拓宽视野 搞好烧伤临床营养支持工作

今年刚刚通过的“十一五”规划纲要中有一项重要内容就是“推进改善公众营养行动”。作为从事烧伤救治工作的专科医师，随时都面临着给予烧伤患者相应的营养支持治疗。那么今后如何做好这项工作呢？笔者认为不仅要精通有关烧伤后机体代谢水平变化和营养需求的知识，还需要了解国内外其他相关临床学科和基础学科营养支持工作的研究进展。在此，笔者简单介绍国内外重要营养学会的组织机构、主办杂志以及这些学会近年来针对临床营养支持的主要研究方向。     

烧伤治疗中的肠外营养支持策略

Parenteral nutrition support for burn injury in China began to develop in 1970s along with improvement in burn foundational research of burn injury and the marketing of parenteral nutrition solutions manufactured by Chinese amino acids pharmaceutical industry. Up to 1980s many kinds of parenteral nutrition products were used in clinical therapy, and they were proved to be effective and safe. Meanwhile the guide for parenteral nutrition support of China was drafted to ensure standard ized administration. Some problems should be called for attention in present practice of parenteral nutrition support. First, immunonutrients have been proved to possess synergistic effect on parenteral/enteral nutrition support. But for those critical patients in sepsis/MODS period, more attention should be paid to the use of immunonutrients in time of administration and optimal dosage because of the complicate physiopathologic reactions. Secondly,the use of growth hormone has been proved to be effective for promoting healing in patients with burn in many cases. However, the indications of growth hormone should be strictly observed and the regime of a low dose and short course should be adopted 7 days after burn for ensuring safety. Thirdly, we should pay attention to the best path of giving nutrition, whether enteral or parenteral. Parcnteral nutrition support should be adopted for critical burn patients in early period with intestinal dysfunction, and enteral nutrition support should be used when intestinal functions recover partially. For patients with burn hypermetabolism, the application of enteral and parenteral nutrition support is complimentary, and it is aptly called total nutrition.     

烧伤患者的营养支持

烧伤后由于组织严重毁损,以及受剧烈应激反应的影响,机体在糖、蛋白质、脂肪、维生素、微量元素等代谢方面都发生一系列极为复杂的变化。一方面组织分解加剧,蛋白质大量丢失,能量消耗增加,代谢率升高,导致严重负氮平衡、体重下降、免疫功能低下及创面愈合延迟等;另一方面机体恢复及创面修复又需要大量营养物质。合理的营养支持及代谢调理,有利于降低机体代谢消耗,维护脏器功能,增强免疫机制,预防和控制感染,促进烧伤创面愈合。烧伤患者是否需要营养支持,取决于患者伤前营养状况、烧伤的严重程度以及对烧伤患者营养状况的评估。对于重度营养…     

严重烧伤患者早期肠内营养治疗的研究进展

严重烧伤会导致持续性的代谢亢进,研究显示尽早开展肠内营养治疗与改善严重烧伤患者预后、降低病死率、减少胃肠道并发症和感染性并发症等存在相关性。本文介绍了严重烧伤患者早期肠内营养治疗的营养益处及非营养益处（维持肠黏膜功能和结构的完整性及促进创面愈合）、营养治疗介入的时机和途径、能量评估方法及营养监测等,旨在为早期肠内营养治...     

烧伤患者胃肠外营养

营养支持绝不仅仅是烧伤患者的饱腹手段和维持生命之所需,更重要的是应作为综合治疗手段之一,必须予以充分重视.     

重视危重烧伤患者代谢和营养支持的研究

营养是涉及人类生存、与健康息息相关的一个永恒的话题。古代中外医学文献就有天灾和战争给人类带来饥荒、成为传染性疾病肆虐祸首的记载。第二次世界大战集中营里的战俘死于营养不良与疾病的资料 ,更证实营养不良、免疫功能低下是直接造成疾病的原因。196 7年美国Ｄｕｄｅｉｃｋ与Ｗｉｌｍｏｒｅ医生创建了完全胃肠外营养支持 (ＴＰＮ)。通过提供合理配比的外源性营养底物使外科危重患者营养支持得到重视。196 8年 1975年ＴＰＮ应用达到狂热程度 ,1975年 1985年进入合理应用的阶段 ,随后的发展是对肠内营养重要性的重新认识。 1988年Ｃｅｒ…     

烧伤代谢影响和营养支持

严重烧伤以明显的超高代谢为特征,这些特征涉及机体基础代谢率、体内激素和代谢介质、蛋白质、脂肪、碳水化合物等一系列病理生理改变,从而造成了烧伤病人的负氮平衡、免疫功能低下以及创面愈合障碍等严重后果,因此合理的烧伤营养支持是非常重要的。     

