Nutritional practices and their relationship to clinical outcomes in critically ill children--an international multicenter cohort study*.
Nutritional practices and their relationship to clinical outcomes in critically ill children--an international multicenter cohort study*.
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DOI：
10.1097/ccm.0b013e31824e18a8
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发表时间：
2012-07
影响因子：
8.8
通讯作者：
Heyland DK
中科院分区：
文献类型：
--
作者：
Mehta NM;Bechard LJ;Cahill N;Wang M;Day A;Duggan CP;Heyland DK
研究影响儿科重症监护病房能量和蛋白质摄入充分性的因素，并描述其与机械通气儿童临床结局的关系。我们进行了一项国际前瞻性队列研究，研究对象为在儿科重症监护病房需要机械通气时间超过48小时的连续儿童(1个月至18岁)。在儿科重症监护病房住院期间，记录最多10天的营养做法，并对患者进行60天的随访或直到出院。多变量分析，考虑了儿科重症监护病房的聚集性和重要的混杂变量，用来检查营养变量和儿科重症监护病房特征对60天死亡率和获得性感染患病率的影响。8个国家的学术医院的31个儿科重症监护室参与了这项研究。500名平均年龄4.5(5.1)岁的患者入选并纳入分析。60天的死亡率为8.4%，500名患者中有107名(22%)在儿科重症监护病房期间至少感染了一次。超过30%的患者入院时有严重营养不良，入院时体重指数z评分为2(13.2%)或−为2(17.1%)。每日能量和蛋白质摄入量的平均处方目标分别为1.7g/kg和1.7g/kg。67%的患者使用了肠内营养，大多数患者在入院后48小时内开始使用肠内营养。在500名患者中，有357名(71%)的肠内营养随后平均中断至少2天。每日营养摄入量(肠内营养)的平均百分比(SD)与处方目标相比，能量为38%，蛋白质为43%(44)。通过肠内营养途径摄入较高的目标能量与较低的60天死亡率显著相关(将能量摄入从33.3%增加到66.6%的优势比为0.27[0.11，0.67]，p=0.002)。接受肠外营养的患者死亡率更高(优势比2.61[1.3，5.3]，p=0.008)。住进使用喂养方案的单位的患者获得性感染的患病率较低(优势比0.18[0.05，0.64]，p=0.008)，这种关联与能量或蛋白质摄入量无关。世界各地机械通风儿童的营养供应普遍不足。通过肠内途径摄入较高比例的规定膳食能量目标与改善60天的存活率有关；相反，使用肠外营养与较高的死亡率相关。儿科重症监护病房采用了启动和推进肠道营养摄入的方案，其获得性感染的发病率较低。优化营养治疗是改善危重儿童临床结局的潜在途径。
To examine factors influencing the adequacy of energy and protein intake in the pediatric intensive care unit and to describe their relationship to clinical outcomes in mechanically ventilated children. We conducted an international prospective cohort study of consecutive children (ages 1 month to 18 yrs) requiring mechanical ventilation longer than 48 hrs in the pediatric intensive care unit. Nutritional practices were recorded during the pediatric intensive care unit stay for a maximum of 10 days, and patients were followed up for 60 days or until hospital discharge. Multivariate analysis, accounting for pediatric intensive care unit clustering and important confounding variables, was used to examine the impact of nutritional variables and pediatric intensive care unit characteristics on 60-day mortality and the prevalence of acquired infections. 31 pediatric intensive care units in academic hospitals in eight countries participated in this study. Five hundred patients with mean (sd) age 4.5 (5.1) yrs were enrolled and included in the analysis. Mortality at 60 days was 8.4%, and 107 of 500 (22%) patients acquired at least one infection during their pediatric intensive care unit stay. Over 30% of patients had severe malnutrition on admission, with body mass index z-score >2 (13.2%) or <−2 (17.1%) on admission. Mean prescribed goals for daily energy and protein intake were 64 kcals/kg and 1.7 g/kg respectively. Enteral nutrition was used in 67% of the patients and was initiated within 48 hrs of admission in the majority of patients. Enteral nutrition was subsequently interrupted on average for at least 2 days in 357 of 500 (71%) patients. Mean (sd) percentage daily nutritional intake (enteral nutrition) compared to prescribed goals was 38% for energy and 43% (44) for protein. A higher percentage of goal energy intake via enteral nutrition route was significantly associated with lower 60-day mortality (Odds ratio for increasing energy intake from 33.3% to 66.6% is 0.27 [0.11, 0.67], p = .002). Mortality was higher in patients who received parenteral nutrition (odds ratio 2.61 [1.3, 5.3], p = .008). Patients admitted to units that utilized a feeding protocol had a lower prevalence of acquired infections (odds ratio 0.18 [0.05, 0.64], p = .008), and this association was independent of the amount of energy or protein intake. Nutrition delivery is generally inadequate in mechanically ventilated children across the world. Intake of a higher percentage of prescribed dietary energy goal via enteral route was associated with improved 60-day survival; conversely, parenteral nutrition use was associated with higher mortality. Pediatric intensive care units that utilized protocols for the initiation and advancement of enteral nutrient intake had a lower prevalence of acquired infections. Optimizing nutrition therapy is a potential avenue for improving clinical outcomes in critically ill children.