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脓毒症患者肠内喂养不耐受风险预测模型构建

杨羚 张莉 彭虎 辜新 于湘友

杨羚, 张莉, 彭虎, 辜新, 于湘友. 脓毒症患者肠内喂养不耐受风险预测模型构建[J]. 中华全科医学, 2024, 22(3): 384-388. doi: 10.16766/j.cnki.issn.1674-4152.003408
引用本文: 杨羚, 张莉, 彭虎, 辜新, 于湘友. 脓毒症患者肠内喂养不耐受风险预测模型构建[J]. 中华全科医学, 2024, 22(3): 384-388. doi: 10.16766/j.cnki.issn.1674-4152.003408
YANG Ling, ZHANG Li, PENG Hu, GU Xin, YU Xiangyou. Development of a prediction model for enteral feeding intolerance in patients with sepsis[J]. Chinese Journal of General Practice, 2024, 22(3): 384-388. doi: 10.16766/j.cnki.issn.1674-4152.003408
Citation: YANG Ling, ZHANG Li, PENG Hu, GU Xin, YU Xiangyou. Development of a prediction model for enteral feeding intolerance in patients with sepsis[J]. Chinese Journal of General Practice, 2024, 22(3): 384-388. doi: 10.16766/j.cnki.issn.1674-4152.003408

脓毒症患者肠内喂养不耐受风险预测模型构建

doi: 10.16766/j.cnki.issn.1674-4152.003408
基金项目: 

国家自然科学基金项目 82160360

吴阶平医学基金会临床科研专项资助基金项目 320.6750.2023-02-3

详细信息
    通讯作者:

    张莉,E-mail:121449072@qq.com

  • 中图分类号: R631  R459.3

Development of a prediction model for enteral feeding intolerance in patients with sepsis

  • 摘要:   目的  探讨脓毒症患者肠内喂养不耐受(EFI)的危险因素,了解脓毒症患者EFI的发生情况。构建脓毒症患者发生EFI的风险预测模型,便于高危人群的筛查,以防控EFI的发生。  方法  采用方便抽样法选取2022年1月—2023年6月新疆某三级甲等医院重症医学科收治的行肠内营养治疗的脓毒症患者作为研究对象,以患者是否发生EFI分为喂养耐受组和喂养不耐受组,对患者的一般资料、临床资料、喂养不耐受相关资料进行单因素分析,应用LASSO回归解决各变量间的共线性问题,将LASSO回归分析结果中的变量纳入logistic回归分析,得出脓毒症患者发生EFI的危险因素,并基于此构建脓毒症患者EFI风险预测模型,绘制列线图、ROC曲线、决策曲线、校准曲线,对预测模型的诊断效能进行评价及验证。  结果  共纳入199例行肠内营养治疗的脓毒症患者,其中不耐受组93例,耐受组106例,EFI发生率为46.7%。多因素分析显示序贯性器官功能衰竭(SOFA)评分、营养风险筛查2002(NRS-2002)评分、镇痛剂、ICU住院时间是脓毒症患者发生EFI的独立影响因素。ROC曲线分析显示,脓毒症患者发生EFI的曲线下面积为0.885(95% CI:0.833~0.933),最大约登指数为0.689,敏感度为0.849,特异度为0.839。  结论  SOFA评分、NRS-2002评分、镇痛剂、ICU住院时间是脓毒症患者发生EFI的影响因素,基于此构建的风险预测模型,经验证后发现该模型可较准确地预测脓毒症患者发生EFI的风险,有助于临床医护人员对患者进行科学、个体化的肠内营养治疗。

     

  • 图  1  基于Lambda模型的相关危险因素筛选

    注:A为基于10倍交叉验证法确定交叉验证误差最优lambda值为0.083 205 97;B为7个筛选变量的回归系数。

    Figure  1.  Screening of relevant risk factors based on the Lambda model

    图  2  脓毒症患者发生EFI的列线图

    Figure  2.  Nomogram depicting EFI occurrence in septic patients

    图  3  脓毒症患者肠内喂养不耐受预测模型的ROC曲线和校准曲线

    Figure  3.  ROC curves and calibration curves for the EFI prediction model in patients with sepsis

