重症急性胰腺炎早期肠内免疫营养支持

Randomized controlled prospective trial of the effect of the early enteralimmunonutrition versus the standard enteral nutrition in patients with severe acute pancreatitis

目的 :比较观察免疫营养配方与标准配方肠内营养 (EN)对重症急性胰腺炎 (SAP)炎症反应和病人预后的影响。 方法 :所有病人均符合SAP诊断标准 ,APACHEⅡ评分 8分以上。随机分为两组 :即免疫营养组 (n =1 6 ) ,给予免疫型EN ;对照组 (n =1 6 ) ,给予标准型EN。第 1天给予 4 1 84kJ ,第 3天增至 836 8kJ ,共 1 0天。两组病人的一般情况和病情严重度相似 ,并给予相同的处理 ,在发病 1周左右 ,通过内镜放置鼻空肠管行EN。观察全身炎症反应、营养指标的变化、比较感染等并发症发生率和病死率。 结果 :①两组病人均无死亡 ;②两组的胰周感染、成人呼吸窘迫综合征、休克、急性肾功能障碍的发生率无显著性差异 ;③ICU停留时间、住院时间、CT评分也无显著性差异 ;④治疗后两组病人的血清清蛋白、转铁蛋白、前清蛋白均有不同程度升高 ,但两组间无显著性差异(P >0 .0 5 ) ;⑤两组治疗后C反应蛋白、白细胞计数均明显下降 (P <0 .0 5 ) ;⑥免疫营养组伴全身性炎症反应综合征时间 (5 .0 0± 3.6 0 )天 ,短于对照组 (5 .75± 2 .2 3)天 ,但无显著性差异 (P =0 .5 7)。 结论 :早期EN能明显减轻SAP病人的炎症反应 ,改善营养状况。

Objectives: To compare and assess the effect of early enteral immunonutrition vs early standard enteral nutrition on the systemic inflammatory response and incidence of the infection about pancreatic tissue and prognosis in patients with severe acute pancreatitis. Methods: A total of 32 patients complied with Atlanta recommendations for SAP(APACHE II score>8) and were included in the prospective study. Patients with acute pancreatitis were randomized into enteral immunonutrition group( n =16) and the control group( n =16). The general conditions and severity of the disease were similar in both groups.Two groups were fed by an endoscopically placed nasogastrojejunal tube within 7～10 days after admission. Enteral immunonutrition group received Stresson Multifibre  in a dose of 4 184～8 368 kJ for 10 days,the control group received Fresubin  in similar dose for 10 days. The variety of the markers of the systemic inflammatory response(eg.T,Bp,R,P,Leucocyte and CRP) and nutrition indicators (albumin,transferrin and prealbumin) were observed. Results: ①No mortality in both groups was observed. ②Infected pancreatic necrosis and abscess occurrence rate,incidence of ARDS,shock and acute renal dysfunction in both groups were not different. ③There was no difference on CT socre, ICU and hospital stay in enteral immunonutrition group compared with the control group.④The serum concentration of albumin,transferrin and prealbumin increased remarkably in both groups, but there was no difference between two groups( P >0.05). ⑤There was remarkable decrease in CRP and amount of leucocyte in both groups. ⑥The SIRS time was (5.00±3.60) days in enteral immunonutrition group versus (5.75±2.23) days in the control group( P = 0.57). Conclusions: ①It is suggested that the early enteral nutrition was safe and effective to be adopted by intrajejunal delivery of nutrients in patients with SAP , did not make SAP clinical pathological features deteriorate, and decreased the occurrence rate of infected pancreatic necrosis and abscesses. ②However, the early enteral immunonutrition is not more efficient than the early standardized enteral nutrition on alleviating systemic inflammatory response.