不同热卡供给对脓毒性休克100例预后的影响_王彩虹.pdf

安 徽 医 药 Anhui Medical and Pharmaceutical Journal 2023 Jul，27（7）不同热卡供给对脓毒性休克100例预后的影响王彩虹1，王美霞2，姚哲放3，王亚丽1，李小洋1作者单位：1山西医科大学第一临床医学院，山西 太原030001；2山西医科大学第一医院重症医学科，山西 太原030001；3山西省心血管病医院重症医学科，山西 太原030001通信作者：王美霞，女，主任医师，硕士生导师，研究方向为重症营养与消化，Email：sdyy_基金项目：黎介寿肠道屏障研究专项基金（LJS-201613）摘要：目的 比较不同热卡供给对脓毒性休克病人预后的影响，以期为脓毒性休克病人提供最佳热卡供给。方法 采用回顾性分析方法，选取山西医科大学第一临床医学院2019年8月至2021年8月符合纳入标准的100例脓毒性休克病人行营养支持治疗的临床资料，将病人按非蛋白热卡供给量分为A组、B组2组。A组喂养方式为渐进式喂养，入ICU第3天热卡达到目标热卡的70%，逐渐增加热卡到第7天达到目标热卡。B组喂养方式为等热卡喂养，入ICU第3天达到目标热卡，第3天到第7天目标热卡喂养。两组入院时一般资料相近，蛋白提供量相似。分别记录两组病人每日热卡供给量、蛋白供给量，第1天及第7天营养指标、肝肾功、血糖、胰岛素用量，记录住院期间机械通气时间、住院时间、住ICU时间、院内感染率、ICU病死率、28 d病死率等并进行比较。探讨热卡供给量与脓毒性休克病人预后的关系。结果 两组给予7 d营养支持后，A组的胰岛素用量少于B组 20.00（0.00，50.00）IU比50.00（0.00，70.00）IU，A组的机械通气时间比B组短 （7.696.80）d比（12.4414.02）d，A组的住院时间比B组短 （18.9212.33）d比（28.0222.07）d，A组的ICU住院时间比B组短 （14.9210.91）d比（22.2216.76）d，A组的28 d病死率低于B组 6例（12.2%）比22例（43.1%），A组的院内感染率低于B组 3例（6.1%）比10例（19.6%），差异有统计学意义（P0.05）。结论 脓毒性休克病人在提供充足蛋白质时，在急性期早期（13 d）给予低热卡喂养，急性期晚期（47 d）给予等热卡喂养，可以减少胰岛素需求，缩短机械通气时间、住院时间、住ICU时间，降低院内感染率、28 d病死率，改善预后。关键词：休克，脓毒性；低热卡喂养；等热卡喂养；营养支持；病死率The effect of different calorie supply on the prognosis of 100 cases of septic shockWANG Caihong1,WANG Meixia2,YAO Zhefang3,WANG Yali1,LI Xiaoyang1Author Affiliations:1The First Clinical Medical College of Shanxi Medical University,Taiyuan,Shanxi 030001,China;2Department of Critical Care Medicine,The First Hospital of Shanxi Medical University,Taiyuan,Shanxi 030001,China;3Department of Critical Care Medicine,Shanxi Cardiovascular Disease Hospital,Taiyuan,Shanxi 030001,ChinaAbstract：Objective To compare the effect of different caloric supply on the prognosis of patients with septic shock,in order to provide the best caloric supply for patients with septic shock.Methods A retrospective analysis was conducted to select the clinical data of 100 patients with septic shock who met the inclusion criteria from August 2019 to August 2021 and received nutritional support therapy in The First Clinical Medical College of Shanxi Medical University.The patients were divided into group A and group B according to the amount of non-protein calorie supply.Group A was fed gradually,70%of the target caloric calorie was reached on the third day in ICU,and the target caloric calorie was reached on the seventh day by gradually increasing calorie.The feeding method of group B was isocaloric diet,and the target calorie feeding was achieved on the 3rd day after admission to ICU,and the target calorie feeding was achieved from the 3rd day to the 7th day.The general information of the two groups at admission was similar and the amount of protein available was similar.Daily caloric calorie supply,protein supply,nutritional indexes,liver and kidney function,blood glucose and insulin dosage on day 1 and day 7,mechanical ventilation duration,hospitalization duration,ICU stay duration,nosocomial infection rate,ICU mortality rate and 28-day mortality rate were recorded and compared between the two groups.The relationship between caloric intake and prognosis of patients with septic shock was investigated.Results After 7 days of nutritional support,the insulin dosage in group A was less than that in group B 20.00(0.00,50.00)IU vs.50.00(0.00,70.00)IU,and the mechanical ventilation duration in group A was shorter than that in group B(7.696.80)d vs.(12.4414.02)d.The length of hospital stay in group A was shorter than that in group B(18.9212.33 vs.28.0222.07),and the length of ICU stay in group A was shorter than that in group B(14.9210.91)d vs.(22.2216.76)d.The 28-day mortality in group A was lower than that in group B 6(12.2)cases vs.22(43.1)cases,and the nosoco临床医学引用本文：王彩虹，王美霞，姚哲放，等.不同热卡供给对脓毒性休克100例预后的影响 J.安徽医药，2023，27（7）：1441-1446.DOI：10.3969/j.issn.1009-6469.2023.07.037.1441安 徽 医 药 Anhui Medical and Pharmaceutical Journal 2023 Jul，27（7）mial infection rate in group A was lower than that in group B 3(6.1)cases vs.10(19.6)cases,the difference was statistically significant(P0.05).Conclusion Providing adequate protein in patients with septic shock,in the early acute phase(1-3 days)for hypocaloricorunder-feeding,acute late(4-7 days)to give such as isocaloricdiet,can reduce insulin demand,shortening the time of mechanical ventilation,length of hospital stay,ICU time,reduce the nosocomial infection rate and the 28-day mortality to improve the prognosis.Key words：Shock,septic;Hypocaloricorunder-feeding;Isocaloricdiet;Nutrition support;Mortality营养支持治疗是重症医学科重要的治疗手段之一，尽管目前营养支持在重症医学科中得到重视，但是重症病人的营养改善情况仍不理想。大多数重症病人接受的热卡供给与其实际所需的热卡并不相符，容易出现营养不良与营养过剩，有研究表明重症病人营养不良的发生率可高达40%50%1。营养不良会使重症病人感染加重，死亡率增加，住院时间延长2。营养过剩则会引发高血糖、肝功能损害等并发症3。对全球疾病的研究发现，全世界有4 900万人患有脓毒症，全球20%的死亡与脓毒症有关，脓毒症是危重病病人的首要死因 4。Fleischmann等 5 研究中提到脓毒症病人住院期间病死率为17%，脓毒性休克病人的住院死亡率为26%。目前有研究表明，重症病人的最佳的营养支持与病人的低死亡率和长期预后有关 6，但关于脓毒性休克病人方面的证据很少 7-8。本研究选取脓毒性休克病人为研究对象，探讨不同热卡供给对脓毒性休克病人死亡率及预后的影响。1资料与方法1.1一般资料回顾性分析山西医科大学第一临床医学院2019年8月至2021年8月100例脓毒性休克病人的临床资料，其中男 59 例，女 41 例；年龄（62.6315.44）岁。入选标准：符合Sepsis 3.0中脓毒性休克的诊断标准；营养支持治疗时间7 d；入住ICU时间7 d；NRS 2002营养评分3分。排除标准：年龄0.0