镇静治疗对特重度烧伤患者静息能量消耗的影响及能量估算公式的选择

沈涛; 张莉萍; 汪怡然; 朱志康; 韩春茂

doi:10.3760/cma.j.cn501225-20220530-00207

镇静治疗对特重度烧伤患者静息能量消耗的影响及能量估算公式的选择

doi: 10.3760/cma.j.cn501225-20220530-00207

1.
浙江大学医学院附属第二医院中医康复科，杭州　　310009
2.
浙江大学医学院附属第二医院烧伤与创面修复科，杭州　　310009

基金项目:

浙江省急危重症临床医学研究中心建设项目 2021E50004

详细信息

通讯作者:
韩春茂，Email：zrssk@zju.edu.cn

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出版历程
- 收稿日期: 2022-05-30

Effect of sedation on resting energy expenditure in patients with extremely severe burns and the choice of energy estimation formula

1.
Rehabilitation Department of Traditional Chinese Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
2.
Department of Burn and Wound Repair, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China

Funds:

Construction Project of Clinical Medical Research Center for Acute and Critical Care of Zhejiang Province of China 2021E50004

More Information

Corresponding author: Han Chunmao, Email: zrssk@zju.edu.cn

摘要

摘要: 目的探究镇静治疗对特重度烧伤患者静息能量消耗（REE）的影响以及该治疗过程中REE估算公式的选择。方法采用回顾性非随机对照临床研究方法。2020年4月—2022年4月，浙江大学医学院附属第二医院烧伤与创面修复科收治21例符合入选标准的行机械通气治疗的特重度烧伤患者，其中男16例、女5例，年龄60（50，69）岁。对所有患者进行早期抗休克治疗、清创、植皮、营养支持等常规治疗；当患者出现明显躁动或有拔管倾向等会导致病情加重的情况时，对其进行镇静治疗。于伤后3、5、7、9、11、14 d及此后每7天对患者采用间接测热法进行REE测量直至患者成功脱离呼吸机或死亡，共进行99次测量，其中58次为在患者镇静状态下测量，41次为在患者非镇静状态下测量。统计测量REE当日（以下简称测量当日）患者的年龄、体重、体表面积、残余创面面积、伤后天数，采用重症监护病房常规REE估算公式Thumb公式及烧伤专用REE估算公式第三军医大学公式、彭曦团队线性公式、Hangang公式计算测量当日患者的REE。采用Mann-Whitney U检验及独立样本t检验比较镇静状态与非镇静状态下患者测量当日的临床资料、REE的测量值及公式计算值的差异。使用Wilcoxon符号秩和检验比较镇静状态下REE公式计算值与REE测量值的差异（反映总体一致性），采用Bland-Altman法评估镇静状态下REE公式计算值与REE测量值的个体一致性并计算在REE测量值±10%范围内的REE公式计算值的占比（以下称为准确率），采用均方根误差（RMSE）评估REE公式计算值相对REE测量值的准确性。结果与非镇静状态相比，镇静状态下测量当日患者年龄与伤后天数均无明显变化（P>0.05），但体重更重（Z=-3.58，P<0.01），体表面积与残余创面面积均更大（Z值分别为-2.99、-4.52，P<0.01）。镇静状态与非镇静状态下，患者REE测量值相近（P>0.05）；与非镇静状态相比，镇静状态下采用Thumb公式、第三军医大学公式、彭曦团队线性公式、Hangang公式计算的测量当日患者REE值均明显升高（Z值分别为-3.58、-5.70，t值分别为-3.58、-2.74，P<0.01）。镇静状态下，与REE测量值比较，采用Thumb公式、第三军医大学公式、Hangang公式计算的测量当日患者REE值均有明显变化（Z值分别为-2.13、-5.67、-3.09，P<0.05或P<0.01），采用彭曦团队线性公式计算的测量当日患者REE值无明显变化（P>0.05）。Bland-Altman法分析显示，在镇静状态下，相对REE测量值而言，各公式计算值个体一致性良好，Thumb公式与Hangang公式均明显低估了患者的REE值（公式计算值-测量值的差值平均值分别为-1 463、-1 717 kJ/d，95%置信区间分别为-2 491~-434、-2 744~-687 kJ/d），但个体差异性均较小；第三军医大学公式明显高估了患者的REE值（公式计算值-测量值的差值平均值为3 530 kJ/d，95%置信区间为2 521~4 539 kJ/d），但个体差异性较小；彭曦团队线性公式没有明显高估患者的REE值（公式计算值-测量值差值平均值为294 kJ/d，95%置信区间为-907~1 496 kJ/d），但其差值标准差达4 568 kJ/d，个体差异性较大。在镇静状态下，相对REE测量值，采用Thumb公式、第三军医大学公式、彭曦团队线性公式、Hangang公式计算的REE值的准确率分别为25.9%（15/58）、15.5%（9/58）、10.3%（6/58）、15.5%（9/58），RMSE分别为4 143.6、5 189.1、4 538.6、4 239.8 kJ/d。结论镇静治疗会导致行机械通气治疗的特重度烧伤患者的REE显著下降。当无法通过间接测热法定期监测REE以确定营养支持方案时，对进行镇静治疗的特重度烧伤患者，可优先考虑使用Thumb公式估算REE。
- 烧伤 /
- 量热法，间接 /
- 营养支持 /
- 镇静 /
- 静息能量消耗
