Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients

Peter J M Weijs, Wilhelmus G P M Looijaard, Ingeborg M Dekker, Sandra N Stapel, Armand R Girbes, H M Oudemans-van Straaten, Albertus Beishuizen, Peter J M Weijs, Wilhelmus G P M Looijaard, Ingeborg M Dekker, Sandra N Stapel, Armand R Girbes, H M Oudemans-van Straaten, Albertus Beishuizen

Abstract

Introduction: Higher body mass index (BMI) is associated with lower mortality in mechanically ventilated critically ill patients. However, it is yet unclear which body component is responsible for this relationship.

Methods: This retrospective analysis in 240 mechanically ventilated critically ill patients included adult patients in whom a computed tomography (CT) scan of the abdomen was made on clinical indication between 1 day before and 4 days after admission to the intensive care unit. CT scans were analyzed at the L3 level for skeletal muscle area, expressed as square centimeters. Cutoff values were defined by receiver operating characteristic (ROC) curve analysis: 110 cm2 for females and 170 cm2 for males. Backward stepwise regression analysis was used to evaluate low-muscle area in relation to hospital mortality, with low-muscle area, sex, BMI, Acute Physiologic and Chronic Health Evaluation (APACHE) II score, and diagnosis category as independent variables.

Results: This study included 240 patients, 94 female and 146 male patients. Mean age was 57 years; mean BMI, 25.6 kg/m2. Muscle area for females was significantly lower than that for males (102 ± 23 cm2 versus 158 ± 33 cm2; P < 0.001). Low-muscle area was observed in 63% of patients for both females and males. Mortality was 29%, significantly higher in females than in males (37% versus 23%; P = 0.028). Low-muscle area was associated with higher mortality compared with normal-muscle area in females (47.5% versus 20%; P = 0.008) and in males (32.3% versus 7.5%; P < 0.001). Independent predictive factors for mortality were low-muscle area, sex, and APACHE II score, whereas BMI and admission diagnosis were not. Odds ratio for low-muscle area was 4.3 (95% confidence interval, 2.0 to 9.0, P < 0.001). When applying sex-specific cutoffs to all patients, muscle mass appeared as primary predictor, not sex.

Conclusions: Low skeletal muscle area, as assessed by CT scan during the early stage of critical illness, is a risk factor for mortality in mechanically ventilated critically ill patients, independent of sex and APACHE II score. Further analysis suggests muscle mass as primary predictor, not sex. BMI is not an independent predictor of mortality when muscle area is accounted for.

Figures

Figure 1
Figure 1
Consort diagram showing the inclusion process.
Figure 2
Figure 2
Kaplan-Meier survival plot for low- and normal-muscle area group (log rank test, P < 0.001).

