特重度烧伤患者代谢高涨期进行基于间接测热法的营养治疗的效果

姜彬; 都勇; 夏一兰; 陈华清; 卢福长

doi:10.3760/cma.j.cn501225-20240320-00103

特重度烧伤患者代谢高涨期进行基于间接测热法的营养治疗的效果

doi: 10.3760/cma.j.cn501225-20240320-00103

浙江大学医学院附属第二医院护理部,杭州　　310000

基金项目:

浙江省医药卫生科技计划项目 2024KY087, 2024KY1075

详细信息

通讯作者:
夏一兰,Email：2202088@zju.edu.cn

计量
- 文章访问数: 316
- HTML全文浏览量: 87
- PDF下载量: 21
- 被引次数: 0
出版历程
- 收稿日期: 2024-03-20

Effects of nutritional therapy based on indirect calorimetry in patients with extremely severe burns during hypermetabolic stage

Nursing Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310000, China

Funds:

Zhejiang Province Medical and Health Science and Technology Plan Project 2024KY087, 2024KY1075

More Information

Corresponding author: Xia Yilan, Email: 2202088@zju.edu.cn

摘要

摘要: 目的探讨特重度烧伤患者代谢高涨期进行基于间接测热法的营养治疗的效果。方法该研究为回顾性队列研究。2022年3月25日—2024年3月30日,浙江大学医学院附属第二医院烧伤与创面修复科收治了20例符合入选标准的特重度烧伤患者,其中男15例、女5例,年龄为（46±12）岁。根据患者治疗结局,将患者分为死亡组（6例）和存活组（14例）。伤后第3、7、14、21天,应用间接测热法测定2组患者静息能量消耗（REE）,每天1次,并根据REE结果制订营养治疗方案。收集2组患者伤后第3、7、14、21天的REE值及白蛋白、白细胞介素6（IL-6）水平以及实际摄入能量、肠内营养摄入能量（最后2个指标分别以伤后第3~6、7~10、14~17、21~24天的均值表示）,并计算实际摄入能量/REE值、肠内营养摄入能量/实际摄入能量。结果存活组和死亡组患者伤后第3、7、14、21天的REE值分别为（8 143±2 328）、（9 843±2 610）、（10 149±2 248）、（9 608±2 838）kJ和（6 816±2 057）、（10 691±2 515）、（11 031±2 850）、（8 990±2 018）kJ。2组患者伤后第3~21天REE值、肠内营养摄入能量均呈先上升后下降的趋势,但2组患者各时间点2个指标组间两两比较,差异均无统计学意义（P>0.05）。存活组患者伤后第21天实际摄入能量显著高于伤后第3天（P<0.05）,死亡组患者伤后第14天肠内营养摄入能量明显高于伤后第3天（P<0.05）。2组患者伤后各时间点实际摄入能量/REE值、肠内营养摄入能量/实际摄入能量组间和组内总体比较,差异均无统计学意义（P>0.05）。存活组患者伤后第21天IL-6水平明显低于伤后第3、7天（P值均<0.05）,明显高于伤后第14天（P<0.05）；死亡组患者伤后第21天IL-6水平明显高于伤后第3、7、14天（P值均<0.05）。存活组患者伤后第7天白蛋白水平明显高于伤后第3天（P<0.05）。结论特重度烧伤患者代谢高涨期REE值和肠内营养摄入能量均呈先上升后下降的趋势,但对患者临床结局无显著影响。基于间接测热法的营养治疗方案能基本满足特重度烧伤患者代谢高涨期的能量需求。白蛋白和IL-6水平对特重度烧伤患者临床结局的影响仍需进一步研究证实。
- 烧伤 /
- 量热法,间接 /
- 能量代谢 /
- 营养支持 /
- 预后
Abstract: Objective To explore the effects of nutritional therapy based on indirect calorimetry in patients with extremely severe burns during hypermetabolic stage. Methods This study was a retrospective cohort study. From March 25, 2022 to March 30, 2024, 20 extremely severe burn patients who met the inclusion criteria were admitted to the Department of Burn and Wound Repair of the Second Affiliated Hospital of Zhejiang University School of Medicine. There were 15 males and 5 females, aged (46±12) years. The patients were divided into death group (6 cases) and survival group (14 cases) according to their treatment outcomes. At the 3^rd, 7^th, 14^th, and 21^st d after injury, the resting energy expenditure (REE) of patients in the two groups was measured by indirect calorimetry once a day, and the nutritional treatment scheme was formulated according to the results of REE. The REE value, levels of albumin and interleukin-6 (IL-6), actual energy intake, and enteral nutrition energy intake of patients in the