早期肠内营养对重症脓毒症患者免疫调节与预后的影响

Effect of early enteral nutrition on immune regulation and prognosis in patients with severe sepsis

目的探讨重症脓毒症患者采用早期肠内营养治疗的临床效果。方法本研究共纳入2022年9月至2024年1月南阳市第一人民医院(南阳市脓毒症转换重点实验室)收治的86例重症脓毒症患者进行回顾性分析,将所有患者按照进行肠内营养的时机分为研究组43例和对照组43例。两组患者均接受肠内营养治疗,在入院24 h内留置胃管,其中研究组患者在入院24 h内接受肠内营养治疗,对照组患者在入院48~72 h内接受肠内营养治疗。研究组中,男24例,女19例;年龄(64.32±15.21)岁;急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分(19.85±4.10)分;感染部位:呼吸道32例,泌尿道6例,皮肤3例,其他2例。对照组中,男25例,女18例;年龄(64.17±14.89)岁;APACHEⅡ评分(20.06±3.87)分;感染部位:呼吸道33例,泌尿道7例,皮肤2例,其他1例。对两组患者治疗第1天、第7天肠黏膜屏障指标、炎症反应相关指标及免疫功能相关指标进行对比,对两组患者入住ICU时长、28 d病死率进行对比。采用t检验、χ^(2)检验、Fisher确切概率法。结果治疗第7天,两组患者肠黏膜屏障相关指标水平均较治疗第1天下降,且研究组患者治疗第7天上述指标水平均低于对照组(均P<0.05)。治疗第7天,两组患者免疫球蛋白A(IgA)、IgG、CD4^(+)、CD4^(+)/CD8^(+)比值均较治疗第1天上升,且研究组患者上述指标水平均高于对照组(均P<0.05)。治疗第7天,两组患者白细胞计数(WBC)、C-反应蛋白(CRP)、降钙素原(PCT)水平均较治疗第1天下降,且研究组上述指标水平均低于对照组(均P<0.05)。研究组患者ICU入住时长较对照组短[(11.32±4.50)d比(15.02±3.78)d](P<0.05);研究组患者28 d病死率较对照组低[2.33%(1/43)比4.71%(2/43)],但差异无统计学意义(P>0.05)。结论相较于延迟肠内营养,早期肠内营养用于重症脓毒症患者,可对肠道微循环起到改善作用,有助于提升机体免疫功能水平,减轻炎症反应,改善预后。

Objective To investigate the clinical effect of early enteral nutrition on patients with severe sepsis.Methods A total of 86 patients with severe sepsis admitted to Nanyang First People's Hospital(Nanyang Key Laboratory of Sepsis Transformation)from September 2022 to January 2024 were included in this study for retrospective analysis.All patients were divided into a study group(43 cases)and a control group(43 cases)according to the timing of enteral nutrition.Both groups received enteral nutrition therapy,and gastric tubes were placed within 24 h after admission.The patients in the study group received enteral nutrition therapy within 24 h after admission,and the patients in the control group received enteral nutrition therapy within 48-72 h after admission.In the study group,there were 24 males and 19 females,aged(64.32±15.21)years,the Acute Physiology and Chronic Health EvaluationⅡ(APACHEⅡ)score was(19.85±4.10)points,and the sites of infection were at respiratory tract in 32 cases,urinary tract in 6 cases,skin in 3 cases,and other in 2 cases.In the control group,there were 25 males and 18 females,aged(64.17±14.89)years,the APACHEⅡscore was(20.06±3.87)points,and the sites of infection were at respiratory tract in 33 cases,urinary tract in 7 cases,skin in 2 cases,and other in 1 case.Intestinal mucosal barrier indexes,inflammatory response related indexes,and immune function related indexes were compared between the two groups on day 1 and day 7 after treatment,and the length of ICU stay and 28-day mortality were compared between the two groups.t test,χ^(2)test,and Fisher exact probability method were used.Results On day 7 after treatment,the levels of intestinal mucosal barrier related indexes in both groups were decreased compared with those on day 1 after treatment,and the levels of these indexes in the study group were lower than those in the control group(all P<0.05).On day 7 after treatment,the levels of immunoglobulin A(IgA),IgG,CD4^(+),and CD4^(+)/CD8^(+)in both groups were increased compared with those on day 1 after treatment,and the levels of the above indexes in the study group were higher than those in the control group(all P<0.05).On day 7 after treatment,the levels of white blood cell count(WBC),C-reactive protein(CRP),and procalcitonin(PCT)in both groups were decreased compared with those on day 1 after treatment,and the levels of the above indexes in the study group were lower than those in the control group(all P<0.05).The length of ICU stay in the study group was shorter than that in the control group[(11.32±4.50)days vs.(15.02±3.78)days](P<0.05).The 28-day mortality rate of the study group was lower than that of the control group[2.33%(1/43)vs.4.71%(2/43)],but the difference was not statistically significant(P>0.05).Conclusion Compared with delayed enteral nutrition therapy,early enteral nutrition therapy applied in patients with severe sepsis can improve the intestinal microcirculation,contributes to the improvement of immune function,and can reduce the inflammatory response and improve the prognosis.