多发伤患者早期代谢特点及静脉营养支持

Metabolic Characteristics and Parenteral Nutrition Support in the Early Stage after Multiple Trauma

目的探讨多发伤患者早期代谢变化、细胞因子的释放以及两者间的关系,多发伤后早期静脉营养支持的安全性和有效性。方法 12例多发伤患者,伤后24小时内放置Swan-Ganz导管检测氧输送(DO_2)、氧摄取(VO_2)和氧摄取率(O_2ER)以评价代谢状况,同时取静脉血测血清肿瘤坏死因子α(TNFα)、白细胞介素-1β(IL-1β)和白细胞介素-6(IL-6),并与各代谢指标进行相关性分析。伤后48小时,给予含脂肪乳剂的静脉营养支持,检测静脉营养前后的血糖、甘油三脂、氧合指数(PaO_2／FiO_2)、血清白蛋白、前白蛋白,评价早期静脉营养的安全性和有效性。结果多发伤患者早期DO_2为(798±132)ml／min、VO_2为(281+60)ml／min,O_2ER为(36±8)％；DO_2、VO_2均显著高于正常值(P＜0.05),O_2ER与正常值相比差异无显著性；多发伤患者TNFα、IL-1β、IL-6分别为(127±26)、(193±62)、(40.6±7.7)ng／L,三者均显著高于正常对照组；DO_2与TNFα存在正相关(r=0.67)。早期静脉营养对血糖、甘油三脂水平无显著影响,不降低氧合指数。与对照组相比连续5天的TPN能显著提高血清前白蛋白水平[TPN组(0.15±0.03)g／L对照组(0.12±0.03)g／L,P＜0.05]。结论多发伤患者早期存在高代谢,有细胞因子的过度分泌,两者间存在一定联系。多发伤患者早期静脉营养是安全、有效的。

To investigate the metabolic characteristics of total parenteral nutrition （PN） in the early stage after multiple trauma and to evaluate its safety and effectiveness. Methods Twelve multiple trauma patients were surgically placed with Swan-Ganz catheter 24 hrs after trauma to measure the oxygen delivery （DO2）, oxygen consumption （VO2）, and oxygen extraction ratio （O2ER）, so as to estimate the metabolic rate. Serum tumor necrosis factor α （TNFα）, interleukin-1β （IL-1β）, and interleukin-6 （IL-6） were also measured. Relationship among DO2, VO2, O2ER and TNFα, IL-1β, IL-6 was analyzed. Patients were given TPN （include fat emulsion） 48 hrs after trauma. Serum glucose, triglyceride, oxygen index （PaO2/FiO2）, albumin, and prealbumin were measured to assess the safety and advantage of PN in the early stage after trauma. Results DO2 and VO2 significantly increased compared with the normal data （P 〈 0.05）, and serum TNFα, IL-1β and IL-6 increased significantly compared with uninjured controls （P 〈 0.01）. Highly positive correlation existed between DO2 and serum TNF （r = 0.67）. Serum glucose and triglyceride levels had no significant difference before and after TPN. Decrease of oxygen index was not significant. Five day TPN alone significantly increased serum PA compared with non- TPN controls （P〈 0.05）. Conclusion PN is safe and effective in the early stage after multiple trauma.