不同喂养不耐受变化轨迹外科危重症患者预后及影响因素的多中心研究

Prognosis and influencing factors in critically ill surgical patients of different feeding intolerance trajectories:a multicentre study

目的探讨不同喂养不耐受变化轨迹外科危重症患者预后及影响因素.方法采用回顾性队列研究方法.收集2018年3月至2019年7月中国重症营养临床研究小组-NEED数据库中69家医学中心收治的354例外科危重症患者的临床资料;男247例,女107例;年龄为58(46,68)岁.根据354例患者喂养不耐受变化轨迹模型,分为无喂养不耐受、喂养不耐受下降、喂养不耐受持续分别为164、49、141例.观察指标:(1)不同喂养不耐受变化轨迹患者一般情况.(2)不同喂养不耐受变化轨迹患者营养治疗情况.(3)不同喂养不耐受变化轨迹患者生存情况.(4)外科危重症患者预后影响因素分析.正态分布的计量资料以(x)±s表示,组间比较采用单因素方差分析;偏态分布的计量资料以M(Q1,Q3)表示,组间比较采用Kruskal-Wallis秩和检验.计数资料以绝对数或百分比表示,组间比较采用χ^(2)检验.等级资料比较采用Kruskal-Wallis秩和检验.两两比较采用Bonferroni校正.根据Stata17.0统计软件中Traj插件构建组基轨迹模型,最佳轨迹模型采用贝叶斯信息准则、平均后验概率参数评价.采用Kaplan-Meier法绘制生存曲线并计算生存率,Log-Rank检验进行生存分析.采用COX比例风险回归模型进行单因素和多因素分析.结果(1)不同喂养不耐受变化轨迹患者一般情况.354例外科危重症患者中,行肠内营养治疗257例、行肠内营养+肠外营养治疗97例,急性生理与慢性健康(APACHEⅡ)评分为17(13,21)分,序贯性器官功能衰竭(SOFA)评分为6(5,8)分,改良危重症营养风险(mNUTRIC)评分为4(2,5)分,合并症数量为2(1,3)个,急性胃肠损伤分级为Ⅰ级、Ⅱ级、Ⅲ级分别为293、55、6例,行机械通气、连续肾替代治疗、血管活性药物使用分别为224、17、61例.354例患者喂养不耐受发生率呈先上升后下降趋势,第3天发生率达峰值为25.42%(90/354),7d内发生率为53.67%(190/354)o 354例外科危重症患者中,无喂养不耐受、喂养不耐受下降、喂养不耐受持续患者APACHEⅡ评分,mNUTRIC评分,合并症数量,急性胃肠损伤分级,机械通气分别为16(12,20)分、17(14,25)分、18(13,22)分,3(2,5)分、4(3,6)分、4(3,5)分,2(1,2)个、2(2,3)个、2(2,3)个,Ⅰ级(152例、27例、114例)、Ⅱ~Ⅲ级(12例、22例、27例),95、39、90例,三者上述指标比较,差异均有统计学意义(H=6.14、13.11、28.05,χ^(2)=37.96、7.65,P<0.05);进一步分析,与无喂养不耐受患者比较,喂养不耐受下降、喂养不耐受持续患者均有更高的合并症数量和急性胃肠损伤分级(Z=60.32、54.69,χ^(2)=39.72、9.52,P<0.05);与无喂养不耐受患者比较,喂养不耐受下降患者有更高的mNUTRIC评分和机械通气比例(Z=53.41,χ^(2)=7.59,P<0.05).(2)不同喂养不耐受变化轨迹患者营养治疗情况.无喂养不耐受患者促胃动力药物使用,幽门后喂养分别为36例,13例,喂养不耐受下降患者上述指标分别为25例,10例,喂养不耐受持续患者上述指标分别为46例,19例,三者上述指标比较,差异均有统计学意义(χ^(2)=15.76,6.20,P<0.05).进一步分析,与无喂养不耐受患者比较,喂养不耐受下降患者有更高的促胃动力药物使用和幽门后喂养比例(χ^(2)=15.60,6.10,P<0.05).(3)不同喂养不耐受变化轨迹患者生存情况.无喂养不耐受、喂养不耐受下降、喂养不耐受持续患者28 d总生存率分别为96.96%、95.92%、87.94%,三者比较,差异有统计学意义(χ^(2)=10.39,P<0.05);进一步分析,无喂养不耐受与喂养不耐受持续患者比较,差异有统计学意义(χ^(2)=9.19,P<0.05).(4)外科危重症患者预后影响因素分析.多因素分析结果显示:喂养不耐受持续是外科危重症患者28 d死亡的独立危险因素(风险比=3.92,95%可信区间为1.43~10.79,P<0.05).结论与无喂养不耐受患者比较,喂养不耐受持续的外科危重症患者28 d总生存率下降,喂养不耐受持续是外科危重症患者28 d死亡的独立危险因素.

