老年重症患者蛋白质供给量与预后的相关性

Correlation between protein intake and prognosis in critically ill elderly patients

目的探讨老年重症患者蛋白质供给量与预后的关系,以期为这一特殊群体制定最优营养方案。方法回顾性分析2019年7月至2020年7月山西医科大学第一医院ICU收住的行营养支持治疗的103例老年重症患者临床资料,根据入院后1周内蛋白质供给量是否达到1.2 g/(kg·d)进行分组,分为高蛋白组[蛋白质供给量≥1.2 g/(kg·d)]和非高蛋白组[蛋白质供给量<1.2 g/(kg·d)]。分别比较2组患者初始急性生理功能和慢性健康状况评估Ⅱ(APACHEⅡ)评分、营养风险筛查(NRS 2002)评分、机械通气时间、ICU住院时间、院内感染率、28 d病死率的差异及营养支持治疗第1天(D1)、第7天(D7)白蛋白、转铁蛋白、前白蛋白水平。采用单因素Logistic回归筛选可能影响28 d病死率的9项因素(年龄、性别、热量供给、蛋白质供给、APACHEⅡ评分、NRS 2002评分、机械通气时间、ICU住院时间、院内感染),以28 d病死率作为因变量进行多因素Logistic回归分析,探讨蛋白质供给量与老年重症患者预后的关系。结果2组患者性别、年龄、APACHEⅡ评分、NRS 2002评分比较差异均无统计学意义(P>0.05)。对比2组D7热量供给,差异无统计学意义[(27.52±8.77)kcal/(kg·d)vs(25.73±8.20)kcal/(kg·d),P>0.05]。高蛋白组每日蛋白质供给量明显高于非高蛋白组[(1.59±0.32)g/(kg·d)vs(0.84±0.25)g/(kg·d),P<0.05]。对比2组在营养支持治疗D1时,白蛋白、转铁蛋白、前白蛋白水平差异均无统计学意义(P>0.05);在治疗D7时,非高蛋白组中转铁蛋白、前白蛋白较前有所改善(P<0.05),高蛋白组白蛋白、转铁蛋白、前白蛋白较前均有所改善(P<0.05),且高蛋白组较非高蛋白组营养指标均显著升高(P<0.05)。高蛋白组对比非高蛋白组机械通气时间、ICU住院时间明显缩短(P<0.05)。另外,院内感染率、28 d病死率高蛋白组较非高蛋白组降低,但院内感染率无统计学意义(P>0.05),28 d病死率有统计学意义(P<0.05)。多因素Logistic回归分析显示,年龄越大,28 d病死率越高(OR=1.113,95%CI:1.023~1.211,P=0.012);蛋白质供给剂量越少,28 d病死率越高(OR=0.089,95%CI:0.017~0.476,P=0.005);存在院内感染患者28 d病死率高(OR=0.097,95%CI:0.016~0.597,P=0.012)。结论老年重症患者易出现临床营养状况差、机械通气时间长、住院时间长、预后差的特点。通过增加蛋白质摄入量可以明显改善老年重症患者临床营养状况,缩短机械通气时间及住院时间并降低28 d病死率。年龄、蛋白质供给量、院内感染均为老年重症患者28 d病死率的独立影响因素,其中,增加蛋白质供给量、无院内感染为保护因素,高龄为危险因素。

Objective To investigate the correlation between protein intake and prognosis in critically ill elderly patients.Methods A retrospective survey was conducted on 103 elderly patients with severe illness who were admitted to the intensive care unit(ICU)of the First Hospital of Shanxi Medical University from July 2019 to July 2020 for nutritional support treatment.According to whether the protein intake reached 1.2 g/(kg·d)within 1 week after admission or not,the patients were divided into either a standard group or a non-high-protein group.APACHEⅡscore,NRS 2002 score,mechanical ventilation time,length of ICU stay,nosocomial infection rate,28 d mortality rate,and levels of albumin(ALB),transferrin(TFR),and prealbumin(PAB)before and 1 and 7 days after treatment were compared between the two groups.Univariate Logistic regression was used to analyze nine factors(age,gender,caloric intake,protein intake,APACHEⅡscore,NRS 2002 score,duration of mechanical ventilation,length of ICU stay,and nosocomial infection)that may affect 28 d mortality.Multivariate Logistic regression was constructed with 28 d mortality as the dependent variable to analyze the relationship between protein intake and the prognosis of critically ill elderly patients.Results There were no significant differences in gender,age,APACHEⅡscore,or NRS2002 score between the two groups(P>0.05).There was no significant difference in caloric intake on day 7 between the two groups[(27.52±8.77)kcal/(kg·d)vs(25.73±8.20)kcal/(kg·d),P>0.05].The daily protein intake of the high-protein group was significantly higher than that of the non-highprotein group[(1.59±0.32)g/(kg·d)vs(0.84±0.25)g/(kg·d),P<0.05].There was no statistically significant difference in ALB,TFR,or PAB levels on day 1 after nutritional support between the two groups;the levels of ALB,TFR,and PAB on day 7 in the standard group were further improved compared with the non-high-protein group(P<0.05).The nosocomial infection rate and 28 d mortality rate in the standard group were lower than those in the non-high-protein group;the difference in nosocomial infection rate was not statistically significant(P>0.05),but the difference in the 28 d mortality rate was statistically significant(P<0.05).Multivariate Logistic regression analysis showed that older age[odds ratio(OR)=1.113,95%confidence interval(CI):1.023-1.211,P=0.012],higher protein intake(OR=0.089,95%CI:0.017-0.476,P=0.005),and non-nosocomial infection(OR=0.097,95%CI:0.016-0.597,P=0.012)were significantly associated with the 28 d mortality rate.Conclusion Critically ill elderly patients are prone to poor clinical nutrition,long mechanical ventilation,long hospital stay,and poor prognosis.Increasing protein intake can significantly improve clinical nutritional status,the time of mechanical ventilation and hospitalization,and 28 d mortality.Age,protein intake,and nosocomial infection are independent factors affecting 28 d mortality.Increasing protein intake and no nosocomial infection are protective factors for 28 d mortality.Advanced age is a risk factor for 28 d mortality in critically ill elderly patients.