不同营养评估工具在ICU患者营养状况评估中的应用比较

Comparative study on nutritional status of patients in intensive care unit with different assessment tools

目的应用营养风险筛查2002量表(NRS2002)、主观全面评定法(SGA)和危重症营养风险评分(NUTRIC)评估重症监护病房(ICU)患者的营养状况,比较3种评估工具的特点和适用性。方法采用横断面调查研究方法,选择2018年4月至2019年7月青岛大学附属青岛市市立医院综合ICU收治的315例患者。收集患者基本信息,以65岁为标准将患者分组,比较不同性别、年龄患者的营养状况。应用NRS2002、SGA、NUTRIC对患者进行营养状况评估,测量患者的身高、体重、体重指数(BMI)、肱三头肌皮肤褶折厚度(TSF)、上臂围(AC)、小腿围(LC)等人体测量指标,并检测总蛋白(TP)、白蛋白(Alb)、前白蛋白(PA)、血肌酐(SCr)、尿素氮(BUN)、总胆固醇(TC)、三酰甘油(TG)、淋巴细胞总数(LYM)、血红蛋白(Hb)、C-反应蛋白(CRP)等血生化指标。应用Spearman秩相关分析3种营养评估量表与其他客观营养指标的相关性;采用二元多因素Logistic回归分析筛选3种量表评估ICU患者营养状态的影响因素。结果315例ICU患者中男性183例,女性132例;年龄<65岁143例,≥65岁172例。在男性患者中,与年龄<65岁者相比,年龄≥65岁者急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、年龄、BUN显著升高,身高、体重、BMI、TSF、AC、LC、Alb、PA显著降低,其他指标差异无统计学意义;在女性患者中,与年龄<65岁者相比,年龄≥65岁者APACHEⅡ评分、年龄、SCr、BUN显著升高,身高、Alb、PA、Hb显著降低,其他指标差异无统计学意义。NRS2002评估存在营养风险(NRS2002≥3分)的患者比例为87.62%(276/315);SGA评估显示营养不良(SGA为B级或C级)的患者比例为62.86%(198/315);NUTRIC显示高营养风险(NUTRIC≥5分)的患者比例为66.03%(208/315)。Spearman秩相关分析显示,ICU患者NRS2002、SGA与NUTRIC之间均呈显著正相关(rNRS2002与SGA=0.522,rNRS2002与NUTRIC=0.392,rSGA与NUTRIC=0.442,均P<0.01)。在3种评估工具中,SGA与评估营养状态的血生化指标和人体测量指标的相关性最好,NRS2002次之,NUTRIC最差。二元多因素Logistic回归分析显示,APACHEⅡ评分、BMI、AC、BUN和TG是NRS2002筛查ICU患者营养不良的影响因素〔优势比(OR)分别为2.535、0.404、1.438、0.858、2.391,均P<0.05〕;APACHEⅡ评分、年龄、体重、TP、BUN、LYM和CRP是SGA评估营养不良的影响因素(OR分别为1.074、1.038、0.921、0.947、1.077、1.625、0.991,均P<0.05);APACHEⅡ评分、年龄、LYM和CRP是NUTRIC评估营养不良的影响因素(OR分别为1.159、1.049、0.715、0.995,均P<0.05)。结论NRS2002、SGA、NUTRIC评估ICU患者营养状态简便易操作,其中NRS2002阳性筛查率最高,适用于ICU病情较轻患者;SGA最能反映ICU住院患者的营养状态;NUTRIC与反映营养状态的客观指标的相关性较差,但其指标客观且易获取,适用于ICU中病情危重且意识不清的患者。营养评估工具应与患者的性别、年龄、人体测量指标及血生化指标相结合进行综合评估。

