严重烧伤病人的全肠外营养

我们对9例烧伤总面积平均为42%,Ⅲ°面积平均为26%的病人,应用18F氨基酸作为氮源,进行全肠外营养治疗的前瞻性研究.结果表明,在适当的氮/热卡比例下,大部分病例(7/9)可获得正氮平衡.2例病人未获得正氮平衡,说明营养支持的效果除烧伤面积,深度,还有其它影响因素,有待于进一步研究.     

Nutrition support strategies for severely burned patients.

Significant weight loss is a common complication of a major burn injury. Before the modern era of early enteral nutrition support, such a complication contributed significantly to impaired wound healing, raised risk of infectious morbidity, and ultimately increased mortality. Nutrition management of the burn patient is designed to promote wound healing while minimizing loss of lean body mass. The burn patient characteristically demonstrates an increase in energy expenditure after the initial injury and period of resuscitation. Studies have demonstrated that early institution of enteral feeding can attenuate the stress response, abate hypermetabolism, and improve patient outcome.     

大面积烧伤病人的营养支持疗法

为了评价中心静脉营养在大面积烧伤治疗中的作用,总结近11年总面积大于50％的烧伤病人96例。分两组:中心静脉营养组(C组),非中心静脉营养组(N组)。结果显示C组肠道热量摄入较N组低,但总热量明显提高。与N组相比愈合时间缩短,并发症较少,死亡率降低。     

Early enhanced enteral nutrition in burned patients is associated with fewer infective complications and shorter hospital stay

Background: Major burn injury causes a catabolic state associated with depressed immunocompetence and a high incidence of morbidity and mortality. Previous studies have shown that provision of patients’ energy and nitrogen requirements early in the postburn period reduces net catabolism and supports the immune response. Methods: This observational study determined the effect of providing at least 50% of a patient's estimated requirement of energy and nitrogen (‘enhanced enteral nutrition, EN’) in 106 burned patients requiring intravenous fluid resuscitation. Multiple regression was used to determine associations between the delay to enhanced EN and the incidence of death, infection and total complications, and hospital stay. Results: Delay to enhanced EN was associated with infective complications (P=0.01) when adjusted for potential confounding factors. The risk of infection increases from 29% at 24 h to 66% at 48 h (number needed to treat, NNT: 3, and 1.5, respectively). In addition, the delay to enhanced EN was associated with hospital stay (P=0.001, 95% CI 1.5–5.5). A delay of 24 h was associated with an increase in hospital stay of 3.5 days. The associations held in survivors as well as the total group and therefore were not the result of early death causing a reduction in infections and hospital stay. No associations were found with death or total complications. Conclusion: Earlier commencement of EN which meets 50% of estimated energy and nitrogen requirements may reduce the incidence of infection and hospital stay. The potential clinical benefits and cost savings must be confirmed in prospective randomized controlled trials.     

严重烧伤病人微量元素的动态变化

目的：了解重度烧伤后血及２４ｈ尿中七种微量元素的变化规律。方法：选择烧伤面积，３０％的病人１０例，动态测定伤后至创面基本愈合时血、２４ｈ尿中锌、铜，铁、钼、硒、铬的浓度，同时选择未烧伤者３９例正常对照组。结果：２４ｈ尿中七种元素排泄量均增加，血锌明显下降，铜、铬、钼水平增加、铁、硒、锰未见明显变化。结论：严重烧伤后微量元素代谢发生较大变化，但是否需要补充及何时补充仍值得探讨。     

日间手术对缩短平均住院日的影响

目的研究日间手术对缩短平均住院日的影响。方法采用SAS8．2统计软件,通过方差分析比较2005年9月-2008年7月的3个时间段仁济医院全院和6个开展日问手术科室之间的数据．并分析日间手术例数占出院人数的比例与平均住院天数缩短时间的相关性以及拟合直线回归方程。结果全院和6个手术科室日间手术例数占出院人数的比例存在统计学差异,日间手术例数占出院人数的比例与平均住院日缩短时间之间存在显著正相关。结论开展日间手术对缩短平均住院日有积极意义。     

Noise and hospital stay.

Length of hospital stay for simple cataract surgery was compared retrospectively for a period of construction noise and for two similar periods without construction noise. Hospital stay was significantly longer during the period of construction.     

大面积烫伤合并难治性糖尿病的营养治疗

患者女 ,4 8岁。锅炉爆炸沸水烫伤双上、下肢 ,面部 ,胸 ,背部等处 ,烫伤面积达 70 % ,均为Ⅱ° ,同时伴头皮挫裂伤 ,头皮血肿。入院查生命体征平稳 ,血电解质、肝肾功能基本正常 ,因伤势较重 ,未测身高、体重、臂围、肌围 ,自述身高 15 6ｃｍ ,体重 6 5ｋｇ。给予抗休克、抗感染、清创 ,择期手术等治疗 ,在抢救治疗过程中 ,该例先后合并血糖升高 ,餐前 18.6ｍｍｏｌ/Ｌ ,餐后 2 2 .0ｍｍｏｌ/Ｌ ,肾小球滤过率增高 ,ＢＵＮ 7.7～ 9.2ｍｍｏｌ/Ｌ ,Ｃｒ 5 1～ 142 μｍｏｌ/Ｌ ,低蛋白血症 ,白蛋白为 2 5 ｇ/Ｌ ,球蛋白 2 1.7ｇ/Ｌ ,总蛋白4…     

