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识别最能从营养治疗中获益的重症患者:“改良NUTRIC”营养风险评估工具的进一步验证

Identifying critically-ill patients who will benefit most from nutritional therapy: Further validation of the "modified NUTRIC" nutritional risk assessment tool.

作者信息

Rahman Adam, Hasan Rana M, Agarwala Ravi, Martin Claudio, Day Andrew G, Heyland Daren K

机构信息

Department of Medicine, University of Western Ontario, London, Ontario, Canada; Gastroenterology, St. Joseph's Healthcare Centre/London Health Sciences Centre, Canada.

Department of Medicine, University of Western Ontario, London, Ontario, Canada.

出版信息

Clin Nutr. 2016 Feb;35(1):158-162. doi: 10.1016/j.clnu.2015.01.015. Epub 2015 Jan 28.

Abstract

INTRODUCTION

Better tools are needed to assist in the identification of critically ill patients most likely to benefit from artificial nutrition therapy. Recently, the Nutrition Risk in Critically ill (NUTRIC) score has been developed for such purpose. The objective of this study was to externally validate a modified version of the NUTRIC score in a second database.

METHODS

We conducted a post hoc analysis of a database of a randomized control trial of intensive care unit (ICU) patients with multi-organ failure. Data for all variables of the NUTRIC score with the exception of IL-6 levels were collected. These included age, APACHE II score, SOFA score, number of co-morbidities, days from hospital admission to ICU admission. The NUTRIC score was calculated using the exact same thresholds and point system as developed previously except the IL-6 item was omitted. A logistic model including the NUTRIC score, the nutritional adequacy and their interaction was estimated to assess if the NUTRIC score modified the association between nutritional adequacy and 28-day mortality. We also examined the association of elevated NUTRIC scores and 6-month month mortality and the interaction between NUTRIC score and nutritional adequacy.

RESULTS

A total of 1199 patients were analyzed. The mean total calories prescribed was 1817 cal (SD 312) with total mean protein prescribed of 98.3 g (SD 23.6). The number of patients who received PN was 9.5%. The overall 28-day mortality rate in this validation sample was 29% and the mean NUTRIC score was 5.5 (SD 1.6). Based on the logistic model, the odds of mortality at 28 days was multiplied by 1.4 (95% CI, 1.3-1.5) for every point increase on the NUTRIC score. The mean (SD) nutritional adequacy was 50.2 (29.5) with an interquartile range from 24.8 to 74.1. The test for interaction confirmed that the association between nutritional adequacy and 28-day mortality is significantly modified by the NUTRIC score (test for interaction p = 0.029). In particular, there is a strong positive association between nutritional adequacy and 28 day survival in patients with a high NUTRIC score but this association diminishes with decreasing NUTRIC score. Higher NUTRIC scores are also significantly associated with higher 6-month mortality (p < 0.0001) and again the positive association between nutritional adequacy and 6 month survival was significantly stronger (and perhaps only present) in patients with higher NUTRIC score (test for interaction p = 0.038).

CONCLUSION

The NUTRIC scoring system is externally validated and may be useful in identifying critically ill patients most likely to benefit from optimal amounts of macronutrients when considering mortality as an outcome.

摘要

引言

需要更好的工具来协助识别最有可能从人工营养治疗中获益的重症患者。最近,为此目的开发了重症患者营养风险(NUTRIC)评分。本研究的目的是在第二个数据库中对NUTRIC评分的修改版本进行外部验证。

方法

我们对一个多器官功能衰竭重症监护病房(ICU)患者的随机对照试验数据库进行了事后分析。收集了NUTRIC评分中除IL-6水平外所有变量的数据。这些变量包括年龄、急性生理与慢性健康状况评分系统II(APACHE II)评分、序贯器官衰竭评估(SOFA)评分、合并症数量、从入院到入住ICU的天数。使用与之前开发的完全相同的阈值和评分系统计算NUTRIC评分,但省略了IL-6项目。估计一个包括NUTRIC评分、营养充足率及其相互作用的逻辑模型,以评估NUTRIC评分是否改变了营养充足率与28天死亡率之间的关联。我们还研究了NUTRIC评分升高与6个月死亡率之间的关联以及NUTRIC评分与营养充足率之间的相互作用。

结果

共分析了1199例患者。规定的平均总热量为1817千卡(标准差312),规定的平均总蛋白为98.3克(标准差23.6)。接受肠外营养(PN)的患者比例为9.5%。该验证样本的总体28天死亡率为29%,平均NUTRIC评分为5.5(标准差1.6)。根据逻辑模型,NUTRIC评分每增加1分,28天死亡几率乘以1.4(95%置信区间,1.3 - 1.5)。平均(标准差)营养充足率为50.2(29.5),四分位间距为24.8至74.1。相互作用检验证实,NUTRIC评分显著改变了营养充足率与28天死亡率之间的关联(相互作用检验p = 0.029)。特别是,在NUTRIC评分高的患者中,营养充足率与28天生存率之间存在强正相关,但随着NUTRIC评分降低,这种关联减弱。较高的NUTRIC评分也与较高的6个月死亡率显著相关(p < 0.0001),并且在NUTRIC评分较高的患者中,营养充足率与6个月生存率之间的正相关再次显著更强(可能仅存在)(相互作用检验p = 0.038)。

结论

NUTRIC评分系统得到了外部验证,在将死亡率作为结果时,可能有助于识别最有可能从最佳量的宏量营养素中获益的重症患者。

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