Abstract: Objective To investigate the effect of sedation on resting energy expenditure (REE) in patients with extremely severe burns and the choice of REE estimation formula during the treatment. Methods A retrospective non-randomized controlled clinical study was conducted. From April 2020 to April 2022, 21 patients with extremely severe burns who met the inclusion criteria and underwent mechanical ventilation treatment were admitted to the Department of Burn and Wound Repair of Second Affiliated Hospital of Zhejiang University School of Medicine, including 16 males and 5 females, aged 60 (50, 69) years. Early anti-shock therapy, debridement, skin transplantation, nutritional support, and other conventional treatments were applied to all patients. Patients were sedated when they had obvious agitation or a tendency to extubate, which might lead to aggravation of the disease. REE measurement was performed on patients using indirect calorimetry on post-injury day 3, 5, 7, 9, 11, 14 and every 7 days thereafter until the patient died or being successfully weaned from ventilator. Totally 99 times of measurements were carried out, of which 58 times were measured in the sedated state of patients, and 41 times were measured in the non-sedated state of patients. The age, weight, body surface area, residual wound area, post-injury days of patients were recorded on the day when REE was measured (hereinafter briefly referred to as the measurement day). The REE on the measurement day was calculated with intensive care unit conventional REE estimation formula Thumb formula and special REE estimation formulas for burns including the Third Military Medical University formula, the Peng Xi team's linear formula, Hangang formula. The differences between the sedated state and the non-sedated state in the clinical materials, measured and formula calculated values of REE of patients on the measurement day were compared by Mann-Whitney U test and independent sample t test. The differences between the REE formula calculated values and the REE measured value (reflecting the overall consistency) in the sedated state were compared by Wilcoxon signed rank-sum test. The Bland-Altman method was used to assess the individual consistency between the REE formula calculated value and the REE measured value in the sedated state, and to calculate the proportion of the REE formula calculated value within the range of ±10% of the REE measured value (hereinafter referred to as the accuracy rate). Root mean square error (RMSE) was used to evaluate the accuracy of the REE formula calculated value relative to the REE measured value. Results Compared with those in the non-sedated state, there was no statistically significant change in patient's age or post-injury days on the measurement day in the sedated state (P>0.05), but the weight was heavier (Z=-3.58, P<0.01), and both the body surface area and the residual wound area were larger (with Z values of -2.99 and -4.52, respectively, P<0.01). Between the sedated state and the non-sedated state, the REE measured values of patients were similar (P>0.05). Compared with those in the