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Uso do escore NUTRIC pelo mundo: uma revisão sistemática

RESUMO

Objetivo:

Coletar dados a respeito do uso do escore Nutrition Risk in Critically Ill (NUTRIC).

Métodos:

Conduziu-se pesquisa sistemática da literatura em conformidade com as especificações PRISMA. Excluíram-se da pesquisa os trabalhos referentes a revisões, resumos, dissertações, protocolos e relatos de caso. Foram incluídos estudos que avaliaram especificamente o escore NUTRIC publicados em inglês, espanhol ou português.

Resultados:

Incluímos 12 (0,8%) estudos de nossa busca nesta revisão. Dez eram estudos observacionais (83,3%), um estudo piloto (8,3%) e um ensaio randomizado e controlado (8,3%). Em todos os estudos incluídos (100%), os autores decidiram não utilizar dosagem de interleucina 6 e consideraram como ponto de corte para alto risco nutricional um escore ≥ 5. Dentre os estudos selecionados, 11 (91,7%) estavam em idioma inglês e um (8,3%) em espanhol. Ventilação mecânica e o escore NUTRIC tiveram correlação significante em quatro estudos. A associação entre o tempo de permanência no hospital ou na unidade de terapia intensiva e o alto risco nutricional apresentou correlação significante em três estudos. Sete estudos identificaram associação estatisticamente significante entre escore NUTRIC e mortalidade.

Conclusão:

O escore NUTRIC tem relação com desfechos clínicos, como tempo de permanência no hospital, e seu uso é apropriado em pacientes críticos na unidade de terapia intensiva.

Descritores:
Desnutrição; Estado nutricional; Avaliação nutricional; Estado terminal; Unidades de terapia intensiva

ABSTRACT

Objective:

To collect data on the use of The Nutrition Risk in Critically Ill (NUTRIC) score.

Methods:

A systematic literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Reviews, abstracts, dissertations, protocols and case reports were excluded from this review; to be included in the review, studies needed to specifically evaluate the NUTRIC score and to have been published in English, Spanish or Portuguese.

Results:

We included 12 (0.8%) studies from our search in this review. Ten studies (83.3%) were observational, 1 was a pilot study (8.3%) and 1 was a randomized control trial (8.3%). All of the included studies (100%) chose not to use IL-6 and considered a high nutritional risk cutoff point ≥ 5. There were 11 (91.7%) English language studies versus 1 (8.3%) Spanish language study. Mechanical ventilation and a high NUTRIC score were significantly correlated in four studies. The association between intensive care unit or hospital length of stay and nutritional high risk was significant in three studies. Seven studies found a statistically significant association between the NUTRIC score and mortality.

Conclusion:

The NUTRIC score is related to clinical outcomes, such as length of hospital stay, and is appropriate for use in critically ill patients in intensive care units.

Keywords:
Malnutrition; Nutritional status; Nutrition assessment; Critical illness; Intensive care units

INTRODUÇÃO

A desnutrição é comum em pacientes hospitalizados e altamente prevalente na população de pacientes críticos.(11 White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275-83.,22 Edington J, Boorman J, Durrant ER, Perkins A, Giffin CV, James R, et al. Prevalence of malnutrition on admission to four hospitals in England. The Malnutrition Prevalence Group. Clin Nutr. 2000;19(3):191-5.) Ela se associa com maior morbidade, mortalidade, ocorrência de infecções nosocomiais, tempo de hospitalização mais longo, pior condição funcional quando da alta da unidade de terapia intensiva (UTI) e maior custo da internação.(33 Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003;22(3):235-9.,44 Schneider SM, Veyres P, Pivot X, Soummer AM, Jambou P, Filippi J, et al. Malnutrition is an independent factor associated with nosocomial infections. Br J Nutr. 2004;92(1):105-11.)

