重症监护病房期间肠外营养起始时间早晚对体重恶化的影响：PEPaNIC 随机对照试验的二次分析。

Effect of late versus early initiation of parenteral nutrition on weight deterioration during PICU stay: Secondary analysis of the PEPaNIC randomised controlled trial.

机构信息

Department of Paediatrics and Paediatric Surgery, Intensive Care Unit, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.

Department of Paediatrics, Division of Paediatric Gastroenterology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.

出版信息

Clin Nutr. 2020 Jan;39(1):104-109. doi: 10.1016/j.clnu.2019.02.014. Epub 2019 Mar 4.

DOI:10.1016/j.clnu.2019.02.014

PMID:30879734

Abstract

BACKGROUND & AIMS: Critically ill children are at increased risk of weight deterioration in the paediatric intensive care unit (PICU). Whether early initiation of parenteral nutrition (PN) prevents weight deterioration is unknown. The aims of this study were to assess the effect of withholding supplemental PN during the first week on weight Z-score change in PICU and to evaluate the association between weight Z-score change in the PICU and clinical outcomes.

METHODS

This is a secondary analysis of the Paediatric Early versus Late Parenteral Nutrition in Intensive Care Unit (PEPaNIC) randomised controlled trial (N = 1440), which focused on the subgroup of patients with longitudinal weight Z-scores available on admission and on the last day in PICU. Patients were randomly allocated to initiation of supplemental PN after one week (Late-PN) or within 24 h (Early-PN) when enteral nutrition was insufficient. The effect of Late-PN versus Early-PN on the change in weight Z-score was investigated, adjusted for risk factors. Moreover, the association between weight Z-score change and clinical outcomes was explored, adjusted for risk factors.

RESULTS

Longitudinal weight Z-scores were available for 470 patients. Enteral nutrition intake was equal in the Early-PN and Late-PN group. Less weight Z-score deterioration during PICU stay was associated with a lower risk of new infections (adjusted OR per Z-score increase 0.72 [0.55-0.96], p = 0.02), and with a higher likelihood of an earlier discharge from PICU alive (adjusted HR per Z-score increase 1.22 [1.10-1.37], p < 0.001). During PICU-stay, the change in weight Z-score did not differ among both groups (Late-PN median 0.00 [-0.34-0.12] vs Early-PN median -0.03 [-0.48-0.01], adjusted β = 0.10 [-0.05-0.25], p = 0.18).

CONCLUSIONS

Weight deterioration during the PICU stay was associated with worse clinical outcomes. Withholding supplemental PN during the first week did not aggravate weight Z-score deterioration during PICU stay.

TRIAL REGISTRATION

clinicaltrials.gov NCT01536275.

摘要

背景与目的

危重症患儿在儿科重症监护病房（PICU）中体重恶化的风险增加。早期开始肠外营养（PN）是否能预防体重恶化尚不清楚。本研究的目的是评估在 PICU 中第一周内停止补充 PN 对体重 Z 评分变化的影响，并评估 PICU 中体重 Z 评分变化与临床结局之间的关系。

方法

这是儿科早期与晚期肠外营养在重症监护病房（PEPaNIC）随机对照试验（N=1440）的二次分析，该研究主要关注入院时和 PICU 最后一天有纵向体重 Z 评分的患者亚组。患者被随机分配到肠内营养不足时一周后（迟 PN）或 24 小时内（早 PN）开始补充 PN。研究了迟 PN 与早 PN 对体重 Z 评分变化的影响，并对危险因素进行了调整。此外，还探讨了体重 Z 评分变化与临床结局之间的关系，并对危险因素进行了调整。

结果

470 名患者有纵向体重 Z 评分。早 PN 和迟 PN 组的肠内营养摄入量相同。PICU 期间体重 Z 评分恶化程度较低与新发感染风险降低相关（每增加 1 个 Z 评分，调整后的比值比为 0.72 [0.55-0.96]，p=0.02），并且更有可能更早地活着从 PICU 出院（每增加 1 个 Z 评分，调整后的 HR 为 1.22 [1.10-1.37]，p<0.001）。在 PICU 期间，两组间体重 Z 评分变化无差异（迟 PN 中位数 0.00[-0.34-0.12]vs 早 PN 中位数-0.03[-0.48-0.01]，调整后的β=0.10[-0.05-0.25]，p=0.18）。