肠外肠内营养支持对有营养风险的住院病人临床结局的影响：中美教学医院多中心队列研究

【作者】 揭彬；

【导师】 蒋朱明； Marie T. Nolan；

【作者基本信息】 中国协和医科大学 ， 护理学， 2009， 博士

【摘要】 背景和目的:欧洲肠外肠内营养学会推荐营养风险筛查工具(Nutritional Risk ScreeningTool 2002,NRS-2002)用于住院病人的营养筛查。对NRS-2002筛查为有营养风险者给予肠外肠内营养支持能否改善临床结局缺乏前瞻性研究报道,也没有中国和美国医院住院病人的相关资料。因此,本研究以NRS-2002为工具,比较北京和美国巴尔的摩的教学医院中住院病人营养风险状况及营养支持的使用情况;分析肠外肠内营养支持对有营养风险的患者临床结局的影响。方法:本研究为前瞻性队列研究,对北京协和医院、北京大学第三医院、美国约翰霍普金斯医院的消化内科、呼吸内科、腹部外科的住院病人,在入院24小时内以NRS-2002进行营养风险筛查(NRS评分≥3分为有营养风险),观察、记录住院期间肠外肠内营养支持的使用、手术、治疗、并发症、住院时间、死亡率等信息。分析营养风险、营养支持与并发症、住院时间的关系。结果:1、北京协和医院与美国约翰霍普金斯医院病人营养风险状况及营养支持应用情况的比较:共1041例病人纳入研究。营养风险的发生率两医院无显著差异(P=0.15),但肥胖病人的比例霍普金斯医院显著高于协和医院(P＜0.001)。内科病人营养支持的使用率两医院无显著差异(P=0.58),但协和医院以肠外营养为主,霍普金斯医院以肠内营养为主,差异显著(P=0.01)。腹部外科中,协和医院无营养风险的病人(尤其是胃肠手术病人)营养支持的使用率显著高于霍普金斯医院(P＜0.001)。2、营养支持对有营养风险的患者临床结局的影响:三个医院共1831例患者纳入研究。有营养风险的病人中(n=827),得到营养支持者总并发症发生率显著低于无营养支持者(P=0.009);感染性并发症的发生率也显著低于无营养支持者(P＜0.001)。从营养支持的方式来看,肠内营养组总并发症率及感染性并发症率均显著低于无营养支持组;肠外营养组的并发症率与无营养支持组相比无显著差异。此外,入院前一周有明显饮食摄入减少(NRS评分中饮食评分≥1分)的患者中,三个医院的资料均显示营养支持组感染性并发症率显著低于无营养支持组(P=0.004,0.04,0.03)。对有营养风险者并发症率的多因素分析结果显示,营养支持是并发症的保护因素(OR:0.54,P＜0.001)。无营养风险(NRS评分＜3分)的患者中(n=1004),营养支持组与无营养支持组的并发症率无显著差异(P=0.12)。3、术前营养支持对有营养风险的腹部手术病人临床结局的影响:1168例腹部手术患者纳入研究,其中556例有营养风险。NRS评分5-6分的病人中,规范的术前营养支持的应用率为37.8%(48/127)。术前营养支持组与无术前营养组相比,总并发症率、感染性并发症率、非感染性并发症率均显著降低(P=0.009,0.04,0.03),术后平均住院时间缩短4天(P=0.03),总住院时间无显著差异(P=0.84)。NRS评分3-4分的病人中,规范的术前营养支持的应用率为4.9%(21/429)。术前营养支持组与无术前营养组相比,总并发症率、感染性并发症率、非感染性并发症率均无显著差异(P=0.96,0.52,0.76),术后住院时间无显著差异(P=0.77)。结论:1、美国约翰普金斯医院与北京协和医院住院病人营养风险的发生率无显著差异,但肥胖病人的比例霍普金斯医院显著高于北京协和医院。2、北京的医院中部分无营养风险的腹部外科病人也得到了肠外营养支持,尤其是胃肠道手术的病人。本研究发现营养支持对无营养风险的患者的并发症发生率没有明显影响。3、内科病人中北京的医院营养支持以肠外营养为主,约翰霍普金斯医院以肠内营养为主。本研究发现肠内营养对临床结局的改善作用优于肠外营养。4、对有营养风险的患者给予营养支持可以减少并发症(尤其是感染性并发症)的发生。其中有营养风险且伴有入院前一周饮食摄入明显减少的病人,从肠外肠内营养支持中获益的机会更大。5、NRS≥5分的病例中,规范的术前营养支持能够显著减少并发症的发生,缩短术后住院时间,不延长总的住院时间。更多还原