two groups at the 3^rd, 7^th, 14^th, and 21^st d after injury were collected (the last two indicators were respectively expressed as the mean values of the 3^rd to 6^th, 7^th to 10^th, 14^th to 17^th, and 21^st to 24^th d after injury). The actual energy intake/REE value and enteral nutrition energy intake/actual energy intake were calculated. Results The REE values of patients in survival group and death group were (8 143±2 328), (9 843±2 610), (10 149±2 248), (9 608±2 838) kJ and (6 816±2 057), (10 691±2 515), (11 031±2 850), (8 990±2 018) kJ, respectively at the 3^rd, 7^th, 14^th, and 21^st d after injury. The REE value and enteral nutrition energy intake of patients in the two groups showed trends of increase first and decrease then from the 3^rd to 21^st d after injury, while the differences in the above two indicators at each time point between the two groups of patients were not statistically significant (P>0.05). The actual energy intake of patients in survival group at the 21^st d after injury was significantly higher than that at the 3^rdd after injury (P<0.05), and the enteral nutrition energy intake of patients in death group at the 14^th d after injury was significantly higher than that at the 3^rd d after injury (P<0.05). There were no statistically significant differences in overall comparison in actual energy intake/REE value and enteral nutrition energy intake/actual energy intake at each time point after injury between and within the two groups of patients (P>0.05). The level of IL-6 of patients in survival group at the 21^st d after injury was significantly lower than that at the 3^rd and 7^th d after injury, respectively (with both P values <0.05), and significantly higher than that at the 14^th d after injury (P<0.05); the level of IL-6 of patients in death group at the 21^st d after injury was significantly higher than that at the 3^rd, 7^th, and 14^th d after injury (with P values all <0.05). The albumin level of patients in survival group at the 7^th d after injury was significantly higher than that at the 3^rd d after injury (P<0.05). Conclusions The REE value and enteral nutrition energy intake of extremely severe burn patients showed trends of increase first and decrease then, while they have no significant effects on the clinical outcome of the patients. The nutritional treatment scheme based on the indirect calorimetry can basically meet the energy demand of patients with extremely severe burns during hypermetabolic stage. The impacts of the albumin and IL-6 levels on the clinical outcome of extremely severe burn patients still need further research.
- Burns /
- Calorimetry, indirect /
- Energy metabolism /
- Nutritional support /
- Prognosis
姜彬：论文撰写及修改；都勇：数据分析、表格绘制；夏一兰：论文指导、经费支持；陈华清、卢福长：数据收集与分析

所有作者声明不存在利益冲突

HTML全文

参考文献(40)

