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. 2022 Nov 22;38(3):120–121.

2022 SASPEN Abstracts

PMCID: PMC9869487
South Afr J Crit Care. 2022 Nov 22;38(3):120–121.

Assessment of the clinical usability of adult undernutrition diagnostic criteria in an academic hospital, Gauteng Province, South Africa

V Kotze

Groenkloof Life Hospital, Pretoria, South Africa; SASPEN, South Africa

Background: The Global Leadership Initiative on Malnutrition (GLIM) provides possible consensus for diagnosing adult undernutrition. There is uncertainty on the utilisation of these criteria in resource-limited hospitals.

Objectives: To determine (i) the clinical usability of selected GLIM criteria in a resource-limited academic hospital in Gauteng Province; and (ii) the number of patients diagnosed as undernourished using provided equipment compared with available hospital resources.

Methods: A descriptive, observational, cross-sectional study was conducted in adult internal medicine and surgical wards in an academic hospital in Gauteng during April 2020. Ethical approval was obtained from the Faculty of Health Sciences Research Ethics Committee, University of Pretoria, and the academic hospital’s Research Committee. Ninety-five patients were included using non-random convenient sampling. Patients were screened on admission using phenotypical criteria (nonvolitional weight loss, body mass index (BMI), reduced muscle mass (mid-upper arm circumference (MUAC) and handgrip strength (HGS)) and aetiological criteria (reduced food intake, inflammation prevalence (C-reactive protein (CRP) and medical diagnosis)).

Results: Fifty-four (56.84%) patients were identified as undernourished using provided equipment compared with seven (11.58%) utilising hospital resources. Weight loss could be determined in 45.26% of patients compared with 75.59% for BMI, 98.95% for MUAC and 94.74% for HGS, respectively. CRP could only be obtained from 43.16% patient files and medical diagnosis from 77.89% patient files. Ninety-two (96.84%) patients could report on food intake.

Conclusion: Undernutrition prevalence in adult hospitalised patients in South Africa is high. However, inadequate resources may result in under-reporting. MUAC and oral history intake seem to be the most clinical usable GLIM criteria in resource-limited hospitals.

South Afr J Crit Care. 2022 Nov 22;38(3):120–121.

Early economical benefits of peri-operative nasojejunal tube feeding in non-critical care adult surgical patients with gastric feed intolerance

G Chinnery, A-L du Toit, C Robinson, I Kippie, E Jonas, M Scriba

Groote Schuur Hospital, Cape Town, South Africa

Background: Peri-operative short- or medium-term enteral nutrition (EN) via nasojejunal tube (NJT) is an option for anatomical gastric feed intolerance.

Objectives: To determine duration of usage required to justify the high insertion costs of fluoroscopic-guided endoscopically placed NJTs.

Methods: Indication, successful insertion, and duration of NJT patency were determined. NJT insertion costs were compared with central venous catheter (CVC) insertion. EN costs over a hypothetical 28-day period factored in expected NJT replacements owing to blockage and were compared with parenteral nutrition (PN) via CVC, including routine CVC changes every 10 days. Public and private sectors were compared (University of Cape Town HREC 658/2020).

Results: One hundred and two NJTs were placed successfully (93.6%), with gastric outlet obstruction the most frequent indication (40.4%) with a median 10 days’ (range 1 - 68 days, interquartile range (IQR) 6 - 16.75 days) usage. Irrevocable blockage occurred in 33 tubes after a median 9 days (range 3 - 34 days; IQR 4.75 - 16 days). Calculated EN costs over 28 days, including NJT replacement every 9 days, reached US$1 676.12 and PN costs with CVC replacement every 10 days, US$3 461.35 (p<0.001) in the public sector. In the private sector, PN costs at 28 days were significantly higher (p<0.001) at US$5 261.14 compared with EN US$3 780.71. The cost benefit of EN via NJT over PN is seen after 3 days in public, and 4 days in the private sector.

Conclusion: Exponential cost saving occurs with EN via NJT, even when factoring in the likelihood of endoscopic NJT replacements.

South Afr J Crit Care. 2022 Nov 22;38(3):120–121.

The incidence of hypophosphataemia in at-risk upper gastrointestinal surgical patients treated according to refeeding guidelines

G Chinnery, A-L du Toit, C Robinson, G Davids, B Gibson, I Kippie, E Jonas, M Scriba

Groote Schuur Hospital, Cape Town, South Africa

Background: Refeeding syndrome (RFS) is a severe fluid and electrolyte shift occurring in malnourished patients on commencing oral, enteral or parenteral nutrition, with severe hypophosphataemia described as the hallmark thereof.

Objectives: To determine the incidence of refeeding hypophosphataemia developing despite the controlled introduction of nutrition according to refeeding guidelines.

Methods: A retrospective review of electrolyte disturbances occurring within 72 hours of commencement of perioperative nutritional support in patients identified at risk of RFS (University of Cape Town HREC 800/2018).

