神经重症康复患者的营养风险评价指标与1年预后的关系

Relationship between the nutritional risk assessment indicators and 1-year prognosis in the patients with severe neurological rehabilitation

目的探索神经重症康复病房患者住院期间营养风险评价指标与1年预后的关系。方法回顾性分析2020年12月至2022年8月首都医科大学附属北京康复医院神经重症康复病房276例患者的临床资料。记录患者入科时性别、年龄、主要诊断、格拉斯哥昏迷评分(Glasgow coma scale,GCS)、血红蛋白、血清白蛋白、营养风险筛查量表2002(NRS2002);出重症监护病房(ICU)时,记录患者ICU住院期间的最低血磷、最低前白蛋白、最高降钙素原(PCT)、病重当天24 h内(或住ICU期间最差)的急性生理学和慢性健康状况评价Ⅱ(APACHEⅡ)评分、序贯器官衰竭评估(SOFA)评分、改良危重症营养风险评分(m-NUTRIC)及ICU住院时间;出院时,记录总住院时间。根据1年随访时患者是否死亡分为生存组(n=220)和死亡组(n=56)。采用多因素Logistic回归模型分析神经重症康复患者1年内死亡的危险因素。绘制受试者工作特征(ROC)曲线,计算ROC曲线下面积(AUC)及其95%置信区间(95%CI),评价各营养风险评价指标和最低血磷联合最低前白蛋白及最高PCT对神经重症康复患者1年死亡的预测价值。结果生存组和死亡组年龄,病种结构,入院血红蛋白和入院时NRS200,住院期间最低前白蛋白、最低血磷和最高PCT,住院期间最差APACHEⅡ、SOFA、m-NUTRIC评分和总住院时间差异有统计学意义(P值均<0.05)。以上指标为自变量,1年内死亡做因变量行多元Logistic回归分析显示,方程含有以上6个变量时,P=0.358>0.200,较好地拟合了原始数据。在校正了年龄、主要诊断及血红蛋白后,以上指标均为神经重症康复患者1年内死亡的独立危险因素。最低血磷、最低前白蛋白和最高PCT联合预测及NRS2002评分和m-NUTRIC评分预测神经重症康复1年预后的AUC(95%CI)分别为0.887(0.844~0.922)、0.679(0.595~0.763)和0.689(0.631~0.743),最佳截断值分别为联合预测值>0.252、NRS2002>4和m-NUTRIC>3,约登指数分别为0.658、0.321和0.326。结论神经重症康复患者在ICU期间的最低血磷联合最低前白蛋白和最高PCT可以更好地预测神经重症康复患者的1年预后。

Objective To explore the relationship between the nutritional risk assessment indicators and the 1-year prognosis of patients in the neurological intensive rehabilitation ward during hospitalization.Methods It′s a retrospective study.The clinical data of patients in the neurological intensive rehabilitation ward of Beijing Rehabilitation Hospital Affiliated to Capital Medical University from December 2020 to August 2022 were analyzed.The following variables were collected at admission:gender,age,primary diagnosis,Glasgow coma scale(GCS),hemoglobin,serum albumin,nutrition risk screening 2002(NRS2002);the lowest blood phosphorus,the lowest prealbumin,the highest procalcitonin(PCT),the acute physiology and chronic health evaluationⅡ(APACHEⅡ)score within 24 h on the day of serious illness(or the worst APACHEⅡscore during ICU),sequential organ failure assessment(SOFA)score,the modified nutrition risk in critically ill(m-NUTRIC)score and the length of ICU stay were recorded during ICU stay.The total length of stay was recorded at discharge,and the follow-up was 1 year.The patients were divided into survival group(n=220)and death group(n=56)according to whether the patients died or not at the endpoint of 1-year follow-up.Multivariate Logistic regression analysis was used to evaluate the risk factors for 1-year mortality in the patients with severe neurological rehabilitation.The receiver operating characteristic(ROC)curve was drawn,and the area under the ROC curve(AUC)and its 95%confidence interval(95%CI)were calculated with the purpose of evaluating the value of nutritional risk predictors and the lowest blood phosphorus combined with the lowest prealbumin and the highest PCT during hospitalization in predicting the death of patients in neurological intensive rehabilitation ward within a year.Results There were statistical differences in age,disease structure,hemoglobin and NRS2002 at admission,the lowest prealbumin,the lowest blood phosphorus,the highest PCT,the worst APACHEⅡ,the SOFA,the m-NUTRIC and the total hospital stay between the survival group and the death group(P<0.05).Multiple Logistic regression analysis with the above variables as independent variables and 1-year death as dependent variables showed that when the equation contained the above 6 variables,the P value was 0.358>0.200,which was a good fit to the original data.After adjusting age,major diagnosis and hemoglobin,the above indicators were independent risk factors for 1-year death in the patients recovering in neurological intensive rehabilitation ward.The area under ROC curves(95%CI)of the combined forecast containing the lowest blood phosphorus,the lowest prealbumin and the highest PCT,NRS2002 and m-NUTRIC predicting 1-year prognosis of severe neurological rehabilitation patients were 0.887(0.844-0.922),0.679(0.595-0.763)and 0.689(0.631-0.743),the best cutoff values were combined forecast>0.252,NRS2002>4 and blood m-NUTRIC>3,and the Jorden index was 0.658,0.321 and 0.326.Conclusions The lowest blood phosphorus combined with the lowest prealbumin and the highest PCT during ICU stay can better predict the 1-year prognosis of patients recovering in a neurological intensive rehabilitation ward.