Kris M. Mogensen

Improving Nutritional Screening of Hospitalized Patients: The Role of Prealbumin

BACKGROUND Limited resources prevent hospitals from having all patients formally evaluated by a nutrition expert. Thus, hospitals rely on nutrition-screening tools to identify malnourished patients. The purpose of this study was to determine the effectiveness of a nutrition-screening protocol, prealbumin (PAB), retinol binding protein (RBP), and albumin (ALB) in identifying malnourished hospitalized patients. METHODS A nutrition screening protocol was prospectively used in medical and surgical patients and consisted of a nurse administering a questionnaire to patients and requesting formal evaluation by a registered dietitian (RD) only if nutritional issues were identified. Patients also had ALB, PAB, and RBP drawn, which were used to both screen and identify the malnourished. PAB, RBP, and ALB were compared as predictors of RD classification of patient nutritional status. RESULTS The nutrition-screening protocol classified 104 of 320 patients (33%) as malnourished. However, 43% of the patients were not deemed at nutritional risk according to this protocol and therefore did not receive RD assessment. PAB was a significant predictor of RD-determined nutritional status (p < .05), whereas RBP and ALB were not. PAB screening/assessment identified 50% (162/320) of the patients as being malnourished. Notably, 50% of the patients (71 of 142) who were not evaluated by an RD were identified as malnourished using PAB criteria. The nutrition-screening protocol took 1.2 days longer to determine malnourishment compared with PAB (p = .0021). CONCLUSIONS Use of screening questionnaires may miss or delay identification of malnourished patients. PAB screening/assessment may improve identification of those patients requiring nutrition intervention and thus enhance the care of hospitalized individuals.

Improved care and reduced costs for patients requiring peripherally inserted central catheters: the role of bedside ultrasound and a dedicated team.

BACKGROUND We conducted a prospective quality assurance (QA) study to determine if a team dedicated to placing peripherally inserted central catheters (PICCs) would improve patient care and reduce costs. METHODS In April 2000, a dedicated team of physicians, physician assistants, nurses, and interventional radiologists (IR) was established to coordinate and approve all PICC placements at our hospital. Ultrasound (US) became available in November 2000 to assist with bedside PICC placement. A QA database was created allowing data from 3 time periods reflecting initiation of the PICC service (April-June 2000), initial implementation of bedside US-guided PICC placement (October-December 2000), and the current service (October-December 2002) to be analyzed and compared. RESULTS For all time periods analyzed, the PICC team found that one-third of PICC requests was inappropriate and, therefore, disapproved placement. With addition of US, the bedside PICC placement rate increased to 94% compared with 73% at service initiation. This was associated with an overall 80% decrease in average patient waiting time for a PICC, facilitating more timely discharges from the hospital. Finally, placement costs were reduced by 9% six months after initiation of our service and by 24% after US became available. CONCLUSIONS A dedicated PICC team improves patient care by preventing inappropriate PICC placements and decreasing patient waiting times. A PICC team with US capability also reduces costs by minimizing expensive use of IR facilities and reducing hospital lengths of stay. A dedicated PICC service should become the standard of care for all hospitals with high-volume PICC use.

The relationship among obesity, nutritional status, and mortality in the critically ill.