References

    1. Gruther W, Benesch T, Zorn C, Paternostro-Sluga T, Quittan M, Fialka-Moser V, Spiss C, Kainberger F, Crevenna R. Muscle wasting in intensive care patients: ultrasound observation of the M. quadriceps femoris muscle layer. J Rehabil Med. 2008;40:185–189. doi: 10.2340/16501977-0139.
    1. Villet S, Chiolero RL, Bollmann MD, Revelly JP, Cayeux RN, Delarue J, Berger MM. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr. 2005;24:502–509. doi: 10.1016/j.clnu.2005.03.006.
    1. Dvir D, Cohen J, Singer P. Computerized energy balance and complications in critically ill patients: an observational study. Clin Nutr. 2006;25:37–44. doi: 10.1016/j.clnu.2005.10.010.
    1. Oliveros H, Villamor E. Obesity and mortality in critically ill adults: a systematic review and meta-analysis. Obesity (Silver Spring) 2008;16:515–521. doi: 10.1038/oby.2007.102.
    1. Hogue CWJ, Stearns JD, Colantuoni E, Robinson KA, Stierer T, Mitter N, Pronovost PJ, Needham DM. The impact of obesity on outcomes after critical illness: a meta-analysis. Intensive Care Med. 2009;35:1152–1170. doi: 10.1007/s00134-009-1424-5.
    1. World Health Organization. Obesity: preventing and managing the global epidemic: report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i–253.
    1. Martino JL, Stapleton RD, Wang M, Day AG, Cahill NE, Dixon AE, Suratt BT, Heyland DK. Extreme obesity and outcomes in critically ill patients. Chest. 2011;140:1198–1206. doi: 10.1378/chest.10-3023.
    1. Sakr Y, Elia C, Mascia L, Barberis B, Cardellino S, Livigni S, Fiore G, Filippini C, Ranieri VM. Being overweight or obese is associated with decreased mortality in critically ill patients: a retrospective analysis of a large regional Italian multicenter cohort. J Crit Care. 2012;27:714–721. doi: 10.1016/j.jcrc.2012.08.013.
    1. Pickkers P, de Keizer N, Dusseljee J, Weerheijm D, van der Hoeven JG, Peek N. Body mass index is associated with hospital mortality in critically ill patients: an observational cohort study. Crit Care Med. 2013;41:1878–1883. doi: 10.1097/CCM.0b013e31828a2aa1.
    1. Kalantar-Zadeh K, Streja E, Molnar MZ, Lukowsky LR, Krishnan M, Kovesdy CP, Greenland S. Mortality prediction by surrogates of body composition: an examination of the obesity paradox in hemodialysis patients using composite ranking score analysis. Am J Epidemiol. 2012;175:793–803. doi: 10.1093/aje/kwr384.
    1. Mourtzakis M, Prado CMM, Lieffers JR, Reiman T, McCargar LJ, Baracos VE. A practical and precise approach to quantification of body composition in cancer patients using computed tomography images acquired during routine care. Appl Physiol Nutr Metab. 2008;33:997–1006. doi: 10.1139/H08-075.
    1. Baracos VE, Reiman T, Mourtzakis M, Gioulbasanis I, Antoun S. Body composition in patients with non-small cell lung cancer: a contemporary view of cancer cachexia with the use of computed tomography image analysis. Am J Clin Nutr. 2010;91:1133S–1137S. doi: 10.3945/ajcn.2010.28608C.
    1. Prado CMM, Lieffers JR, McCargar LJ, Reiman T, Sawyer MB, Martin L, Baracos VE. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol. 2008;9:629–635. doi: 10.1016/S1470-2045(08)70153-0.
    1. Thoresen L, Frykholm G, Lydersen S, Ulveland H, Baracos V, Prado CMM, Birdsell L, Falkmer U. Nutritional status, cachexia and survival in patients with advanced colorectal carcinoma: different assessment criteria for nutritional status provide unequal results. Clin Nutr. 2013;32:65–72. doi: 10.1016/j.clnu.2012.05.009.
    1. Weijs PJM, Vansant GAAM. Validity of predictive equations for resting energy expenditure in Belgian normal weight to morbid obese women. Clin Nutr. 2010;29:347–351. doi: 10.1016/j.clnu.2009.09.009.
    1. Weijs PJM, Wischmeyer PE. Optimizing energy and protein balance in the ICU. Curr Opin Clin Nutr Metab Care. 2013;16:194–201. doi: 10.1097/MCO.0b013e32835bdf7e.
    1. Heymsfield SB, Wang Z, Baumgartner RN, Ross R. Human body composition: advances in models and methods. Annu Rev Nutr. 1997;17:527–558. doi: 10.1146/annurev.nutr.17.1.527.
