摘要
目的比较容许性低热量喂养与足量喂养对机械通气（MV）重症患者预后的影响。方法采用前瞻性随机对照研究方法，选择2015年1月至2017年3月浙江省安吉县人民医院重症医学科（ICU）收治的82例MV危重患者，按随机数字表法分成容许性低热量喂养组（40例，非蛋白热量52.3～62.8 kJ·kg-1·d-1，蛋白质1.2～1.5 g·kg-1·d-1）和足量喂养组（42例，非蛋白热量104.6～125.5 kJ·kg-1·d-1，蛋白质1.2～1.5 g·kg-1·d-1），两组患者均于入ICU 24～48 h内按预期热量采用营养泵持续泵入瑞先进行肠内营养（EN），容许性低热量喂养组按预期热量的50%摄入，足量喂养组按预期热量100%摄入。分别于治疗前及治疗7 d检测患者营养指标〔血清前白蛋白（PA）、白蛋白（ALB）〕和炎症指标〔血清降钙素原（PCT）、超敏C-反应蛋白（hs-CRP）〕，记录MV时间、ICU住院时间、每日胰岛素用量、28 d病死率，医院获得性肺炎（HAP）、泌尿系感染、感染性休克等继发感染发生情况，营养相关并发症发生情况。结果与治疗前比较，两组患者治疗后血清PA、ALB均明显升高，PCT、hs-CRP明显下降〔低热量喂养组：PA（mg/L）为127.42±65.83比80.92±60.14，ALB（g/L）为30.16±4.32比25.36±6.21，PCT（ng/L）为375.8±227.2比762.3±314.5，hs-CRP（mg/L）为32.19±7.53比120.48±60.24；足量喂养组：PA（mg/L）为132.56±61.32比86.78±47.06，ALB（g/L）为31.25±4.63比26.71±5.48，PCT（ng/L）为412.1±323.4比821.7±408.6，hs-CRP（mg/L）为35.86±5.69比116.38±72.16，均P〈0.05〕，但两组治疗后各指标差异并无统计学意义（均P〉0.05）。与足量喂养组比较，低热量喂养组治疗后MV时间（h：162.35±20.37比153.48±18.65）、ICU住院时间（d：7.52±1.61比6.34±1.87）、28 d病死率（17.5%比19.0%）、院内感染发生率（45.0%比47.6%）比较差异均无统计学意义（均P〉0.05），但每日胰岛素用量（U：13.68±10.36比26.24±18.53）及呕吐、反流、腹胀、腹泻、便秘等营养相关并发症发生率（32.5%比54.8%）明显低于足量喂养组（均P〈0.05）。Kaplan-Meier生存曲线分析显示，两组28 d累积生存率差异无统计学意义（χ2＝3.216，P＝0.068）。结论MV重症患者接受容许性低热量喂养的疗效及预后与足量喂养相当，但可减少胰岛素用量，且患者胃肠道耐受性更好。
ObjectiveTo compare the impact of permissive underfeeding versus standard enteral feeding on outcomes in critical patients requiring mechanical ventilation （MV）.MethodsA prospective randomized controlled study was conducted. Eighty-two patients requiring MV admitted to intensive care unit （ICU） of Anji People＇s Hospital from January 2015 to March 2017 were enrolled, and they were randomly divided into the permissive underfeeding group （n = 40, non-protein heat was 52.3-62.8 kJ·kg-1·d-1, protein was 1.2-1.5 g·kg-1·d-1） and standard enteral feeding group （n = 42, non-protein heat was 104.6-125.5 kJ·kg-1·d-1, protein was 1.2-1.5 g·kg-1·d-1）. Permissive underfeeding group received 50% of their daily energy expenditure via enteral nutrition （EN） and standard enteral feeding group received 100% of their daily energy expenditure via EN in 24-48 hours after admitted to ICU. Nutritional status [pro-albumin （PA）, serum albumin （ALB）], inflammation state [procalcitonin （PCT）, hypersensitive C-reactive protein （hs-CRP）] were detected before treatment and 7 days after treatment. Duration of MV, length of ICU stay, daily insulin dosage, 28-day mortality, hospital acquired pneumonia （HAP）, urinary tract infection, septic shock and other secondary infection, and the nutrition related complications were recorded.ResultsCompared with before treatment, the levels of serum PA （mg/L） and ALB （g/L） were significantly increased, the levels of PCT （ng/L） and hs-CRP （mg/L） were significantly decreased at 7 days after treatment in both groups [permissive underfeeding group： PA was 127.42±65.83 vs. 80.92±60.14, ALB was 30.16±4.32 vs. 25.36±6.21, PCT was 375.8±227.2 vs. 762.3±314.5, hs-CRP was 32.19±7.53 vs. 120.48±60.24; standard enteral feeding group： PA was 132.56±61.32 vs. 86.78±47.06, ALB was 31.25±4.63 vs. 26.71±5.48, PCT was 412.1±323.4 vs. 821.7±408.6, hs-CRP was 35.86±5.69 vs. 116.38±72.16, all P 〈 0.05], but there was no significant difference in PA, ALB, PCT or hs-CRP at 7 days after treatment between two groups （all P 〉 0.05）. There was no significant difference in the duration of MV, length of ICU stay, 28-day mortality or ICU-associated infection between two groups [duration of MV （hours）： 162.35±20.37 vs. 153.48±18.65, length of ICU stay （days）： 7.52±1.61 vs. 6.34±1.87, 28-day mortality： 17.5% vs. 19.0%, ICU-associated infection： 45.0% vs. 47.6%, all P 〉 0.05]. Compared with standard enteral feeding, insulin demand was significantly decreased （U/d： 13.68±10.36 vs. 26.24±18.53）, and gastrointestinal intolerance was less frequent （32.5% vs. 54.8%） in the permissive underfeeding group （both P 〈 0.05）. Kaplan-Meier survival curve analysis showed that there was no significant difference between the two groups （χ2 = 3.216, P = 0.068）.ConclusionThe curative effect and prognosis of MV severe patients receiving permissive underfeeding are similar to those of standard enteral feeding, but it can reduce the dosage of insulin with better gastrointestinal tolerance.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2018年第2期176-180,共5页
Chinese Critical Care Medicine
基金
浙江省安吉县科技计划项目（201420）
关键词
容许性低热量喂养
足量喂养
机械通气
预后
Permissive underfeeding
Standard enteral feeding
Mechanical ventilation
Outcome
