危重症患者优化营养支持治疗的临床研究

Study of optimization nutrition support in critically ill patients

目的研究在重症监护室（ICU）住院期间第4~8天,通过给予肠内营养（EN）结合补充肠外营养（SPN）的方式提供患者接近100%的目标营养量,是否对临床预后有意义。方法将300例入ICU 3dEN提供的能量不超过目标能量的60%的危重症患者分为干预组（n=150）和对照组（n=150）,采用间接测热法反复测定营养目标量,第4~8天分别接受EN及EN结合SPN的支持治疗。结果治疗期间,干预组患者平均能量供给为28kcal·kg-1·d-1,对照组患者为20kcal·kg-1·d-1。第9~28天随访期间,干预组患者院内感染的发生率显著低于对照组（P〈0.05）,无院内感染发生患者的机械通气时间明显少于对照组（P〈0.05）;2组ICU死亡率及院内死亡率差异无统计学意义（P〉0.05）。结论通过间接测热法确定目标营养量,并在入ICU第4天开始给予EN结合SPN,可以有效减少院内感染发生率。对于ICU中单独使用EN无法达到目标营养量的患者,可作为改善临床预后的手段。

Objective To assess whether the delivery of 100% of the nutritional target from days 4to 8in the ICU with enteral nutrition plus supplemental parenteral nutrition（SPN）could optimize clinical outcome.Methods A total of 300 critically ill patients who had received less than 60% of their energy target from enteral nutrition（EN）were randomized to treatment group（n=150）and control group（n=150）.After using the stochastic indicator method after day 3of admission to the ICU,one received EN and the other received EN plus SPN during days 4to 8,then we calculated energy targets with indirect calorimetry repeatedly.ResultsThe mean energy delivery between day 4and 8 was 28kcal·kg-1·d-1 for the EN plus SPN group,compared with 20kcal·kg-1·d-1 for the EN group.Between days 9and 28,the EN plus SPN group had a lower incidence of nosocomial infection compared with EN group（P〈0.05）,the mechanical ventilation time of the patients without nosocomial infection in EN plus SPN group was significantly lower than that of the EN group（P〈0.05）.The in-hospital mortality and the in-ICU mortality were similar in the two groups（P〉0.05）.Conclusion Individually optimized nutritional supplementation with enteral nutrition plus supplemental parenteral nutrition starting 4days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient.