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Several systematic reviews and meta-analyses of randomized controlled trials concluded that probiotics administration in critically ill patients was safe and associated with reduced rates of ventilator-associated pneumonia and diarrhea. However, a recent large multicenter trial found probiotics administration, compared to placebo, was not efficacious and increased adverse events. An updated meta-analysis that controls for type-1 and -2 errors using trial sequential analysis, with a detailed account of adverse events associated with probiotic administration, is warranted to confirm the safety and efficacy of probiotic use in critically ill patients. RCTs that compared probiotics or synbiotics to usual care or placebo and reported clinical and diarrheal outcomes were searched in 4 electronic databases from inception to March 8, 2022 without language restriction. Four reviewers independently extracted data and assessed the study qualities using the Critical Care Nutrition (CCN) Methodological Quality Scoring System. Random-effect meta-analysis and trial sequential analysis (TSA) were used to synthesize the results. The primary outcome was ventilator-associated pneumonia (VAP). The main subgroup analysis compared the effects of higher versus lower quality studies (based on median CCN score). Seventy-five studies with 71 unique trials (n = 8551) were included. In the overall analysis, probiotics significantly reduced VAP incidence (risk ratio [RR] 0.70, 95% confidence interval [CI] 0.56–0.88; I2 = 65%; 16 studies). However, such benefits were demonstrated only in lower (RR 0.47, 95% CI 0.32, 0.69; I2 = 44%; 7 studies) but not higher quality studies (RR 0.89, 95% CI 0.73, 1.08; I2 = 43%; 9 studies), with significant test for subgroup differences (p = 0.004). Additionally, TSA showed that the VAP benefits of probiotics in the overall and subgroup analyses were type-1 errors. In higher quality trials, TSA found that future trials are unlikely to demonstrate any benefits of probiotics on infectious complications and diarrhea. Probiotics had higher adverse events than control (pooled risk difference: 0.01, 95% CI 0.01, 0.02; I2 = 0%; 22 studies). High-quality RCTs did not support a beneficial effect of probiotics on clinical or diarrheal outcomes in critically ill patients. Given the lack of benefits and the increased incidence of adverse events, probiotics should not be routinely administered to critically ill patients. CRD42022302278. [ABSTRACT FROM AUTHOR]

The concepts and elements determining quality of care at the End of Life may vary across professional groups but there is consensus that high-quality care at the End of Life is beneficial for the patient, families, health systems and society at large. This scoping review aimed to elucidate gaps in the delivery of this specific type of care in older people from the clinicians' perspective, and to identify potential solutions to both improve this care and promote work satisfaction by the involved clinicians. Twelve studies published since 2010 with data from 18 countries identified four major gaps: (1) Core clinical competencies; (2) Shared decision-making; (3) Health care system, environmental context, and resources; and (4) Organisational leadership, culture and legislation. Multiple suggestions for staff communications training, multidisciplinary mentoring, and advance care planning alignment with patient wishes were identified. However, a clear picture arose of consistently unmet needs that have been previously highlighted in research for more than a decade. This indicates poor uptake of previous recommendations and highlights the difficulties in changing the service culture to ensure provision of optimal services at the End of Life. Future investigations on the reasons for poor uptake and identification of effective approaches to execute the agreed recommendations are warranted. [ABSTRACT FROM AUTHOR]