Introduction:The association between obesity and mortality in critically ill patients is unclear based on the current literature. To clarify this relationship, we analyzed the association between obesity and mortality in a large population of critically ill patients and hypothesized that mortality would be impacted by nutritional status. Methods:We performed a single-center observational study of 6,518 adult patients treated in medical and surgical ICUs between 2004 and 2011. All patients received a formal, in-person, and standardized evaluation by a registered dietitian. Body mass index was determined at the time of dietitian consultation from the estimated dry weight or hospital admission weight and categorized a priori as less than 18.5 kg/m2 (underweight), 18.5–24.9 kg/m2 (normal/referent), 25–29.9 kg/m2 (overweight), 30–39.9 kg/m2 (obesity class I and II), and more than or equal to 40.0 kg/m2 (obesity class III). Malnutrition diagnoses were categorized as nonspecific malnutrition, protein-energy malnutrition, or well nourished. The primary outcome was all-cause 30-day mortality determined by the Social Security Death Master File. Associations between body mass index groups and mortality were estimated by bivariable and multivariable logistic regression models. Adjusted odds ratios were estimated with inclusion of covariate terms thought to plausibly interact with both body mass index and mortality. We utilized propensity score matching on baseline characteristics and nutrition status to reduce residual confounding of the body mass index category assignment. Results:In the cohort, 5% were underweight, 36% were normal weight, 31% were overweight, 23% had class I/II obesity, and 5% had class III obesity. Nonspecific malnutrition was present in 56%, protein-energy malnutrition was present in 12%, and 32% were well nourished. The 30-day and 90-day mortality rate for the cohort was 19.1 and 26.6%, respectively. Obesity is a significant predictor of improved 30-day mortality following adjustment for age, gender, race, medical versus surgical patient type, Deyo-Charlson index, acute organ failure, vasopressor use, and sepsis: underweight odds ratio 30-day mortality is 1.09 (95% CI, 0.80–1.48), overweight 30-day mortality odds ratio is 0.93 (95% CI, 0.80–1.09), class I/II obesity 30-day mortality odds ratio is 0.80 (95% CI, 0.67–0.96), and class III obesity 30-day mortality odds ratio is 0.69 (95% CI, 0.49–0.97), all relative to patients with body mass index 18.5–24.9 kg/m2. Importantly, there is confounding of the obesity-mortality association on the basis of malnutrition. Adjustment for only nutrition status attenuates the obesity–30-day mortality association: underweight odds ratio is 0.74 (95% CI, 0.54–1.00), overweight odds ratio is 1.05 (95% CI, 0.90–1.23), class I/II obesity odds ratio is 0.96 (95% CI, 0.81–1.15), and class III obesity odds ratio is 0.81 (95% CI, 0.59–1.12), all relative to patients with body mass index 18.5–24.9 kg/m2. In a subset of patients with body mass index more than or equal to 30.0 kg/m2 (n = 1,799), those with either nonspecific or protein-energy malnutrition have increased mortality relative to well-nourished patients with body mass index more than or equal to 30.0 kg/m2: odds ratio of 90-day mortality is 1.67 (95% CI, 1.29–2.15; p < 0.0001), fully adjusted. In a cohort of propensity score matched patients (n = 3,554), the body mass index–mortality association was not statistically significant, likely from matching on nutrition status. Conclusions:In a large population of critically ill adults, the association between improved mortality and obesity is confounded by malnutrition status. Critically ill obese patients with malnutrition have worse outcomes than obese patients without malnutrition.

Nutritional Status and Mortality in the Critically Ill.

Objectives:The association between nutritional status and mortality in critically ill patients is unclear based on the current literature. To clarify this relation, we analyzed the association between nutrition and mortality in a large population of critically ill patients and hypothesized that mortality would be impacted by nutritional status. Design:Retrospective observational study. Setting:Single academic medical center. PatientsSix thousand five hundred eighteen adults treated in medical and surgical ICUs between 2004 and 2011. Interventions:None. Measurements and Main Results:All cohort patients received a formal, in-person, standardized evaluation by a registered dietitian. The exposure of interest, malnutrition, was categorized as nonspecific malnutrition, protein-energy malnutrition, or well nourished and determined by data related to anthropometric measurements, biochemical indicators, clinical signs of malnutrition, malnutrition risk factors, and metabolic stress. The primary outcome was all-cause 30-day mortality determined by the Social Security Death Master File. Associations between nutrition groups and mortality were estimated by bivariable and multivariable logistic regression models. Adjusted odds ratios were estimated with inclusion of covariate terms thought to plausibly interact with both nutrition status and mortality. We used propensity score matching on baseline characteristics to reduce residual confounding of the nutrition status category assignment. In the cohort, nonspecific malnutrition was present in 56%, protein-energy malnutrition was present in 12%, and 32% were well nourished. The 30-day and 90-day mortality rates for the cohort were 19.1% and 26.6%, respectively. Nutritional status is a significant predictor of 30-day mortality following adjustment for age, gender, race, medical versus surgical patient type, Deyo-Charlson index, acute organ failure, vasopressor use, and sepsis: nonspecific malnutrition 30-day mortality odds ratio, 1.17 (95% CI, 1.01–1.37); protein-energy malnutrition 30-day mortality odds ratio, 2.10 (95% CI, 1.70–2.59), all relative to patients without malnutrition. In the matched cohort, the adjusted odds of 30-day mortality in the group of propensity score-matched patients with protein-energy malnutrition was two-fold greater than that of patients without malnutrition. Conclusion:In a large population of critically ill adults, an association exists between nutrition status and mortality.

