应用代谢车监测ICU患者REE变化规律并指导营养支持的前瞻性研究

Changing laws of rest energy expenditure in critically ill patients and the intervention effect for nutritional support:a prospective study

目的探讨应用代谢车监测重症医学科(ICU)患者静息能量消耗(REE)变化规律并以其指导营养支持的价值.方法采用前瞻性随机对照研究,选择2016年12月至2017年6月蚌埠医学院第一附属医院ICU收治的预计能够持续肠内和(或)肠外营养且ICU住院时间≥7 d的58例重症患者.按随机数字表法将患者分为REE组(n=29)和HBREE组(n=29),于入ICU第1~7天(D1~D7),分别应用能量代谢车和Harris-Benedict(HB)公式监测REE,分别得出REE值和HBREE值;并分别以REE值和HBREE值为指导进行营养支持.记录D1、D3、D5、D7和出科前的血红蛋白(Hb)、白蛋白(Alb)、前白蛋白(PA)、C-反应蛋白(CRP)、氧合指数(OI)等营养相关指标,观察两组血管活性药物和胰岛素使用情况、机械通气时间、ICU住院时间和28 d病死率.结果①患者刚入科后,REE水平均较高,随着住院时间延长逐渐下降,D2、D3时差异均有统计学意义(kJ/d:7088.38±559.41、6751.34±558.72比7553.44±645.55,均P<0.05);从D5开始,能量消耗进入相对稳定的状态,呈现出前高后低、快速下降-缓慢下降-到达稳态的变化规律,中间还有2 d的平台期.D1、D2时REE值明显高于HBREE值(kJ/d:7553.44±645.55比6759.21±668.14,7088.38±559.41比6759.21±668.14,均P<0.01);D3、D4时REE值与HBREE值基本持平(kJ/d:6751.34±558.72比6759.21±668.14,6568.03±760.19比6759.21±668.14,均P>0.05);随后时间,REE值均明显低于HBREE值(kJ/d:6089.55±560.70比6759.21±668.14,5992.55±501.82比6759.21±668.14,5860.84±577.59比6759.21±668.14,均P<0.01).②启动营养支持后,Hb在营养支持前期上升较慢,REE组在前3 d、HBREE组在前7 d上升均不明显;REE组D5后明显升高,组间比较,HBREE组Hb上升更慢一些,但两组在出科前均升到接近正常水平,且REE组与HBREE组比较差异无统计学意义(g/L:113.75±17.28比110.86±15.35,P>0.05).PA和OI两组均上升较快,D3时即有升高,且REE组日均升高幅度较HBREE组明显〔如D3,PA(mg/L):110.38±27.65比96.28±18.06,OI(mmHg,1 mmHg=0.133 kPa):259.29±49.36比231.74±28.02,均P<0.05〕.REE组Alb和CRP于D3时开始改善,但HBREE组要延迟到D5才有好转.同期比较,REE组好于HBREE组,但出科前HBREE组PA、CRP和OI较REE组差〔PA(mg/L):252.28±56.94比295.86±57.56,CRP(mg/L):73.14±17.63比56.52±14.91,OI(mmHg):353.59±70.36比417.52±71.58,均P<0.01〕.③REE组血管活性药物使用天数较HBREE组少(d:2.26±0.82比2.95±1.22,P<0.05),但两组平均均未超过3 d;HBREE组胰岛素用量多于REE组(U:101.97±21.05比84.59±22.21,P<0.01),机械通气时间和ICU住院时间较REE组明显延长(h:113.07±25.96比93.41±27.25,d:10.41±3.11比8.45±2.44,均P<0.01);而REE组和HBREE组28 d病死率差异无统计学意义(17.24%比24.14%,P>0.05).结论代谢车监测能够更为精确地掌握重症患者REE的变化趋势,以REE值为指导进行营养支持可以使相关营养指标尽快趋好,减少胰岛素用量,缩短血管活性药物使用时间、ICU住院时间和机械通气时间,但不能改善28 d病死率.