Risk factors for poor outcomes after critical illness are incompletely understood. While nutritional risk is associated with mortality in critically ill patients, its association with disability, cognitive, and health-related quality of life is unclear in survivors of critical illness. This study's objective was to determine whether greater nutritional risk at ICU admission is associated with greater disability, worse cognition, and worse HRQOL at 3 and 12-month follow-up. We enrolled adults (≥18 years of age) with respiratory failure or shock treated in medical and surgical intensive care units from two U.S. centers. We measured nutritional risk using the modified Nutrition Risk in Critically Ill (mNUTRIC) score (range 0–9 [ highest risk ]) at intensive care unit admission. We measured associations between mNUTRIC scores and discharge destination, disability in basic activities of daily living (ADLs) using the Katz ADL, instrumental ADLs using the Functional Activities Questionnaire (FAQ), global cognition using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), executive function using the Trail Making Test Part B (Trails B), and health-related quality of life using the SF-36, adjusting for sex, education, BMI, baseline frailty, disability, and cognition, severity of illness, days of delirium, coma, and mechanical ventilation. Of the 821 patients enrolled in the ICU, 636 patients survived to hospital discharge. We assessed outcomes in 448 of 535 survivors (84%) at 3 months and 382 of 476 survivors (80%) at 12 months. Higher mNUTRIC scores predicted greater odds of discharge to an institution (OR 2.0, 95% CI: 1.6 to 2.6; P < 0.01). Higher mNUTRIC scores were associated with a trend towards greater disability in basic activities of daily living (IRR 1.3, 95% CI 1.0 to 1.7) at 3 months that did not reach significance (p = 0.09) with no association demonstrated at 12 months. There were no associations between mNUTRIC scores and FAQ, RBANS, or Trails B scores. mNUTRIC scores were inconsistently associated with SF-36 physical and mental component scale scores. Greater nutritional risk at ICU admission is associated with disability in survivors of critical illness. Future studies should evaluate interventions in those at high nutritional risk as a means to speed recovery. [ABSTRACT FROM AUTHOR]

In critically ill patients, direct measurement of skeletal muscle using bedside ultrasound (US) may identify a patient population that might benefit more from optimal nutrition practices. When US is not available, survey measures of nutrition risk and functional status that are associated with muscle status may be used to identify patients with low muscularity. This study aims to determine the association between baseline and changing ultrasound quadriceps muscle status with premorbid functional status and 60-day mortality. This single-center prospective observational study was conducted in a general ICU. Mechanically ventilated critically ill adult patients (age ≥18 years) without pre-existing systemic neuromuscular diseases and expected to stay for ≥96 h in the ICU were included. US measurements were performed within 48 h of ICU admission (baseline), at day 7, day 14 of ICU stay and at ICU discharge (if stay >14 days). Quadriceps muscle layer thickness (QMLT), rectus femoris cross sectional area (RFCSA), vastus intermedius pennation angle (PA) and fascicle length (FL), and rectus femoris echogenicity (mean and standard deviation [SD]) were measured. Patients' next-of-kin were interviewed by using established questionnaires for their pre-hospitalization nutritional risk (nutrition risk screening-2002) and functional status (SARC-F, clinical frailty scale [CFS], Katz activities of daily living [ADL] and Lawton Instrumental ADL). Ninety patients were recruited. A total of 86, 53, 24 and 10 US measures were analyzed, which were performed at a median of 1, 7, 14 and 22 days from ICU admission, respectively. QMLT, RFCSA and PA reduced significantly over time. The overall trend of change of FL was not significant. The only independent predictor of 60-day mortality was the change of QMLT from baseline to day 7 (adjusted odds ratio 0.95 for every 1% less QMLT loss, 95% confidence interval 0.91–0.99; p = 0.02). Baseline measures of high nutrition risk (modified nutrition risk in critically ill ≥5), sarcopenia (SARC-F ≥4) and frailty (CFS ≥5) were associated with lower baseline QMLT, RFCSA and PA and higher 60-day mortality. Every 1% loss of QMLT over the first week of critical illness was associated with 5% higher odds of 60-day mortality. SARC-F, CFS and mNUTRIC are associated with quadriceps muscle status and 60-day mortality and may serve as a potential simple and indirect measures of premorbid muscle status at ICU admission. [ABSTRACT FROM AUTHOR]