    图  4  脓毒症患者肠内喂养不耐受预测模型的临床决策曲线

    Figure  4.  Decision curve analysis for the EFI prediction model in patients with sepsis

    表  1  2组脓毒症患者一般资料比较

    Table  1.   Comparison of clinical data between two groups of sepsis patients

    项目 耐受组(n=106) 不耐受组(n=93) 统计量 P 项目 耐受组(n=106) 不耐受组(n=93) 统计量 P
    性别[例(%)] 0.895a 0.344 镇痛剂[例(%)] 43.983a < 0.001
      男性 75(70.8) 59(63.4)   否 75(70.8) 22(23.7)
      女性 31(29.2) 34(36.6)   是 31(29.2) 71(76.3)
    年龄(x±s, 岁) 59.0±17.2 76.2±10.1 8.693b < 0.001 使用抗菌药物种类[例(%)] 0.103a 0.748
    基础疾病[例(%)] 0.178a 0.672    < 2 22(20.8) 22(23.7)
      无 17(16.0) 12(12.9)   ≥2 84(79.2) 71(76.3)
      有 89(84.0) 81(87.1) 抑酸剂[例(%)] 0.211a 0.646
    NRS-2002评分[例(%)] 59.938a < 0.001   否 40(37.7) 39(41.9)
       < 3 75(70.8) 14(15.1)   是 66(62.3) 54(58.1)
      ≥3 31(29.2) 79(84.9) 营养液类型[例(%)] 1.507a 0.471
    mNUTRIC评分[例(%)] 8.200a 0.007   短肽类 69(65.1) 68(73.1)
       < 5 33(31.1) 13(14.0)   整蛋白类 33(31.1) 22(23.7)
      ≥5 73(68.9) 80(86.0)   短肽+整蛋白 4(3.8) 3(3.2)
    APACHEⅡ评分[例(%)] 0.026a 0.873 血清白蛋白[例(%)] 2.192a 0.146
       < 20 57(53.8) 52(55.9)   ≥35 g/L 45(42.5) 30(32.3)
      ≥20 49(46.2) 41(44.1)    < 35 g/L 61(57.5) 63(67.7)
    SOFA评分[M(P25, P75), 分] 7(5, 12) 12(10, 15) -6.799c < 0.001 血红蛋白(x±s, g/L) 103.6±32.9 108.1±27.9 1.036b 0.307
    CRRT[例(%)] 4.271a 0.040 白细胞计数[M(P25, P75),×109/L] 13.3(10.5, 16.9) 13.1(9.4, 16.9) -0.419c 0.675
      否 70(66.0) 48(51.6) ICU住院时间[M(P25, P75),d] 12(7, 17) 14(9, 22) -2.777c 0.005
      是 36(34.0) 45(48.4) 机械通气时间[M(P25, P75),d] 11(7, 15) 11(8, 17) -0.983c 0.325
    注:a为χ2值,bt值, cZ值。
    下载: 导出CSV

    表  2  变量赋值情况

    Table  2.   Variable assignment

    变量 赋值方法
    年龄 以实际值赋值
    SOFA评分 以实际值赋值
    ICU住院时间 以实际值赋值
    NRS-2002评分 <3分=0,≥3分=1
    mNUTRIC评分 <5分=0,≥5分=1
    CRRT 否=0,是=1
    镇痛剂 否=0,是=1
    下载: 导出CSV

    表  3  脓毒症患者肠内喂养不耐受危险因素的logistic多因素回归分析

    Table  3.   Logistic multivariable regression analysis of risk factors for enteral feeding intolerance

