title: Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients.
abstract: BACKGROUND
  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.
authors.forename: Peter J M
authors.initials: PJ
authors.lastname: Weijs
authors.forename: Wilhelmus G P M
authors.initials: WG
authors.lastname: Looijaard
authors.forename: Ingeborg M
authors.initials: IM
authors.lastname: Dekker
authors.forename: Sandra N
authors.initials: SN
authors.lastname: Stapel
authors.forename: Armand R
authors.initials: AR
authors.lastname: Girbes
authors.forename: H M
authors.initials: HM
authors.lastname: Oudemans-van Straaten
authors.forename: Albertus
authors.initials: A
authors.lastname: Beishuizen
mesh_terms: D000328:Adult; D000368:Aged; D016638:Critical Illness / Q000401:mortality* / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000000981:diagnostic imaging*; D012121:Respiration, Artificial / Q000401:mortality* / Q000639:trends; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D014057:Tomography, X-Ray Computed / Q000639:trends