Burn patients pose a number of clinical challenges for doctors and dietitians to achieve optimal nutrition practice. The objective of this study was to describe nutrition practices in burn center intensive care units (ICUs) compared to the most recent ESPEN and SCCM/ASPEN guidelines (hereafter referenced as "the Guidelines") and highlight the variation in practice and what is "best achievable." In 2014–15, we prospectively enrolled 283 mechanically ventilated patients who were admitted to one of 14 burn ICUs for at least 72 h. Data collected included information on the estimation of energy and protein requirements, their actual delivery as well as route and time of feeding, and administration of micronutrients. We describe site practices and data per patient-day. Adherence to the Guidelines for the use of enteral nutrition (EN) over parenteral nutrition (PN) was 90.5% of patient-days (site range 79.2%–97.0%). However, adherence to the Guidelines for the measurement of energy requirements was 6.0% of patient-days (site range 0.0%–93.3%), supplementation with glutamine took place in 22.4% of patient-days (site range 0.0%–61.8%). Provision of 80% of energy requirements within 48–72 h was achieved in 35.3% of patients (site range 0.0%–80.0%), and provision of 80% of protein needs within 48–72 h was achieved in 34.3% of patients (site range 0.0%–80.0%). Average nutritional adequacy was 64.9 ± 40.0% for energy (best site: 80.2%, worst site: 42.0%) and 65.6 ± 42.1% for protein (best site: 87.3%, worst site: 43.6%). The present findings indicate that despite high adherence to providing EN over PN, there is still a large gap between many recommendations and clinical practice, and the achievement of nutrition goals for patients in burn centers is suboptimal. [ABSTRACT FROM AUTHOR]

The quantity and quality of skeletal muscle and adipose tissue is an important prognostic factor for clinical outcomes across several illnesses. Clinically acquired computed tomography (CT) scans are commonly used for quantification of body composition, but manual analysis is laborious and costly. The primary aim of this study was to develop an automated body composition analysis framework using CT scans. CT scans of the 3rd lumbar vertebrae from critically ill, liver cirrhosis, pancreatic cancer, and clear cell renal cell carcinoma patients, as well as renal and liver donors, were manually analyzed for body composition. Ninety percent of scans were used for developing and validating a neural network for the automated segmentation of skeletal muscle and adipose tissues. Network accuracy was evaluated with the remaining 10 percent of scans using the Dice similarity coefficient (DSC), which quantifies the overlap (0 = no overlap, 1 = perfect overlap) between human and automated segmentations. Of the 893 patients, 44% were female, with a mean (±SD) age and body mass index of 52.7 (±15.8) years old and 28.0 (±6.1) kg/m2, respectively. In the testing cohort (n = 89), DSC scores indicated excellent agreement between human and network-predicted segmentations for skeletal muscle (0.983 ± 0.013), and intermuscular (0.900 ± 0.034), visceral (0.979 ± 0.019), and subcutaneous (0.986 ± 0.016) adipose tissue. Network segmentation took ~350 milliseconds/scan using modern computing hardware. Our network displayed excellent ability to analyze diverse body composition phenotypes and clinical cohorts, which will create feasible opportunities to advance our capacity to predict health outcomes in clinical populations. [ABSTRACT FROM AUTHOR]

