Selection and analysis of calculation formulas for resting energy expenditure in patients with severe burns based on different metabolic stages
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摘要:
目的 探究不同代谢分期下重症烧伤患者静息能量消耗（REE）值的变化及其最佳计算公式的选择。 方法 该研究为回顾性观察性研究。2020年4月—2023年12月,浙江大学医学院附属第二医院收治40例符合入选标准的重症烧伤患者,其中男32例、女8例,年龄（54±17）岁。入院后,对患者实施镇静镇痛、清创、植皮等临床常规治疗。于伤后3、5、7、9、11、14 d及此后每7天,对符合测量条件的患者采用间接测热法测量REE值（即REE测量值）,直到患者康复或死亡。在测量患者REE的当日,分别采用Milner公式、Hangang公式、第三军医大学公式、Carlson公式、彭曦团队线性公式计算REE值（即REE公式计算值）。统计测量患者REE的伤后时间,并对患者在急性抑制期、代谢高涨期、代谢平衡期、代谢重塑期的临床特征进行比较。统计患者在4个不同代谢分期下REE测量值以及其与REE公式计算值的差值的变化。相对于REE测量值,计算REE公式计算值的10%准确率及20%准确率以评估其准确性,计算REE公式计算值的绝对百分比误差（APE）以评估其偏离情况,筛选4个不同代谢分期中最接近REE测量值的代谢公式（即最佳计算公式）,进一步地探索影响不同代谢分期下最佳计算公式准确性的关键因子。 结果 测量重症烧伤患者REE的时间为伤后（40±19）d。在4个不同代谢分期中,患者在代谢重塑期的年龄最大、身高最高、体重最重、体重指数最大、体表总面积最大。患者代谢重塑期的年龄显著大于急性抑制期和代谢高涨期（t值分别为-3.02、-4.20,P值均<0.05）,体重显著重于代谢高涨期和代谢平衡期（t值分别为-1.97、-2.61,P值均<0.05）,体重指数显著高于代谢高涨期（t=-2.90,P<0.05）,体表总面积显著大于代谢高涨期和代谢平衡期（t值分别为-2.02、-2.27,P值均<0.05）。患者REE测量值在4个不同代谢分期中无显著变化（P>0.05）；除彭曦团队线性公式（P>0.05）外,在不同代谢分期中REE的Milner公式、Hangang公式、第三军医大学公式、Carlson公式计算值分别与REE测量值的差值总体比较,差异均具有统计学意义（H值分别为14.50、27.15、37.26,F=11.80,P<0.05）。10%准确率、20%准确率、APE的综合分析显示,在急性抑制期,REE的彭曦团队线性公式计算值最接近REE测量值,且REE的彭曦团队线性公式计算值的APE显著低于Milner公式、Hangang公式、第三军医大学公式、Carlson公式（t值分别为9.00、-2.10、5.95、6.68,P值均<0.05）；在代谢高涨期,REE的Hangang公式计算值最接近REE测量值,且REE的Hangang公式计算值的APE显著低于Milner公式、第三军医大学公式、Carlson公式、彭曦团队线性公式（t值分别为10.20、10.33、10.65,5.87,P值均<0.05）；在代谢平衡期,REE的Hangang公式计算值最接近REE测量值,且REE的Hangang公式计算值的APE显著低于Milner公式、第三军医大学公式、Carlson公式（t值分别为7.11、8.52、8.60,P值均<0.05）；在代谢重塑期,REE的第三军医大学公式计算值最接近REE测量值,且REE的第三军医大学公式计算值的APE显著低于Milner公式、Hangang公式、Carlson公式（t值分别5.12、2.45、6.26,P值均<0.05）。在急性抑制期,不存在影响彭曦团队线性公式计算准确性的关键因子（P>0.05）；在代谢高涨期,烧伤总面积是影响Hangang公式计算准确性的关键因子（比值比为1.00,95%置信区间为1.00~1.10,P<0.05）；在代谢平衡期,伤后天数是影响Hangang公式预测准确性的关键因子（比值比为1.30,95%置信区间为1.10~1.40,P<0.05）；在代谢重塑期,不存在影响第三军医大学公式计算准确性的关键因子（P>0.05）。 结论 推荐在急性抑制期使用彭曦团队线性公式、代谢高涨期和代谢平衡期使用Hangang公式、代谢重塑期使用第三军医大学公式对重症烧伤患者REE值进行估算,并且要保障代谢高涨期和代谢平衡期影响最佳计算公式关键因子的准确性。 Abstract:Objective To explore the changes in resting energy expenditure (REE) values in patients with severe burns under different metabolic stages and the selection of the optimal calculation formula. Methods This study was a retrospective and observational study. From April 2020 to December 2023, 40 patients (32 males and 8 females, aged (54±17) years) with severe burns meeting inclusion criteria were treated in the Second Affiliated Hospital of Zhejiang University School of Medicine. After admission, the patients were given routine clinical treatments such as sedation and analgesia, debridement, and skin grafting. At 3, 5, 7, 9, 11, 14 days after injury and every 7 days thereafter, the REE values (i.e., REE measured values) were measured by indirect calorimetry in patients with severe burns who met the measurement conditions till the patients recovered or died. On the day the patient's REE was measured, Milner, Hangang, the Third Military Medical University, Carlson, and Peng Xi team's linear formula were used respectively to calculate the REE value (i.e., REE formula values). The post-injury time to measure REE in