等热量不同肠内营养制剂对机械通气患者血糖的影响

Effects of preparations with same calorie but different in enteral nutrition on blood glucose in patients with mechanical ventilation

目的 观察等热量不同肠内营养（EN）制剂对机械通气患者血糖的影响.方法 选取2015年1月至2017年1月入住浙江省台州市中西医结合医院重症医学科（ICU）且接受机械通气的60例危重患者为研究对象,按随机数字表法将患者分为对照组和研究组,每组30例.对照组给予EN混悬液能全力治疗,研究组给予EN乳剂瑞代治疗,两组患者均在第1天给予1/3标准热量供给量,若无不适感,第2天给予1/2标准热量供给量,第3~10天内给予全量,直到达到完全肠内营养（TEN）.观察两组患者EN支持前及支持后10 d空腹血糖（FBG）、餐后2 h血糖（2 h PBG）及糖化血红蛋白（HbA1）水平,分析两组胃肠耐受情况、胰岛素用量、炎症相关指标、呼吸机相关性肺炎（VAP）发生率及病死率等情况.结果 与EN前比较,两组患者EN后10 d FBG及2 h PBG水平均下降,胰岛素用量减少,且研究组的下降程度较对照组更显著〔FBG（mmol/L）：8.03±1.69比8.87±1.75,2 h PBG（mmol/L）：8.25±1.98比10.43±2.34,胰岛素用量（U/d）：38.02±3.24比40.87±3.48,均P〈0.05〕,而两组HbA1比较差异无统计学意义〔（7.36±1.53）%比（7.37±1.29）%,P〉0.05〕.研究组胃肠不耐受发生率低于对照组〔6.67%（2/30）比10.0%（3/30）〕,但两组比较差异无统计学意义（P〉0.05）.与EN前比较,两组EN后10 dγ-干扰素（IFN-γ）水平均明显升高,肿瘤坏死因子-α（TNF-α）、白细胞介素（IL-6及IL-8）水平均明显下降（均P〈0.05）,但两组上述指标比较差异均无统计学意义（均P〉0.05）;两组治疗期间VAP发生率及病死率均较低,差异均无统计学意义（均P〉0.05）.结论 瑞代对机械通气患者的血糖控制情况优于能全力,可减少患者胰岛素的临床使用量,降低炎症因子水平,利于改善患者预后.

Objective To investigate the effects of same calorie intake of different enteral nutrition （EN） on blood glucose in patients with mechanical ventilation.Methods A total of 60 critically ill patients who were admitted to the Department of Intensive Care Unit （ICU） of Taizhou Combined Traditional Chinese and Western Medicine Hospital and received mechanical ventilation from January 2015 to January 2017 were selected. According to the random number table method, the patients were divided into a control group and a study group, 30cases in each group. The patients in the control group were given EN suspension （nutrison fibre）, patients in the study group received EN emulsion （fresubin diabetes）, on the first day, 1/3 standard calorie was supplied, if the patient had no any discomfort, on the second day 1/2 standard heat was given, from the third day to the tenth day they took the full amount and achieved complete EN （TEN）.The fasting blood glucose （FBG）, 2 hours postprandial blood glucose （2 h PBG） and glycated hemoglobin （HbA1） level before and after the EN for 10 days were observed, the gastrointestinal tolerance, dosage of insulin, inflammation related indexes, the incidence of ventilator associated pneumonia （VAP） and fatality were analyzed in the two groups.Results Compared with those before EN support, the FBG and 2 h PBG were decreased after the support for 10 days in both groups, the dosage of insulin used was decreased, and the degrees of decrease were more marked in the study group than those in the control group [FBG （mmol/L）： 8.03±1.69 vs. 8.87±1.75, 2 h PBG （mmol/L）： 8.25±1.98 vs. 10.43±2.34, dosage of insulin （U/d）： 38.02±3.24 vs. 40.87±3.48, allP 〈 0.05], but there was no statistical significant difference in HbA1 level between the two groups [（7.36±1.53）% vs. （7.37±1.29）%,P 〉 0.05]. The incidence of gastrointestinal intolerance was lower in study group than that in control group [6.67% （2/30） vs. 10.0% （3/30）], but there was no statistical significant difference between the two groups （P 〉 0.05）. Compared with those before EN support, the levels of γ-interferon （IFN-γ） were significantly increased （P 〈 0.05）, while the tumor necrosis factor-α （TNF-α）, interleukins （IL-6 and IL-8） levels were significantly decreased after 10 days of EN support, but no statistical significant differences were found （allP 〉 0.05） between the two groups. During the treatment in the two groups, the incidence of VAP and mortality were relatively low, and there were no statistical significant differences were seen between the two groups （bothP 〉 0.05）.Conclusions The blood glucose control of fresubin diabetes in patients with mechanical ventilation is superior to that of nutrison fibre, fresubin diabetes can reduce the dosage of insulin, decrease the levels of inflammatory factors and conducive to the prognosis of the patients.