Pharmacokinetics (PK) of pharmaceuticals and pharmaconutrients are poorly understood in critically ill patients, and dosing is often based on healthy subject data. This might be particularly problematic with enteral medications due to metabolic abnormalities and impaired gastrointestinal tract absorption common in critically ill patients. Utilizing enteral fish oil, this study was undertaken to better understand and define PK of enteral omega-3 fatty acids (eicospentaenoic acid [EPA] and docosahexaenoic acid [DHA]) in critically ill patients with severe sepsis. Healthy volunteers (n = 15) and mechanically ventilated (MV) adults with severe sepsis (n = 10) were recruited and received 9.75 g EPA and 6.75 g DHA daily in two divided enteral doses of fish oil for 7 days. Volunteers continued their normal diet without other sources of fish oil, and sepsis patients received standard enteral feeding. Blood was collected at frequent intervals during the 14-day study period. Peripheral blood mononuclear cells (PMBCs) and neutrophils were isolated and analyzed for membrane fatty acid (FA) content. Mixed linear models and t-tests were used to analyze changes in FA levels over time and FA levels at individual time points, respectively. PK parameters were obtained based on single compartment models of EPA and DHA kinetics. Healthy volunteers were 41.1 ± 10.3 years; 67% were women. In patients with severe sepsis (55.6 ± 13.4 years, 50% women), acute physiologic and chronic health evaluation (APACHE) II score was 27.2 ± 8.8 at ICU admission and median MV duration was 10.5 days. Serum EPA and DHA were significantly lower in sepsis vs. healthy subjects over time. PBMC EPA concentrations were generally not different between groups over time, while PBMC DHA was higher in sepsis patients. Neutrophil EPA and DHA concentrations were similar between groups. The half-life of EPA in serum and neutrophils was significantly shorter in sepsis patients, whereas other half-life parameters did not vary significantly between healthy volunteers and sepsis patients. While incorporation of n-3 FAs into PBMC and neutrophil membranes was relatively similar between healthy volunteers and sepsis patients receiving identical high doses of fish oil for one week, serum EPA and DHA were significantly lower in sepsis patients. These findings imply that serum concentrations and EPA and DHA may not be the dominant driver of leukocyte membrane incorporation of EPA and DHA. Furthermore, lower serum EPA and DHA concentrations suggest that either these n-3 FAs were being metabolized rapidly in sepsis patients or that absorption of enteral medications and pharmaconutrients, including fish oil, may be impaired in sepsis patients. If enteral absorption is impaired, doses of enteral medications administered to critically ill patients may be suboptimal. [ABSTRACT FROM AUTHOR]

The NUTrition Risk in the Critically Ill (NUTRIC) scoring system is a tool useful, discriminating critically-ill patients benefiting from optimal nutrition intake (>80% of prescription). Recent recommendations advocate for withholding artificial nutrition among low-NUTRIC patients, however, we hypothesized that some low-NUTRIC patients would show an association between nutrition intake and outcome. Patients were selected from the 2013–2014 International Nutrition Surveys when ICU length of stay (LICU) ≥72 h, baseline mNUTRIC score ≤4 and had at least three evaluable nutrition days (N = 2781). Proportion of prescription received during evaluable days was associated to 60-day hospital mortality by a logistic regression modelling. A priori, we expected that the association between proportion of prescription received and mortality might differ according to: LICU, BMI and prior unintentional weight loss or reduced oral intake. A total of 2781 patients fulfilled the inclusion criteria and participated in the study. Ten percent of the sample had a BMI <20 kg/m2 and 20% experienced either unintentional weight loss during the last 3 months, or reduced food intake over the last week. Sixty-day hospital mortality was 15% and median LICU reached 11.3 [6.3–21.7] days. Mean total prescription received by any means of nutritional support during the first 12 evaluable days was 57.4 ± 28.1% for energy and 53.7 ± 29.2% for protein. In the pooled, subgroup and sensitivity analyses, no significant associations were identified. Low-NUTRIC (≤4) patients demonstrate a prolonged LICU, while experiencing significant mortality and a high prevalence of malnutrition risk factors. Although improvements in mortality were not achieved with increased nutritional intake, this should not be construed as a rationale for withholding artificial nutrition among this patient group. [ABSTRACT FROM AUTHOR]