A maioria das ferramentas utilizadas para avaliar o risco nutricional inclui uma variedade de critérios para identificar risco nutricional, como ingestão de alimentos/ingestão nutricional, exame físico, severidade da doença, dados antropométricos e avaliação funcional.(55 Preiser JC, van Zanten AR, Berger MM, Biolo G, Casaer MP, Doig GS, et al. Metabolic and nutritional support of critically ill patients: consensus and controversies. Crit Care. 2015;19:35.) Muitos destes critérios são de difícil obtenção em pacientes críticos, pois quase todos eles demandam ventilação mecânica (VM) e sedação.(55 Preiser JC, van Zanten AR, Berger MM, Biolo G, Casaer MP, Doig GS, et al. Metabolic and nutritional support of critically ill patients: consensus and controversies. Crit Care. 2015;19:35.) As alterações do peso podem ser influenciadas por questões relacionadas a fluidos, dados os grandes volumes necessários para manutenção da estabilidade hemodinâmica.(55 Preiser JC, van Zanten AR, Berger MM, Biolo G, Casaer MP, Doig GS, et al. Metabolic and nutritional support of critically ill patients: consensus and controversies. Crit Care. 2015;19:35.) Muitas das ferramentas tradicionais não fornecem informações com relação à condição inflamatória, crucial para pacientes críticos, por ser um dos fatores responsáveis pelo estado hipermetabólico e perda muscular.(55 Preiser JC, van Zanten AR, Berger MM, Biolo G, Casaer MP, Doig GS, et al. Metabolic and nutritional support of critically ill patients: consensus and controversies. Crit Care. 2015;19:35.)

Em 2011, Heyland et al. apresentaram uma nova ferramenta, o escore Nutrition Risk in Critically Ill (NUTRIC), que foi validada para uso em pacientes de UTI.(66 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):R268.) Esse escore avalia o risco de desfechos desfavoráveis (mortalidade e VM), que é modificável por intervenção nutricional intensiva.(66 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):R268.) As variáveis incorporadas a este escore são idade, escore do Acute Physiology and Chronic Health Evaluation II (APACHE II), escore do Sequential Organ Failure Assessment (SOFA), comorbidades, dias no hospital antes da admissão à UTI, e níveis de interleucina 6 (IL-6).(66 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):R268.) Proposto em 2016, o NUTRIC modificado, sem a dosagem de IL-6, pode ser utilizado considerando ponto de corte para alto risco nutricional ≥ 5.(77 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):158-62.)

A finalidade desta revisão é coletar dados a respeito do uso do escore NUTRIC.

MÉTODOS

Em dezembro de 2017, conduziu-se revisão sistemática da literatura em conformidade com o sistema Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).(88 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. Open Med. 2009;3(3):e123-30.) A busca foi realizada em quatro bases de dados: Medical Literature Analysis and Retrieval System Online (MEDLINE), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scientific Electronic Library Online (SciELO) e Cochrane Collaboration. A estratégia de busca para estas bases de dados foi definida em termos relacionados ao escore NUTRIC [NUTRIC, Nutrition Risk in Critically Ill] e à avaliação nutricional [nutritional risk, nutritional status] além de "critical illness". Os termos foram incluídos entre aspas, e utilizaram-se os operadores de busca "and" e "or". Excluíram-se revisões, resumos, protocolos de estudo, dissertações e relatos de caso.

Além disto, para inclusão na revisão, os estudos deveriam avaliar especificamente o escore NUTRIC e ter sido publicados em idioma inglês, espanhol ou português. Finalmente, os artigos foram triados conforme as seguintes fases: incialmente, excluíram-se as duplicidades. Então, os demais artigos foram triados por título, resumo e texto completo. Os artigos foram selecionados com base nos critérios de elegibilidade já descritos. Caso a elegibilidade não pudesse ser determinada durante a triagem inicial do título e resumo, avaliava-se o texto completo do artigo, para determinar ou não sua inclusão. Tanto a seleção de estudos quanto a extração de dados foram realizadas concomitantemente por dois dos autores. Em caso de alguma dúvida concernente aos critérios de elegibilidade, um terceiro avaliador, também autor, tomava a decisão final. As bases de dados MEDLINE, LILACS, Cochrane e SciELO proporcionaram, respectivamente 1.189, 30, 179 e 89 artigos. A figura 1 apresenta detalhes deste fluxo de seleção.

