间接能量消耗测定技术在腹部外科重症病人中的应用

目的比较外科重症病人间接测热法(indirect calorimetry,IC)与校正Harris-Benedict公式计算的能耗值之间的差异,并且评估接受机械通气的危重症病人能耗水平与疾病严重程度的相关性。方法 2015年2月至2016年10月间进入外科重症监护病房、符合本项研究入选标准的成年危重症病人共24例。24例病人在本研究开始时正在接受机械通气治疗。营养治疗期间收集入选病人急性生理与既往健康状况评分(APACHEⅡ评分)和器官功能不全评分(Marshall评分),以评价其疾病严重程度。营养治疗1周内,每日采用IC测定能耗;同时,由依据疾病严重程度而校正的HarrisBenedict公式计算能耗值,以便比较接受机械通气治疗的外科重症病人能耗测定值与计算值的差异。结果营养治疗1周内,24例病人平均能耗计算值为(8 670.88±1 828.53)k J/d[即(2 072.39±437.03)kcal/d],明显高于平均能耗测定值的(6 683.90±1 981.75)k J/d[即(1 597.49±473.65)kcal/d],两者间差异具有统计学意义(P0.001);营养治疗当天、第1、2、4天的能耗计算值明显高于测定值,其差异具有统计学意义(P0.05)。营养治疗1周内,入选病人的能耗计算值与测定值之间无相关性(r=0.048,P=0.565)。另外,营养治疗1周内的能耗测定值与APACHEⅡ评分之间也没有相关性(r=-0.032,P=0.602)。结论接受机械通气的外科重症病人的能耗与疾病严重程度无关;基于病情状态和严重程度而校正的Harris-Benedict公式明显高估了病人实际能耗水平;IC是评价危重症病人能耗水平的标准方法。     

外科机械通气重症患者静息能量代谢评估

目的 比较间接能量测定法测定的机械通气条件下外科重症患者静息能量代谢值与Harris-Benedict公式法和体重法计算值的差异,探讨外科重症患者静息能量代谢评估方法.方法 以2014年4月-2015年4月在首都医科大学宣武医院外科重症监护室接受机械通气的29例重症患者为研究对象,共纳入患者29例,其中男性13例,女性16例,测量静息能量代谢值188例次.采用间接能量测定法测定机械通气后第1、3、5天的静息能量代谢值,与根据身高、体重采用Harris-Benedict公式法和体重法所计算的静息能量代谢值比较,采用配对样本t检验方法分析重症患者代谢水平分布规律,探讨不同方法计算的静息能量代谢值之间的差异性.结果 根据Harris-Benedict公式法计算标准分析患者代谢水平分布规律:低代谢状态1 17次(62.24％),正常状态59次(31.38％),高代谢状态12次(6.38％).其中18例患者采用3种方法测得的第1、3、5天静息能量代谢值:间接能量测定法为(1 627.11±323.63) kcal、(1 614.67±308.93) kcal、(1 576.11±263.96) kcal;体重法为(1 479.44±200.24) kcal、(1 488.40±227.72) kcal、(1 434.14±216.56) kcal;Harris-Benedict公式法为(1 777.43±253.00) kcal、(1 730.08±265.18) kcal、(1 689.33±236.69) kcal.分析得出通过Harris-Benedict公式法和体重法测得的静息能量代谢值与通过间接能量测定法测得值均存在显著差异,Harris-Benedict公式法显著高于间接能量测定法(均P＜0.05),体重法显著低于间接能量测定法(均P ＜0.05).结论 虽然Harris-Benedict公式法和体重法临床上使用简便易行,但与间接能量测定法测定结果仍有较大差距.临床应尽量按照间接能量测定法测得的静息能量代谢值提供营养支持.     

外科危重病人静息能量消耗值测定及其评价

采用开放式间接测热法测定５８例危重病人的静息能量消耗值，选择同期非应激状态的住院病人作对照组。结果示：危重病人实际能量消耗值比对照组高３０．２％（１６６９±１９４Ｖｓ．１２６０±１１２Ｋｃａｌ／ｋｇ·ｄ）；比按Ｈａｒｒｉｓ－Ｂｅｎｅｄｉｃｔ公式估算值高２０％左右（１６６９±１９４Ｖｓ．１３８６±１４９Ｋｃａｌ／ｄ）。危重病人实际能量消耗与体重呈显著相关（ｒ＝０．５８，Ｐ＜０．００１），其均值为２９．７±２．５Ｋｃａｌ／ｄ。危重病人每分钟通气量、氧耗量及二氧化碳产生量均明显高于对照组．而呼吸商却低于对照组。     

机械支持通气与外科

自微机调控呼吸机问世以来,出现了不少新的通气模式,提高了机械支持通气的治疗效果。本文介绍了几种新型的通气模式,并强调了对呼吸生理的了解是成功地应用机械支持通气的关键。     

eCASH策略预防ICU机械通气患者谵妄效果评价

目的降低ICU机械通气患者谵妄发生率,优化患者临床转归。方法将100例ICU机械通气患者按入院先后分为两组各50例,在常规治疗的基础上对照组按常规防范患者发生IUC谵妄,观察组实施早期以患者为中心的舒适化浅镇静(eCASH)策略防范。结果观察组谵妄发生率、谵妄持续时间、机械通气时间、ICU停留时间均显著低于对照组,临床转归好于对照组(P0.05,P0.01)。结论 eCASH策略应用于ICU机械通气患者谵妄预防管理,可有效降低谵妄发生率,改善患者临床结局。     