代谢车在重度烧伤病人能量代谢测定中的应用

目的:研究重度烧伤病人能量代谢特点,并分析疾病严重程度和手术等因素对静息能量消耗(REE)的影响. 方法:将机械通气治疗的20例重度烧伤病人,通过代谢车测定REE,并将伤后第1、3、7、14和28天测得的REE(mREE)与H-B公式计算所得REE(pREE)相比较.同时,比较APACHEⅡ评分≥15分与＜15分组、手术前1d与术后24h的mREE. 结果:①伤后第1、3、7、14和28天时,mREE值介于pREE 1.5与pREE 2.0之间.②APACHEⅡ≥15分组的mREE高于APACHEⅡ＜15分组(P＜0.05).③术后24 h的mREE水平较术前1d显著降低(P＜0.05). 结论:重度烧伤病人应用代谢车测定的REE介于pREE 1.5与pREE 2.0之间.病情危重程度和手术可能对REE水平有影响.     

严重烧伤病人血脂变化的研究

1995年4月～1997年11月系统地观察了43例大面积烧伤病人的血脂变化，同时观察了输入脂肪乳剂（Intralipid）对大面积烧伤病人血脂代谢的影响。血脂包括总胆固醇（TC），甘油三酯（TG），高密度脂蛋白（HDL），低密度脂蛋白（LDL），载脂蛋白A（apoA）和载脂蛋白B（apoB），经检测未发现高血脂异常。输入20％脂肪乳剂250ml，未发现对血脂代谢不良影响。本组深度烧伤病例约56％出现胆固醇水平降低，同时还发现34％病例肝功能异常。因此，对严重烧伤病人在促进肝功能恢复的同时，可适当补充高脂、高糖食物。     

四种生长激素对重度烧伤患者血糖的影响

明显增多(P＜0.01);在应用同种生长激素的情况下,使用剂量为0.2U·kg-1·d-1的治疗组比使用剂量为0.15 U·kg-1·d-1的治疗组患者平均胰岛素用量也明显增多(P＜0.01).除空白对照组外,其他各治疗组停用生长激素后血糖均恢复到正常值范围之内且不需要胰岛素控制,恢复至正常的时间差异无统计学意义(P＞0.05).结论 重度烧伤患者血糖水平与生长激素的使用剂量呈正相关;不同技术生产的生长激素对重度烧伤患者血糖影响基本相同;规范应用生长激素进行治疗,不会导致糖尿病.     

四种生长激素对重度烧伤患者血糖的影响

目的探讨不同生长激素对重度烧伤患者血糖的影响。方法选取我院1999年1月～2007年12月间收治的既往无糖尿病史的重度烧伤住院患者共630例,随机分为9组（n=70）,其中8组分别使用4种不同生产技术生产的生长激素,每种生长激素设0．15U·kg^-1·d^-1和0．2U·kg^-1·d^-1两个剂量组,空白对照组使用等量生理盐水。入院4周内,观察并比较各组患者血糖水平和胰岛素用量的变化。结果共571例患者完成试验。各组平均血糖控制水平差异无统计学意义（P〉0．05）。各治疗组比空白对照组平均胰岛素用量明显增多（P〈0．01）;在应用同种生长激素的情况下,使用剂量为0．2U·kg^-1·d^-1的治疗组比使用剂量为0．15U·kg^-1·d^-1的治疗组患者平均胰岛素用量也明显增多（P〈0．01）。除空白对照组外,其他各治疗组停用生长激素后血糖均恢复到正常值范围之内且不需要胰岛素控制,恢复至正常的时间差异无统计学意义（P〉0．05）。结论重度烧伤患者血糖水平与生长激素的使用剂量呈正相关;不同技术生产的生长激素对重度烧伤患者血糖影响基本相同;规范应用生长激素进行治疗,不会导致糖尿病。     

The metabolic basis of the increase of the increase in energy expenditure in severely burned patients.

BACKGROUND: Severe burn trauma is characterized by an elevated rate of whole-body energy expenditure. APPROACH: In this short review, we have attempted to assess the metabolic characteristics of and basis for the persistent increase in energy expenditure during the flow phase of the injury. We consider some aspects of normal energy metabolism, including the contribution of the major adenosine triphosphate (ATP)-consuming reactions to the standard or basal metabolic rate. Rate estimates are compiled from the literature for a number of these reactions in healthy adults and burned patients, and the values are related to the increased rates of whole-body energy expenditure with burn injury. RESULTS: Whole-body protein synthesis, gluconeogenesis, urea production, and substrate cycles (total fatty acid and glycolytic-gluconeogenic) account for approximately 22%, 11%, 3%, 17%, and 4%, respectively, of the burn-induced increase in total energy expenditure. CONCLUSIONS: These ATP-consuming reactions, therefore, seem to explain approximately 57% of the increase in energy expenditure. The remainder of the increase may be due, in large part, to altered Na(+)-K(+)-ATPase activity and increased proton leakage across the mitochondrial membrane.