动态监测瓜氨酸对重度胃肠损伤患者早期肠内营养的指导价值  

Guiding value of dynamic monitoring citrulline for early enteral nutrition in patients with severe gastrointestinal injury

作　　者：钱春霞 陆件[1] 陈亚欧 朱金伟 Qian Chunxia;Lu Jian;Chen Yaou;Zhu Jinwei(Department of Critical Care Medicine,Suzhou Hospital Affiliated to Nanjing Medical University(Suzhou College of Nanjing Medical University,Suzhou Municipal Hospital),Suzhou 215000,Jiangsu,China)

机构地区：[1]南京医科大学附属苏州医院(南京医科大学姑苏学院,苏州市立医院本部)重症医学科,江苏苏州215000

出　　处：《中华危重病急救医学》2023年第4期409-414,共6页Chinese Critical Care Medicine

基　　金：江苏省苏州市卫生计生委科技项目(LCZX202112);江苏省临床重点专科建设项目(2016-8)。

摘　　要：目的探讨动态监测瓜氨酸(Cit)对重度胃肠损伤患者早期肠内营养(EN)是否具有指导价值。方法采用观察性研究方法,选择2021年2月至2022年6月南京医科大学附属苏州医院不同重症监护病房收治的76例重度胃肠损伤患者。所有患者均按照指南推荐意见于入院24~48 h实施早期EN;EN 7 d未终止者纳入早期EN成功组,7 d内因持续性喂养不耐受或全身情况恶化而终止EN者纳入早期EN失败组,治疗过程中不进行干预。分别于入院时、EN开始前及EN 24 h通过质谱分析测定血清Cit水平,并计算EN 24 h内Cit变化值(ΔCit=EN 24 h Cit-EN开始前Cit)。绘制受试者工作特征曲线(ROC曲线),探讨ΔCit对早期EN失败的预测价值,并计算最佳预测值;采用多因素非条件Logistic回归法分析早期EN失败及28 d死亡的独立危险因素。结果76例患者均纳入最终分析,其中早期EN成功40例,失败36例;两组患者年龄、主要诊断、入院时急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、EN开始前血乳酸(Lac)及ΔCit差异均有统计学意义。多因素Logistic回归分析显示,年龄〔优势比(OR)=0.929,95%可信区间(95%CI)为0.874~0.988,P=0.018〕、ΔCit(OR=2.026,95%CI为1.322~3.114,P=0.001)及48 h内增加喂养量(OR=13.719,95%CI为1.795~104.851,P=0.012)是重度胃肠损伤患者早期EN失败的独立危险因素。ROC曲线分析显示,ΔCit对重度胃肠损伤患者早期EN失败具有良好的预测价值〔ROC曲线下面积(AUC)=0.787,95%CI为0.686~0.887,P<0.001〕,通过约登指数计算出ΔCit最佳预测值为0.74μmol/L(敏感度为65.0%,特异度为75.0%)。结合ΔCit最佳预测值,定义ΔCit<0.74μmol/L且48 h内需要增加喂养量为"过度喂养"。多因素Logistic回归分析显示,年龄(OR=0.825,95%CI为0.732~0.930,P=0.002)、APACHEⅡ评分(OR=0.696,95%CI为0.518~0.936,P=0.017)及早期EN失败(OR=181.803,95%CI为3.916~8439.606,P=0.008)是重度胃肠损伤患者28 d死亡的独立危险因素;新增变量"过度�Objective To investigate whether dynamic monitoring of citrulline(Cit)has guiding value for early enteral nutrition(EN)in patients with severe gastrointestinal injury.Methods A observational study was conducted.A total of 76 patients with severe gastrointestinal injury admitted to different intensive care units of Suzhou Hospital Affiliated to Nanjing Medical University from February 2021 to June 2022 were enrolled.Early EN was performed in 24-48 hours after admission as recommended by the guidelines.Those who did not terminate EN after 7 days were enrolled in the early EN success group,and those who terminated EN within 7 days due to persistent feeding intolerance or deterioration of general condition were enrolled in the early EN failure group.There was no intervention during the treatment.Serum Cit levels were measured by mass spectrometry at admission,before EN starting and EN 24 hours,respectively,and the changes in Cit within EN 24 hours(ΔCit)were calculated(ΔCit=EN 24-hour Cit-Cit before EN starting).Receiver operator characteristic curve(ROC curve)was plotted to investigate the predictive value ofΔCit for early EN failure,and the optimal predictive value was calculated.Multivariate unconditional Logistic regression was used to analyze the independent risk factors for early EN failure and death at 28 days.Results Seventy-six patients were enrolled in the final analysis,of which 40 succeeded in early EN and 36 failed.There were significant differences in age,main diagnosis,acute physiology and chronic health evaluationⅡ(APACHEⅡ)score at admission,blood lactic acid(Lac)before EN initiation andΔCit between the two groups.Multivariate Logistic regression analysis showed that age[odds ratio(OR)=0.929,95%confidence interval(95%CI)was 0.874-0.988,P=0.018],ΔCit(OR=2.026,95%CI was 1.322-3.114,P=0.001)and increased feeding rate within 48 hours(OR=13.719,95%CI was 1.795-104.851,P=0.012)were independent risk factors for early EN failure in patients with severe gastrointestinal injury.ROC curve analysis showed

关 键 词：瓜氨酸 重度胃肠损伤 肠内营养 过度喂养 延迟性喂养不耐受 

分 类 号：R57[医药卫生—消化系统] R459.3[医药卫生—内科学]