patients was calculated, and the clinical characteristics of patients in acute inhibition, hypermetabolic, metabolic balance, and metabolic remodeling phases were compared. The REE measured values and the difference between the REE formula values and the REE measured values of patients under the 4 different metabolic phases were calculated.Compared with the REE measured values, the 10% accuracy rate and 20% accuracy rate were calculated to evaluate the accuracy of the REE formula values. The absolute percentage error (APE) of the REE formula values were calculated to evaluate the deviation. The metabolic formula (i.e., the optimal calculation formula) that was closest to the measured REE values was screened out, and further exploration was conducted to identify the key factors that affected the accuracy of the optimal calculation formula under different metabolic phases. Results The post-injury time to measure REE in patients with severe burns was (40±19) days. Comparisons showed that under the 4 different metabolic phases, patients in the metabolic remodeling phase had the highest age, height, weight, body mass index, total body surface area. Age in the metabolic remodeling phase was significantly higher than that in the acute inhibition and hypermetabolic phases (with t values of -3.02 and -4.20, respectively, with all P values <0.05), weight was significantly higher than that in the hypermetabolic and metabolic balance phases (with t values of -1.97 and -2.61, respectively, with all P values <0.05), body mass index was significantly higher than that in the hypermetabolic phase (t=-2.90, P<0.05), and total body surface area was significantly larger than that in the hypermetabolic and metabolic balance phases (with t values of -2.02 and -2.27, respectively, with all P values <0.05). There was no significant change in patients' REE measured values under the 4 different metabolic stages (P>0.05). Except for the Peng Xi team's linear formula (P>0.05), the difference between REE measured values and REE formula values calculated by using Milner, Hangang, the Third Military Medical University, and Carlson formulas respectively was statistically significant under different metabolic stages (with H values of 14.50, 27.15, and 37.26, respectively, F=11.80, P<0.05). Comprehensive analysis of 10% accuracy, 20% accuracy, and APE showed that in the acute inhibition phase, the REE formula values calculated by Peng Xi team's linear formula was closest to REE measured values, and the APE of the REE formula values calculated by Peng Xi team's linear formula was significantly lower than those calculated by Milner formula, Hangang formula, the Third Military Medical University formula, and Carlson formula (with t values of 9.00, -2.10, 5.95, and 6.68, respectively, with all P values <0.05). In the hypermetabolic phase, the REE formula values calculated by Hangang formula were closest to REE measured values, with significantly lower APE of the REE formula values calculated by Hangang formula than those calculated by using Milner formula, the Third Military Medical University formula, Carlson formula, and Peng Xi team's