Results: Seventy-six patients (mean age 54.2 years (range 26 - 80 years; 44 (57.9%) male) admitted for perioperative nutritional optimisation at risk of RFS with a median admission body mass index (BMI) of 18.47 kg/m² , (interquartile range (IQR) 16.26 - 22.47 kg/ m² ) were included. The most common underlying pathology was gastric outlet obstruction (70; 92.1%). The majority (90.8%) had at least one major risk criterion for RFS according to the National Institute for Clinical Excellence. Enteral nutrition (via nasojejunal tube in 82.9%) was given in 41 (53.9%) patients; and parenteral nutrition in 35 (46.1%). Forty-four patients (57.9%) met the criteria for refeeding hypophosphataemia (drop in phosphate to <0.65 mmol/L or a drop by >0.16 mmol/L). Forty-two (55.3%) required intravenous electrolyte replacement (potassium in 35.5%, phosphate in 38.2%, magnesium in 27.6%, calcium in 2.6%).

Conclusion: Despite strict adherence to refeeding guidelines, the majority of patients at risk of RFS developed refeeding hypophosphataemia, with most requiring one or more electrolytes replaced.

South Afr J Crit Care. 2022 Nov 22;38(3):120–121.

Bedside ultrasound: A reliable tool to assess musculoskeletal quantity and quality in critical illness

L Veldsman,1 A Lupton-Smith,2 G A Richards,3 R Blaauw1

1. Division of Human Nutrition, Stellenbosch University, Cape Town, South Africa

2. Division of Physiotherapy, Stellenbosch University, Cape Town, South Africa

3. Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Background: Bedside ultrasound (US) is a non-invasive tool to monitor musculoskeletal quantity (cross-sectional area (CSA)) and quality (echogenicity) in critically ill patients.

Objectives: This pilot determined the accuracy and reliability of imaging performed by investigators and of analyses by blinded assessors.

Methods: The study was approved by the Stellenbosch University Health Research Ethics Committee (m20/08/023). The investigators (one trained for US and one a trainee) performed rectus femoris quadriceps B-mode US with a 4-12 MHz linear transducer array (Philips Lumify 795005, RSA) using standardised methodology. For inter-rater accuracy, imaging was performed independently on 32 participants by both investigators, and for intra-rater reliability both obtained a second image on 15 participants. Two blinded assessors performed image acquisition analyses (CSA and echogenicity) on 11 of the participants using ImageJ software (NIH, Bethesda, MD). Inter- and intra-rater reliability were determined by calculating intraclass correlation coefficients (ICC) and 95% confidence intervals, based on an absolute-agreement, 2-way mixed-effects model. ICC values were classified as poor (ICC<0.40), fair (ICC=0.40 - 0.59), good (ICC=0.60 - 0.74) and excellent (ICC=0.75 - 1.0).

Results: Imaging accuracy showed good to excellent reliability for inter-rater (ICC=0.85 - 0.95) and excellent intra-rater reliability (ICC=0.91 - 0.94). There were no statistically significant differences between the two investigators (mean for CSA=0.18 cm² , 95% confidence interval (CI) 1.10 - 0.75, p=0.704; mean for echogenicity=-6.62, CI 11.97 - 25.22, p=0.479). Inter-rater reliability for measurement analysis between assessors was excellent (ICC=0.97 - 1.0).

Conclusion: US technique showed good to excellent reliability and reproducibility. Training dietitians to perform bedside US is potentially valuable to identify high-risk patients with low muscle mass and quality.

South Afr J Crit Care. 2022 Nov 22;38(3):120–121.

Malnutrition prevalence and severity grading in South African public and private hospitals using the GLIM criteria

E Van Tonder,1, 2 F Wenhold,3 T Esterhuizen,2 R Blaauw,2

1. Nelson Mandela University, Gqeberha, South Africa

2. Stellenbosch University, Cape Town, South Africa

3. University of Pretoria, South Africa

Background: The Global Leadership Initiative on Malnutrition (GLIM) is a developed consensus to standardise global diagnosis of adult malnutrition and comparison across clinical and geographical settings.

Objectives: To determine the prevalence and severity of malnutrition according to the GLIM criteria in South African public and private hospitals, and to determine its comparative validity relative to the ESPEN malnutrition diagnostic criteria (EDC).

Methods: A diagnostic accuracy study was conducted in three public and two private hospitals, following ethical approval. Malnutrition risk was assessed using the Malnutrition Universal Screening Tool (MUST). For GLIM, bio-electrical impedance quantified muscle mass, and biomarkers the presence of inflammation. Associations were evaluated with chi-square tests, while Cohen’s kappa, sensitivity (Se), specificity (Sp), and positive (PPV) and negative predictive values (NPV) determined strength of agreement.

Results: Half (n=350) of 696 patients screened for malnutrition risk (MUST>1), were at increased risk (public n=580, 51%; private: n=116, 48%) and included in the final sample; 29% (n=203) were malnourished according to GLIM, with public hospital patients significantly more (p<0.001) malnourished (n=183, 31.6%) than private hospital patients (n=20, 17.2%). Of the final, whole sample, 55% and 39% were classified as moderate malnutrition and 31% and 27% as severe according to percentage weight loss and low body mass index ,respectively. Agreement between GLIM and EDC was low (kappa=0.161; 95% CI 0.057 - 0.265; p=0.03; Se=64%; Sp=52%; PPV=64%; NPV=49%).

Conclusion: A third of patients were malnourished (per GLIM), of whom almost a third were severely malnourished. Low agreement existed between GLIM and EDC to diagnose malnutrition.

Articles from Southern African Journal of Critical Care are provided here courtesy of South African Medical Association

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