[1]	ClarkA,ImranJ,MadniT,et al.Nutrition and metabolism in burn patients[J/OL].Burns Trauma,2017,5:11[2024-03-20].https://pubmed.ncbi.nlm.nih.gov/28428966/.DOI: 10.1186/s41038-017-0076-x.
[2]	KnuthCM,AugerC,JeschkeMG.Burn-induced hypermetabolism and skeletal muscle dysfunction[J].Am J Physiol Cell Physiol,2021,321(1):C58-C71.DOI: 10.1152/ajpcell.00106.2021.
[3]	彭曦.重症烧伤患者的代谢分期及营养治疗策略[J].中华烧伤杂志,2021,37(9):805-810.DOI: 10.3760/cma.j.cn501120-20210802-00264.
[4]	彭曦.烧伤临床营养新视角[J].中华烧伤杂志,2019,35(5):321-325.DOI: 10.3760/cma.j.issn.1009-2587.2019.05.001.
[5]	Radzikowska-BüchnerE,ŁopuszyńskaI,FliegerW,et al.An overview of recent developments in the management of burn injuries[J].Int J Mol Sci,2023,24(22):16357.DOI: 10.3390/ijms242216357.
[6]	SingerP,BlaserAR,BergerMM,et al.ESPEN practical and partially revised guideline: clinical nutrition in the intensive care unit[J].Clin Nutr,2023,42(9):1671-1689.DOI: 10.1016/j.clnu.2023.07.011.
[7]	CompherC,BinghamAL,McCallM,et al.Guidelines for the provision of nutrition support therapy in the adult critically ill patient: the American Society for Parenteral and Enteral Nutrition[J].JPEN J Parenter Enteral Nutr,2022,46(1):12-41.DOI: 10.1002/jpen.2267.
[8]	KimH,StottsNA,FroelicherES,et al.Enteral nutritional intake in adult korean intensive care patients[J].Am J Crit Care,2013,22(2):126-135.DOI: 10.4037/ajcc2013629.
[9]	刘飞跃,全殷殷,李飞,等.重症监护室机械通气患者喂养不达标现状及影响因素分析[J].中国实用护理杂志,2023,39(2):151-156.DOI: 10.3760/cma.j.cn211501-20220310-00712.
[10]	BaiuI,SpainDA.Parenteral nutrition[J].JAMA,2019,321(21):2142.DOI: 10.1001/jama.2019.4410.
[11]	KahveciFS,DemirkanK,DoganayM,et al.Parenteral nutrition consensus report from KEPAN[J].Nutrition,2024,123:112424.DOI: 10.1016/j.nut.2024.112424.
[12]	孙萱,张杰,李佳欢,等. 早期肠内营养支持在大面积重度烧伤患者中的应用效果[J]. 中国食物与营养,2018,24(9):65-67. DOI: 10.3969/j.issn.1006-9577.2018.09.016.
[13]	PuH,DoigGS,HeighesPT,et al.Early enteral nutrition reduces mortality and improves other key outcomes in patients with major burn injury: a meta-analysis of randomized controlled trials[J].Crit Care Med,2018,46(12):2036-2042.DOI: 10.1097/CCM.0000000000003445.
[14]	van ZantenA,De WaeleE,WischmeyerPE.Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases[J].Crit Care,2019,23(1):368.DOI: 10.1186/s13054-019-2657-5.
[15]	NunezJH,ClarkAT.Burn patient metabolism and nutrition[J].Phys Med Rehabil Clin N Am,2023,34(4):717-731.DOI: 10.1016/j.pmr.2023.06.001.
[16]	RousseauAF,PantetO,HeylandDK.Nutrition after severe burn injury[J].Curr Opin Clin Nutr Metab Care,2023,26(2):99-104.DOI: 10.1097/MCO.0000000000000904.
[17]	Fuentes PadillaP,MartínezG,VernooijRW,et al.Early enteral nutrition (within 48 hours) versus delayed enteral nutrition (after 48 hours) with or without supplemental parenteral nutrition in critically ill adults[J].Cochrane Database Syst Rev,2019,2019(10):CD012340.DOI: 10.1002/14651858.CD012340.pub2.
[18]	CastanonL,AsmarS,BibleL,et al.Early enteral nutrition in geriatric burn patients: is there a benefit?[J].J Burn Care Res,2020,41(5):986-991.DOI: 10.1093/jbcr/iraa109.
[19]	马年斌,沈明富,万珍,等. 容许性低热量喂养与足量喂养对机械通气重症患者预后的影响:一项前瞻性随机对照研究[J]. 中华危重病急救医学,2018,30(2):176-180. DOI: 10.3760/cma.j.issn.2095-4352.2018.02.016.
[20]	中华医学会肠外肠内营养学分会.中国成人患者肠外肠内营养临床应用指南(2023版)[J].中华医学杂志,2023,103(13):946-974.DOI: 10.3760/cma.j.cn112137-20221116-02407.