【Abstract】 Background:Nutritional Risk Screening Tool 2002(NRS-2002) was recommended by E(?)can Socitey of Parenteral and Enteral Nutrtition for use in hospitalized patients.Th(?)as no prospective study on the effect of parenteral nutrition and enteral nutrition on(?)l outcome in patients at nutritional risk defined by NRS-2002,also no such data(?)e patients in China and the United States.The aim of this study was to compare(?) nutritional risk status and application of nutritional support in teaching hospita(?) China and the United States,to evaluate the effect of parenteral nutrition/enteral nutr(?)n clinical outcomes in patient at nutritional risk.Methods:In this prospective cohort study,patients admitted to departments of gastro(?)nal medicine,respiratory medicine and abdominal surgery in the Johns Hopkins H(?)al (JHH) in Baltimore in the US,in the Peking Union Medical College Hospital(PUMCH) and Beijing University Third Hospital(BUTH) in Beijing,China were recruited and received nutritional risk screening using NRS-2002 on admission.A NRS score of≥3 means at nutritional risk.Patients were monitored daily until discharge to collect data on the application of parenteral nutrition(PN) and enteral nutrition(EN),treatment(?)rgery, complications,mortality and length of stay(LOS).Results:1.The difference between the teaching hospitals in Beijing and Baltimore:Totally 1041 patients were recruited.The rate of nutritional risk was similar between PUMC(?)d JHH(P=0.15),although the rate of obesity was significantly higher in JHH(P＜(?)1). Among the medical patients,there was more frequent use of PN and less freq(?)se of EN in PUMCH(P=0.01).The application rate of nutritional support was sign(?)tly higher in PUMCH in surgical patients at no nutritional risk(P＜0.001),especi(?) patients undergoing gastrointestinal surgery(P＜0.001).3.The impact of parenteral/enteral nutrition on clinical outcomes:Totally 18(?)tients were recruited.Among the "at risk" patients(n=827),the complication rate wa(?)er in the "nutritional support" group than that in the "no support" group(P=0.009),(?)ainly because of the significantly reduced rate of infectious complications(P＜0.001).Among the "at risk" patients with obviously reduced oral intake before admission,the association of nutritional support and the reduced rate of infectious complications was obs(?) in each hospital(P=0.004,0.04,0.03,respectively).In addition,the complicati(?)te was significantly lower in the patients who received EN but not in the patients who received PN when compared to the "no support" group.Among the patients without nutritional risk(n=1004),the complication rate was not different between the "nutritional support" group and the "no support" group(P=0.12).The multivariate analysis showed nutrition support was a protective factor for complication rate in the "at risk" patients when adjusted for confounders(odds ratio:0.54,P＜0.001).4.the impact of preoperative nutritional support on clinical outcomes:Among the patients with NRS score of≥5(n=127),the complication rate was lower in the "preoperative nutrition" group compared to the control group(P=0.009).The postoperative hospital stay was 4 days shorter in the "preoperative nutrition" group (P=0.03),while the LOS was similar in the two groups(P=0.84).Among the patients with NRS score of 3-4(n=429),the complication rate and postoperative hospital stay was similar between patients with or without preoperative nutrition(P=0.96,0.77).Conclusions:1.The rate of nutritional risk was similar between Beijing and Baltimore while there was more obesity in Baltimore.2.Parenteral nutrition was overused in Beijing in surgical patients at no nutritional risk, especially among those undergoing gastrointestinal surgery.However,no effect of nutritional support on clinical outcome was found among the patients at no nutritional risk in this study.3.Among the medical patients,there was more frequent use of PN and less frequent use of EN in Beijing when compared to Baltimore.It revealed that EN was associated with significantly reduced complication rate in this study.4.This finding revealed that nutritional support was beneficial to the patients at nutritional risk by reduced rate of infectious complications,especially among the patients with obviously reduced oral intake before admission.5.It suggests that preoperative nutritional support is beneficial to the patients with NRS score of≥5 by reduced complication rate.更多还原