所有重症营养风险评分低的患者是否相同？
确定哪些患者可对营养干预获益十分重要，重症营养风险（NUTRIC）评分即可用于重症患者的营养不良评估工具。
为此，希腊亚里士多德大学与加拿大维多利亚女王大学从2013～2014年国际营养调查数据中收集ICU患者8052例，筛选出NUTRIC评分≤5且至少可评价3天的患者4060例。
结果发现，NUTRIC评分低的重症患者仍然ICU入住时间较长（中位11天）、60天院内死亡率较高（18%）和营养不良风险因素较多。此外，患者的死亡率与能量及蛋白摄入情况无相关性。
JPEN J Parenter Enteral Nutr. 2017;41(2):280-282.
Are all low NUTRIC score patients the same? The impact of optimal nutrition intake in low NUTRIC patient subgroups.
Michael Chourdakis; Andrew G. Day; Emmanouil Bouras; Ioannis Doundoulakis; Daren K. Heyland.
Aristotle University of Thessaloniki, Thessaloniki, Greece; Queen's University, Kingston, Ontario, Canada.
PURPOSE: Identifying patients who are more likely to benefit from nutrition interventions is very important. We have previously described the NUTrition Risk in the Critically Ill (NUTRIC) score as a tool to help discriminate such patients who will benefit from optimal nutrition intake (>80% of prescription). In fact, current recommendations advocate that low NUTRIC score patients have artificial nutrition withheld. We hypothesized that there would be some low NUTRIC patients who would still benefit from optimal nutrition intake.
METHODS: This analysis includes patients from the 2013 and 2014 International Nutrition Survey who remained in the intensive care unit (ICU) for at least 72 hours and had a baseline NUTRIC score ≤5 and at least 3 evaluable nutrition days. We examined the association between the proportion of prescriptions received during the evaluable days and 60-day hospital mortality by a logistic regression model using generalized estimating equations (GEEs) to account for potential between ICU heterogeneity. A priori, we expected that the association between proportion of prescriptions received and mortality may differ according to ICU length of stay (<12 days vs ≥12 days), body mass index (BMI; <20, 20-<35, and ≥35), and prior unintentional weight loss or reduced oral intake (both, one, or none). Within-subgroup estimates were obtained and interaction terms were tested for statistical significance.
RESULTS: There were 4334 (out of 8052) patients with a NUTRIC score ≤5, of which 4060 had at least 3 evaluable days. Twenty-four percent had 1 or both markers of malnutrition and 10% of patients had a BMI <20. The overall 60-day hospital mortality in this sample was 714 of 4060 (18%). The median [Q1-Q3] ICU length of stay was 11.0 [6.4-20.9] days. The mean ± SD total percent prescription received by enteral nutrition, parenteral nutrition, propofol, or protein supplements during the first 12 evaluable days was 56.7 ± 28.0 for energy and 53.0 ± 29.1 for protein. After controlling for evaluable days, admission type, age, Acute Physiology and Chronic Health Evaluation II (APACHE II), and region, there was no suggestion of an overall association between mortality and energy or protein received. Per 20% increase in proportion of prescriptions received, the adjusted odds ratio (OR) for 60-day hospital mortality was 1.04 (95% confidence interval [CI], 0.96-1.13) for energy and 1.03 (95% CI, 0.96-1.11) for protein, and these estimates did not change substantially if energy controlled for protein or protein controlled for energy. In the various subgroup analyses, no significant associations were identified.
CONCLUSIONS: Low NUTRIC score patients still remain in the ICU for prolonged periods of time, experience significant mortality, and have a high prevalence of malnutrition risk factors. Although we cannot show an improvement in mortality with higher nutrition intake, this should not be construed as a rationale for withholding artificial nutrition in patients requiring at least 3 days of mechanical ventilation. We were not able to show any significant differences from improved nutrition intake in any subgroups of low NUTRIC patient populations. There may be a benefit in other clinically important outcomes (other than mortality) with increased nutrition intake in these groups of patients. Given the morbidity and mortality of low NUTRIC patients, further exploration of the value of nutrition support is warranted.
DOI: 10.1177/0148607116686023