[21]	AchamrahN,DelsoglioM,De WaeleE,et al.Indirect calorimetry: the 6 main issues[J].Clin Nutr,2021,40(1):4-14.DOI: 10.1016/j.clnu.2020.06.024.
[22]	WischmeyerPE,MolingerJ,HainesK.Point-counterpoint: indirect calorimetry is essential for optimal nutrition therapy in the intensive care unit[J].Nutr Clin Pract,2021,36(2):275-281.DOI: 10.1002/ncp.10643.
[23]	都勇,夏一兰.重度烧伤患者肠内营养应用管理的研究进展[J].中华急危重症护理杂志,2022,3(2):163-167.DOI: 10.3761/j.issn.2096-7446.2022.02.013.
[24]	RollinsC,HuettnerF,NeumeisterMW.Clinician's guide to nutritional therapy following major burn injury[J].Clin Plast Surg,2017,44(3):555-566.DOI: 10.1016/j.cps.2017.02.014.
[25]	韩珍,叶向红,张锐,等.普外科重症患者肠内营养中断影响因素分析及对预后影响的研究[J].中国实用护理杂志,2022,38(28):2203-2208.DOI: 10.3760/cma.j.cn211501-20220228-01402.
[26]	BechtoldML,BrownPM,EscuroA,et al.When is enteral nutrition indicated?[J].JPEN J Parenter Enteral Nutr,2022,46(7):1470-1496.DOI: 10.1002/jpen.2364.
[27]	ISBI Practice Guidelines Committee, SubcommitteeAdvisory, SubcommitteeSteering. ISBI practice guidelines for burn care, part 2[J]. Burns, 2018, 44(7):1617-1706. DOI: 10.1016/j.burns.2018.09.012.
[28]	HeylandDK,OrtizA,StoppeC,et al.Incidence, risk factors, and clinical consequence of enteral feeding intolerance in the mechanically ventilated critically ill: an analysis of a multicenter, multiyear database[J].Crit Care Med,2021,49(1):49-59.DOI: 10.1097/CCM.0000000000004712.
[29]	潘艳艳,徐思达,范友芬,等.特重度烧伤患者早期肠内营养不耐受的危险因素分析[J].中华烧伤杂志,2021,37(9):831-838.DOI: 10.3760/cma.j.cn501120-20210511-00180.
[30]	XuC,ZhouG,WangX,et al.Correlation analysis of serum miR-21 and miR-210 with hs-CRP, TNF-α, IL-6, and ICAM-1 in patients with sepsis after burns[J].Burns,2022,48(3):633-638.DOI: 10.1016/j.burns.2021.05.026.
[31]	SaxenaJ,DasS,KumarA,et al.Biomarkers in sepsis[J].Clin Chim Acta,2024,562:119891.DOI: 10.1016/j.cca.2024.119891.
[32]	何凤棣,宋贵芳,冶秀花,等.ICU脓毒症患者血清炎症因子水平与多器官功能障碍综合征风险的关系[J].中国急救复苏与灾害医学杂志,2022,17(11):1458-1461.DOI: 10.3969/j.issn.1673-6966.2022.11.015.
[33]	PardoE,JabaudonM,GodetT,et al.Dynamic assessment of prealbumin for nutrition support effectiveness in critically ill patients[J].Clin Nutr,2024,43(6):1343-1352.DOI: 10.1016/j.clnu.2024.04.015.
[34]	DonohueSJ,BacaJ,SpeiserN,et al.Lower admission prealbumin and albumin levels in unhoused burn patients is a marker for poorer outcomes[J].J Burn Care Res,2024,45(5):1148-1153.DOI: 10.1093/jbcr/irae089.
[35]	陈卫平,杨慧,蔡爱玲,等.严重烧伤患者血清前白蛋白、C反应蛋白及其比值的变化[J].海南医学院学报,2015,21(1):86-88,92.DOI: 10.13210/j.cnki.jhmu.20141112.002.
[36]	FaragCM,AntarR,AkosmanS,et al.What is hemoglobin, albumin, lymphocyte, platelet (HALP) score? A comprehensive literature review of HALP's prognostic ability in different cancer types[J].Oncotarget,2023,14:153-172.DOI: 10.18632/oncotarget.28367.
[37]	BandeiraNG,BarrosoMVVS,MatosMAA,et al.Serum albumin concentration on admission as a predictor of morbidity and mortality in patients with burn injuries[J].J Burn Care Res,2021,42(5):991-997.DOI: 10.1093/jbcr/irab004.
[38]	SeoYJ,YuJ,ParkJY,et al.Red cell distribution width/albumin ratio and 90-day mortality after burn surgery[J/OL].Burns Trauma,2022,10:tkab050[2024-03-20].https://pubmed.ncbi.nlm.nih.gov/35097135/.DOI: 10.1093/burnst/tkab050.
[39]	潘选良,朱志康,沈涛,等.成人特重度烧伤患者脓毒症预后预测指标分析[J].中华急诊医学杂志,2023,32(9):1235-1240.DOI: 10.3760/cma.j.issn.1671-0282.2023.09.015.
[40]	王震,荣新洲,张涛,等.家兔烫伤后早期痂下水肿液中白蛋白吸收现象及药代动力学观察[J].中华烧伤杂志,2009,25(6):441-443.DOI: 10.3760/cma.j.issn.1009-2587.2009.06.015.