Nutrition and Metabolic Support Recommendations for the Bariatric Patient

Managing the metabolic needs of the patient with obesity is a challenge unto itself without the added demands of accounting for an altered gastrointestinal tract. Nevertheless, with about 200,000 bariatric procedures being performed annually in the United States, clinicians must be prepared to manage the critically ill bariatric surgery patient. This article reviews the recent literature relating to nutrient needs and metabolic support for the bariatric patient. Bariatric patients are at risk for several micronutrient deficiencies, including vitamins D and B₁₂, calcium, and iron; some bariatric procedures affect macronutrient needs as well. Literature on nutrition support guidelines for the bariatric population is limited. However, with an understanding of the anatomical and physiological effects of bariatric surgery, recent guidelines for critically ill patients with obesity can be applied to the bariatric surgery population. The unique needs of the bariatric population, such as susceptibility to micronutrient deficiencies and specialized access routes, must be considered to provide safe and efficacious nutrition support. Further research is necessary to develop specific nutrition support recommendations for the bariatric population.

Association between prehospital vitamin D status and incident acute respiratory failure in critically ill patients: a retrospective cohort study

Objective We hypothesise that low 25-hydroxyvitamin D (25(OH)D) levels before hospitalisation are associated with increased risk of acute respiratory failure. Design Retrospective cohort study. Setting Medical and Surgical Intensive care units of two Boston teaching hospitals. Patients 1985 critically ill adults admitted between 1998 and 2011. Interventions None. Measurements and main results The exposure of interest was prehospital serum 25(OH)D categorised as ≤10 ng/mL, 11–19.9 ng/mL, 20–29.9 ng/mL and ≥30 ng/mL. The primary outcome was acute respiratory failure excluding congestive heart failure determined by International Classification of Diseases Ninth Edition (ICD-9) coding and validated against the Berlin Definition of acute respiratory sistress syndrome. Association between 25(OH)D and acute respiratory failure was assessed using logistic regression, while adjusting for age, race, sex, Deyo-Charlson Index and patient type (medical vs surgical). In the cohort, the mean age was 63 years, 45% were male and 80% were white; 25(OH)D was ≤10 ng/mL in 8% of patients, 11–19.9 ng/mL in 24%, 20–29.9 ng/mL in 24% and ≥30 ng/mL in 44% of patients. Eighteen per cent (n=351) were diagnosed with acute respiratory failure. Compared to patients with 25(OH)D ≥30 ng/mL, patients with lower 25(OH)D levels had significantly higher adjusted odds of acute respiratory failure (≤10 ng/mL, OR=1.84 (95% CI 1.22 to 2.77); 11–19.9 ng/mL, OR=1.60 (95% CI 1.19 to 2.15); 20–29.9 ng/mL, OR=1.37 (95% CI 1.01 to 1.86)). Conclusions Prehospital 25(OH)D was associated with the risk of acute respiratory failure in our critically ill patient cohort.

American Society for Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition Support

This 2014 revision of the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians Nutritionists (RDNs) in Nutrition Support represents an update of the 2007 Standards composed by content experts of the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics. The revision is based upon the Revised 2012 SOP in Nutrition Care and SOPP for RDs, which incorporates the Nutrition Care Process and the six domains of professionalism: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. These SOP and SOPP are designed to promote the provision of safe, effective, and efficient nutrition support services, facilitate evidence-based practice, and serve as a professional evaluation resource for RDNs who specialize or wish to specialize in nutrition support therapy. These standards should be applied in all patient/client care settings in which RDNs in nutrition support provide care. These settings include, but are not limited to, acute care, ambulatory/outpatient care, and home and alternate site care. The standards highlight the value of the nutrition support RDNs roles in quality management, regulatory compliance, research, teaching, consulting, and writing for peer-reviewed professional publications. The standards assist the RDN in nutrition support to distinguish his or her level of practice (competent, proficient, or expert) and would guide the RDN in creating a personal development plan to achieve increasing levels of knowledge, skill, and ability in nutrition support practice.

