Optimizing nitrogen balance is associated with better outcomes in neurocritically ill patients

Abstract

Background Marked protein catabolism is common in patients with critical illness. We hypothesized that optimal protein supplementation using nitrogen balance might be associated with better clinical outcomes in patients in the neurointensive care unit (NICU).Methods A retrospective observational analysis was performed among patients admitted to the NICU between July 2017 and December 2018. Nitrogen balance was measured within 72 hours after NICU admission and measurements were repeated after 10 days in those who stayed in the NICU for more than 7 days. Nitrogen balance was calculated using a standard formula: total protein intake (grams)/6.25 – (urine urea nitrogen + 4 grams). Included patients were categorized into two groups (positive or negative) based on the initial nitrogen balance results. The rate of neurological worsening, defined by a worsening of ≥2 in the Glasgow Coma Scale (GCS) score, and in-hospital mortality were compared between patients who achieved the improvement of nitrogen balance on a follow-up measurement and those who failed to.Results A total of 175 patients were included, and 140 (80.0%) had a negative nitrogen balance on the initial assessment. The negative nitrogen balance group had a lower GCS, longer NICU stay, more events of neurological worsening, and higher in-hospital mortality. Among the 77 patients (44.0%) who underwent a follow-up measurement of nitrogen balance (on a median day of 10), 39 (50.6%) showed an improvement in nitrogen balance and thus received a higher amount of protein (1.94 g/kg/day) than those who did not show this improvement (1.28 g/kg/day) ( P < 0.001). The improvement group had fewer events of neurological worsening (15.4% vs. 36.8%, P = 0.032) and lower in-hospital mortality (12.8% vs. 31.6%, P = 0.047). However, there were no significant differences in baseline nitrogen balance, GCS, and the development of acute kidney injury between the two groups.Conclusions This study demonstrated that a significant proportion of patients in NICU were under protein hypercatabolism. An adequate provision of protein was associated with improved outcomes, suggesting the importance of protein supplementation in neurocritically ill patients.

Prehospital triage of intracranial hemorrhage and anterior large vessel occlusion ischemic stroke: the value of the rapid arterial occlusion evalution

“…These characteristics and observations were selected based upon previous literature, and included age, sex, history of atrial fibrillation, use of oral anticoagulation, mean arterial blood pressure, glucose level, consciousness as measured with the AVPU and Glasgow Coma Scale, pupillary assessment, and presence of nausea/vomiting. [16][17][18][19][20][21][22]33 We calculated adjusted odds ratios (aOR) with 95% confidence intervals (CI) to determine associations with a final diagnosis of ICH or aLVO stroke, with the RACE score as (a) a dichotomized variable (positive ≥5 points or negative <5 points) and (b) as a categorical variable ranging from 0 to 9 points. A 2-sided p-value of ≤0.05 was considered statistically significant.…”

“…advanced age, use of oral anticoagulation, decreased consciousness, vomiting and elevated blood pressure, are associated with ICH. [16][17][18][19][20][21][22] However, sample sizes of these studies were generally small and they often assessed only a few features. Furthermore, other studies demonstrated that it is difficult to specifically identify ICH patients based solely on clinical assessment, and that current triage scores are insufficient.…”