下载: 全尺寸图片幻灯片

Table 1. 2组特重度烧伤患者一般资料比较

组别	例数	性别（例）		年龄（岁,x¯±s）	体重指数（kg/m²,x¯±s）	烧伤总面积[%TBSA,M（min,max）]	Ⅲ度烧伤面积[%TBSA,M（min,max）]	吸入性损伤（例）
组别	例数	男	女	年龄（岁,x¯±s）	体重指数（kg/m²,x¯±s）	烧伤总面积[%TBSA,M（min,max）]	Ⅲ度烧伤面积[%TBSA,M（min,max）]	无	有
死亡组	6	6	0	50±14	26.1±2.5	82（51,98）	45（21,98）	1	5
存活组	14	9	5	44±11	26.4±6.1	85（51,98）	66（7,93）	3	11
统计量值		—		t=0.99	t=-0.14	Z=0.04	Z=0.37	—
P值		0.260		0.336	0.894	>0.999	0.718	>0.999
注：TBSA为体表总面积；“—”表示无此项

下载: 导出CSV

Table 2. 2组特重度烧伤患者伤后各时间点营养治疗能量情况比较

组别与伤后时间点	例数	REE值（kJ,x¯±s）	实际摄入能量（kJ/d,x¯±s）	肠内营养摄入能量[kJ/d,M（min,max）]	实际摄入能量/REE值[M（min,max）]	肠内营养摄入能量/实际摄入能量[M（min,max）]
存活组	14
第3天		8 143±2 328	6 767±2 813	3 143（700,9 113）	0.80（0.39,1.87）	0.64（0.19,1.30）
第7天		9 843±2 610	8 085±2 971	6 285（1 077,10 266）	0.81（0.48,1.36）	0.86（0.15,1.32）
第14天		10 149±2 248	8 814±2 288	7 525（503,10 936）	0.85（0.60,1.71）	0.70（0.07,1.12）
第21天		9 608±2 838	9 659±2 430^a	5 761（2 933,12 738）	1.01（0.36,1.73）	0.64（0.26,1.11）
死亡组	6
第3天		6 816±2 057	5 199±1 188	3 143（2 765,4 190）	0.84（0.38,1.16）	0.67（0.45,0.85）
第7天		10 691±2 515	7 164±2 102	4 462（3 423,7 647）	0.72（0.46,0.83）	0.79（0.48,0.99）
第14天		11 031±2 850	8 149±1 939	5 483（4 400,9 847）^a	0.73（0.58,1.00）	0.86（0.46,1.08）
第21天		8 990±2 018	8 176±3 271	5 359（3 352,9 428）	0.84（0.63,1.63）	0.65（0.48,1.12）
统计量值₁		F=4.30	F=4.96	χ²=11.10	χ²=6.05	χ²=2.33
P₁值		0.007	0.003	0.011	0.109	0.506
统计量值₂		F=1.49	F=3.02	χ²=4.55	χ²=5.22	χ²=1.58
P₂值		0.229	0.038	0.208	0.157	0.663
统计量值₃		F=2.52	F=2.31	χ²=11.41	χ²=2.85	χ²=1.31
P₃值		0.088	0.107	0.010	0.416	0.728