non-sedated state, the REE values of patients calculated by Thumb formula, the Third Military Medical University formula, the Peng Xi team's linear formula, and Hangang formula on the measurement day in the sedated state were significantly increased (with Z values of -3.58 and -5.70, t values of -3.58 and -2.74, respectively, P<0.01). In the sedated state, compared with the REE measured value, there were statistically significant changes in REE values of patients calculated by Thumb formula, the Third Military Medical University formula, and Hangang formula on the measurement day (with Z values of -2.13, -5.67, and -3.09, respectively, P<0.05 or P<0.01), while the REE value of patients calculated by the Peng Xi team's linear formula on the measurement day did not change significantly(P>0.05). The analysis of the Bland-Altman method showed that in the sedated state, compared with the REE measured value, the individual consistency of the calculated value of each formula was good; Thumb formula and Hangang formula significantly underestimated the patients' REE value (with the average value of the difference between the formula calculated value and the measured value of -1 463 and -1 717 kJ/d, the 95% confidence interval of -2 491 to -434 and -2 744 to -687 kJ/d, respectively), but the individual differences were small; the Third Military Medical University formula significantly overestimated the patients' REE value (with the average value of the difference between the formula calculated value and the measured value of 3 530 kJ/d, the 95% confidence interval of 2 521 to 4 539 kJ/d), but the individual difference was small; the Peng Xi team's linear formula did not significantly overestimate the patients' REE value (with the average value of the difference between the formula calculated value and the measured value of 294 kJ/d, the 95% confidence interval of -907 to 1 496 kJ/d), while the difference standard deviation was 4 568 kJ/d, which showed a large individual difference. In the sedated state, relative to the REE measured value, the accuracy rates of REE values calculated by Thumb formula, the Third Military Medical University formula, the Peng Xi team's linear formula, and Hangang formula were 25.9% (15/58), 15.5% (9/58), 10.3% (6/58), and 15.5% (9/58), respectively, and RMSE values were 4 143.6, 5 189.1, 4 538.6, and 4 239.8 kJ/d, respectively. Conclusions Sedative therapy leads to a significant decrease in REE in patients with extremely severe burns undergoing mechanical ventilation treatment. When REE cannot be regularly monitored by indirect calorimetry to determine nutritional support regimens, patients with extremely severe burns undergoing sedation may be prioritized to estimate REE using Thumb formula.
- Burns /
- Calorimetry, indirect /
- Nutritional support /
- Sedation /
- Resting energy expenditure
沈涛、张莉萍：研究操作与数据采集以及论文撰写；汪怡然：数据整理、统计分析；朱志康、韩春茂：研究指导、论文修改