Recent studies indicate that vitamin D deficiency is associated with increased morbidity and mortality in critically ill patients. Knowledge about the functional role and clinical relevance of vitamin D for patients undergoing cardiac surgery is sparse. Therefore, we investigated the clinical significance of vitamin D levels on outcome of cardiac surgery patients. 92 patients undergoing elective cardiac surgery with cardiopulmonary arrest were included in this prospective observational pilot study. 25-hydroxyvitamin D (25OHD) and 1,25-dihydroxyvitamin D (1,25(OH) 2 D) levels were measured prior to surgery, immediately postoperatively as well as 6, 12 and 24 h after surgery. We assessed postoperative organ dysfunctions, infections and death until hospital discharge. The serum concentration of 1,25(OH) 2 D significantly decreased intraoperatively by 29.3% (p < 0.001) and was significantly lower at any postoperative time point compared to baseline values, whereas 25OHD levels did not show significant changes during the observation period. Coronary artery bypass graft (CABG) patients had significant higher baseline 1,25(OH) 2 D values than patients with valve surgery (39.7 ± 13.9 ng/l vs. 30.1 ± 14.1 ng/l, p = 0.010) or CABG + valve surgery (39.7 ± 13.9 ng/l vs. 32.6 ± 11.8 ng/l, p = 0.044). Our data showed a significant odds ratio to develop postoperative organ dysfunction (OR 0.95; p = 0.009) and PCT levels ≥5 μg/l (OR 0.94; p = 0.046) for every ng/l increment in 1,25(OH) 2 D, when performing multivariable analysis and after adjusting for preoperative illness and demographics. In addition, multivariable-adjusted statistical analyses revealed that patients stayed significantly shorter on ICU (−0.21 h; p = 0.001) and in hospital (−2.6 days; p = 0.009) for every ng/l increment in 1,25(OH) 2 D. Our data highlight important evidence about the clinical significance of 1,25(OH) 2 D levels in cardiac surgery patients. Higher levels were associated with significantly less postoperative organ dysfunctions, elevated PCT levels, death and prolonged hospital stay. 1,25(OH) 2 D levels decreased significantly intra- and postoperatively, while serum levels of 25OHD did not. clinicaltrials.gov (NCT 02488876), registered May 1, 2015. [ABSTRACT FROM AUTHOR]

Summary The purpose of this review is to explain the historical and clinical background for intravenous fish oil administration, to evaluate its results by using a product specific metaanalysis, and to stimulate further research in the immune-modulatory potential of fish oil. Concerning the immune-modulatory effects of fatty acids, a study revealed that ω-3 as well as ω-6 fatty acids would prolong transplant survival, and only a mixture with an ω-6:ω-3 ratio of 2.1:1 would give immune-neutral results. In 1998, the label of a newly registered fish oil emulsion also acknowledged this immune-neutral ratio in conjunction with ω-6 lipids. Also, two fish oil-supplemented fat emulsions, registered in 2004, used a similar ω-6:ω-3 ratio. Such an immune-neutral ω-6:ω-3 ratio denoted progress for most patients compared to pure ω-6 lipid emulsions. However, this immune-neutrality might on the other hand be responsible for the limited positive clinical results gained so far in critically ill and surgical patients where in most cases significance could only be shown for the pooled effect of numerous trials. Our product specific metaanalysis also did not reveal any differences, neither in infections rates nor in ICU or hospital length of stay. To evaluate the immune-modulatory effect of fish oil administered alone, new dose finding studies, reporting relevant clinical outcome parameters, are required. Precise mechanistic or physiological biomarkers for the indication of such a therapy should also be developed and validated. [ABSTRACT FROM AUTHOR]

Summary Background & aims Lean body mass (LBM), quantified using computed tomography (CT), is a significant predictor of clinical outcomes in the critically ill. While CT analysis is precise and accurate in measuring body composition, it may not be practical or readily accessible to all patients in the intensive care unit (ICU). Here, we assessed the agreement between LBM measured by CT and four previously developed equations that predict LBM using variables (i.e. age, sex, weight, height) commonly recorded in the ICU. Methods LBM was calculated in 327 critically ill adults using CT scans, taken at ICU admission, and 4 predictive equations (E1–4) that were derived from non-critically adults since there are no ICU-specific equations. Agreement was assessed using paired t -tests, Pearson's correlation coefficients and Bland–Altman plots. Results Median LBM calculated by CT was 45 kg (IQR 37–53 kg) and was significantly different (p < 0.001) from E1 (52.5 kg; IQR: 42–61 kg), E2 (55 kg; IQR 45–64 kg), E3 (55 kg; IQR 44–64 kg), and E4 (54 kg; IQR 49–61 kg). Pearson correlation coefficients suggested moderate correlation (r = 0.739, 0.756, 0.732, and 0.680, p < 0.001, respectively). Each of the equations overestimated LBM (error ranged from 7.5 to 9.9 kg), compared with LBM calculated by CT, suggesting insufficient agreement. Conclusions Our data indicates a large bias is present between the calculation of LBM by CT imaging and the predictive equations that have been compared here. This underscores the need for future research toward the development of ICU-specific equations that reliably estimate LBM in a practical and cost-effective manner. [ABSTRACT FROM AUTHOR]