Figura 1
Fluxograma da elegibilidade.

RESULTADOS

Dentre os 1.487 estudos, 12 (0,8%) foram incluídos nesta revisão.(77 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):158-62.,99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.

10 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.

11 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.

12 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.

13 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.

14 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.

15 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.

16 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.

17 de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.

18 Lew CC, Cheung KP, Chong MF, Chua AP, Fraser RJ, Miller M. Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone. JPEN J Parenter Enteral Nutr. 2017 Aug 1:148607117726060. doi: 10.1177/0148607117726060. [Epub ahead of print]
https://doi.org/10.1177/0148607117726060...
-1919 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.) Todos os artigos incluídos (100%) se referiam a pacientes adultos.(77 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):158-62.,99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.

10 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.

11 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.

12 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.

13 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.

14 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.

15 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.

16 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.

17 de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.

18 Lew CC, Cheung KP, Chong MF, Chua AP, Fraser RJ, Miller M. Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone. JPEN J Parenter Enteral Nutr. 2017 Aug 1:148607117726060. doi: 10.1177/0148607117726060. [Epub ahead of print]
https://doi.org/10.1177/0148607117726060...
-1919 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.) Dez dos estudos (83,3%) tinham delineamento observacional,(77 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):158-62.,99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.

10 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.

11 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.
-1212 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.,1414 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.

15 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.

16 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.

17 de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.

18 Lew CC, Cheung KP, Chong MF, Chua AP, Fraser RJ, Miller M. Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone. JPEN J Parenter Enteral Nutr. 2017 Aug 1:148607117726060. doi: 10.1177/0148607117726060. [Epub ahead of print]
https://doi.org/10.1177/0148607117726060...
-1919 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.) um era estudo piloto (8,3%)(1313 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.) e um era ensaio randomizado e controlado (8,3%).(77 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):158-62.) Em todos os estudos incluídos (100%), os autores decidiram não utilizar IL-6.(77 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):158-62.,99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.

10 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.

11 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.

12 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.

13 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.

14 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.

15 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.

16 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.

17 de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.

18 Lew CC, Cheung KP, Chong MF, Chua AP, Fraser RJ, Miller M. Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone. JPEN J Parenter Enteral Nutr. 2017 Aug 1:148607117726060. doi: 10.1177/0148607117726060. [Epub ahead of print]
https://doi.org/10.1177/0148607117726060...
-1919 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.) Onze dos estudos (91,7%) eram em inglês(1010 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.

11 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.

12 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.

13 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.

14 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.

15 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.

16 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.

17 de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.

18 Lew CC, Cheung KP, Chong MF, Chua AP, Fraser RJ, Miller M. Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone. JPEN J Parenter Enteral Nutr. 2017 Aug 1:148607117726060. doi: 10.1177/0148607117726060. [Epub ahead of print]
https://doi.org/10.1177/0148607117726060...
-1919 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.) e um estudo (8,3%) estava em espanhol.(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.) A tabela 1 apresenta os principais resultados.

Tabela 1
Detalhes dos estudos
Tabela 2
Principais resultados

Aplicabilidade do NUTRIC

Um estudo piloto foi conduzido no Brasil;(1313 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.) para sua utilização no país, foi necessário proceder à tradução e à adaptação do escore NUTRIC para o português.(1313 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.) Os autores avaliaram 50 pacientes cujos dados foram facilmente obtidos a partir de prontuários médicos, e nem nutricionistas nem médicos relataram dificuldades para registrá-los.(1313 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.) Os cinco profissionais de saúde que tomaram parte do estudo piloto relataram que a nova versão do NUTRIC foi clara e fácil de entender, assim como prática e de aplicação rápida.(1313 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.)

NUTRIC alterado

Moretti et al. conduziram estudo que utilizou a dosagem de proteína C-reativa (PCR) em vez de IL-6 (NUTRIC-2 ≥ 6 pontos) em comparação ao escore sem qualquer marcador inflamatório (NUTRI-1 ≥ 5 pontos).(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.)

