Tesis

Akurasi Prognostic Nutritional Index, Subjective Global Assessment, dan Nutritional Risk Screening 2002 sebagai Prediktor Mortalitas Rawat Inap Pasien Sepsis = The Accuracy of Prognostic Nutritional Index, Subjective Global Assessment, and Nutritional Risk Screening 2002 for InHospital Mortality Prediction in Sepsis.

Latar Belakang: Sepsis merupakan penyebab utama kematian akibat infeksi. Berbagai faktor mempengaruhi kematian akibat sepsis seperti usia, komorbiditas, skor Sequential (sepsis-related) Organ Failure Assessment (SOFA), kadar laktat serum, serta status nutrisi. Untuk menilai status nutrisi, terdapat banyak parameter, antara lain: Prognostic Nutritional Index (PNI), Subjective Global Assessment (SGA), dan Nutritional Risk Screening 2002 (NRS 2002). Parameter SGA dan NRS 2002 merupakan standar evaluasi status nutrisi sedangkan PNI sangat sederhana dan obyektif. Tujuan: Penelitian ini bertujuan menilai akurasi ketiga parameter nutrisi tersebut sebagai prediktor mortalitas rawat inap sepsis serta menganalisis seberapa besar malnutrisi berkontribusi terhadap mortalitas sepsis dibandingkan faktor-faktor lainnya. Metode: Desain penelitian adalah kohort prospektif. Kriteria inklusi adalah pasien rawat inap berusia minimal 18 tahun dengan diagnosis sepsis. Kriteria eksklusi adalah pasien yang tidak memungkinkan untuk diwawancara maupun pasien yang sedang hamil. Kriteria drop out adalah pasien yang pulang atas permintaan sendiri. Pengambilan sampel dilakukan secara consecutive sampling. Status nutrisi dan parameter klinis lain dinilai dalam 48 jam pertama sejak diagnosis sepsis. Luaran rawat inap dicatat sebagai mortal atau hidup. Titik potong variabel numerik ditentukan dengan kurva ROC. Analisis bivariat menggunakan tes Chisquare atau Fisher, analisis multivariat menggunakan regresi logistik biner. Hasil: Sebanyak 158 subyek diikutkan dalam penelitian ini. Angka mortalitas sebesar 62,7%. Sebagai prediktor mortalitas, PNI memiliki nilai prediksi positif (NPP) 72,7% dan nilai prediksi negatif (NPN) 54,2% dengan titik potong 30,55, sedangkan SGA memiliki NPP 70,4% dan NPN 54,0%, dan NRS 2002 memiliki NPP 64,7% dan NPN 75,0%. Terhadap mortalitas sepsis, status malnutrisi berdasarkan PNI memiliki aRR 3,0 (95% CI 1,4-6,6), SGA memiliki aRR 2,4 (95% CI 1,1-5,3), NRS 2002 memiliki aRR 1,6 (95% CI 0,2-10,1). Variabel lain yang juga memiliki signifikansi terhadap kejadian mortalitas sepsis adalah skor komorbiditas, SOFA, dan kadar laktat serum. Faktor resistensi patogen tidak didapatkan sebagai penyebab signifikan mortalitas sepsis pada penelitian ini. Simpulan: Malnutrisi berhubungan signifikan dengan mortalitas rawat inap sepsis. Baik PNI maupun SGA sama efektifnya dalam memprediksi mortalitas sepsis. Parameter NRS 2002 merupakan prediktor yang paling lemah dibandingkan PNI dan SGA dalam memprediksi mortalitas sepsis. Faktor lain yang juga memiliki hubungan signifikan dengan mortalitas rawat inap sepsis adalah Charlson Comorbidity Index (CCI), skor SOFA, dan kadar laktat serum.
Kata kunci: sepsis, mortalitas, malnutrisi, Prognostic Nutritional Index, Subjective Global Assessment, Nutritional Risk Screening 2002


Background: Sepsis is a leading cause of infection-related mortality. Various factors contribute to sepsis-related mortality, including age, comorbidities, Sequential (sepsis-related) Organ Failure Assessment (SOFA) score, serum lactate levels, and nutritional status. Several parameters are available to assess nutritional status, including the Prognostic Nutritional Index (PNI), Subjective Global Assessment (SGA), and Nutritional Risk Screening 2002 (NRS 2002). The SGA and NRS 2002 parameters are standard tools for evaluating nutritional status, while the PNI is very simple and objective. Objective: This study aimed to evaluate the accuracy of these three nutritional parameters as predictors of in-hospital mortality in sepsis patients and to analyze the extent to which malnutrition contributes to sepsis-related mortality compared to other factors. Methods: This study design was a prospective cohort. Inclusion criteria were hospitalized patients aged 18 years or older with a diagnosis of sepsis. Exclusion criteria were patients who could not be interviewed or those who were pregnant. Dropout criteria included patients who were discharged against medical advice. Sampling was conducted using consecutive sampling. Nutritional status and other clinical parameters were assessed within the first 48 hours of sepsis diagnosis. Inhospital outcomes were recorded as either mortal or survive. Cut-off points for numerical variables were determined using ROC curves. Bivariate analysis was performed using Chi-square or Fisher’s exact test, and multivariate analysis was conducted using binary logistic regression. Results: A total of 158 subjects were included in the study. The mortality rate was 62.7%. As predictors of mortality, PNI had a positive predictive value (PPV) of 72.7% and a negative predictive value (NPV) of 54.2% with a cut-off point of 30.55, while SGA had a PPV of 70.4% and an NPV of 54.0%, and NRS 2002 had a PPV of 64.7% and an NPV of 75.0%. Regarding sepsis mortality, malnutrition status based on PNI had an aRR 3.0 (95% CI 1.4-6.6), SGA had an aRR 2.4 (95% CI 1.1-5.3), and NRS 2002 had an aRR 1.6 (95% CI 0.2-10.1). Other variables that were also significantly associated with sepsis mortality included comorbidity score, SOFA score, and serum lactate level. Pathogen resistance was not identified as a significant factor contributing to sepsis-related mortality in this study. Conclusions: Malnutrition was significantly associated with in-hospital sepsis mortality. Both PNI and SGA are equally effective in predicting sepsis mortality. The NRS 2002 is the least predictive to both PNI and SGA in predicting sepsis mortality. Other factors that also have significant association with in-hospital sepsis mortality are Charlson Comorbidity Index (CCI) score, SOFA score, and serum lactate level.
Keywords: sepsis, mortality, malnutrition, Prognostic Nutritional Index, Subjective Global Assessment, Nutritional Risk Screening 2002