Peripherally Inserted Central Catheter (PICC) Complications During Pregnancy

BACKGROUND Peripherally inserted central catheters (PICCs) are routinely used in women with hyperemesis gravidarum. However, little is known about the consequences of PICC insertion in these patients. Our aim was to analyze PICC-related complication rates among pregnant women. MATERIALS AND METHODS Pregnant women with PICC insertion between January 2000 and June 2006 were studied retrospectively. Infusate type, comorbid conditions, and PICC duration were characterized. Major complications, defined as need for surgical intervention, bacteremia requiring intravenous antibiotics, or thromboembolic events, were identified. Minor complications, including phlebitis, PICC malfunction, early PICC removal, infection requiring oral antibiotics, or hospitalization for PICC evaluation, were also studied. RESULTS Eighty-four catheters in 66 women were eligible for study, totaling 2544 PICC days. Catheters remained in place for 1-177 days; median duration was 21.0 days. PICCs were used for intravenous fluid (IVF, 59.4%), parenteral nutrition (PN, 34.5%), and antibiotics (6%). The overall complication rate was 18.5 per 1000 PICC days (55.9% of PICCs); 22.6% were major, with bacteremia being most frequent (20.2%). A diagnosis of diabetes was the only factor that significantly predicted complications (hazard ratio, 2.71; 95% confidence interval, 1.13-6.13). PICC duration and type of infusate (PN vs IVF alone) were not associated with complications. CONCLUSIONS PICC insertion in pregnant women is associated with a high complication rate, which appears to be independent of the type of infusate and occurs in the majority of women. PICCs should be used judiciously and only when clearly necessary during pregnancy. Further studies are needed to determine how to reduce PICC-related complications in this population.

Metabolites Associated With Malnutrition in the Intensive Care Unit Are Also Associated With 28-Day Mortality: A Prospective Cohort Study.

Background: We hypothesized that metabolic profiles would differ in critically ill patients with malnutrition relative to those without. Materials and Methods: We performed a prospective cohort study on 85 adult patients with systemic inflammatory response syndrome or sepsis admitted to a 20-bed medical intensive care unit (ICU) in Boston. We generated metabolomic profiles using gas and liquid chromatography and mass spectroscopy. We followed this by logistic regression and partial least squares discriminant analysis to identify individual metabolites that were significant. We then interrogated the entire metabolomics profile using metabolite set enrichment analysis and network model construction of chemical-protein target interactions to identify groups of metabolites and pathways that were differentiates in patients with and without malnutrition. Results: Of the cohort, 38% were malnourished at admission to the ICU. Metabolomic profiles differed in critically ill patients with malnutrition relative to those without. Ten metabolites were significantly associated with malnutrition (P < .05). A parsimonious model of 5 metabolites effectively differentiated patients with malnutrition (AUC = 0.76), including pyroglutamine and hypoxanthine. Using pathway enrichment analysis, we identified a critical role of glutathione and purine metabolism in predicting nutrition. Nutrition status was associated with 28-day mortality, even after adjustment for known phenotypic variables associated with ICU mortality. Importantly, 7 metabolites associated with nutrition status were also associated with 28-day mortality. Conclusion: Malnutrition is associated with differential metabolic profiles early in critical illness. Common to all of our metabolome analyses, glutathione and purine metabolism, which play principal roles in cellular redox regulation and accelerated tissue adenosine triphosphate degradation, respectively, were significantly altered with malnutrition.

Parenteral Nutrition Electrolyte and Mineral Product Shortage Considerations

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is a professional society of physicians, nurses, dietitians, pharmacists, other allied health professionals, and researchers. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high-quality patient care. A.S.P.E.N.’s mission is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. A.S.P.E.N. has developed parenteral nutrition (PN) shortage considerations in order to assist its members and other clinicians in coping with PN shortages for their patients. These parenteral nutrition electrolyte and mineral product shortage considerations were approved by the A.S.P.E.N. Clinical Practice Committee and the Board of Directors.