Objective To investigate the changing laws of rest energy expenditure(REE)in intensive care unit(ICU)patients and the intervention effect for nutritional support.Methods A prospective randomized control trial was conducted.Fifty-eight critically ill patients who were expected to be able to receive sustained enteral and(or)parenteral nutrition for more than 7 days admitted to ICU of the First Affiliated Hospital of Bengbu Medical College from December 2016 to June 2017 were enrolled.The patients were divided into REE group(n=29)and HBREE group(n=29)according to the random number table.On the 1st to 7th day after ICU admission,the indirect calorimetry and the Harris-Benedict(HB)formula were used to obtain the REE and HBREE values,and nutritional support was given according to REE and HBREE values respectively.The data of hemoglobin(Hb),albumin(Alb),prealbumin(PA),C-reactive protein(CRP),oxygenation index(OI)on 1st,3rd,5th,7th and discharged day,and insulin dosage,vasopressor time,mechanical ventilation time,the length of ICU stay,and 28-day mortality were collected.Results①At the beginning,the REE level was high,and then decreased gradually with the extension of hospitalization,and the decline was obvious on the 2nd to 3rd day(kJ/d:7088.38±559.41,6751.34±558.72 vs.7553.44±645.55,both P<0.05),and was stable from the 5th day,the changing laws showed high at first,then the low,the first rapid decline,then the slow decline,and then reached the steady,there was a 2-day plateau in the middle.During the first 2 days,the REE value was significantly higher than the HBREE value(kJ/d:7553.44±645.55 vs.6759.21±668.14,7088.38±559.41 vs.6759.21±668.14,both P<0.01);on the 3rd,4th day,the REE value was almost the same as the HBREE value(kJ/d:6751.34±558.72 vs.6759.21±668.14,6568.03±760.19 vs.6759.21±668.14,both P>0.05).After that,the REE value was significantly lower than the HBREE value(kJ/d:6089.55±560.70 vs.6759.21±668.14,5992.55±501.82 vs.6759.21±668.14,5860.84±577.59 vs.6759.21±668.14,all P<0.01).②After the initiation of nutritional support,Hb in the REE group(the first 3 days)and HBREE group(the first 7 days)all increased slowly in the early stage.It increased obviously on the 5th day in the REE group.Compared with the REE group,Hb increased more slowly in the HBREE group,however,there was no difference between the two groups at the time of discharge(g/L:113.75±17.28 vs.110.86±15.35,P>0.05).PA and OI all enhanced significantly on the 3rd day since the nutritional support was initiated,but the daily increase of the REE group was significantly higher than that of the HBREE group[3rd day,PA(mg/L):110.38±27.65 vs.96.28±18.06,OI(mmHg,1 mmHg=0.133 kPa):259.29±49.36 vs.231.74±28.02,both P<0.05].The Alb and CRP in the REE group began to improve on the 3rd day,while the index in the HBREE group was delayed on the 5th day,overall,at the time of discharge,the PA,CRP and OI were lower in the HBREE group than in the REE group[PA(mg/L):252.28±56.94 vs.295.86±57.26,CRP(mg/L):73.14±17.63 vs.56.52±14.91,OI(mmHg):353.59±70.36 vs.417.52±71.58,all P<0.01].③The vasopressor was used in both groups for less than 3 days,but the REE group was shorter(days:2.26±0.82 vs.2.95±1.22,P<0.05),the insulin dosage in the HBREE group was much more than that in the REE group(U:101.97±21.05 vs.84.59±22.21,P<0.01);compared with the REE group,the time of mechanical ventilation and the length of ICU stay in the HBREE group were longer(hours:113.07±25.96 vs.93.41±27.25,days:10.41±3.11 vs.8.45±2.44,both P<0.01).There was no significant difference in the 28-day mortality between the REE group and HBREE group(17.24%vs.24.14%,P>0.05).Conclusions Indirect calorimetry can more accurately grasp the changing laws of REE in critically ill patients.Nutritional support with REE value can make relevant nutritional indicators as good as possible,and reduce insulin dosage,shorten vasopressor use time,the length of ICU stay and mechanical ventilation time,but does not change the 28-day mortality.