| BackgroundRefeeding syndrome(RFS)refers to the clinical symptoms,and metabolic abnormalities in long-term period of starved or malnourished patients undergoing refeeding,and the hallmark of this phenomenon is hypophosphatemia.According to a previous study by our group,the incidence of RFS in neurocritical patients is not uncommon in neurocritical patients.RFS is fatal,but it can be prevented,and the key is early screening to identify those who are at risk for RFS.However,there is no unified screening tool for RFS,and the existing scales lack quality validation.According to the 2020 American Society for Enteral and Parenteral Nutrition(ASPEN)guidelines,the Short Nutritional Assessment Questionnaire(SNAQ),the Global Leadership Initiative on Malnutrition(GLIM),and Britain’s National Institute for Health and Care Excellence(NICE)can be used to screen RFS,but it is also noted that these scales have a terrible ability to identify people at risk of RFS.2018 Friedli et al.improved the NICE to form a new risk stratification(mNICE),ASPEN proposed a new RFS screening scale,but both two scales have failed to further verify its efficacy.Furthermore,none of the above scales has been validated in neurocritical patients so far.ObjectiveIn this study,we aimed to verify and compare the efficacy of the SNAQ,GLIM,mNICE,and ASPEN screening scales in identifying individuals at high risk for RFS in patients with severe neurological conditions,and we sought to identify the risk factors associated with the development of RFS to improve the effectiveness of scales in identifying patients at risk of RFS.MethodsThis is a single-center,observational,retrospective cohort study,research objects were neurocritically ill adult patients who were admitted to the neurocritical care unit(NCU)of Nanfang Hospital and received enteral nutrition for 72 h or longer from January 2014 to September 2020.The patients were rigorously scored according to the criteria of SNAQ,GLIM,mNICE,and ASPEN scales,and the risk of RFS was assessed.RFS was defined as the occurrence of new-onset hypophosphatemia within 72 hours after starting nutritional support,which meant a drop of more than 0.16 mmol/L on serum phosphate from any previous baseline and under the threshold of 0.65 mmol/L.The performance of each scale in predicting RFS was evaluated according to the sensitivity and specificity of RFS recognition,adding to the receiver operating characteristic curve and area under the curve(AUC).In addition,the independent risk factors of RFS were explored by logistic regression analysis and quantified into the above scale,and then the effectiveness of the improved scale was tested.ResultsOf the 478 patients included,84(17.57%)developed RFS.The sensitivity of the SNAQ and GLIM was only 20.2%(12.6%-30.7%),although they had excellent specificity of 84.8%(80.8%-88.1%)and 86.0%(82.1%-89.2%),respectively,mNICE predicted RFS with the sensitivity of 48.8%(37.8%-59.9%)and specificity of 65.0%(60.0%-69.9%),ASPEN had the highest Youden index,with sensitivity and specificity of 53.6%(42.4%-64.4%)and 64.7%(59.8%-69.4%).The AUC of SNAQ,GLIM,mNICE,and ASPEN to predict RFS was 0.515(0.470-0.561),0.533(0.487-0.579),0.568(0.523-0.613)and 0.597(0.551-0.641),respectively.There was no statistical difference between the AUCs of these scores.We identified disease severity score and age as independent risk factors of RFS,and the combination of glasgow coma score(GCS)and age can improve the AUC of ASPEN to 0.664(0.620-0.706)for predicting RFS.ConclusionThe incidence of RFS in neurocritical patients is not rare,in which SNAQ and GLIM have good specificity in predicting the occurrence of RFS,and ASPEN has acceptable sensitivity,but the combined effects of each screening scale in predicting RFS are unsatisfactory.Modified scales can improve the identification of RFS,but there is still much room for improvement.This reveals that an RFS screening scale with higher sensitivity and specificity is imperative for clinical routine. |
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