注：伤后第3、7、14、21天的实际摄入能量、肠内营养摄入能量分别是伤后第3~6、7~10、14~17、21~24天连续4 d的结果的均值；静息能量消耗（REE）值、实际摄入能量分组因素主效应,F值分别为0.02、1.45,P值分别为0.971、0.242；时间因素主效应,F值分别为9.74、8.28,P值分别为<0.001、<0.001；两者交互作用,F值分别为2.00、0.24,P值分别为0.127、0.872；肠内营养摄入能量、实际摄入能量/REE值、肠内营养摄入能量/实际摄入能量分组因素主效应,Wald χ²值分别为1.03、2.84、0.07,P值分别为0.310、0.092、0.787；时间因素主效应,Wald χ²值分别为61.34、6.31、4.48,P值分别为<0.001、0.098、0.214；两者交互作用,Wald χ²值分别为1.60、0.87、0.99,P值分别为0.659、0.833、0.803；统计量值₁、P₁值为2组间各指标总体比较所得；统计量值₂、P₂值及统计量值₃、P₃值分别为存活组、死亡组各指标组内总体比较所得；与组内伤后第3天比较,^aP<0.05

下载: 导出CSV

Table 3. 2组特重度烧伤患者伤后各时间点营养治疗相关检验指标的比较

组别与伤后时间点	例数	白蛋白（g/L,x¯±s）	前白蛋白[mg/L,M（min,max）]	IL-6[pg/mL,M（min,max）]
存活组	14
第3天		25.3±3.9	92（72,139）	237.5（31.4,1 427.0）
第7天		30.1±4.8^a	86（66,108）	412.0（91.8,2 395.0）
第14天		28.7±4.0	76（30,129）	213.0（59.6,2 089.0）
第21天		29.5±4.2	82（44,145）	229.0（26.4,2 145.0）^abc
死亡组	6
第3天		27.5±4.1	99（97,124）	195.5（120.0,423.0）
第7天		29.2±4.8	86（63,126）	294.0（126.0,1 248.0）
第14天		29.8±2.6	65（63,116）	673.0（185.0,3 700.0）
第21天		23.9±12.0	59（20,102）	787.5（26.4,3 490.0）^abc
统计量值₁		F=2.10	χ²=8.41	χ²=8.41
P₁值		0.107	0.038	<0.001
统计量值₂		F=3.58	χ²=4.35	χ²=31.89
P₂值		0.020	0.226	<0.001
统计量值₃		F=0.49	χ²=4.42	χ²=13.50
P₃值		0.690	0.220	0.004
注：白蛋白分组因素主效应,F=0.41,P=0.526；时间因素主效应,F=1.75,P=0.185；两者交互作用,F=1.81,P=0.156；前白蛋白和白细胞介素6（IL-6）分组因素主效应,Wald χ²值分别为0.30和0.31,P值分别为0.583和0.579；时间因素主效应,Wald χ²值分别为25.72和28.26,P值分别为<0.001和<0.001；两者交互作用,Wald χ²值分别为6.86和1.71,P值分别为0.076和0.425；统计量值₁、P₁值为2组间各指标总体比较所得；统计量值₂、P₂值及统计量值₃、P₃值分别为存活组、死亡组各指标组内总体比较所得；与组内伤后第3天比较,^aP<0.05；与组内伤后第7天比较,^bP<0.05；与组内伤后第14天比较,^cP<0.05