重型颅脑损伤患者早期肠内营养支持中不同营养剂对临床预后、营养状态、炎症指标及胃肠耐受性的影响

Influence of early enteral nutrition support therapy with different nutrients on clinical prognosis,nutritional status,inflammation indicators and gastrointestinal tolerance in patients with severe traumatic brain injury

目的探讨重型颅脑损伤(sTBI)患者早期肠内营养(EN)支持中不同营养剂对临床预后、营养状态、炎症指标及胃肠耐受性的影响。方法将162例sTBI患者随机分为A组、B组和C组,每组54例。三组均在转入重症监护室(ICU)后48h内开始EN,A使用百普力,B组使用瑞能,C组使用瑞能加益生菌。对比三组的胃肠道耐受性、并发症发生情况、平均血糖值(MBG)和血糖变异系数(GluCV),治疗前后测定营养指标[血清白蛋白(Alb)、总蛋白(PA)、血红蛋白(Hb)、肱三头肌皮褶厚度(TSF)、体重指数(BMI)]、炎症指标[C反应蛋白(CRP)、降钙素原(PCT)、肿瘤坏死因子α(TNF-α)],随访90d根据格拉斯哥预后评分(GOS)评价临床预后。结果三组间治疗前后TSF、BMI比较,差异无统计学意义(P>0.05);治疗10d后,C组的血清Alb、PA、Hb高于A、B组,急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分低于A、B组(P<0.05),但A组和B组间比较差异无统计学意义(P>0.05)。B组、C组的MBG和GluCV均低于A组(P<0.05),但B组和C组间比较差异无统计学意义(P>0.05)。治疗10d后,B组的血清CRP、PCT水平均低于A组,C组的血清CRP、PCT和TNF-α水平均低于A、B组(P<0.05)。B组的消化道不良反率高于A组和C组(P<0.05),A组和C组比较差异无统计学意义(P>0.05)。C组院内感染率为5.56%,低于A组的18.52%和B组的16.67%(P<0.05),但A组和B组间比较,差异无统计学意义(P>0.05)。三组预后良好率比较(80.39%、76.92%、86.54%),差异无统计学意义(P>0.05)。结论早期EN支持中应用短肽EN制剂(百普力)与整蛋白EN制剂(瑞能)均能够改善sTBI患者的营养状况,百普力具有更好的胃肠耐受性但血糖波动较大,而瑞能联合益生菌的肠内免疫微生态营养支持更有利于抑制炎症反应、降低血糖波动、提高胃肠耐受性并降低院内感染风险,有利于改善临床转归。

Objective To investigate the early enteral nutrition(EN)support therapy with different nutrients on clinical prognosis,nutritional status,inflammation indicators and gastrointestinal tolerance in patients with severe traumatic brain injury(sTBI).Methods 162 sTBI patients were randomly divided into group A,group B and group C,with 54 cases in each group.All three groups started EN within 48 hours after being transferred to the intensive care unit(ICU).A was used with Baipuli,group B was with Reno,group C was with Reno plus probiotics.The gastrointestinal tolerance,the occurrence of complications,mean blood glucose(MBG)and blood glucose coefficient of variation(GluCV)of the three groups were compared,the nutritional indicators[serum albumin(Alb),total protein(PA),hemoglobin)(Hb),triceps skinfold thickness(TSF),body mass index(BMI)],inflammation indicators[C reactive protein(CRP),procalcitonin(PCT),tumor necrosis factor alpha(TNF-α)]were determined before and after treatment.After 90 days of follow-up,the clinical prognosis was evaluated according to the Glasgow Prognostic Score(GOS).Results There was no significant difference in TSF and BMI between the three groups before and after treatment(P>0.05);after 10 days of treatment,the serum Alb,PA,and Hb in group C were higher than those in groups A and B,acute physiology and chronic health status scoring system scoreⅡ(APACHEⅡ)was lower than that of groups A and B(P<0.05),but there was no statistically significant difference between groups A and B(P>0.05).The MBG and GluCV of group B and group C were lower than that of group A(P<0.05),but there was no significant difference between group B and group C(P>0.05).After 10 days of treatment,the serum CRP and PCT levels in group B were lower than those in group A,the serum CRP,PCT and TNF-αlevels in group C were lower than group A and B(P<0.05).The adverse reaction rate of gastrointestinal tract in group B was higher than that in groups A and C(P<0.05),but there was no statistically significant difference between groups A and C(P>0.05).The nosocomial infection rate in group C was 5.56%,lower than 18.52%in group A and 16.67%in group B(P<0.05),but there was no statistically significant difference between group A and group B(P>0.05).The difference of good prognosis rates of the three groups(80.39%,76.92%,86.54%)was not statistically significant(P>0.05).Conclusions The application of short peptide EN preparation(Baipuli)and integrin EN preparation(Reno)in early EN support can improve the nutritional status of patients with sTBI.Baipuli has better gastrointestinal tolerance but large fluctuations in blood glucose,intestinal immune microecological nutritional support of Reno combined with probiotics is more conducive to suppressing inflammatory response,reducing blood sugar fluctuations,improving gastrointestinal tolerance and reducing the risk of nosocomial infection,which is conducive to improving clinical outcomes.