基于体重指数的营养状况与PICU机械通气患儿发病率和死亡率的相关性

　　2016年8月，美国重症医学会官方期刊《重症医学》正式发表哈佛大学医学院、波士顿儿童医院、新泽西州立罗格斯大学、加拿大维多利亚女王大学金斯顿总医院的研究报告，考察了基于体重指数的营养状况与儿科重症监护病房（PICU）机械通气患儿发病率和死亡率的相关性。结果显示，体重过低与较高的院内感染风险和较低的出院率可能相关，体重过轻儿童的死亡风险较高、无呼吸机天数较少。

　　该研究为了确定人体测量对PICU机械通气患儿临床结局的影响，收集了2项多中心队列研究16个国家90个PICU（PICU的床位数≥8）1622例年龄1个月～18岁之间（平均年龄为4.5±5.1岁）入住PICU需要机械通气超过48h的患儿（54.8%为男性）数据，使用多变量分析，考察体重指数z评分定义的营养状况对60天死亡率、院内感染、住院时长、无呼吸机天数的特殊贡献。基于入院时的体重指数z评分，将受试者分为体重过低（17.9%）、体重正常（54.2%）、超重（14.5%）和肥胖（13.4%）组。

　　结果发现，校正疾病和部位的严重程度后，体重过低儿童的60天死亡比例较高（比值比：1.53；p＜0.001）。体重过低儿童（比值比：1.88；p=0.008）和肥胖儿童（比值比：1.64；p＜0.001）的院内感染比例较高。体重过低儿童（风险比，0.71；p＜0.001）和肥胖儿童（风险比，0.82；p=0.04）的出院风险较低。体重过低的无呼吸机天数分别比体重正常和超重少1.3（p=0.001）和1.6（p＜0.001）。

　　就世界范围而言，营养不良在入住PICU需要机械通气的儿童中非常普遍，体重过低与较高的院内感染风险和较低的出院率可能相关，体重过轻儿童的死亡风险较高、无呼吸机天数较少。

Crit Care Med. 2016 Aug;44(8):1530-7.

Nutritional Status Based on Body Mass Index Is Associated With Morbidity and Mortality in Mechanically Ventilated Critically Ill Children in the PICU.

Bechard LJ, Duggan C, Touger-Decker R, Parrott JS, Rothpletz-Puglia P, Byham-Gray L, Heyland D, Mehta NM.

Center for Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA; Rutgers University School of Health Related Professions, Newark, NJ; Kingston General Hospital and Queen's University, Kingston, ON, Canada.

OBJECTIVE: To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the PICU.

DESIGN: Data from two multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by body mass index z score, to 60-day mortality, hospital-acquired infections, length of hospital stay, and ventilator-free days, using multivariate analysis.

SETTING: Ninety PICUs from 16 countries with eight or more beds.

PATIENTS: Children aged 1 month to 18 years, admitted to each participating PICU and requiring mechanical ventilation for more than 48 hours.

MEASUREMENTS AND MAIN RESULTS: Data from 1,622 eligible patients, 54.8% men and mean (SD) age 4.5 years (5.1), were analyzed. Subjects were classified as underweight (17.9%), normal weight (54.2%), overweight (14.5%), and obese (13.4%) based on body mass index z score at admission. After adjusting for severity of illness and site, the odds of 60-day mortality were higher in underweight (odds ratio, 1.53; p < 0.001) children. The odds of hospital-acquired infections were higher in underweight (odds ratio, 1.88; p = 0.008) and obese (odds ratio, 1.64; p < 0.001) children. Hazard ratios for hospital discharge were lower among underweight (hazard ratio, 0.71; p < 0.001) and obese (hazard ratio, 0.82; p = 0.04) children. Underweight was associated with 1.3 (p = 0.001) and 1.6 (p < 0.001) fewer ventilator-free days than normal weight and overweight, respectively.

CONCLUSIONS: Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide. Classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge. Underweight children had a higher risk of mortality and fewer ventilator-free days.

PMID: 26985636

PMCID: PMC4949117

DOI: 10.1097/CCM.0000000000001713