management software developed by the author which helps in suggestion and optimization of feeding process All the data were compiled and analyzed with the Chi square test and t-test. Level of agreement (Kappa) and Odds ratio were also calculated. Results Of the 348 patients studied, 221 (63.5%) were males and 127 (36.5%) were females as seen in Table 1. In males, 32.13% were at a low risk while 67.87% were at a high risk. In females, 28.35% were at a low risk while 71.65% were at a high risk. Chi square test was used and the p value was found to be 0.462 (p>0.05). Table 2 shows the chronic comorbidities and admission diagnosis of the patients. The mean APACHE 2 score for low risk patients was 8.04 with a standard deviation of 3.4 whereas for high risk patients it was 15.11 with a standard deviation of 6.1. Using the T test the p value was calculated to be 0.000 (p<0.05) which is statistically significant. This suggests that patients with high risk of nutrition had a higher APACHE 2 score. The Nutric score, NRS 2002 and SGA identified high-risk of malnutrition in 10.63%, 64.94% and 40.81% patients respectively Page 2 of 4 Citation: Sanjith S. (2019) IComparison of Nutric Score, Nutritional Risk Screening (NRS) 2002 and Subjective Global Assessment (SGA) in the ICU: a Cohort Study. J Nutrition Health Food Sci 7(4):1-4. DOI: 10.15226/jnhfs.2019.001165 Comparison of Nutric Score, Nutritional Risk Screening (NRS) 2002 and Subjective Global Assessment (SGA) in the ICU: a Cohort Study Copyright: © 2019 Sanjith S, et al. as shown in Table 3. 67.87% males and 71.65% females were found to be at a high risk of malnutrition by at least one of the scores as shown in Table 1. The mean APACHE 2 score for patients at high risk (using any one screening tool) was 15.11 (SD 6.10) and 8.04 for the low risk group (SD 3.34; p <0.01). 64.9 percent and 40.8 percent of patients were detected as high risk for malnutrition by NRS 2002 and SGA respectively, while only 10.6 percent patients were classified as high risk for malnutrition by the Nutric score. A statistically significant highest level of agreement (kappa score-0.38) was seen between SGA and NRS 2002 in screening out patients with high and low risk of malnutrition Table 4. The NRS 2002 and SGA demonstrated statistically significant correlation (p=0.001) for length of ICU stay for both the high risk and low risk group whereas only the NRS 2002 correlated significantly for the length of hospital stay (p=0.002). Mortality was significantly higher in high risk patients identified using all 3 scores but the odds ratio of mortality in high risk patients vs low risk patients was highest with the nutric was 168.7 as compared to 8.08 with NRS 2002 and 7.95 with SGA Table 5. Table 1: Baseline characteristics of 348 ICU patients at low risk and high risk of malnutrition Patient Characteristics Total Low-risk group N= 107 High-risk group N= 241 P value Sex Males 221 71 (32.13%) 150 (67.87%) 0.462 Females 127 36 (28.35%) 91 (71.65%) Table 2: Chronic comorbidities and admission diagnosis Chronic Comorbidities Diabetes Mellitus 42 (35.9%) 97 (30.4%) Hypertension 41 (35%) 108 (33.9%) Ischemic Heart Disease 11 (9.4%) 37 (11.6%) Chronic kidney disease 4 (3.4%) 24 (7.5%)