Fatores associados ao comprometimento da circunferência do braço em pacientes pediátricos graves em ventilação mecânica

Dissertação (mestrado) - Universidade Federal de Santa Catarina, Centro de Ciências da Saúde, Programa de Pós-Graduação em Nutrição, Florianópolis, 2016.Introdução: Pacientes pediátricos graves são frequentemente diagnosticados com desnutrição na admissão em Unidade de Terapia Intensiva Pediátrica (UTIP), e o comprometimento do estado nutricional está associado com o desenvolvimento de desfechos clínicos desfavoráveis. Assim, para prevenir o comprometimento do estado nutricional e suas complicações durante a internação na UTIP, é essencial a identificação precoce da depleção nutricional.Objetivo: Avaliar a associação entre parâmetros antropométricos, bioquímicos, de terapia nutricional e clínicos com o comprometimento da circunferência do braço (CB); e avaliar a associação entre o comprometimento da CB com os desfechos clínicos, em pacientes pediátricos graves em ventilação mecânica.Métodos: Estudo de coorte prospectivo, realizado na UTIP do Hospital Infantil Joana de Gusmão, Florianópolis, Santa Catarina, Brasil, com pacientes pediátricos graves, entre 3 meses e 15 anos de idade, de ambos os sexos. A avaliação nutricional foi realizada na admissão e após 7 dias, sendo avaliados: peso, estatura/comprimento, CB e prega cutânea triciptal, pelo escore-z dos indicadores antropométricos. A avaliação bioquímica foi composta por albumina, Proteína C-Reativa (PCR) e PCR/albumina. A TN foi avaliada pelo recebimento de TN prévia, tempo para implementação, via de administração e adequação de energia e proteína. Os dados clínicos coletados foram: Índice Prognóstico de Mortalidade 2 (PIM2), motivo da internação (clínico e cirúrgico), doenças crônicas complexas, balanço hídrico e sobrecarga de fluidos. O desfecho primário foi o comprometimento da CB em 7 dias, e os secundários foram os dias de internação, mortalidade e presença de infecção nosocomial. Foram realizados os testes de Qui-quadrado e Mann-Whitney para comparação entre os pacientes com e sem comprometimento. A regressão logística foi aplicada para avaliar a associação entre variáveis clínicas e nutricionais com o comprometimento da CB, sendo realizada análise ajustada para idade e PIM 2 (Ajuste 1), e idade e sobrecarga de fluidos (Ajuste 2). Ainda, a regressão logística foi utilizada para avaliar a associação entre o comprometimento da CB com desfechos clínicos. Valor de p Abstract : Background: Critically ill children are frequently diagnosed with undernutrition on admission at Pediatric Intensive Care Unit (PICU) which is associated with development of worse clinical outcomes. Thus, to prevent the impairment of nutritional status and its complications, during PICU stay, it is essential the early identification of nutritional depletion.Aim: To evaluate the association between anthropometric, biochemical, nutritional therapy (NT) and clinical parameters with the impairment of mid-upper arm circumference (MUAC); and to evaluate the association between the impairment of MUAC with clinical outcomes, in critically ill patients on mechanical ventilation.Methods: A prospective cohort study conducted in the PICU of the Children's Hospital Joana de Gusmão, Florianópolis, Santa Catarina, Brazil, with critically ill children aged between 3 months and 15 years, of both sexes. Nutritional status assessment was performed at PICU admission and after 7 days, evaluated by z-score of weight-for-age, body mass index-for-age (BMI/A), MUAC-for-age and triceps skinfold thickness-for-age. Biochemical evaluation was composed of serum albumin, C-reactive protein (CRP) and CRP/albumin. TN was evaluated by prior TN, time to initiation, route of administration and energy and protein adequacy. Pediatric Index of Mortality 2 (PIM 2), diagnostic category (medical and surgical), Complex Chronic Conditions (CCC), fluid balance and fluid overload were evaluated. The primary outcome was the impairment of MUAC in 7 days, and the secondary outcomes were PICU and hospital length of stay, mortality and nosocomial infection. Chi-square test and Mann Whitney for comparison between patients with and without impairment of MUAC was applied. Logistic regression crude was used to evaluate the association between clinical and nutritional parameters with the impairment of MUAC and, it was performed analysis adjusted for age and PIM 2 (Adjustment 1), and age and fluid overload (Adjustment 2). Also, logistic regression was used to evaluate the association between the impairment of MUAC with clinical outcomes. P value < 0.05 was considered significant.Results: There were included 53 patients, with median age of 43.8 (Interquartile range 8.7 - 124.6) months. The prevalence of undernutrition at admission was 7.7% according BMI/A and, 32% of the patients developed impairment of MUAC. Hypoalbuminemia at admission was associated with the impairment of MUAC in the crude analysis (OR 5.3; p = 0.013), in adjustment 1 (OR 6.8; p = 0.008) and in adjustment 2 (OR 5.2; p = 0.020). The increase of 1 g/dL of albumin was associated with the impairment of MUAC in the crude analysis (OR 0.2; p = 0.017), in adjustment 1 (OR 0.2; p = 0.013) and in adjustment 2 (OR 0.2; p = 0.021). Higher values of CRP/albumin were associated with the impairment of MUAC in the crude analysis (OR 11.7; p = 0.023), in adjustment 1 (OR 40.5; p = 0.018) and in adjustment 2 (OR 14.1; p = 0.024). There were no association between demographic, clinical and NT parameters with the impairment of MUAC. Patients with impairment of MUAC were more likely to acquire nosocomial infections (OR 3.6; p = 0.045) and there were no association between the impairment of MUAC and mortality and length of stay.Conclusion: It is recommended the evaluation of albumin and CRP/albumin at PICU admission for early identification of the risk of nutritional status impairment, evaluated by MUAC, and its possible consequences