我国烧伤代谢营养支持研究进展

1958年我国掀起救治大面积烧伤的热潮 ,各单位纷纷成立烧伤病房、烧伤专科。 6 0年代 ,少数单位已认识到烧伤后代谢营养的重要性 ,并建立实验室 ,或借助校、院中心实验室开展了烧伤代谢研究 ,十年动乱时被迫下马 ,研究基本处于停滞状态。 70年代末才逐步恢复组建实验室。 80年代以来 ,我国烧伤代谢营养的研究进入蓬勃发展时期。在以下问题上 ,有了新的认识。一、烧伤后代谢紊乱1.应激反应 :烧伤后应激反应包含下丘脑 -垂体 -肾上腺轴反应、急性相反应及植物神经系统反应。观察统计 2 0例烧伤患者的血浆皮质醇、肾素、血管紧张素、胰岛素、血…     

胃肠外科患者的肠道免疫与营养支持治疗

胃肠外科患者常伴有营养不良,肠外营养是肠功能障碍者的主要营养方式。正常肠道黏膜免疫系统能有效防御肠道细菌,而缺乏肠内营养刺激的肠外营养会导致肠道黏膜免疫损伤,增加感染风险,通过营养支持治疗保护肠道黏膜屏障十分重要。     

我国烧伤代谢营养研究

The achievements of burn metabolism and nutrition in China are briefly presented. Advance a new theory "Enterogenous Hypermetabolism". Develop a formula to calculate calorie needs in Chinese burn adults. Put forward new ideas on glucose absorption, neoglycogenesis, insulin resistance, and the use of hypoglycemic agent after burn inury. Observe the variation of plasma level of free aminoacids, investigate the changes and mechanisms of 26S proteasome and 19S regulator in skeletal muscle of burn trauma, and the clinical application and its mechanism of glutamine and arginine. Introduce the approach of 13 C NMR spectroscopy to investigate the alterations of hepatic anabolism functions in severely burned rats. Offer supplying the suitable dosage of vitamin A,C,E and microeiement of zinc, copper, ferrum for burn patients. Carry out serial studies of early enteral and parenteral nutrition, and compare enteral nutrition with parenteral nutrition. Early ehteral nutrition with synbiotics might be beneficial to the controlling of burn infection. Both glucagon like peptide-2(GLP-2) and intestinal trefoil factor(ITF) exhibit protective effect on intestinal mucosa in minimizing injury and protecting barrier function. The choice of suitable opportunity to use rhGH (growth hormone) is investigated. In addition, advance the view points of isehemia and anoxia in metabolism, anti-inflammatory immune and nutrition.     

Validation of the modified NUTrition Risk Score (mNUTRIC) in mechanically ventilated,severe burn patients: A prospective multinational cohort study

BackgroundWhether nutrition therapy benefits all burn victims equally is unknown. To identify patients who will benefit the most from optimal nutrition, the modified Nutrition Risk in Critically Ill (mNUTRIC) Score has been validated in the Intensive Care Unit. However, the utility of mNUTRIC in severe burn victims is unknown. We hypothesized that a higher mNUTRIC (≥5) will be associated with worse clinical outcomes, but that greater nutritional adequacy will be associated with better clinical outcomes in patients with higher mNUTRIC score.MethodsThis prospective study included data from mechanically ventilated, severe burn patients (n = 359) from 51 Burn Units worldwide included in a randomized trial. Our primary and secondary outcomes were hospital mortality and the time to discharge alive (TTDA) from hospital. We described the association between nutrition performance and clinical outcomes.ResultsCompared to low mNUTRIC (n = 313), the high mNUTRIC group (n = 46) had higher mortality (61% vs. 19%, p = 0.001), and longer TTDA (>90 [87–>90] vs. 64 [38–90] days, p = <0.0001). Only in the high mNUTRIC group, increased calorie intake (per 20% increase) was associated with lower mortality and a faster TTDA.ConclusionsThe mNUTRIC score identifies those with poor clinical outcomes and may identifies those mechanically ventilated, severe burn patients in whom optimal nutrition therapy may be more advantageous.     

Practical guidelines for nutritional management of burn injury and recovery

Nutrition practice in burn injury requires a multifaceted approach aimed at providing metabolic support during a heightened inflammatory state, while accommodating surgical and medical needs of the patient. Nutritional assessment and determination of nutrient requirements is challenging, particularly given the metabolic disarray that frequently accompanies inflammation. Nutritional therapy requires careful decision making, regarding the safe use of enteral or parenteral nutrition and the aggressiveness of nutrient delivery given the severity of the patient's illness and response to treatment. With the discovery that specific nutrients can actually alter the course of disease, the role of nutrition support in critical illness has shifted from one of preventing malnutrition to one of disease modulation. Today the use of glutamine, arginine, essential fatty acids, and other nutritional factors for their effects on immunity and cell regulation is becoming more common, although the evidence is often lagging. An exciting dichotomy exits, forcing nutrition support specialists to make responsible choices while remaining open to new potential helpful therapeutic options.     

