Phase Angle as Predictor of ICU

Outcomes
Niken Puruhita
Nutrition Department
Medical Faculty Diponegoro University/dr Kariadi Central
Hospital
 Introduction
• BIA is a simple, non-invasive technique that estimates
body composition by measuring the opposition
(impedance) to an applied current while passing
through the body.
• Impedance (Z) is a function of Resistance and
Reactance
• Resistance (R) is the restriction to the flow of an
electric current through the body, primarily related
to the amount of water present in tissue.
• Reactance (Xc) is the opposition to current flow
caused by capacitance (voltage storage) produced
by the cell membrane (Kushner 1992)
Stapel et al. European Journal of Clinical Nutrition (2018) 72:1019–1025
Moonen and Zanten. Crit Care. 2021 (27): 344-53
Low-frequency currents will not penetrate cell membranes, and as such will measure
extracellular water impedance. High-frequency currents will go through cells, at which point
the impedance reflects total body water (TBW)

Moonen and Zanten. Crit Care. 2021 (27):

344-53
Reactance Xc
Quantity

Q
u
a
l
i
t
y

t
PA is regarded as a biological marker of cellular health, as it reflects cell mass, membrane integrity,
and hydration status
Phase angle: A different angle of nutritional assessment

High Phase Angle Low Phase Angle

• Increased muscle • Muscle wasting

mass • Weight loss
• Weight gain • Malnutrition
• Good supply of • Edema
nutrients • Cell membrane
• Reduction of water damage (infection,
retention stress, intoxication)
• Sufficient sleep
Aim

The aim of this literature review was to describe

the use of Phase Angle in critically ill setting,
including medical and surgical ICU.
Methods

• Literature searching of published articles from

2011 to 2021
• Keyword “Phase Angle”, “bioelectrical
impedance”, “Malnutrition”, “ICU outcome”
• All relevant articles found were considered
eligible.
• Abstract and articles in non-English language
were excluded.
Results: PhA and Malnutrition
Associations of a low PA with indicators of undernutrition, muscle
strength,
and immune function

• *p ≤ 0.05 #0.05 < p ≤ 0.10 §Fisher

• a PA < 5.38°, b PA ≥ 5.38°, c BMI < 21 kg/m2, d 10% UWL in the last 6 months, e FFMI ≤ 14.6 kg/m2 for women and ≤ 16.7 kg/m2
for men, f HGS < age and sex matched reference (21), g Albumin ≤ 39 g/L, h CRP 5 mg/L

Visser M, et al. Clinical Nutrition 2012; 31(6): 981‐986

Result: PhA and Malnutrition
Mean PhA according to the classes of nutritional status diagnosed by Nutritional Risk Screening (NRS
2002), Subjective Global Assessment (SGA), Body mass index (BMI) and Total Lymphocytes Count
(TLC)

• NRS 2002, Nutritional Risk Screening 2002: NRS 2002 < 3 normal nutrition; NRS 2002 ≥ 3: nutritional risk
• SGA, Subjective Global Assessment: SGA A: normal nutrition; SGA B + C malnutrition;
• BMI, Body Mass Index: BMI ≥ 18 kg/m2 : normal nutrition; BMI < 18.5 kg/m2 malnutrition;
• TLC; Total Lymphocytes Count TLC ≥ 1,200 mm3 : normal nutrition; TLC < 1,200 mm3 : malnutrition;
Scheunemann L et al, Nutr Hosp. 2011;26(3):
480-487
Results: PhA and Malnutrition
Nutritional characteristics and clinical outcomes of critically ill patients according to
the standardized phase angle classification.

Jansen AK et al. Clin Nutr 2019 (34) : 68 - 72

 Result: PhA and ICU Outcome
Regression analyses of a low PhA and adverse clinical
outcome

Multivariate analyses adjusted for sex, age, operative procedure, risk score, inflammatory activity, hypoalbuminemia,
heart failure, cardiopulmonary bypass time, and aortic cross clamp time.
Visser M, et al. Clinical Nutrition 2012; 31(6):
981‐986
Results: PhA and Mortality
A 28-day mortality according to phase angle values on day 1 (admission) and day 5.

Thibault et al. Intensive Care Med (2016) 42:

1445–1453
Results: PhA and Mortality
MV analysis for factors associated with 28 day mortality of ICU
Patients

Thibault et al. Intensive Care Med (2016) 42:

1445–1453
 Results: PhA and Mortality
Univariable and multivariable logistic regression analysis for 90-day
mortality

• a Model summary: −2logLH: 119.2, Nagelkerke R2: 0.381, Hosmer–Lemeshow test: χ2: 8.971, p = 0.345; Phase angle entered as a continuous variable
• b Model summary: −2logLH: 117.33, Nagelkerke R2: 0.395, Hosmer–Lemeshow test: χ2: 9.021, p = 0.341; Phase angle entered as a categorical variable (with a cutoff of 4.8°)

Stapel et al. European Journal of Clinical Nutrition (2018) 72:

1019–1025
 Discussion
• Visser (2012) showed that low PhA (< 5.38°) is associated with
low BMI and low FFMI and predictor for ICU and hospital
dicharge
• Scheunemann L, et al. (2011) reported that low PhA was highly
correlated with NRS 2002, SGA and TLC, but not BMI
• PhA was also associates with MUAC and SGA (Jansen, 2019)
• Jansen also reported that PhA was associated with Length of
ICU and Hospital stay
• Thibault (2016) and Stapel (2018) reported that PhA is
associated with 28 and 90 days mortality respectively
Conclusion
• PhA is associated with malnutrition parameter in
critically ill patients
• PhA is predictor for ICU outcomes including ICU and
hospital length of stay and mortality