機械通氣下外科危重癥患者靜息能量消耗評價_《中國普外基礎與臨床雜志》

作者：

陳宏 , 孫家邦 , 李非 , 賈建國

首都醫科大學宣武醫院普外科（北京100053）;

關鍵詞：

能量消耗間接能耗測定法機械通氣危重癥患者

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導出 下載 收藏 掃碼 引用

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目的比較機械通氣下外科危重癥患者測定的靜息能量消耗（MREE）與校正Harris-Benedict公式計算的靜息能量消耗（CREE）之間的差異，并且評估各靜息能量消耗與疾病嚴重程度的相關性。方法2008年8月至2010年2月符合本研究入選標準的外科危重癥患者21例，收集入選患者相關數據，計算急性生理與既往健康狀況評分（APACHE Ⅱ評分）和器官功能不全評分（Marshall評分）。 MREE采用美國MedGraphics CCM/D 間接能耗測定法（IC法）測定; 同時，CREE由校正Harris-Benedict公式計算得出。根據入院時APACHE Ⅱ評分，將患者分為2組，即≥20分組（n=8）和 lt;20分組（n=13），對不同疾病嚴重程度患者的MREE與CREE進行比較。結果營養治療1周內患者MREE總的變化趨勢的差異無統計學意義（P=0.625），而CREE總的變化趨勢的差異有統計學意義（P lt;0.001）。營養治療1周內，患者的CREE〔(1 984.49±461.83) kcal/d〕明顯高于MREE 〔(1 563.88±496.93) kcal/d〕， P lt;0.001，其中營養治療后0、1、2和4 d的MREE均明顯低于相應時間的CREE（P lt;0.01），而其余時間點兩者的差異無統計學意義（P gt;0.05）。在營養治療1周內患者APACHEⅡ評分和Marsha Ⅱ評分均呈逐漸下降趨勢，總的變化趨勢的差異均有統計學意義（P lt;0.001）。在營養治療0~7 d，≥20分組患者的APACHE Ⅱ評分和Marsha Ⅱ評分分別高于 lt;20分組患者的APACHE Ⅱ評分和Marsha Ⅱ評分，差異均有統計學意義（P lt;0.05或P lt;0.01）; 2組患者在營養治療1周內，APACHE Ⅱ和Marsha Ⅱ評分均明顯降低，其差異有統計學意義（P lt;0.001）。營養治療1周內，患者的CREE與APACHE Ⅱ評分（r=0.656，P lt;0.001）和Marsha Ⅱ評分（r=0.608，P lt;0.001）的變化之間呈正相關; 而MREE與APACHE Ⅱ評分（r=-0.045，P=0.563）之間無相關性，但與Marsha Ⅱ評分（r=0.263，P=0.001）成正相關; MREE與CREE的變化趨勢之間無相關性（r=0.064，P=0.408）。營養治療1周內，APACHE Ⅱ評分≥20分組患者的MREE變化趨勢的差異有統計學意義（P=0.034），而APACHE Ⅱ評分 lt;20分組患者的MREE變化趨勢差異無統計學意義（P=0.223）。營養治療0~7 d，APACHE Ⅱ評分≥20分組患者的MREE與APACHE Ⅱ評分 lt;20分組患者的MREE之間比較差異無統計學意義（P gt;0.05）; APACHE Ⅱ評分≥20分組患者總體CREE〔(1 999.55±37273) kcal/d〕與APACHE Ⅱ評分 lt;20分組患者總體CREE〔(1 918.39±375.27) kcal/d〕之間的差異亦無統計學意義（P=0.887）。 APACHE Ⅱ評分≥20組患者除營養治療3和5 d外，其余時間的CREE均明顯高于MREE （P lt;0.05）; 而APACHE Ⅱ評分 lt;20組患者僅在營養治療0~2 d的CREE顯著高于MREE（P lt;0.01或P lt;0.05）。營養治療0~7 d，APACHE Ⅱ 評分≥20分組患者的MREE和CREE分別與APACHE Ⅱ評分 lt;20分組患者的MREE和CREE比較，差異均無統計學意義（P gt;0.05）。結論基于病情校正的HarrisBenedict公式明顯高估了外科危重癥患者，特別是APACHE Ⅱ評分≥20分患者的靜息能量消耗水平; IC法是評價靜息能量消耗的標準方法。

引用本文： 陳宏,孫家邦,李非,賈建國. 機械通氣下外科危重癥患者靜息能量消耗評價. 中國普外基礎與臨床雜志, 2011, 18(8): 854-860. doi: 復制

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17.	Frankenfield DC, Sarson Y, Blosser SA, et al. Validation of a 5minute steady state indirect calorimetry protocol for resting EE in critically ill patients [J]. J Am Coll Nutr, 1996, 15(3): 397402.
18.	McClave SA, Spain DA, Skolnick JL, et al. Achievement of steady state optimizes results when performing indirect calorimetry [J]. J Parenter Enter Nutr, 2003, 27(1): 1620.
19.	Reeves MM, Davies PS, Bauer J, et al. Reducing the time period of steady state does not affect the accuracy of energy expenditure measurements by indirect calorimetry [J]. J Appl Physiol, 2004, 97(1): 130134.
20.	Petros S, Engelmann L. Validity of an abbreviated indirect calorimetry protocol for measurement of resting energy expenditure in mechanically ventilated and spontaneously breathing critically ill patients [J]. Intensive Care Medicine, 2001, 27(7): 11641168.
21.	Branson RD, Johannigman JA. The measurement of energy expenditure [J]. Nutr Clin Pract, 2004, 19(5): 622636.
22.	Brandi LS, Bertolini R, Santini L, et al. Effects of ventilator resetting on indirect calorimetry measurement in the critically ill surgical patient [J]. Crit Care Med, 1999, 27(3): 531539.
23.	Haugen HA, Chan LN, Li F. Indirect calorimetry: a practical guide for clinicians [J]. Nutr Clin Pract, 2007, 22(4): 377388.
24.	Compher C, Frankenfield D, Keim N, et al. Best practice methods to apply to measurement of resting metabolic rate in adults: a systematic review [J]. J Am Diet Assoc, 2006, 106(6): 881903.
25.	da Rocha EE, Alves VG, Silva MH, et al. Can measured resting energy expenditure be estimated by formulae in daily clinical nutrition practice?[J]. Curr Opin Clin Nutr Metab Care, 2005, 8(3): 319328.
26.	黎介壽. 臨床營養支持策略的變遷 [J]. 中國普外基礎與臨床雜志, 2009, 16(12): 953955.
27.	秦環龍, 楊俊. 外科營養的現狀與展望 [J]. 中國普外基礎與臨床雜志, 2008, 15(11): 791793.
28.	Hwang TL, Huang SL, Chen MF. The use of indirect calorimetry in critically ill patients—the relationship of measured energy expenditure to Injury Severity Score, Septic Severity Score, and APACHE Ⅱ Score [J]. J Trauma, 1993, 34(2): 247251.
29.	Blackburn GL, Wollner S, Bistrian BR. Nutrition support in the intensive care unit: an evolving science [J]. Arch Surg, 2010, 145(6): 533538.
30.	Burke PA, Young LS, Bistrian BR. Metabolic vs nutrition support: a hypothesis [J]. J Parent Enteral Nutr, 2010, 34(5): 546548.

1. Bistrian BR. Comment on ‘Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient’ [J]. J Parent Enteral Nutr, 2010, 34(3): 348349.
2. McClave SA. Indirect calorimetry: relevance to patient outcome [J]. Respir Care Clin N Am, 2006, 12(4): 635650, vii.
3. Scurlock CS, Raikhelkar J, Mechanick JI. Intensive metabolic support: evolution and revolution [J]. Endocr Pract, 2008, 14(8): 10471054.
4. Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study [J]. Intensive Care Med, 2009, 35(10): 17281737.
5. Smyrnios NA, Curley FJ, Shaker KG. Accuracy of 30minute indirect calorimetry studies in predicting 24hour energy expenditure in mechanically ventilated, critically ill patients [J]. J Parenter Enteral Nutr, 1997, 21(3): 168174.
6. Rocha EEM. Determination of caloric expenditure in critically ill patients [J]. Clin Bras Terap Intens, 2001, 11(1): 123.
7. McClave SA, Lowen CC, Kleber MJ, et al. Clinical use of the respiratory quotient obtained from indirect calorimetry [J]. J Parenter Enter Nutr, 2003, 27(1): 2126.
8. Walker RN, Heuberger RA. Predictive equations for energy needs for the critically ill [J]. Respir Care, 2009, 54(4): 509521.
9. da Rocha EE, Alves VG, da Fonseca RB. Indirect calorimetry: methodology, instruments and clinical application [J]. Curr Opin Clin Nutr Metab Care, 2006, 9(3): 247256.
10. Elizabeth Weekes C. Controversies in the determination of energy requirements [J]. Proc Nutr Soc, 2007, 66(3): 367377.
11. Wooley JA. Indirect calorimetry: applications in practice [J]. Respir Care Clin N Am, 2006, 12(4): 619633.
12. Frankenfield D, Smith SJ, Cooney RN. Validation of 2 approaches to predicting resting metabolic rate in critically ill patients [J]. J Parenter Enter Nutr, 2004, 28(4): 259264.
13. Lev S, Cohen J, Singer P. Indirect calorimetry measurements in the ventilated critically ill patient: facts and controversies—the heat is on [J]. Crit Care Clin, 2010, 26(4): e1e9.
14. Faisy C, Lerolle N, Dachraoui F, et al. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation [J]. Br J Nutr, 2009, 101(7): 10791087.
15. Brandi LS, Bertolini R, Calafà M. Indirect calorimetry in critically ill patients: clinical applications and practical advice [J]. Nutrition, 1997, 13(4): 349358.
16. Reid CL, Carlson GL. Indirect calorimetry—a review of recent clinical applications [J]. Curr Opin Clin Nutr Metab Care, 1998, 1(3): 281286.
17. Frankenfield DC, Sarson Y, Blosser SA, et al. Validation of a 5minute steady state indirect calorimetry protocol for resting EE in critically ill patients [J]. J Am Coll Nutr, 1996, 15(3): 397402.
18. McClave SA, Spain DA, Skolnick JL, et al. Achievement of steady state optimizes results when performing indirect calorimetry [J]. J Parenter Enter Nutr, 2003, 27(1): 1620.
19. Reeves MM, Davies PS, Bauer J, et al. Reducing the time period of steady state does not affect the accuracy of energy expenditure measurements by indirect calorimetry [J]. J Appl Physiol, 2004, 97(1): 130134.
20. Petros S, Engelmann L. Validity of an abbreviated indirect calorimetry protocol for measurement of resting energy expenditure in mechanically ventilated and spontaneously breathing critically ill patients [J]. Intensive Care Medicine, 2001, 27(7): 11641168.
21. Branson RD, Johannigman JA. The measurement of energy expenditure [J]. Nutr Clin Pract, 2004, 19(5): 622636.
22. Brandi LS, Bertolini R, Santini L, et al. Effects of ventilator resetting on indirect calorimetry measurement in the critically ill surgical patient [J]. Crit Care Med, 1999, 27(3): 531539.
23. Haugen HA, Chan LN, Li F. Indirect calorimetry: a practical guide for clinicians [J]. Nutr Clin Pract, 2007, 22(4): 377388.
24. Compher C, Frankenfield D, Keim N, et al. Best practice methods to apply to measurement of resting metabolic rate in adults: a systematic review [J]. J Am Diet Assoc, 2006, 106(6): 881903.
25. da Rocha EE, Alves VG, Silva MH, et al. Can measured resting energy expenditure be estimated by formulae in daily clinical nutrition practice?[J]. Curr Opin Clin Nutr Metab Care, 2005, 8(3): 319328.
26. 黎介壽. 臨床營養支持策略的變遷 [J]. 中國普外基礎與臨床雜志, 2009, 16(12): 953955.
27. 秦環龍, 楊俊. 外科營養的現狀與展望 [J]. 中國普外基礎與臨床雜志, 2008, 15(11): 791793.
28. Hwang TL, Huang SL, Chen MF. The use of indirect calorimetry in critically ill patients—the relationship of measured energy expenditure to Injury Severity Score, Septic Severity Score, and APACHE Ⅱ Score [J]. J Trauma, 1993, 34(2): 247251.
29. Blackburn GL, Wollner S, Bistrian BR. Nutrition support in the intensive care unit: an evolving science [J]. Arch Surg, 2010, 145(6): 533538.
30. Burke PA, Young LS, Bistrian BR. Metabolic vs nutrition support: a hypothesis [J]. J Parent Enteral Nutr, 2010, 34(5): 546548.

《中國普外基礎與臨床雜志》

機械通氣下外科危重癥患者靜息能量消耗評價

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《中國普外基礎與臨床雜志》

機械通氣下外科危重癥患者靜息能量消耗評價

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