Objective To evaluate the nutritional status of patients in intensive care unit(ICU)by using nutritional risk screening 2002 scale(NRS2002),subjective general assessment(SGA)and critical illness nutritional risk score(NUTRIC),and to compare the characteristics and applicability of three scoring tools.Methods A cross-sectional survey was conducted.315 patients admitted to the comprehensive ICU of Affiliated Qingdao Municipal Hospital of Qingdao University from April 2018 to July 2019 were enrolled.Basic information of patients was collected,and patients were divided into two groups with 65 years old as the standard to compare the nutritional status of patients among different genders and ages.The nutritional status of patients were assessed by NRS2002,SGA,and NUTRIC.Height,weight,body mass index(BMI),triceps skinfold thickness(TSF),upper arm circumference(AC),leg circumference(LC),and other related parameters of human nutrition were measured.Total protein(TP),albumin(Alb),prealbumin(PA),serum creatinine(SCr),blood urea nitrogen(BUN),total cholesterol(TC),triglyceride(TG),total number of lymphocytes(LYM),hemoglobin(Hb),C-reactive protein(CRP)and other blood biochemical indicators were performed.Spearman rank correlation analysis was used to analyze the correlation between the three nutrition evaluation scales and other objective nutrition parameters.Binary multivariate Logistic regression analysis was used to evaluate the influencing factors of nutritional status with three scales of patients in ICU.Results Among 315 patients in ICU,183 were male and 132 were female.There were 143 patients<65 years old and 172≥65 years old.In male patients,the acute physiology and chronic health evaluationⅡ(APACHEⅡ)score,age and BUN of patients aged≥65 years old were significantly increased,and the height,weight,BMI,TSF,AC,LC,Alb and PA were significantly lowered as compared with those aged<65 years old,while the difference in other indicators was not statistically significant.In the female patients,the APACHEⅡscore,age,SCr and BUN of the patients aged≥65 years old were significantly increased,the height,Alb,PA and Hb were significantly decreased as compared with those aged<65 years old,and the difference in other indicators was not statistically significant.The proportion of patients with nutritional risk evaluated by NRS2002(NRS2002 score≥3)was 87.62%(276/315).SGA showed that the proportion of malnourished patients(SGA was grade B or C)was 62.86%(198/315).NUTRIC showed 66.03%of patients(208/315)in high nutritional risk(NUTRIC score≥5).Spearman rank correlation analysis showed that there were significant correlations among NRS2002,SGA and NUTRIC of patients in ICU(rNRS2002 with SGA=0.522,rNRS2002 with NUTRIC=0.392,rSGA with NUTRIC=0.442,all P<0.01).Among the three assessment tools,SGA had the best correlation with blood biochemical indicators and body measurements to assess nutritional status,followed by NRS2002,and NUTRIC had the worst correlation.Binary multivariate Logistic regression showed that APACHEⅡscore,BMI,AC,BUN and TG were factors influencing NRS2002 assessment of nutritional status in ICU patients[odds ratio(OR)were 2.535,0.404,1.438,0.858,and 2.391,respectively,all P<0.05];APACHEⅡscore,age,weight,TP,BUN,LYM and CRP were influence factors of SGA for evaluating the malnutrition of patients in ICU(OR values were 1.074,1.038,0.921,0.947,1.077,1.625 and 0.991,respectively,all P<0.05);APACHEⅡscore,age,LYM and CRP were the influence factors of NUTRIC assessment for malnutrition of patients in ICU(OR values were 1.159,1.049,0.715 and 0.995,respectively,all P<0.05).Conclusions The nutrition status of ICU patients evaluated by NRS2002,SGA and NUTRIC was simple and easy to operate,and the positive screening rate of NRS2002 was the highest,which was suitable for patients with mild conditions in ICU.SGA is the most valuable tool to evaluate the nutritional status of ICU patients.NUTRIC has a poor correlation with objective indicators reflecting nutritional status,while its indicators are objective and easy to obtain,which is suitable for ICU patients with critical condition and unclear consciousness.Nutritional assessment tools should be integrated with the patient's gender,age,anthropometric and biochemical indicators.