Background: Conversations about goals of care in hospital are important to patients who have advanced heart failure (HF).Methods: We conducted a multicenter survey of cardiology nurses, fellows, and cardiologists at 8 Canadian teaching hospitals. The primary outcome was the importance of barriers to goals-of-care discussions in hospital (1 = extremely unimportant; 7 = extremely important). We also elicited perspectives on roles of different practitioners in having these conversations.Results: Questionnaires were returned by 770/1024 (75.2%) eligible clinicians. The most important perceived barriers were: family members' and patients' difficulty in accepting a poor prognosis (mean [SD] score 5.9 [1.1] and 5.7 [1.2], respectively), family members' and patients' lack of understanding about the limitations and harms of life-sustaining treatments (5.8 [1.1] and 5.7 [1.2], respectively), and lack of agreement among family members about goals of care (5.8 [1.2]). Interprofessional team members were viewed as having different but important roles in goals-of-care discussions.Conclusions: Cardiology clinicians perceive family and patient-related factors as the most important barriers to goals-of-care discussions in hospital. Many members of the interprofessional team were viewed as having important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication about goals of care in advanced HF. [ABSTRACT FROM AUTHOR]

Summary Background and aims Patients with traumatic brain injury (TBI) experience considerable energy and protein deficits in the intensive care unit (ICU) and these are associated with adverse outcomes. However, nutrition delivery after ICU discharge during ward-based care, particularly from oral diet, has not been measured. This study aimed to quantify energy and protein delivery and deficits over the entire hospitalization for critically ill TBI patients. Methods Consecutively admitted adult patients with a moderate-severe TBI (Glasgow Coma Scale 3–12) over 12 months were eligible. Observational data on energy and protein delivered from all routes were collected until hospital discharge or day 90 and compared to dietician prescriptions. Oral intake was quantified using weighed food records on three pre-specified days each week. Data are mean (SD) unless indicated. Cumulative deficit is the mean absolute difference between intake and estimated requirements. Results Thirty-seven patients [45.3 (15.8) years; 87% male; median APACHE II 18 (IQR: 14–22)] were studied for 1512 days. Median duration of ICU and ward-based stay was 13.4 (IQR: 6.4–17.9) and 19.9 (9.6–32.0) days, respectively. Over the entire hospitalization patients had a cumulative deficit of 18,242 (16,642) kcal and 1315 (1028) g protein. Energy and protein intakes were less in ICU than the ward (1798 (800) vs 1980 (915) kcal/day, p = 0.015; 79 (47) vs 89 (41) g/day protein, p = 0.001). Energy deficits were almost two-fold greater in patients exclusively receiving nutrition orally than tube-fed (806 (616) vs 445 (567) kcal/day, p = 0.016) while protein deficits were similar (40 (5) vs 37 (6) g/day, p = 0.616). Primary reasons for interruptions to enteral and oral nutrition were fasting for surgery/procedures and patient-related reasons, respectively. Conclusions Patients admitted to ICU with a TBI have energy and protein deficits that persist after ICU discharge, leading to considerable shortfalls over the entire hospitalization. Patients ingesting nutrition orally are at particular risk of energy deficit. [ABSTRACT FROM AUTHOR]

Summary Survivors of critical illness commonly experience neuromuscular abnormalities, including muscle weakness known as ICU-acquired weakness (ICU-AW). ICU-AW is associated with delayed weaning from mechanical ventilation, extended ICU and hospital stays, more healthcare-related hospital costs, a higher risk of death, and impaired physical functioning and quality of life in the months after ICU admission. These observations speak to the importance of developing new strategies to aid in the physical recovery of acute respiratory failure patients. We posit that to maintain optimal muscle mass, strength and physical function, the combination of nutrition and exercise may have the greatest impact on physical recovery of survivors of critical illness. Randomized trials testing this and related hypotheses are needed. We discussed key methodological issues and proposed a common evaluation framework to stimulate work in this area and standardize our approach to outcome assessments across future studies. [ABSTRACT FROM AUTHOR]

