早期添加肠外营养对创伤患者营养摄入和预后的影响

Effects of early supplemental parenteral nutrition on nutrition intakes and clinical outcomes in trauma patients

目的观察创伤患者早期添加肠外营养（PN）后蛋白质和能量摄入的变化，及对预后的影响。方法采用回顾性对照研究方法，将195例创伤患者按伤后7d内是否添加PN分为对照组（105例）和混合营养组（90例）。比较两组的营养支持时间、14d内蛋白质和能量的摄入及临床结局的差异。结果两组患者伤情程度一致，急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、损伤严重度评分（ISS）和格拉斯哥昏迷评分（GCS）无明显差异。与对照组相比，混合营养组开始营养支持的时间（h）较早（40．0±21．0比55．1±23．5，P〈0．01），肠内营养（EN）开始时间（h）延迟（75．2±54．5比55．1±23．5，P〈0．01），48h内EN比例低（14．4％（13／90）比43．8％（46／105），P〈0．01]，恢复15服饮食的时间（d）无统计学差异（10．8±3．7比11．4±3．6，P〉0．05）。？昆合营养组在治疗3、7、14d摄入的能量（kJ）均优于对照组（3d：3981．6±2209.3比2683．2±1414．9，7d：5477．5±2008．4比3619．1±1429．9，14d：6250．2±2533．2比5199．9±1972．7，P〈0．05或P〈0．01）；两组蛋白质的摄入量（g）均较低，混合营养组治疗3d明显低于对照组（20．64-18．4比26．5±13．8P〈0．05）。与对照组比较，混合营养组住院时间（d）明显延长（73．9±62．5比50．9±33．3，P〈0．01），而病死率[4．4％（4／90）比3．8％（4／105）]、感染和急性呼吸窘迫综合征（ARDS）的发生率[8．9％（8／90）比3．8％（4／105），5．6％（5／90）比7．6％（8／105）]、机械通气时间（d：8.3±4．6比7.3±4．7）、ICU停留时间（d：17．6±13．2比14．2±113）均无统计学差异（均P〉0．05）。结论虽然创伤患者早期加用PN能增加能量摄入，但不规范的PN不能改变创伤患者的预后，并可增加住院天数。

Objective To evaluate energy and protein intake changes in early supplemental parenteral nutrition （PN） in trauma patients, and to assess its impact on clinical outcomes. Methods Clinical results of patients receiving or not receiving additional PN during the first 7 days after injury were retrospectively analyzed, with a total of 195 patients classified into two groups： control group （n =105） and mixed nutrition group （n ：90）. The time of nutrition support, intakes of protein and energy within 14 days after trauma, and clinical outcomes were compared between two groups. Results The degree of injury was comparable between two groups with no significant differences in acute physiology and chronic health evaluation II score, injury severity score （ISS） and Glasgow coma score （GCS）. Compared with the control group, the mixed nutrition group received parenteral nutritional support earlier （hours, 40.0 ± 21.0 vs. 55.1± 23.5, P〈0.01 ）, with later beginning of enteral nutrition fEN, hours, 75.2± 54.5 vs. 55.1±23.5, P〈0.01 ） and lower rate of EN in 48 hours after admission ± 14.4% （13/90） vs. 43.8% （46/105）, P〈0.01 ]. The time of restoring oral diet （days） was not different between the mixed nutrition group and control group （ 10.8± 3.7 vs. 11.4 ± 3.6, P〉0.05 ）. The energy intake （kJ） was significantly higher in the mixed nutrition group than in the control group in 3, 7, 14 days （3 days： 3981.6 ± 2209.3 vs. 2683.2 ±1414.9, 7 days： 5477.5 ± 2008.4 vs. 3619.1 ± 1429.9, 14 days： 6250.2 ± 2533.2 vs. 5199.9± 1972.7, P〈0.05 or P〈0.01）. In both groups the protein intake （g） was insufficient, and it was significantly lower in the mixed nutrition group than in the control group on day 3 （20.6 ± 18.4 vs. 26.5± 13.8, P〈0.05）. The patients in the mixed nutrition group had longer hospital stay time （days： 73.9± 62.5 vs. 50.9± 33.3, P〈0.01）. The mortality rate of mixed nutrition group and control group was 4.4% （4/90） and 3.8% （4/105） respectively, the rate of infection and acute respiratory distress syndrome （ARDS） were 8.9% （8/90） and 3.8% （4/105）, 5.6% （5/90） and 7.6% （8/105） respectively, duration of mechanical ventilation （days） was 8.3±4.6 and 7.3 ± 4.7, duration of stay in ICU （days） was 17.6 ± 13.2 and 14.2 ± 11.3 respectively, and no significant difference was found between two groups （all P〉0.05）. Conclusion Although early supplemental PN within 7 days after injury increases energy intake, PN without a standard protocol does not improve clinical outcomes and may prolong hospital stay time.