O NUTRIC-2 utilizou valor de corte ≥ 6 pontos para definir alto risco, conforme sugerido por Heyland et al.,(66 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):R268.) e teve sensibilidade e especificidade, respectivamente, de 37,76% e 88,95%.(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.) Valor de corte de 3 pontos levou a uma sensibilidade próxima a 70% e uma especificidade de 60%.(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.) A sensibilidade e a especificidade avaliadas pela área sob a curva Característica de Operação do Receptor (receiver operating characterists - ROC) foram mais baixas para predizer mortalidade do que no estudo original (0,671 e 0,679 versus 0,783, respectivamente).(66 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):R268.,99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.)

NUTRIC e alto risco nutricional

Em todos, exceto um dos estudos incluídos, os pacientes foram classificados como de alto risco nutricional quando o escore NUTRIC ≥ 5 pontos.(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.

10 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.

11 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.

12 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.

13 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.

14 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.

15 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.

16 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.
-1717 de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.) O grupo de Moretti utilizou ponto de corte ≥ 6 para o NUTRIC com PCR.(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.) Neste estudo, foi identificado alto risco nutricional em 93 (25%) dos pacientes.(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.)

Mais de metade (55,8%) dos 203 pacientes estavam em alto risco nutricional no estudo de Lee et al.(1010 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.) Mendes et al., em Portugal, encontraram valores similares (48%),(1111 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.) assim como Rosa et al., no Brasil, que chegaram a 46%,(1313 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.) Kalaiselvan et al., na Índia, a 42,5%,(1414 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.) e Mukhopadhyay et al. (1212 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.)) e Lew et al.,(1818 Lew CC, Cheung KP, Chong MF, Chua AP, Fraser RJ, Miller M. Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone. JPEN J Parenter Enteral Nutr. 2017 Aug 1:148607117726060. doi: 10.1177/0148607117726060. [Epub ahead of print]
https://doi.org/10.1177/0148607117726060...
) em Cingapura, a 53,8% e 67,9%, respectivamente.

Uma menor percentagem de pacientes estava em alto risco nutricional nos estudos conduzidos por Coltman et al., nos Estados Unidos, com 26%,(1515 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.) e por Özbilgin et al.,(1616 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.) na Turquia, com 22,4%.

NUTRIC e ventilação mecânica

Özbilgin et al. não demonstraram qualquer relação entre o escore NUTRIC e uso de VM (p = 0,136) ou tempo de VM (p = 0,245).(1616 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.)) Lew et al. não associaram alto risco com tempo de VM (2,0 [1,0 - 4,3] versus 2,0 [1,0 - 5,0]; p > 0,050).(1818 Lew CC, Cheung KP, Chong MF, Chua AP, Fraser RJ, Miller M. Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone. JPEN J Parenter Enteral Nutr. 2017 Aug 1:148607117726060. doi: 10.1177/0148607117726060. [Epub ahead of print]
https://doi.org/10.1177/0148607117726060...
) Kalaiselvan et al. não encontraram associação entre alto risco nutricional e dias livres de VM (2 [± 2,8] versus 1,7 [± 1,9]; p = 0,100).(1414 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.)

Por outro lado, de Vries et al. incluíram em seu estudo apenas pacientes mecanicamente ventilados.(1717 de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.) Identificaram que a duração mediana da VM aumentou de forma significante nos pacientes com escore NUTRIC alto (+ 2,5 dias; p < 0,001).(1717 de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.) Moretti et al. também incluíram apenas pacientes sob VM(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.) e demonstraram associação entre o escore NUTRIC-1 (sem IL-6) e NUTRIC-2 (em versão com PCR) com o número de dias sob VM nos pacientes que sobreviveram (p = 0,034 e p = 0,010, respectivamente).(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.)

Em estudo conduzido por Mukhopadhyay et al., em 273 pacientes que receberam VM, observaram-se diferenças significantes entre pacientes com alto e baixo risco nutricional em termos de duração da VM (3,3 [1,5 - 5,7] versus 3,5 [2,0 - 7,0]; p < 0,001).(1212 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.) Mendes et al. conduziram análise de regressão logística e identificaram que o escore NUTRIC se associou com menos dias livres de VM (n = 1.124; razão de chance - RC − 1,46; intervalo de confiança de 95% − IC95% 1,16 - 1,85; p = 0,002).(1111 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.)