    预测变量 B SE Waldχ2 P OR 95% CI
    NRS-2002评分 2.104 0.437 23.142 < 0.001 8.199 3.479~19.322
    SOFA评分 0.191 0.048 15.880 < 0.001 1.210 1.102~1.329
    镇痛剂 0.948 0.414 5.236 0.022 2.580 1.146~5.810
    ICU住院时间 0.044 0.019 5.510 0.019 1.045 1.007~1.085
    下载: 导出CSV
  • [1] SINGER M, DEUTSCHMAN C S, SEYMOUR C W, et al. The third international consensus definitions for sepsis and septic shock(Sepsis-3)[J]. JAMA, 2016, 315(8): 801-810. doi: 10.1001/jama.2016.0287
    [2] MUKHOPADHYAY A, TAN Z Y, CHEONG S H L, et al. Differential effects of early energy and protein inadequacies on the outcome of critically ill patients[J]. Nutr Clin Pract, 2021, 36(2): 456-463. doi: 10.1002/ncp.10543
    [3] ABUGROUN A, NAYYAR A, ABDEL-RAHMAN M, et al. Impact of malnutrition on hospitalization outcomes for older adults admitted for sepsis[J]. Am J Med, 2021, 134(2): 221-226. e1. doi: 10.1016/j.amjmed.2020.06.044
    [4] MCLAUGHLIN J, CHOWDHURY N, DJURKOVIC S, et al. Clinical outcomes and financial impacts of malnutrition in sepsis[J]. Nutr Health, 2020, 26(3): 175-178. doi: 10.1177/0260106020930145
    [5] 华美芳, 陈莉. 鼻肠管用于神经外科重症机械通气患者的效果研究[J]. 现代医药卫生, 2019, 35(22): 3512-3514. doi: 10.3969/j.issn.1009-5519.2019.22.033

    HUA M F, CHEN L. Study of the effect of nasointestinal tubes in neurosurgical intensive mechanical ventilation patients[J]. J Mod Med Health, 2019, 35(22): 3512-3514. doi: 10.3969/j.issn.1009-5519.2019.22.033
    [6] 亚洲急危重症协会中国腹腔重症协作组. 重症病人胃肠功能障碍肠内营养专家共识(2021版)[J]. 中华消化外科杂志, 2021, 20(11): 1123-1136. doi: 10.3760/cma.j.cn115610-20211012-00497

    Chinese Abdominal Intensive Care Association, Asia Society for Emergency and Critical Care Medicine. Expert consensus on enteral nutrition for gastrointestinal dysfunction in critically ill patients (2021 edition)[J]. Chin J Dig Surg, 2021, 20(11): 1123-1136. doi: 10.3760/cma.j.cn115610-20211012-00497
    [7] 张丽华, 张莉, 张丽萍, 等. 脓毒症患者肠内营养喂养不耐受现况及影响因素研究[J]. 华南预防医学, 2023, 49(2): 174-178. https://www.cnki.com.cn/Article/CJFDTOTAL-GDWF202302011.htm

    ZHANG L H, ZHANG L, ZHANG L P, et al. Enteral nutrition feeding intolerance and its influencing factors in patients with sepsis[J]. South China J Prev Med, 2023, 49(2): 174-178. https://www.cnki.com.cn/Article/CJFDTOTAL-GDWF202302011.htm
    [8] 向艳, 金静芬, 王丽竹, 等. 脓毒症患者肠内营养不耐受现状及影响因素分析[J]. 护理与康复, 2022, 21(7): 12-16, 22. doi: 10.3969/j.issn.1671-9875.2022.07.003

    XIANG Y, JIN J F, WANG L Z, et al. Present status on enteral nutrition intolerance for septic patients and analysis on influencing factor[J]. Nursing and Rehabilitation Journal, 2022, 21(7): 12-16, 22. doi: 10.3969/j.issn.1671-9875.2022.07.003
    [9] HU K L, DENG X L, HAN L, et al. Development and validation of a predictive model for feeding intolerance in intensive care unit patients with sepsis[J]. Saudi J Gastroenterol, 2021, 28(1): 32-38.
    [10] 周田田. 老年脓毒症患者肠内营养喂养不耐受的相关因素分析及护理对策[D]. 镇江: 江苏大学, 2018.