术前营养风险筛查对结直肠癌患者围手术期营养支持治疗的临床意义

目的探讨术前营养风险筛查对结直肠癌患者围手术期营养支持的指导作用,为临床合理开展营养支持提供依据。方法参照营养风险筛查方法2002（NRS2002）。对2009年3月至2010年3月间在无锡市第四人民医院、同济大学附属同济医院及苏州大学附属第二医院住院治疗的290例结直肠癌患者进行术前营养风险评估。并根据评估结果比较术前接受与未接受营养支持患者术后肠功能恢复情况及相关营养指标。结果营养风险筛查结果显示,110例结直肠癌患者术前存在营养风险,其中65例实施了营养支持,其临床结局均明显优于未接受营养支持的45例患者[术后排气时间（2．3±0．5）d比（3．3±0．5）d、排粪时间（3．5±0．5）d比（4．6±0．6）d、恢复半流饮食时间（10．1±1．2）d比（12．4±2．2）d和术后住院时间（15．7±1．1）d比（18．8±1．4）d,均P〈0．05];其术后第7天营养指标也优于未接受营养支持者[血清白蛋白（33．2±4．5）g／L比（26．0±4．0）g／L、前白蛋白（0．28±0．05）g／L比（0．16±0．04）g／L和转铁蛋白（1．92±0．33）g／L比（1．75±0．45）g／L,均P〈0．05]。但对于180例经营养风险筛查术前无营养风险患者,术前是否接受营养支持其上述临床结局及营养指标的差异均无统计学意义（均P〉0．05）。结论对于术前营养风险筛查提示存在营养风险的结直肠癌患者,术前应积极予以营养支持;但对于无营养风险者,围手术期的营养支持或并不必要。     

早期肠内免疫营养对烫伤小鼠肠道免疫功能的影响

目的 了解早期免疫强化肠内营养对烫伤小鼠肠道免疫功能的影响.方法 选择24只雄性BALB/c小鼠制作20%TBSAⅢ度烫伤模型,采用简单随机法分成2组.每组12只.普通营养组:于伤后2 h开始经口灌喂普通肠内营养剂;免疫营养组:方法同前,在普通营养剂基础上加入谷氨酰胺和精氨酸.2组营养剂糖、脂肪、蛋白质供热比均为82:3:15,热量与氮之比为150:1.每只小鼠营养摄入按732.2 kJ·kg-1·d-1计算,第1天摄入标准量的1/3,第2天摄入标准量的1/2,第3天起摄入全量,每天的计划量分4～6次喂完.2组营养摄入为等氮、等热量、等体积.小鼠连续灌喂7d后处死,取全段小肠.另取10只同品系小鼠作为健康对照组,同法取材.记录肠集合淋巴结细胞总数,通过流式细胞仪检测淋巴结中CD3+、CD4+、CD19+及凋亡细胞变化,双抗体夹心酶联免疫吸附测定法检测肠IgA变化.结果 健康对照组、普通营养组、免疫营养组小鼠肠道淋巴结细胞总数分别为(4.5±0.6)×106、(2.3±0.4)×106、(3.8±0.5)×106个,与健康对照组比较,后2组细胞数明显减少(P＜0.05).但免疫营养组高于普通营养组(P＜0.05);3组小鼠肠道淋巴结CD3+、CD4+、CD19+细胞数比较情况类似于淋巴结细胞总数.健康对照组、普通营养组、免疫营养组淋巴细胞凋亡率分别为(4.8±2.1)%、(12.7±2.4)%、(8.0±1.7)%,与健康对照组比较,后2组小鼠细胞凋亡率明显增加(P＜0.05),但免疫营养组低于普通营养组(P＜0.05).健康对照组、普通营养组、免疫营养组肠IgA水平分别为(42±7)、(35±6)、(38±6)μg/cm,与健康对照组相比,后2组水平明显减低(P＜0.05),但免疫营养组高于普通营养组(P＜0.05).结论 用强化免疫营养剂进行早期肠内营养,可以改善烫伤小鼠肠道免疫功能.     

Perceived social support among patients with burn injuries: A perspective from the developing world

Background

Social support is among the most well-established predictors of post-burn psychopathology after burn. Despite a disproportionately large burden of burns in the developing world, the nature of social support among burn patients in this context remains elusive. We, therefore, seek to investigate social support and its biopsychosocial determinants among patients with burn injuries in Pakistan.

Virtual Reality in the treatment of burn patients: A systematic review

AimTo identify studies that approach immersive virtual realities and its main effects in the treatment of burn patients in the context of the scientific world of literature.MethodsA systematic review following the steps of Cochrane. The search was conducted in eight databases between May and August 2016.Results34 studies were analyzed, including 23 randomized clinical trials. VR was applied using three-dimensional features and video games. The findings demonstrate the association of this technology with increased enjoyment and the reduction of pain, anxiety and stress during dressing changes and also during physical rehabilitation and physiotherapy. Few side effects have been reported.ConclusionVR is a complementary drug strategy that has proven beneficial results in the treatment of burn patients.