NUTRIC e complicações

Três estudos analisaram complicações.(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.,1515 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.,1616 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.) A necessidade de reabilitação adicional após a alta esteve mais associada com alto risco nutricional, em comparação a ausência de risco (13% versus 10%).(1515 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.) Özbilgin et al. identificaram relacionamento significativo entre complicações pulmonares e alto escore NUTRIC (p = 0,030).(1616 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.)

Moretti et al. encontraram que o escore médio dos pacientes com pneumonia, em comparação com os sem pneumonia, foi de 3,19 (± 1,58) versus 3,77 (± 1,96) pontos para o NUTRIC -1 (sem marcador de inflamação) (p = 0,034), e 3,62 (± 1,69) versus 4,16 (± 2,06) para o NUTRIC-2 (com PCR) (p = 0,054).(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.)

NUTRIC e tempo de hospitalização

A associação entre tempo de permanência no hospital e o escore NUTRIC foi não significante em apenas um estudo (p = 0,134).(1616 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.)

Coltman et al. identificaram que pacientes em alto risco nutricional tiveram o tempo mais longo de permanência na UTI e no hospital, em comparação com os que não tinham risco (tempo no hospital: 6,9 [± 6,7] versus 12,1 [± 10,7] dias; tempo na UTI: 3,7 [± 3,5] versus 5,4 [± 5,3]).(1515 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.)

Outros estudos encontraram associações significantes entre alto risco nutricional e tempo de permanência na UTI: Kalaiselvan et al. chegaram a 9,0 (± 4,2) versus 7,8 (± 5,8), com p < 0,010;(1414 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.) Mendes et al. a 10,0 (5,0 - 16,5) versus 8 (5,0 - 14,0), p < 0,001;(1111 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.) e Mukhopadhyay et al. a 5,0 (3,0 - 9,0) versus 3,5 (2,0 - 7,0), p < 0,010.(1212 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.)

O tempo de permanência também foi significante: 5,1% mais curto para cada 10% de ingestão proteica em relação ao objetivo nos pacientes em alto risco após 4 dias (p = 0,010) e 12 dias (p = 0,002) e para cada 10% de incremento em ingestão de energia (4 dias: p = 0,019) e (12 dias: p = 0,002).(1919 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.)

NUTRIC e mortalidade

Dez estudos analisaram o relacionamento entre o escore NUTRIC e mortalidade.(77 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):158-62.,99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.

10 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.

11 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.
-1212 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.,1414 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.

15 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.

16 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.
-1717 de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.,1919 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.) Rahman et al. estimaram que a mortalidade aumentou em 1,4 vez para cada ponto de aumento no NUTRIC.(77 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):158-62.) Escores NUTRIC mais altos tiveram associação significante com mortalidade mais alta após 6 meses (p < 0,001).(77 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):158-62.)

Coltman et al. demonstraram que pacientes em alto risco tiveram taxas mais elevadas de óbito em comparação com os sem risco (14,0 versus 3,0%).(1515 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.) Outros autores encontraram associações estatisticamente significantes: Kalaiselvan et al. chegaram a 41,4% versus 26,1%, com p < 0,001;(1414 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.) Mukhopadhyay et al. a 36% versus 12,7% em pacientes com VM, com p < 0,001;(1212 Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, van Dam RM, et al. Association of modified NUTRIC score with 28-day mortality in critically ill patients. Clin Nutr. 2017;36(4):1143-8.) e Lew et al. a 9,2% versus 39,3%, com p < 0,001.(1818 Lew CC, Cheung KP, Chong MF, Chua AP, Fraser RJ, Miller M. Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone. JPEN J Parenter Enteral Nutr. 2017 Aug 1:148607117726060. doi: 10.1177/0148607117726060. [Epub ahead of print]
https://doi.org/10.1177/0148607117726060...
) Outros grupos associaram escore NUTRIC elevado com óbito, incluindo Moretti et al. (NUTRIC-1: 4,23 [± 1,92] versus 3,06 [± 1,72]; p < 0,001; e NUTRIC-2: 4,68 [± 1,98] versus 3,39 [± 1,83]; p < 0,001);(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.) Özbilgin et al. (5,0 [± 2,03] versus 3,17 [± 1,46]; p = 0,002);(1616 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.) e de Vries et al. (6,0 [5,0 - 7,0] versus 5,0 [3,0 - 6,0]; com p < 0,001).(1717 de Vries MC, Koekkoek WK, Opdam MH, van Blokland D, van Zanten AR. Nutritional assessment of critically ill patients: validation of the modified NUTRIC score. Eur J Clin Nutr. 2018;72(3):428-35.)) Mendes et al. demonstraram que alto risco nutricional aumentou risco de mortalidade (n = 1.122; RC 3,84; IC95% 2,80 - 5,26; p < 0,001).(1111 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care. 2017;37:45-9.)