linear formula (with t values of 10.20, 10.33, 10.65, and 5.87, respectively, with all P values <0.05). In the metabolic balance phase, the REE formula values calculated by Hangang formula were again closest to REE measured values, with significantly lower APE of the REE formula values calculated by Hangang formula than those calculated by Milner formula, the Third Military Medical University formula, and Carlson formula (with t values of 7.11, 8.52, and 8.60, respectively, with all P values <0.05). In the metabolic remodeling phase, the REE formula values calculated by the Third Military Medical University were closest to REE measured values, with significantly lower APE of the REE formula values calculated by the Third Military Medical University formula than those calculated by Milner formula, Hangang formula, and Carlson formula (with t values of 5.12, 2.45, and 6.26, respectively, with all P values <0.05). No significant key factors affected the accuracy of the Peng Xi team's linear formula in the acute inhibition phase (P>0.05). In the hypermetabolic phase, total burn area was a key factor affecting the accuracy of Hangang formula (with odds ratio of 1.00, with 95% confidence interval of 1.00-1.10, P<0.05). In the metabolic balance phase, post-injury days was a key factor affecting the accuracy of Hangang formula (with odds ratio of 1.30, with 95% confidence interval of 1.10-1.40, P<0.05). In the metabolic remodeling phase, no significant key factors affected the accuracy of the Third Military Medical University formula (P>0.05). Conclusions When calculating REE values in patients with severe burns, it is recommended to use the Peng Xi team's linear formula during the acute inhibition phase, the Hangang formula during the hypermetabolic and metabolic balance phases, and the Third Military Medical University formula during the metabolic remodeling phase. Additionally, it is crucial to ensure the accuracy of key factors affecting the optimal calculation formula in the hypermetabolic and metabolic balance phases. -
参考文献
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Table 1. 烧伤患者的5种REE计算公式
公式名称 公式内容 Milner公式[8] REE=24×[BMR×（0.274+0.007 9×烧伤总面积-0.004×伤后天数）+BMR]×体表总面积×活动系数 Hangang公式[9] 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） 第三军医大学公式[10] REE=1 000×体表总面积+25×烧伤总面积 Carlson公式[11] REE=24×BMR×（0.891 42+0.013 35×烧伤总面积）×体表总面积×活动系数 彭曦团队线性公式[6] 烧伤总面积>70%TBSA且伤后天数>14 d REE=（1 460+2×烧伤总面积+12×伤后天数）×体表总面积 烧伤总面积>70%TBSA且伤后天数≤14 d REE=（1 350-0.4×烧伤总面积+33×伤后天数）×体表总面积 烧伤总面积≤70%TBSA且伤后天数>14 d REE=（1 330+10×烧伤总面积-14×伤后天数）×体表总面积 烧伤总面积≤70%TBSA且伤后天数≤14 d REE=（1 130+7×烧伤总面积+10×伤后天数）×体表总面积 注：REE为静息能量消耗,BMR为基础代谢率,TBSA为体表总面积；患者为男性时BMR=54.337 821-(1.199 61×年龄)+(0.025 48×年龄2)-(0.000 18×年龄3)、为女性时BMR=54.749 42-(1.548 84×年龄)+(0.035 80×年龄2)-(0.000 26×年龄3)；体重单位为kg,烧伤总面积单位为%TBSA,体表总面积单位为m2 
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Table 2. 不同代谢分期下间接测热法测量REE当日的40例重症烧伤患者临床特征比较