Summary Introduction Better tools are needed to assist in the identification of critically ill patients most likely to benefit from artificial nutrition therapy. Recently, the Nutrition Risk in Critically ill (NUTRIC) score has been developed for such purpose. The objective of this study was to externally validate a modified version of the NUTRIC score in a second database. Methods We conducted a post hoc analysis of a database of a randomized control trial of intensive care unit (ICU) patients with multi-organ failure. Data for all variables of the NUTRIC score with the exception of IL-6 levels were collected. These included age, APACHE II score, SOFA score, number of co-morbidities, days from hospital admission to ICU admission. The NUTRIC score was calculated using the exact same thresholds and point system as developed previously except the IL-6 item was omitted. A logistic model including the NUTRIC score, the nutritional adequacy and their interaction was estimated to assess if the NUTRIC score modified the association between nutritional adequacy and 28-day mortality. We also examined the association of elevated NUTRIC scores and 6-month month mortality and the interaction between NUTRIC score and nutritional adequacy. Results A total of 1199 patients were analyzed. The mean total calories prescribed was 1817 cal (SD 312) with total mean protein prescribed of 98.3 g (SD 23.6). The number of patients who received PN was 9.5%. The overall 28-day mortality rate in this validation sample was 29% and the mean NUTRIC score was 5.5 (SD 1.6). Based on the logistic model, the odds of mortality at 28 days was multiplied by 1.4 (95% CI, 1.3–1.5) for every point increase on the NUTRIC score. The mean (SD) nutritional adequacy was 50.2 (29.5) with an interquartile range from 24.8 to 74.1. The test for interaction confirmed that the association between nutritional adequacy and 28-day mortality is significantly modified by the NUTRIC score (test for interaction p = 0.029). In particular, there is a strong positive association between nutritional adequacy and 28 day survival in patients with a high NUTRIC score but this association diminishes with decreasing NUTRIC score. Higher NUTRIC scores are also significantly associated with higher 6-month mortality (p < 0.0001) and again the positive association between nutritional adequacy and 6 month survival was significantly stronger (and perhaps only present) in patients with higher NUTRIC score (test for interaction p = 0.038). Conclusion The NUTRIC scoring system is externally validated and may be useful in identifying critically ill patients most likely to benefit from optimal amounts of macronutrients when considering mortality as an outcome. [ABSTRACT FROM AUTHOR]

Objectives Validated composite outcomes after complicated cardiac surgery are poorly established. Therefore, the authors evaluated a novel composite endpoint, persistent organ dysfunction (POD)+death, which is defined as any need for life-sustaining therapies or death at any time within 28 days from surgery. Design Secondary analysis extracted from a large-scale prospective randomized trial of critically ill cardiac surgery patients. Setting Multi-institutional, university hospitals. Participants Ninety-five cardiac surgery patients with complicated postoperative courses. Interventions Cardiac surgery with cardiopulmonary bypass. Measurements and Main Results At 28 days following surgery, the prevalence of POD was 15%, and 23% of patients had died (POD+death = 38%). Patients alive with POD at day 28 exhibited a significantly higher extent of organ injury and longer ICU (33 v 7 days; p<0.001) and hospital lengths of stay (49 v 21 days; p<0.001) compared to patients without POD at day 28. At 3 and 6 months, quality-of-life scores (by Short Form 36 questionnaire) showed a significantly reduced rating for most components in patients with POD at day 28 compared to those without POD. The 6-month mortality rate was 21% among patients alive with POD at day 28 compared to 5% among patients alive without POD (p = 0.05). The calculated number of patients needed per arm to detect a 25% relative risk reduction for mortality alone was 762 compared to 386 per arm for POD+ death. Conclusions POD+death at day 28 following cardiac surgery may be a valid composite endpoint and offers statistical efficiencies in terms of sample size calculations for cardiac surgical trials. [ABSTRACT FROM AUTHOR]