危重患儿营养状况及其与临床结局的相关性

Relationship between nutritional status and the clinical outcomes of critically ill children

目的探讨住院危重患儿营养状况、营养风险现状及其与临床结局的关系，为临床营养支持工作的开展提供科学依据。方法应用STRONGkids对2016年10月至2017年10月南京医科大学附属儿童医院儿童重症监护室（PICU）、心胸外科重症监护室（CCU）和外科重症监护室（SICU）收治的1 183例危重患儿进行营养风险筛查。患儿年龄29 d～12.9岁[（2.6±2.4）岁]。采用年龄别体质量Z值（WAZ）（〈5岁）或年龄别体质量指数Z值（BAZ）（≥5岁）评价患儿营养状况。记录患儿重症监护室（ICU）停留时间、机械通气时间、感染性并发症发生率及住院费用等资料并进行统计分析。结果1 183例危重患儿中有134例（11.3%）存在低度营养风险，746例（63.1%）存在中度营养风险，303例（25.6%）存在高度营养风险。入ICU时存在轻度营养不良151例（12.8%），中度营养不良97例（8.2%），重度营养不良96例（8.1%）。重度营养不良组患儿高营养风险发生率明显较其他组高[74.0%（71/96例）比67.0%（65/97例）、40.4%（61/151例），12.6%（106/839例）]，差异均有统计学意义（均P〈0.001）。CCU患儿高度营养风险比例明显高于PICU和SICU[分别为36.5%（96/263例）、23.8%（125/524例）和20.7%（82/396例）]，差异有统计学意义（P〈0.01）。婴儿高度营养风险的发生率[37.6%（198/527例）]明显高于其他年龄段患儿[18.4%（52/282例）、12.0%（21/175例）、16.0%（32/199例）]，差异有统计学意义（χ^2＝68.90，P〈0.000 1）。高度营养风险组患儿较低、中度营养风险组感染性并发症发生率[8.6%（26/303例）比4.7%（35/746例）、3.7%（5/134例）]、机械通气率[66.0%（200/303例）比41.4%（309/746例）、38.8%（52/134例）]、总住院费用（5.25万元比3.97万元、4.87万元）均增高，差异均有统计学意义（均P〈0.05）。死亡患儿16例，高度营养风险组患儿死亡8例（2.7%），明显高于中度营养风险组[8例（1.1%）]和低度营养风险组[0例（0）]，差异有统计学意义（χ^2＝7.60，P＝0.02）。结论住院危重患儿普遍存在中高度营养风险，婴儿和先天性心脏病患儿存在相对较高的营养风险。营养风险评分与患儿临床结局有明显相关性。对危重患儿进行营养风险筛查，尽早给予合理有效的营养支持可改善临床结局。

ObjectiveTo investigate the nutritional status and the clinical outcome of the critically ill children, and to provide scientific evidence for further clinical nutrition management.MethodsNutritional risk screening was performed on 1 183 critically ill children hospitalized at the Intensive Care Unit （ICU）, Children′s Hospital of Nanjing Medical University from October 2016 to October 2017 by using the Screening Tool for Risk on Nutritional Status and Growth （STRONGkids）, the ICU including of Pediatric Intensive Care Unit （PICU）, Surgical Intensive Care Unit （SICU） and Coronary Care Unit （CCU）. Median age of the children was （2.6±2.4） years （29 d-12.9 years）. Nutritional status was estimated, and scores of anthropometric parameters such as weight-for-age Z-score （WAZ） （〈5 years） or body mass index-for-age Z-score （BAZ） （≥5 years）were calculated.The data on incidence of infectious complications, duration of ICU stay and mechanical ventilation, the total hospital expenses and in-hospital mortality were recorded.ResultsOf the 1 183 cases, 134 children（11.3%） had low nutritional risk, 746 children（63.1%） had moderate nutritional risk and 303 children（25.6%） high nutritional risk.The prevalence of severe malnutrition, moderate malnutrition and mild malnutrition was 8.1% （96/1 183 cases）, 8.2% （97/1 183 cases）, and 12.8% （151/1 183 cases） respectively.The severe malnutrition group had a higher incidence of high nutritional risk than other groups [74.0%（71/96 cases） vs.67.0%（65/97 cases）, 40.4%（61/151 cases）, 12.6%（106/839 cases）], and the differe-nce was statistically significant （P〈0.001）. The incidence of high nutritional risk in the CCU was higher than that than that in the PICU and SICU, and the difference was statistically significant [36.5%（96/263 cases）, 23.8%（125/524 cases） and 20.7%（82/396 cases） respectively, P〈0.01]. And the incidence of high nutritional risk was higher in infants[37.6%（198/527 cases）] than those in the other age groups[18.4%（52/282 cases）, 12.0%（21/175 cases）, 16.0%（32/199 cases）], and the difference was statistically significant （χ^2=68.90, P〈0.000 1）. Children with a high nutritional risk had increased incidence of infectious complications [8.6%（26/303 cases） vs.4.7%（35/746 cases）, 3.7%（5/134 cases）], incidence of mechanical ventilation[66.0%（200/303 cases） vs.41.4%（309/746 cases）, 38.8%（52/134 cases）] and total hospital expenses （￥52 500 vs.￥39 700 and ￥48 700 RMB） compared with those with the moderate or the low nutritional risk, and the differences were statistically significant（all P〈0.05）. There were 16 deaths and 8 deaths （2.7%） in the high nutrition risk group, which was significantly higher than those in the moderate nutrition risk group [8 cases （1.1%）] and the low nutrition risk group[0 case（0）] （χ2=7.60, P=0.02）.ConclusionsModerate or high nutritional risk is seen in the critically ill children, especially in infants and the children with congenital heart disease.Nutritional risk score is correlated with clinical outcomes.Nutritional risk screening and standard nutritional support are recommended so as to improve clinical treatment outcomes.