代谢分期 测量次数 伤后天数（d, 性别（例） 年龄（岁, 身高（cm, 体重（kg, 体重指数（kg/m2, 体表总面积（m2, 烧伤总面积（%TBSA, 男 女 急性抑制期 13 2.2±0.8 10 3 47±13a 168±8 78±18 28±6 1.87±0.22 78±25 代谢高涨期 87 15.2±7.5 60 27 49±15a 166±7 72±15a 26±5a 1.80±0.19a 77±18 代谢平衡期 65 39.6±7.5 52 13 58±17 169±6 76±14a 27±4 1.85±0.19a 74±20 代谢重塑期 19 66.6±7.1 18 1 63±14 170±4 88±14 30±4 1.98±0.17 73±22 统计量值 — — χ2=6.28 F=7.34 F=2.75 F=5.29 F=3.83 F=5.21 F=0.57 P值 — — 0.094 <0.001 0.044 0.002 0.011 0.002 0.671 注：REE为静息能量消耗,TBSA为体表总面积；“—”表示无此项；与代谢重塑期相比,aP<0.05
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Table 3. 不同代谢分期下40例重度烧伤患者REE测量值及其与REE公式计算值的差值比较
代谢分期 伤后测量时间[d,M（Q1,Q3）] 测量次数（次） REE测量值（kJ/d, Milner公式计算值与REE测量值的差值[kJ/d,M（Q1,Q3）] Hangang公式计算值与REE测量值的差值[kJ/d,M（Q1,Q3）] 第三军医大学公式计算值与REE测量值的差值[kJ/d,M（Q1,Q3）] Carlson公式计算值与REE测量值的差值[kJ/d,M（Q1,Q3）] 彭曦团队线性公式计算值与REE测量值的差值[kJ/d,M（Q1,Q3）] 急性抑制期 2（2,3） 13 8 824±2 431 7 745（5 518,9 372） 2 071（1 117,2 995） 7 920（5 711,9 004） 8 866（6 916,9 514） 1 799（941,2 493） 代谢高涨期 10（6,17） 87 10 071±2 406 5 038（3 225,6 218） -841（-2 016,787） 3 820（2 410,5 933） 5 778（3 707,7 046） 1 836（560,3 317） 代谢平衡期 38（33,45） 65 9 627±3 648 5 447（3 527,6 364） -1 200（-2 548,154） 2 523（1 154,4 343） 6 627（4 347,8 372） — 代谢重塑期 66（60,72） 18 9 540±2 377 3 715（2 803,5 087） -2 108（-3 564,1 338） 1 180（-192,2 280） 5 481（4 217,7 652） — 统计量值 — — F=1.92 H=14.50 H=27.15 H=37.26 F=11.80 Z=-0.91 P值 — — 0.113 <0.001 <0.001 <0.001 0.008 0.634 注：REE为静息能量消耗；差值=各公式计算值-测量值；“—”表示无此项
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Table 4. 不同代谢分期下40例重症烧伤患者REE公式计算值相对REE测量值的准确性和差异性分析
代谢分期 计算公式 标准差（kJ/d） 10%准确率（%） 20%准确率（%） 绝对百分比误差（%） 绝对百分比误差的95%置信区间（%） 统计量值 P值 急性抑制期 Milner公式 754.63 0 0 95（62,117）a 71.17~111.85 H=34.43 <0.001 Hangang公式 359.94 7.69 38.46 23（16,47）a 18.84~38.37 第三军医大学公式 734.60 0 15.38 81（47,142）a 21.34~41.35 Carlson公式 971.82 15.38 40.76 106（52,127）a 71.20~120.53 彭曦团队线性公式 316.64 15.38 43.08 30（19,46） 17.35~34.58 代谢高涨期 Milner公式 593.57 6.90 12.64 52（32,74）b 48.58~61.56 F=12.10 0.031 Hangang公式 306.82 28.74 65.52 14（9,24） 14.34~19.17 第三军医大学公式 504.97 6.89 13.79 59（36,81）b 54.07~69.10 Carlson公式 732.04 6.89 12.64 60（37,88）b 55.87~70.41 彭曦团队线性公式 437.01 17.24 34.48 29（12,50）b 29.04~40.21 代谢平衡期 Milner公式 629.41 10.77 16.92 58（31,83）b 50.98~69.99 F=28.52 <0.001 Hangang公式 259.28 29.23 58.46 17（9,26） 16.42~24.52 第三军医大学公式 536.35 b 10.77 12.31 82（38,105）b 64.68~86.04 Carlson公式 781.17 6.15 13.85 79（41,100）b 64.90~86.72 代谢重塑期 Milner公式 337.25 5.56 11.11 44（33,77）c 38.22~70.14 H=25.62 <0.001 Hangang公式 153.55 16.67 44.44 23（16,38）c 17.62~33.99 第三军医大学公式 583.41 33.33 61.11 17（9,35） 32.97~48.63 Carlson公式 561.24 0 5.56 63（45,114）c 57.18~103.25 注：REE为静息能量消耗；标准差是公式计算值相对测量值所得；与彭曦团队线性公式相比,aP<0.05；与Hangang公式相比,bP<0.05；与第三军医大学公式相比,cP<0.05
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Table 5. 影响40例重症烧伤患者不同代谢分期下REE最佳计算公式计算值准确性关键因子的logistic回归分析
不同代谢分期下最佳计算公式 关键因子 比值比 95%置信区间 P值 急性抑制期的彭曦团队线性公式 烧伤总面积（%TBSA） 1.10 0.95~1.10 0.394 伤后天数（d） 1.10 0.90~1.40 0.295 体表总面积（m2） 1.10 0.90~1.20 0.550 代谢高涨期的Hangang公式 年龄（岁） 0.98 0.95~1.10 0.360 体重（kg） 0.98 0.96~1.10 0.407 烧伤总面积（%TBSA） 1.00 1.00~1.10 0.027 伤后天数（d） 1.00 0.97~1.10 0.339 代谢平衡期的Hangang公式 年龄（岁） 0.99 0.95~1.00 0.786 体重（kg） 0.96 0.92~1.00 0.143 烧伤总面积（%TBSA） 1.00 0.96~1.00 0.353 伤后天数（d） 1.30 1.10~1.40 0.001 代谢重塑期的第三军医大学公式 体表总面积（m2） 0.99 0.92~1.10 0.634 烧伤总面积（%TBSA） 0.93 0.82~1.10 0.805 注：REE为静息能量消耗,TBSA为体表总面积
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