早期肠内营养对危重症患者免疫状态的影响

Effect of early enteral nutrition on immune status in critically ill patients

目的探讨早期肠内营养对危重症患者免疫状态及预后的影响。方法选取2014—11～2015—12安徽医科大学第一附属医院急诊重症医学科（EICU）收治的危重症患者68例。按随机数字表法分为早期肠内营养组（EEN组）和对照组（PN＋EN组），每组各34例。EEN组采用早期肠内营养法（入住EICU24-48h内给予肠内营养），PN＋EN组按肠外、肠内序贯营养法（静脉营养5d后开始肠内营养）进行营养支持。分别比较EEN组与PN＋EN组患者治疗前与治疗后第7天血免疫球蛋白G（IGG）、免疫球蛋白A（IGA）、免疫球蛋白M（IGM）、补体C3、补体C4、CD4计数、CD8计数、肿瘤坏死因子水平（TNF—α）及皮质醇水平；同时分析比较EEN组与PN＋EN组EICU住院时间和第7、14、28天病死率。结果EEN组治疗前IGG、IGA、IGM、补体C3、补体C4、CD4计数、CD8计数低于正常平均值（P≤0．05），TNF-α水平、皮质醇水平高于正常平均值（P≤0．05）；治疗后7d，EEN组IGG、IGA、IGM、补体C3、补体C4、CD4计数、CD8计数高于治疗前（P）≤0．05），TNF-α水平、皮质醇水平低于治疗前（P≤0．05）。与PN＋EN组比较，EEN组IGG、IGA、IGM、补体C3、补体C4、CD4计数、CD8计数升高（P≤0．05），TNF-α水平、皮质醇水平降低（P≤0．05），EICU住院时间显著减少（P=0．000），且7、14、28d病死率均低于PN＋EN组，但差异无统计学意义（P值分别为0．303、0．393、0．720）。结论危重症病程早期存在免疫抑制状态，早期肠内营养有助于改善其免疫抑制状态，且与肠外肠内序贯营养治疗比较，早期肠内营养能更有效改善危重症患者疾病早期的免疫状态，并减少EICU住院时间，是临床危重症患者有效辅助治疗手段，但本研究结果未能显示其能降低危重症患者病死率。

Objective To explore the effect of early enteral nutrition on immune function and prognosis of critically ill patients. Methods From Nov. 2014 to Dec. 2015, a total of 68 critically ill patients in EICU of the First Affiliated Hospital of Anhui Medical University were analyzed. Patients were divided into enteral nutrition group （EEN group, n = 34） and control group （PN ＋ EN group, n = 34） randomly. The EEN group were given enteral nutrition support within 24 to 48 hours after EICU admission; PN ＋ EN group were given conventional nutritional support （Parenteral for 5 days then enteral sequential therapy）. The serum Immunoglohulin G （IGG）, Immunoglobulin A （IGA）, Immunoglobulin M （IGM）, complement C3, complement C4, CD4 count, CD8 count, tumor necrosis factor （TNF-α） and cortisol levels were analyzed in EEN group （0 day and the 7th day） and PN ＋ EN group （0 day and 7th day） respectively. The day of EICU stay and mortality of 7, 14 and 28 days were also compared whithin two groups. Results In EEN group, the 0 day of IGG, IGA, IGM, complement C3, complement C4, CD4 counts, CD8 counts were less than normal average level （P≤0.05）; nevertheless TNF-α and cortisol levels were higher than normal average level （P≤0.05）; the 7th day of IGG, IGA, IGM, complement C3, complement C4, CD4 counts, CD8 counts were higher than the 0 day （P≤0.05）; TNF-α levels and cortisol levels were less than the 0 day （P40.05）. Compared with the PN ＋ EN group, 7th day of EEN group IGG, IGA, IGM, complement C3, complement C4, CD4 counts, CD8 counts were higher （P≤0.05）; TNF-α and cortisol levels were less than the PN ＋ EN group （P≤0.05）. The day of EEN group EICU stay was shorter （P = 0.000）. The 7, 14,28-days mortality of EEN group was less than the PN ＋ EN group, however, no statistically significant （P = 0.303,0.393,0.720） were found. Conclusion The immunosuppression condition in critical illness appears early. Early enteral nutrition is more effective in improving early immune status of critically ill patients and reducing the days in EICU. It is benefit for clinical critically ill patients, but there is no sufficient evidence to prove that it can reduce mortality in critically ill patients.