| Abstract |
Background: With the evolution of ICUs, an increasing number of patients survive today from critical illness or serious trauma. As a consequence, in recent years a special group of patients with prolonged stay has appeared in the ICU. Thus, "long-stay patients" (LSP) have been characterized in various ways with a stay period of 12 to more than 30 days. These patients present with increased morbidity associated with higher rates of disease severity upon admission, with the need for organ support and readmission leading to higher mortality rates ranging from 9% to 20% compared with patients with short stay. At the same time, constituting only 1% to 8% of ICU patients consume more resources than patients with lower length of stay reaching bed occupancy in ICUs up to 50%. However, knowing that ICU patients present with eating disorders, little is known about the degree of hypercatabolism and muscle mass loss of LSP, as reflected in biochemical and imaging parameters. Recent studies have highlighted the urea: creatinine ratio (ur/cr) as a reliable indicator of the catabolic state of patients with severe disease or trauma. Up to date, the nutritional - metabolic status and caloric - protein coverage of the needs of LSPs in pediatric ICUs and their possible correlation with prognostic indicators of diagnosis and outcome have not been studied.
Objective: The aim of this study is to assess whether the limits (days of stay in the ICU) for the definition of LSPs differ significantly between diagnostic and age categories and to determine whether there are independent correlations between patient characteristics at admission and diagnosis of LSP or their outcome. Secondary aims are to identify demographic, metabolic, and nutritional characteristics of LSPs defined by the length of stay in ICU> 2 weeks and to identify early risk factors for LSP. At the same time, a complementary aim of the previous ones is to compare the longitudinal caloric and protein coverage of LSPs with the age-recommended energy protein needs of ICU patients, in line with recent guidelines.
Methods: This is a retrospective study recording the LSPs (more than 14 days) who were hospitalized in the PICU of PAGNI in the years 2009-2020. Emphasis was placed on the etiology of patients' admission to PICU and the severity of their disease, which was assessed using disease scoring systems (PRISM, PeLOD, TISS). The need for mechanical ventilation, but also other supportive therapies, as well as the existence of comorbidities and re-admissions, were recorded. Patients’ somatometric characteristics, their energy and protein intake during the 7th day of hospitalization, and their clinical and laboratory characteristics on admission and weekly were also recorded. Finally, a control group of short-stay patients (SSP) of less than 14 days) was included in the study. The above data were collected from patients' files followed by statistical analysis of results, comparison of subgroups, and correlation testing.
Results: A total of 249 patients were included in the study, of whom 134 were LSP and 115 were SSP. LSPs were malnourished with a mean weight z-score of -0.45 (p=0.001) and had more severe illness as estimated by the illness severity scoring systems PRISM, PeLOD and TISS (p <0.001), higher comorbidity (p=0.013), and more re-admissions compared to SSPs (p=0.004). Patients with long-term hospitalization also had a tendency to experience more frequent ARDS and sepsis (p=0.065) and were in greater need of support for organic systems (p=0.011) with higher mortality than SSP (13.4% vs. 3,5%, p=0.004). LSPs were given more calories and proteins than SSP (p=0.035), but neither group reached the recommended by the ESPNIC and ESPEN energy guidelines (Schofield equation) or protein coverage. The energy balance was less negative in LSPs (-10.9±22 vs. -16.3±21 kCal/kg/day, p=0.165), although the calories administered in the LSP group were more than SSP (36±25 vs. 26.7±24 kCal/kg/day, p=0.045). The proteins administered to the LSP group were marginally more than SSP (1.45±1.2vs.1.39±0.9 gr/kg/day, p=0.793), very close to the recommended daily protein intake by ESPNIC and ESPEN. An increasing trend (26%) per week was observed in the ur/cr ratio in LSP (7th day, 60.2±30 vs. 51.9±37, p=0.45). Malnutrition (p=0.005), multiorgan failure (p=0.034), and the need to support the patient with mechanical ventilation (p=0.006) were associated with the probability of long-term hospitalization. Strong predictors of mortality in all patients were PRISM and PeLOD scores (p=0.001), the duration of mechanical ventilation (p=0.001) and the duration of hospitalization (p=0.02).
Conclusions: Long-stay patients have many aggravating factors and need multisystem support. Hyper-catabolism of patients due to severe disease is not avoided despite the choice of aggressive intestinal feeding regimens. Patients with malnutrition, multiorgan failure and need for mechanical ventilation have an increased likelihood of long-stay in the ICU. The increased mortality of this group of patients is related to the severity of the disease, comorbidity, long stay, the need for mechanical ventilation and the dynamic effect of increased muscle mass loss.
There is an urgent need for further research to design protocols in accordance with the nutritional coverage guidelines of ICU patients, in order to better support the increased metabolic needs of long-stay patients.
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Μεταβολικά και θρεπτικά χαρακτηριστικά, προγνωστικοί δείκτες διάγνωσης και έκβαση ασθενών μακράς διάρκειας νοσηλείας σε μονάδα παιδιατρικής εντατικής θεραπείας