No estudo de Compher et al., a mortalidade de pacientes com alto risco foi significantemente diminuída em 6,6% (p = 0,003) e 10,1% (p = 0,003) após 4 e 12 dias, respectivamente, para cada 10% de incremento na ingestão proteica em relação ao objetivo.(1919 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.) O mesmo foi observado para cada 10% de incremento na ingestão de energia (4 e 12 dias; p < 0,001).(1919 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.)

Além disso, para Lee et al., dentre os pacientes com baixo risco nutricional, a mortalidade aos 60 dias aumentou em cerca de seis vezes no grupo que recebeu a dieta prescrita ≥ 2/3 em comparação com < 2/3 (RC 6,30; IC95% 1,17 - 33,78; p = 0,032).(1010 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.) Dentre os pacientes com alto risco nutricional, não se identificou qualquer diferença em relação à mortalidade.(1010 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.)

DISCUSSÃO

Esta revisão sistemática mostrou que muitos pacientes estão em alto risco nutricional quando são admitidos à UTI. Demonstramos também que o escore NUTRIC vem cada vez mais se tornando popular no mundo. A aplicação do NUTRIC em pacientes no início da hospitalização neste setor tornou-se relevante e tem associação com VM, complicações clínicas, tempo de hospitalização e óbito.

O escore NUTRIC foi validado por Heyland et al. e é a primeira ferramenta de avaliação do risco nutricional especificamente desenvolvida para pacientes de UTI e que pode identificar pacientes em risco nutricional.(66 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):R268.) Heyland et al. consideraram a necessidade de uma ferramenta de avaliação nutricional mais específica para pacientes de UTI e verificaram que o questionamento a respeito de perda de peso e sua situação nutricional era insuficiente, principalmente em razão da natureza heterogênea dos pacientes de UTI.(66 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):R268.) Desta forma, incorporaram diferentes variáveis ao escore (idade, APACHE II, SOFA, comorbidades, dias no hospital antes da UTI e IL-6).(66 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):R268.) Mais tarde, Rahman et al. validaram o NUTRIC modificado, que permite a exclusão dos níveis de IL-6, caso não estejam disponíveis, para avaliar o risco nutricional por ocasião da admissão.(77 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):158-62.)

O escore NUTRIC baseia-se em modelo conceitual delineado em como mensurar a inflamação aguda e crônica.(66 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):R268.) A importância da inflamação e a severidade da doença são bem reconhecidas na caracterização da desnutrição,(11 White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275-83.) como sua associação com tempo de permanência no hospital.(2020 Jeejeebhoy KN, Keller H, Gramlich L, Allard JP, Laporte M, Duerksen DR, et al. Nutritional assessment: comparison of clinical assessment and objective variables for the prediction of length of hospital stay and readmission. Am J Clin Nutr. 2015;101(5):956-65.) Pacientes com escore mais alto têm desfechos clínicos piores, como taxas de mortalidade.(1616 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.)

