- 學位論文
加護病房存活者出加護病房住院期間蛋白質熱量攝取
Protein and Energy Delivery during the Post-ICU Hospital Stay in Adult ICU Survivors
摘要
蛋白質與熱量的攝取不足會影響重症病患的預後甚至增加死亡率。然而現今文獻對於重症病患蛋白質與熱量攝取多著重於加護病房內，對於出加護病房存活者其蛋白質與熱量攝取概況及建議量所知有限；轉出加護病房的住院期間蛋白質和熱量攝取及其來源也鮮少研究。本研究欲評估成人加護病房存活者在出加護病房住院14天期間內，每日蛋白質與熱量攝取之情況，同時也針對蛋白質與熱量攝取來源，依照人次與觀察日數兩個層面進行分析。研究共收納32名加護病房存活者，搜集其人口學資料、臨床資料、出加護病房後14天的每日蛋白質及熱量攝取情況。採用床邊評估、病歷檢視並搭配飲食24小時回憶法來進行資料搜集。所有資料皆利用SPSS 25.0統計軟體套件進行分析。 32名受試者平均年齡為74.3歲，體重平均為57.4公斤而身體質量指數（body mass index, BMI）為22.3 kg/m2。以每公斤體重1.2克蛋白質與25卡（kcal）熱量作為標準，病患每公斤體重平均攝取0.89克與21.5卡。若以每公斤體重1.2克蛋白質為標準，有87.5%（n=28）的病患無法達到此標準；而病患平均熱量攝取也低於25卡，有約68.8%（n=22）的病患熱量攝取不足於建議需求量。蛋白質熱量攝取不足（< 1.2 g/kg；< 25 kcal/kg）的病患相較於足夠者在體重（58.8 kg vs. 48.2 kg）與BMI （22.7 vs. 19.0）上顯著較高。而以75歲作為切點，蛋白與熱量攝取在年齡分組上並沒有顯著的差異。 在32位受試者，共427天的觀察期中，共有七種進食途徑被記錄，包括單一途徑由口進食（ORAL；122天）、腸道營養（enteral nutrition, EN；168天）及週邊靜脈營養（parenteral nutrition, PN；43天）與合併使用組合包含ORAL+EN（22天）, ORAL+PN （29天）, EN+PN （32天）及ORAL+EN+PN （9天）。在所有途徑中，三者合併使用（ORAL+EN+PN）能提供每日最高的蛋白質與熱量攝取（80.7克/天與1,929.3卡/天），由口進食合併腸道營養則佔第二（61.4克/天、1,555.9卡/天）。近一步進食途徑分成單一由口進食（ORAL-alone；122天）與非單一由口進食（non-ORAL-alone；302天）兩組，非單一由口進食所提供之蛋白質與熱量皆明顯高於單一組（54.3克/天、1,280.8卡/天 vs. 42.4克/天、1,066.7卡/天；p<0.001）。而在第一週（218天）與第二週（209天）間的蛋白質熱量攝取的動態變化上，則無明顯差異。 總結來說，在出加護病房住院的14天期間，蛋白質攝取大部分無法滿足每公斤體重1.2克的目標，熱量攝取也小於25卡/公斤之建議。研究發現，單純由口進食，其蛋白質與熱量攝取量平均每天皆顯著小於使用其他進食途徑。同時出加護病房後第二週的蛋白質與熱量攝取相較於第一週並沒有顯著的進步，未來針對加護病房存活者其住院期間的蛋白質熱量攝取，應更進一步關注，以確保病患的營養狀態與蛋白質及熱量的需求。
並列摘要
Insufficient delivery of protein and energy would lead to poor clinical outcomes, increasing mortality for critically ill patients. Limited studies are available on the protein and energy delivery during the hospital stay in adult critically ill patients who were successfully discharged from the intensive care unit (ICU). This prospective observational cohort study aimed to evaluate the adult ICU survivors’ daily protein and energy delivery status during the 14-day post-ICU hospital stay. The primary sources of protein and energy were analyzed both at the individual or person-level and the observational-day-level as the measurement unit. In total, 32 patients were enrolled upon their discharge from six medical ICUs at the university-affiliated hospital in Taiwan. Patients’ demographics and medical characteristics were collected at the enrollment. Their protein and energy delivery over 14 days (or until death or hospital discharge, whatever occurred first) were collected using the daily 24 hours dietary recall method. The chart review and bedside evaluation protocol were standardized to ensure the accuracy of data collection. The data were analyzed by the SPSS 25.0 statistical package. Of 32 participants enrolled, the mean age was 74.3 years. The average weight was 57.4 kg, and the body mass index (BMI) equaled 22.3 kg/m2. Compared to the recommended protein of 1.2 g/kg and 25 kcal/kg in energy, the participants only received 0.89 g/kg and 21.5 kcal/kg on average. Overall, 87.5% (28/32) of participants did not meet the recommendation of 1.2 g protein, and 68.8% (22/32) whose daily energy delivered was under the recommended target. Participants who failed to meet the protein target had higher body weight (58.8 kg vs. 48.2 kg for those meeting the target), and BMI (22.7 vs. 19.0) was also observed for participants who received less than the targeted energy delivery. When comparing the protein and energy delivered, there were no differences between older (i.e., 75 years and older) versus younger participants (0.85 g/kg in protein and 20.6 kcal/kg in energy vs. 0.92 g/kg for protein and 22.3 kcal/kg for energy in those younger than 75 years). Of 32 participants, there were 427 observational days. Among those days, 7 different nutrition delivery sources were observed, including ORAL-alone (122 days), EN-alone (168 days), PN-alone (43 days), ORAL+EN (22 days), ORAL+PN (29 days), EN+PN (32 days), and the cross combinations of ORAL+EN+PN (9 days). Protein- and energy-wise, the ORAL+EN+PN provided the highest amounts of protein and energy intake delivery (80.7 g/day and 1,929.3 kcal/day), with ORAL+EN as the second highest (61.4 g/day and 1,555.9kcal/day). Further analysis comparing the nutrition delivery between ORAL-alone-day (122 days) and non-ORAL-alone-day (302 days), the non-ORAL-alone provided a significantly higher amount of protein and energy delivery than the ORAL-alone (54.3 g in protein, 1,280.8 kcal in energy vs. 42.4 g in protein and 1,066.7 kcal in energy for ORAL-alone-day; p<0.001). Moreover, comparing the nutrition delivery in the 1st-week (218 days) versus the 2nd-week (209 days) of post-ICU stays, there were no differences in the amount of protein and energy delivery. In conclusion, we found that adult ICU survivors’ daily protein and energy delivery during 14-day post-ICU hospital stay mostly failed to meet the 1.2 g/kg protein target, so as the 25 kcal/kg energy target. Detailed analyzing each observational day, we found that the days with ORAL-intake-alone, protein and energy delivered were significantly lower than the other days. Out of surprise, compared to the 1st-week, protein and energy delivery was not higher in the 2nd-week of post-ICU stays. Future studies warrant paying more attention to the protein and energy delivery during the post-ICU hospital stay for ICU survivors to meet the nutrition target.
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