    ZHOU T T. The nursing countermeasures and analysis of related factors with enteral feeding intolerance in elderly septic patients[D]. Zhenjiang: Jiangsu University, 2018.
    [11] 郭林彬, 高薇薇, 高万朋, 等. 脓毒症急性胃肠损伤治疗研究进展[J]. 中国临床研究, 2023, 36(10): 1504-1508. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGCK202310013.htm

    GUO L B, GAO W W, GAO W P, et al. Progress in the treatment of acute gastrointestinal injury in sepsis[J]. Chinese Journal of Clinical Research, 2023, 36(10): 1504-1508. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGCK202310013.htm
    [12] JENKINS B, CALDER P C, MARINO L V. A systematic review of the definitions and prevalence of feeding intolerance in critically ill adults[J]. Clin Nutr ESPEN, 2022, 49: 92-102. doi: 10.1016/j.clnesp.2022.04.014
    [13] YU K R, GUO N, ZHANG D D, et al. Prevalence and risk factors of enteral nutrition intolerance in intensive care unit patients: a retrospective study[J]. Chin Med J(Engl), 2022, 135(15): 1814-1820.
    [14] 伏添, 王彩凤, 张谞丰, 等. SAP患者早期肠内营养过程FI的预测评估[J]. 昆明医科大学学报, 2019, 40(12): 108-113. doi: 10.3969/j.issn.1003-4706.2019.12.022

    FU T, WANG C F, ZHANG X F, et al. The predictive assessment of feeding intolerance during early enteral nutrition in patients with severe acute pancreatitis[J]. Journal of Kunming Medical University, 2019, 40(12): 108-113. doi: 10.3969/j.issn.1003-4706.2019.12.022
    [15] 刘炳炜, 徐燕平, 席绍松, 等. SOFA评分联合PCT检测对脓毒症患者病情及其预后的临床评估价值[J]. 中华全科医学, 2021, 19(3): 391-393. doi: 10.16766/j.cnki.issn.1674-4152.001818

    LIU B W, XU Y P, XI S S, et al. Clinical value of SOFA combined with procalcitonin test in assessing the condition and prognosis of patients with sepsis[J]. Chinese Journal of General Practice, 2021, 19(3): 391-393. doi: 10.16766/j.cnki.issn.1674-4152.001818
    [16] LI J B, WANG L J, ZHANG H, et al. Different definitions of feeding intolerance and their associations with outcomes of critically ill adults receiving enteral nutrition: a systematic review and meta-analysis[J]. J Intensive Care, 2023, 11(1): 29. doi: 10.1186/s40560-023-00674-3
    [17] 苏小平, 徐静娟, 赵亚东, 等. 危重患者早期肠内营养喂养不耐受风险预测模型的构建[J]. 护理学报, 2022, 29(17): 47-51. https://www.cnki.com.cn/Article/CJFDTOTAL-NFHL202217009.htm

    SU X P, XU J J, ZHAO Y D, et al. Construction of a prediction model for the risk of intolerance to early enteral nutrition feeding in critically ill patients[J]. Journal of Nursing, 2022, 29(17): 47-51. https://www.cnki.com.cn/Article/CJFDTOTAL-NFHL202217009.htm
    [18] XIAO Y J, XU L. Prevalence and risk factors of enteral feeding intolerance in critically ill patients and the effectiveness of preventive treatments: a prospective study[J]. Saudi J Med Med Sci, 2023, 11(2): 135-142. doi: 10.4103/sjmms.sjmms_384_22
    [19] DICKERSON R N, FARRAR J E, BYERLY S, et al. Enteral feeding tolerance during pharmacologic neuromuscular blockade[J]. Nutr Clin Pract, 2023, 38(6): 1236-1246. doi: 10.1002/ncp.11045
    [20] 范小宁, 孙盼盼, 靳玉萍, 等. 护士主导的肠内营养喂养策略在神经重症患者中的应用[J]. 中华全科医学, 2022, 20(12): 2151-2155. doi: 10.16766/j.cnki.issn.1674-4152.002791

    FAN X N, SUN P P, JIN Y P, et al. Application of nurse-led enteral nutritional feeding strategies in neurological intensive care unit patients[J]. Chinese Journal of General Practice, 2022, 20(12): 2151-2155. doi: 10.16766/j.cnki.issn.1674-4152.002791
    [21] HEYLAND D K, ORTIZ A, STOPPE C, et al. Incidence, risk factors, and clinical consequence of enteral feeding intolerance in the mechanically ventilated critically ill: an analysis of a multicenter, multiyear database[J]. Crit Care Med, 2021, 49(1): 49-59.
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  • 收稿日期:  2023-11-28
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