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1 镇静状态下21例特重度烧伤患者58次静息能量消耗公式计算值与间接测热法测量值的个体一致性的Bland-Altman散点图。1A.Thumb公式计算值与测量值比较，个体差异性较小；1B.第三军医大学公式计算值与测量值比较，个体差异性较小；1C.彭曦团队线性公式计算值与测量值比较，个体差异性较大；1D.Hangang公式计算值与测量值比较，个体差异性较小

注：差值=公式计算值-测量值，均值=（测量值+公式计算值）÷2；蓝线代表绝对偏差(测量值与公式计算值的平均差异)，最上、最下水平线代表95%的一致性极限(平均差异±1.96×标准差)，紫色虚线表示差值的趋势线，两侧橙线为趋势线的标准差；以落在差值0上下10%的数据为准确数据；图1A、1B、1D横坐标下a、b、c、d均分别指示5 000、10 000、15 000、20 000，图1B横坐标下e指示25 000，图1C横坐标下a、b、c、d、e分别指示0、5 000、10 000、15 000、20 000

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表1 4种REE估算公式

公式名称	公式内容
Thumb公式	REE=25×体重
第三军医大学公式	REE=1 000×体表面积+25×烧伤总面积
彭曦团队线性公式烧伤总面积>70%TBSA且伤后天数>14 d 烧伤总面积>70%TBSA且伤后天数≤14 d 烧伤总面积≤70%TBSA且伤后天数>14 d 烧伤总面积≤70%TBSA且伤后天数≤14 d	REE=［（1 460.568 9+1.344 0×烧伤总面积+11.939 0×伤后天数）］×体表面积 REE=［（1 346.157 8-0.404 0×烧伤总面积+32.181 9×伤后天数）］×体表面积 REE=［（1 326.428 6+9.882 3×烧伤总面积-13.829 4×伤后天数）］×体表面积 REE=［（1 122.434 5+6.863 4×烧伤总面积+9.115 6×伤后天数）］×体表面积
Hangang公式	REE=867.542-5.546×年龄+13.297×体重+4.879×烧伤总面积-9.844×伤后天数+500.612×呼吸机使用情况（使用=1，未使用=0）
注：表中公式翻译自文献［4, 5, 6, 7］；REE为静息能量消耗，TBSA为体表总面积；体重单位为kg，烧伤总面积单位为%TBSA，体表面积单位为㎡

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表2 镇静状态与非镇静状态下采用间接测热法测量REE当日21例特重度烧伤患者临床特征比较

镇静情况	测量次数	年龄［岁，M（Q ₁，Q ₃）］	体重［kg，M（Q ₁，Q ₃）］	体表面积［㎡，M（Q ₁，Q ₃）］	残余创面面积［%TBSA，M（Q ₁，Q ₃）］	伤后天数（d， x ¯ ± s ）
镇静状态	58	66（50，75）	85.0（71.5，98.0）	2.0（1.8，2.1）	55.0（34.3，71.8）	37±20
非镇静状态	41	60（55，66）	73.0（60.0，85.0）	1.8（1.6，2.0）	25.0（18.0，37.5）	33±18
统计量值		Z=-1.23	Z=-3.58	Z=-2.99	Z=-4.52	t=-0.93
P值		0.218	<0.001	0.003	<0.001	0.357
注：REE为静息能量消耗，TBSA为体表总面积

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表3 镇静状态与非镇静状态下21例特重度烧伤患者REE的测量值及测量REE当日公式计算值比较(kJ/d)

镇静情况	测量次数	测量值［M（Q ₁，Q ₃）］	Thumb公式计算值［M（Q ₁，Q ₃）］	第三军医大学公式计算值［M（Q ₁，Q ₃）］	彭曦团队线性公式计算值（ x ¯ ± s ）	Hangang公式计算值（ x ¯ ± s ）
镇静状态	58	9 091.9 （7 337.2，11 372.9）	8 882.5 （7 417.8，10 241.0）^a	13 358.4 （11 563.1，15 612.3）^b	10 286±3 433	8 276±1 083^b
非镇静状态	41	8 426.9 （7 559.5，10 953.7）	7 628.5 （6 270.0，8 882.5）	9 993.1 （9 090.7，11 286.4）	8 227±2 287	7 616±1 293
统计量值		Z=-0.58	Z=-3.58	Z=-5.70	t=-3.58	t=-2.74
P值		0.565	<0.001	<0.001	<0.001	0.007
注：REE为静息能量消耗，采用间接测热法测量；与镇静状态下测量值比较，^a P<0.05,^b P<0.01

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表4 镇静状态下21例特重度烧伤患者58次REE公式计算值相对REE测量值的一致性与准确性分析

公式名称	差值平均值（kJ/d）	标准差（kJ/d）	95%置信区间（kJ/d）	准确情况［次（%）］	均方根误差（kJ/d）
Thumb公式	-1 463	3 911	-2 491~-434	15（25.9）	4 143.6
第三军医大学公式	3 530	504	2 521~4 539	9（15.5）	5 189.1
彭曦团队线性公式	294	4 568	-907~1 496	6（10.3）	4 538.6
Hangang公式	-1 717	3 911	-2 744~-687	9（15.5）	4 239.8
注：REE为静息能量消耗，采用间接测热法测量；差值为各REE公式计算值与REE测量值之差；准确率为在REE测量值±10%范围内的REE公式计算值的占比