Objective To investigate the prognosis and influencing factors in critically ill surgical patients of different feeding intolerance trajectories.Methods The retrospective cohort study was conducted.The clinical data of 354 critically ill surgical patients who were admitted to 69 medical centers in the Chinese Critical Care Nutrition Trials Group-NEED database from March 2018 to July 2019 were selected.There were 247 males and 107 females,aged 58(46,68)years.According to the trajectory model of feeding intolerance change,354 patients were divided into 3 categories as feeding intolerance,decreased feeding intolerance,continuous feeding intolerance,including 164,49,141 cases respectively.Observation indicators:(1)general situations of patients of different feeding intolerance trajectories;(2)treatment of patients of different feeding intolerance trajectories;(3)survival of patients of different feeding intolerance trajectories;(4)analysis of prognostic factors in critically ill surgical patients.Measurement data of normal distribution were expressed as Mean+SD,and one-way analysis of variance was used for comparison between groups.Measurement data of skewed distribution were expressed as M(Q,Q.),and Kruskal-Wallis rank sum test was used for comparison between groups.Count data were expressed as absolute numbers or percentages,and chi-square test was used for comparison between groups.Ordinal data were compared using the Kruskal-Wallis rank sum test.Bonferroni correction was used for pairwise comparison.Group-based trajectory model was constructed according to Traj plug-in in Stata17.0 statistical software,and the optimal trajectory model was evaluated by Bayesian information criterion and average posterior probability parameter.The Kaplan-Meier method was used to draw the survival curve and calculate the survival rate,and Log-Rank test was used for survival analyses.Univariate and multivariate analyses were conducted using the cox proportional hazard regression model.Results(1)General situations of patients of different feeding intolerance trajectories.Of 354 critically ill surgical patients,257 cases underwent enteral nutrition and 97 cases underwent enteral plus parenteral nutrition.The acute physiological and chronic health score(APACHEIl)was 17(13,21),and the sequential organ failure score(SOFA)was 6(5,8).The modified Critical Illness Nutritional risk score(mNUTRIC)was 4(2,5),the number of complications was 2(1,3).There were 293,55 and 6 patients with grade Ⅰ,grade Ⅱ and grade Ⅲ acute gastrointestinal injury(AGI),and there were 224,17 and 61 patients who were treated with mechanical ventilation,continuous renal replacement therapy and vasoactive drugs,respectively.The incidence of feeding intolerance in 354 patients increased first and then decreased,reaching a peak of 25.42%(90/354)on the third day and 53.67%(190/354)within 7 days.0f 354 critically ill surgical patients,cases with no feeding intolerance,decreased feeding intolerance,continuous feeding intolerance had the APACHE Ⅱ as 16(12,20),17(14,25),18(13,22),mNUTRIC as 3(2,5),4(3,6),4(3,5),the number of complications as 2(1,2),2(2,3),2(2,3).There were 152,27,114 cases with grade I AGI,12,22,27 cases with grade Ⅱ-Ⅲ AGI,95,39,90 cases with mechanical ventilation.There were significant differences in the above indicators among the three groups(H=6.14,13.11,28.05,χ^(2)=37.96,7.65,P<0.05).Further analysis showed that compared with patients with no feeding intolerance,patients with decreased feeding intolerance and continuous feeding intolerance had the higher number of complications and grade of AGI(Z=60.32,54.69,χ^(2)=39.72,9.52,P<0.05),patients with decreased feeding intolerance had the higher mNUTRIC scores and ratio of mechanical ventilation(Z=53.41,χ^(2)=7.59,P<0.05).(2)Treatment of patients of different feeding intolerance trajectories.Cases with prokinetic drugs use and postpyloric feeding were 36,13 of patients with no feeding intolerance,25 and 10 of patients with decreased feeding intolerance,46 and 19 of patients with continuous feeding intolerance,respectively,showing significant differences in the above indicators among the three groups(χ^(2)=15.76,6.20,P<0.05).Further analysis showed that compared with patients with no feeding intolerance,patients with decreased feeding intolerance had higher ratio of prokinetic drugs use and ratio of post-pyloric feeding(2=15.60,6.10,P<0.05).(3)Survival of patients of different feeding intolerance trajectories.The 28-day overall survival rates of patients with no feeding intolerance,decreased feeding intolerance,and continued feeding intolerance were 96.96%,95.92%,and 87.94%,respectively,showing a significant difference(χ^(2)=10.39,P<0.05).Further analysis showed a significant difference between patents with no feeding intolerance and patients with continuous feeding intolerance(χ^(2)=9.19,P<0.05).(4)Analysis of prognostic factors in critically ill surgical patients.Multivariate analysis showed that continuous feeding intolerance was an independent risk factor for 28-day death in critically ill surgical patients(hazard ratio=3.92,95%confidence interval as 1.43-10.79,P<0.05).Conclusion For surgical critically ill patients,patients with continuous feeding intolerance have a higher 28-day mortality than patients with no feeding intolerance,and the continuous feeding intolerance is an independent risk factor for 28-day death in critically ill surgical patients.