重症SARS患者的临床营养支持及血糖水平和胰岛素用量与结局的关系

Clinical Nutrition Support and Relationship of Blood Glucose Level/Insulin Administration with Outcome in Critical SARS Patients

目的观察重症SARS患者接受临床营养支持前后部分与营养有关指标的变化,并分析血糖水平/胰岛素用量与结局的关系。方法以我所英东重症医学监护中心收治的21例临床诊断重症SARS患者为研究对象,转入ICU后均给予呼吸支持及临床营养支持。经肠内营养接受的热量约4184kJ/d(1000kcal/d),蛋白质约38g/d;经肠外营养接受的热量约3347.2kJ/d(800kcal/d)。监测给予患者肠内、肠外营养支持前后的血糖、血清白蛋白、血淋巴细胞总数及谷丙转氨酶等指标的变化。所有患者均接受甲基强的松龙约200mg/d。为将血糖保持在4.44～7.78mmol/L(80～140mg/dl)的较低水平,应用静脉泵入胰岛素,记录血糖及胰岛素用量,再分析其与结局的关系。结果在发病(11.0±2.8)d后转入ICU的21例患者中,16例(76.2%)伴有营养不良。经过平均12d肠内与肠外营养支持后,患者血清白蛋白显著升高犤(28.5±2.2)g/Lvs(37.0±4.1)g/L犦(P=0.0001);血淋巴细胞总数升高犤(0.74±0.47)×109/Lvs(1.22±0.73)×109/L犦(P=0.02);血谷丙转氨酶升高的病例有所下降,但差异不显著(81.0%vs57.1%,P=0.18);生存组血糖降至较低水平犤(9.5±2.3)mmol/Lvs(6.3±1.8)mmol/L犦(P=0.0002);死亡组血糖也有下降犤(13.0±3.3)mmol/Lvs(9.5±1.3)mmol/L犦(P=0.04);

Objectives To evaluate the use of clinical nutritional support in critical SARS patients,and the relationship between blood glucose levels/insulin administration amount and outcome.Methods Twenty-one SARS patients who reached the standard of Ministry of Health' s“critical level”were transferred into our ICU in an average of11days after onset and enrolled in this clinical trial.All patients underwent respiratory support and clinical nutrition support as scheduled.For about 60kg patient per day3347.2kJ(800kcal),36g protein,and125g carbohydrate was given intravenously;4184kJ(1000kcal),38g protein,and125g carbohydrate was provided by enteral route.MCT/LCT as fat resource shared50%calories in take.All patients received similar doses of intravenous Methylprednisolone(about 200mg /d).Blood glucose,serum albumin,blood lymphocyte counts,and serum alanine transaminase(ALT)were checked on the first admission day in ICU and on the12th day after nutrition therapy was started.Insulin was started to pump in to maintain the blood glucose levels between4.44～7.78mmol/L (80～140mg /dl)when the levels exceeded normal range.Results Upon admission into ICU,all patients had poor nutrients intake for an average of11days and16patients(76.2%)were diagnosed as malnutrition.Parenteral and enteral nutrition therapy were then offered for an average of12days.On the12 th day,the serum albumin increased (28.5±2.2)g/L vs(37.0±4.1)g /L(P=0.0001)and so did the lymphocytes count (0.74±0.47)×10 9 /L vs(1.22±0.73)×10 9 /L(P=0.02).The blood glucose maintained at lower level in the surviving patients when compared with those who died(9.5±2.3)mmol/L vs(6.3±1.8)mmol/L(196±70)mg /dl vs(110±21)mg /dl(P=0.0002),and the abnormally high ALT levels presented in some of the patients decreased but not significantly(81.0%vs57.1%)(P=0.18).In order to keep blood glucose within the range4.44～7.78mmo l/L(80～140mg /dl),only18.8%of the surviving patients needed insulin intervention as opposed to80.0%of those who died(P=0.03).The amount of insulin used in the surviving group was significant lower than that in the group who died(24±2)IU/d vs(72±9)IU/d(P=0.01).Conclusions Eleven days after SARS onset,most of the critical patients presented with malnutrition.Some improved nutrition related parameters may be associated with clinical nutritional support.The surviving patients required less insulin when compared to those who died.80.0%of the patients who died need insulin versus only18.8%of the surviving patients.Due to the difficulty of SARS management ,this study was not a randomized controlled clinical trial.More clinical trials will be needed for checking the results of this investigation.