    1. Mitsiopoulos N, Baumgartner RN, Heymsfield SB, Lyons W, Gallagher D, Ross R. Cadaver validation of skeletal muscle measurement by magnetic resonance imaging and computerized tomography. J Appl Physiol. 1998;85:115–122.
    1. Shen W, Punyanitya M, Wang Z, Gallagher D, St-Onge MP, Albu J, Heymsfield SB, Heshka S. Total body skeletal muscle and adipose tissue volumes: estimation from a single abdominal cross-sectional image. J Appl Physiol. 2004;97:2333–2338. doi: 10.1152/japplphysiol.00744.2004.
    1. Moisey L, Mourtzakis M, Cotton B, Premji T, Heyland D, Wade C, Bulger E, Kozar R. Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients. Crit Care. 2013;17:R206. doi: 10.1186/cc12901.
    1. Kiraly L, Hurt RT, Van Way CW. The outcomes of obese patients in critical care. JPEN J Parenter Enteral Nutr. 2011;35:29S–35S. doi: 10.1177/0148607111413774.
    1. Martin L, Birdsell L, Macdonald N, Reiman T, Clandinin MT, McCargar LJ, Murphy R, Ghosh S, Sawyer MB, Baracos VE. Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol. 2013;31:1539–1547. doi: 10.1200/JCO.2012.45.2722.
    1. van Schijndel RJM S, Weijs PJM, Koopmans RH, Sauerwein HP, Beishuizen A, Girbes ARJ. Optimal nutrition during the period of mechanical ventilation decreases mortality in critically ill, long-term acute female patients: a prospective observational cohort study. Crit Care. 2009;13:R132. doi: 10.1186/cc7993.
    1. Weijs PJM, Stapel SN, de Groot SDW, Driessen RH, de Jong E, Girbes ARJ, van Schijndel RJMS, Beishuizen A. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study. JPEN J Parenter Enteral Nutr. 2012;36:60–68. doi: 10.1177/0148607111415109.
    1. Combes A, Luyt CE, Trouillet JL, Nieszkowska A, Chastre J. Gender impact on the outcomes of critically ill patients with nosocomial infections. Crit Care Med. 2009;37:2506–2511. doi: 10.1097/CCM.0b013e3181a569df.
    1. Blankstein R, Ward RP, Arnsdorf M, Jones B, Lou YB, Pine M. Female gender is an independent predictor of operative mortality after coronary artery bypass graft surgery: contemporary analysis of 31 Midwestern hospitals. Circulation. 2005;112:I323–I327.
    1. Caporossi FS, Caporossi C, Borges Dock-Nascimento D, de Aguilar-Nascimento JE. Measurement of the thickness of the adductor pollicis muscle as a predictor of outcome in critically ill patients. Nutr Hosp. 2012;27:490–495.
    1. Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS, Velloso C, Seymour J, Agley CC, Selby A, Limb M, Edwards LM, Smith K, Rowlerson A, Rennie MJ, Moxham J, Harridge SDR, Hart N, Montgomery HE. Acute skeletal muscle wasting in critical illness. JAMA. 2013;310:1591–1600. doi: 10.1001/jama.2013.278481.
    1. Braunschweig C, Sheean P, Peterson S, Perez S, Freels S, Troy K, Ajanaku F, Patel A, Sclamberg J, Wang Z. Exploitation of diagnostic computed tomography scans to assess the impact of nutritional support on body composition changes in respiratory failure patients. JPEN J Parenter Enteral Nutr. 2013; : . Epub ahead of print.
    1. Visser M, van Venrooij LMW, Wanders DCM, de Vos R, Wisselink W, van Leeuwen PAM, de Mol BAJM. The bioelectrical impedance phase angle as an indicator of undernutrition and adverse clinical outcome in cardiac surgical patients. Clin Nutr. 2012;31:981–986. doi: 10.1016/j.clnu.2012.05.002.
    1. Ishibashi N, Plank LD, Sando K, Hill GL. Optimal protein requirements during the first 2 weeks after the onset of critical illness. Crit Care Med. 1998;26:1529–1535. doi: 10.1097/00003246-199809000-00020.
    1. Weijs PJM, Sauerwein HP, Kondrup J. Protein recommendations in the ICU: g protein/kg body weight: which body weight for underweight and obese patients? Clin Nutr. 2012;31:774–775. doi: 10.1016/j.clnu.2012.04.007.
    1. Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, Rock P. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307:795–803.
    1. Casaer MP, Hermans G, Wilmer A, Van den Berghe G. Impact of early parenteral nutrition completing enteral nutrition in adult critically ill patients (EPaNIC trial): a study protocol and statistical analysis plan for a randomized controlled trial. Trials. 2011;12:21. doi: 10.1186/1745-6215-12-21.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren