等热卡不同蛋白质含量肠内营养支持对老年重症肺炎患者蛋白质代谢的影响

摘要

目的 探讨降低老年重症肺炎并发低白蛋白血症患者的肠内营养(EN)支持方法.方法 选择2016年1月至2017年1月杭州市老年病医院重症医学科(ICU)收治的60例给予EN治疗的老年重症肺炎患者,在相等非蛋白质热量(125.52 kJ·kg-1·d-1)摄入条件下,进行不同蛋白质含量EN支持.给予标准营养制剂能全力(热氮比=130:1)的30例患者作为标准营养组,给予高蛋白肠内营养制剂瑞高(热氮比=100:1)的30例患者作为高蛋白营养组,EN治疗14 d后评价临床疗效.比较两组入院时和治疗后血清总蛋白(TP)、白蛋白(Alb)、前白蛋白(PA)、总胆固醇(TC)、三酰甘油(TG)、高密度脂蛋白(HDL)、低密度脂蛋白(LDL)水平的差异.结果 两组治疗后7 d和14 d TP、Alb、PA、TC、HDL、LDL水平均较入院时降低,但高蛋白营养组的降低程度不及标准营养组明显;标准营养组治疗后血糖水平较入院时降低,高蛋白营养组较入院时升高;治疗后14 d高蛋白营养组TP(g/L:62.1±7.6比60.1±5.2)、Alb(g/L:33.0±4.8比32.0±4.2)、PA(mg/L:226.79±79.22比202.79±71.78)、TC(mmol/L:4.88±1.09比4.09±0.80)、HDL(mmol/L:1.07±0.2比0.92±0.20)、LDL(mmol/L:3.16±0.76比2.50±0.56)、血糖(mmol/L:7.68±2.44比6.72±1.75)水平均高于标准营养组;标准营养组治疗后TG表现为先降低后升高的趋势,高蛋白营养组则持续升高,治疗7 d后高蛋白营养组明显高于标准营养组(mmol/L:3.56±1.43比2.78±0.81,P<0.05).发病14 d内,急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分>19分患者高蛋白营养组低白蛋白血症发生率明显低于标准营养组〔66.67%(10/15)比100.00%(13/13), P<0.05〕;APACHEⅡ评分<19分患者高蛋白营养组低白蛋白血症发生率与标准营养组比较差异无统计学意义〔54.54%(6/11)比44.44%(4/9),P>0.05〕.高蛋白营养组3个月病死率有低于标准营养组的趋势〔14 d:13.3%(4/30)比26.7%(8/30),28 d:20.0%(6/30)比30.0%(9/30),60 d:30.0%(9/30)比33.3%(10/30), 90 d:36.7%(11/30)比40.0%(12/30)〕,但两组比较差异均无统计学意义(均P>0.05).结论 老年重症肺炎患者应用高蛋白EN制剂可以改善蛋白代谢,减少低白蛋白血症的发生.%Objective To study the enteral nutritional (EN) approach to decrease the risk of developing hypo-albuminemia in elderly patients with severe pneumonia. Methods Sixty elderly patients with severe pneumonia admitted to the intensive care unit (ICU) of Hangzhou Geriatric Hospital from January 2016 to January 2017 were enrolled, and they were given EN support with different protein contents but the same non-protein calories (125.52 kJ·kg-1·d-1). Thirty patients given standard EN formula [supplied as nutrition fibre, thermal nitrogen ratio (HRN) = 130:1] were assigned as the standard EN group, another 30 patients fed with high-protein EN formula (supplied as fresubin 750 MCT, HRN = 100:1) were arranged as the high-protein EN group, and the clinical efficacy in the two groups was evaluated after treatment for 14 days. The serum levels of total protein (TP), albumin (Alb), pre albumin (PA), total cholesterol (TC), triglyceride (TG), high density lipoprotein (HDL), low density lipoprotein (LDL) of both groups were compared at admission and after treatment. Results The levels of TP, Alb, PA, TC, HDL, LDL in two groups on 7 and 14 days after treatment were lower than those on admission, but the degrees of reduction in high-protein EN group were not as significant as those in standard EN group; the levels of blood glucose (Glu) in the standared EN group after treatment were lower than those on admission, Glu in high-protein EN group were higher than those on admission;after treatment for 14 days, the levels of TP (g/L: 62.1±7.6 vs. 60.1±5.2), Alb (g/L: 33.0±4.8 vs. 32.0±4.2), PA (mg/L: 226.79±79.22 vs. 202.79±71.78), TC (mmol/L: 4.88±1.09 vs. 4.09±0.80), HDL (mmol/L: 1.07±0.2 vs. 0.92±0.20), LDL (mmol/L: 3.16±0.76 vs. 2.50±0.56), Glu (mmol/L: 7.68±2.44 vs. 6.72±1.75) in high-protein EN group were significantly higher than those in standard EN group; after treatment, TG showed a trend of firstly decreasing and then increasing, while TG in high-protein EN group manifested continuously increasing, after 7 days of treatment, TG in the high-protein EN group was significantly higher than that in the standard EN group (mmol/L: 3.56±1.43 vs. 2.78±0.81, P < 0.05). Within 14 days after disease onset, the incidence of hypoalbuminemia in high-protein EN group was significantly lower than that in standard EN group in patients with acute physiology and chronic health evaluationⅡ (APACHE Ⅱ) score > 19 score [66.67% (10/15) vs. 100.00% (13/13), P < 0.05]; there was no statistical significant difference in the incidence of hypoalbuminemia between the two groups in patients with APACHE Ⅱ score < 19 score [54.54% (6/11) vs. 44.44% (4/9), P > 0.05]. Compared with standard EN group, the 3-month mortality in high-protein EN group showed a trend of decreasing [14 days: 13.3% (4/30) vs. 26.7% (8/30), 28 days: 20.0% (6/30) vs. 30.0% (9/30), 60 days: 30.0% (9/30) vs. 33.3% (10/30), 90 days: 36.7% (11/30) vs. 40.0% (12/30)], but there was no statistical significant difference between the two groups (all P > 0.05). Conclusion Application of high-protein EN in elderly patients with severe pneumonia can improve protein metabolism, and reduce the incidence of hypoalbuminemia.