Não existem marcadores tradicionais do risco nutricional, como índice de massa corporal (IMC), perda de peso, ingestão oral, ou avaliação física, e o escore NUTRIC considera apenas a severidade da doença.(66 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):R268.) Entretanto, no estudo original relativo à validação, dados como IMC, porcentagem de ingestão oral na semana prévia, e porcentagem de perda de peso nos últimos 3 meses não se associam com mortalidade.(55 Preiser JC, van Zanten AR, Berger MM, Biolo G, Casaer MP, Doig GS, et al. Metabolic and nutritional support of critically ill patients: consensus and controversies. Crit Care. 2015;19:35.)

A identificação precoce de indivíduos em risco nutricional (e que podem beneficiar-se da terapia nutricional) é fundamental no ambiente do hospital, inclusive nas condições da UTI.(66 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):R268.) Heyland et al. consideraram que ferramentas que geram maior conscientização a respeito da avaliação do risco nutricional, como o escore NUTRIC, e fatores de risco, como IMC e duração da permanência na UTI, podem enfatizar o fornecimento de calorias e proteínas para os pacientes que mais necessitam delas.(66 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):R268.) Embora muitos instrumentos tenham indicado que pacientes críticos se encontram em risco nutricional em razão de suas condições clínicas,(2121 Sheean PM, Peterson SJ, Chen Y, Liu D, Lateef O, Braunschweig CA. Utilizing multiple methods to classify malnutrition among elderly patients admitted to the medical and surgical intensive care units (ICU). Clin Nutr. 2013;32(5):752-7.,2222 Koren-Hakim T, Weiss A, Hershkovitz A, Otzrateni I, Anbar R, Gross Nevo RF, et al. Comparing the adequacy of the MNA-SF, NRS-2002 and MUST nutritional tools in assessing malnutrition in hip fracture operated elderly patients. Clin Nutr. 2016;35(5):1053-8.) eles podem não ter o mesmo risco de eventos adversos relacionados à desnutrição.(66 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):R268.)

O escore NUTRIC mostra a importância do desenvolvimento de escores específicos para indivíduos com condições clínicas particulares.(1313 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.) Além disto, é um instrumento fácil e prático, que pode ser incorporado à rotina das UTI.(1313 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.) Uma clara vantagem do NUTRIC é sua aplicabilidade em situações nas quais os pacientes não são capazes de fornecer respostas verbais, como no caso de VM, já que as variáveis utilizadas neste sistema de escore são objetivamente obtidas a partir de dados rotineiramente registrados nos prontuários clínicos dos pacientes.(1313 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.)

Com relação às perspectivas futuras para o NUTRIC, seu uso é promissor para profissionais de saúde. O uso da dosagem de IL-6 no escore torna-o difícil de usar, já que nenhum estudo incluiu este parâmetro. Precisamos valorizar os estudos que buscam simplificar o NUTRIC com variáveis que são mais comumente disponíveis, como a inclusão da dosagem de PCR.(99 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.) Há muitos estudos observacionais que relacionam o escore NUTRIC com desfechos clínicos desfavoráveis, porém apenas um grupo realizou estudo intervencional.(77 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):158-62.) Portanto, é necessário que se conduzam estudos que demonstrem o relacionamento de desfechos clínicos com intervenções segundo o NUTRIC. Acrescente-se que é também importante que seu uso não se limite ao nutricionista, já que o NUTRIC é capaz de enfatizar importantes desfechos clínicos, como complicações e óbito.

Esta foi a primeira revisão sistemática do uso do escore NUTRIC. O número de estudos que avaliou o desempenho ou a aplicação do escore é relativamente baixo, em razão de sua validação recente. Consideramos isto uma limitação da nossa revisão.

CONCLUSÃO

O escore NUTRIC é relacionado com desfechos clínicos, como tempo de permanência no hospital e óbito, sendo apropriado para utilização em pacientes críticos na unidade de terapia intensiva. São necessários mais estudos para avaliar esta ferramenta nessa população em particular.

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Editado por

Editor responsável: Alexandre Biasi Cavalcanti

Datas de Publicação

  • Publicação nesta coleção
    14 Out 2019
  • Data do Fascículo
    Jul-Sep 2019

Histórico

  • Recebido
    11 Mar 2018
  • Aceito
    05 Nov 2018
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