机械通气期间镇痛—镇静的新概念

近年来对机构通气的概念已有新的改变，认为昼保留自主呼吸有利于气体交换和减少并发症。目前已不再为抑制自主呼吸而使用强效镇痛－镇静药，轻度镇静就能使患者无痛楚，紧张和忧虑，易于唤醒，能合作和在自主呼吸下进行机械通气。肌松药应用的适应征已明显减少。通气方式可采用ＢｉＰＡＰ一ＡＰＲＶ，在自主呼吸的基础上予以通气支持。     

危重症专职护理小组干预提高COPD呼吸衰竭患者序贯机械通气治疗效果

目的探讨危重症专职护理小组在慢性阻塞性肺疾病(COPD)呼吸衰竭患者序贯机械通气治疗中的作用。方法将序贯机械通气治疗的102例COPD呼吸衰竭患者分为两组。对照组(n=51)实施常规护理干预;干预组(n=51)由危重症专职护理小组实施护理干预。比较两组干预前后血气指标、治疗效果、护理质量。结果干预后干预组血气分析结果显著优于对照组(均P0.05);干预组入住ICU时间、住院时间及机械通气时间较对照组显著缩短(P0.05,P0.01),护理质量评分较对照组显著上升(均P0.01)。结论将危重症专职护理小组干预运用于COPD呼吸衰竭患者序贯机械通气治疗中有助于提高临床疗效,有利于改善患者预后。     

维持性血液透析患者的静息能量消耗特点

目的 探讨维持性血液透析(MHD)患者的静息能量消耗特点.方法 选择我院行MHD的终末期肾脏疾病(ESRD)患者50例,采用呼吸间接测热法测量患者实际的静息能量消耗(REE)值,与国际上通用的健康成人的Harris-Benedict公式的计算值比较,使用Spearman相关、配对t检验、吻合比例进行统计分析.结果 MH...     

恶性肿瘤病人能量代谢测定及评价

客观评价恶性肿瘤病人机体能量代谢状况。方法:采用床旁开放式间接测热法对我院外科226例住院的各类恶性肿瘤患者进行静息能量消耗(resting energy expanditure,REE)测定,同时与293例同期非肿瘤住院病人的REE测定值作对照。结果:恶性肿瘤病人REE测定值平均为1186±274kcal/d(4958±1032kj/d);对照组病人REE平均为1155±203kcal/d(4828±849Kj/d);两组之间无统计学差异。24％恶性肿瘤病人处于低代谢状态,46％恶性肿瘤病人属正常代谢状态,而30％恶性肿瘤病人则处于高代谢状态。结论:本研究结果证明恶性肿瘤病人机体并非均处于高代谢状态。     

Energy Expenditure and Weight Regain in Patients Submitted to Roux-en-Y Gastric Bypass

Background  Although Roux-en-Y gastric bypass (RYGBP) is a highly effective treatment for clinically severe obesity, not all patients achieve desirable weight loss and maintenance. There is some evidence that weight loss can induce a disproportionate reduction in resting metabolic rate (RMR). This reduction in RMR can be related to fat-free mass (FFM) loss, as FFM is the greatest responsible for variations in energy expenditure at rest. Abnormally low basal metabolic rate may predispose surgical patients to weight regain. Method  Thirty-six individuals were divided into two groups: patients who have kept a healthy weight 2 years after surgery and patients who showed weight regain of at least 2 kg 2 years after the surgery. Selected patients have signed a consent form. Body mass index and excess weight loss were evaluated. RMR and body fat percentage were measured. FFM is a heterogeneous component that can be partitioned into muscle mass and no-muscle mass. The FFM was calculated as the result of subtracting total fat weight from total body weight in kilogram. We also wanted to know if the predictive formulas to assess RMR overestimate energy expenditure in these patients. Statistical tests were used to analyze the two groups. Results  We found out that the RMR of the weight regain group was statistically inferior to the mean of the healthy weight group—the difference between the two groups was about 260 kcal/day. We also found out that the predictive formulas overestimate the RMR in the weight regain group. Conclusion  This study suggests that a lower RMR may contribute to weight regain in patients who undergo RYGBP. It is important to ensure ways to elevate energy expenditure in the patient, such as increasing the percentage of fat-free mass in the body and the practice of physical activities.     

Effects of Roux-en-Y Gastric Bypass on Resting Energy Expenditure in Women

Background  Bariatric surgery is the gold standard treatment for morbid obesity, but little is known about its effects on resting energy expenditure. Method  Twenty-one women underwent anthropometric and resting energy expenditure (REE) measurements before and 3 months after bariatric surgery using the Roux-en-Y gastric bypass (RYGBP) technique developed by Capella. Results  The patients experienced a significant reduction in body weight, body mass index, waist circumference, and waist-to-hip ratio (WHR). The cardiopulmonary variables oxygen uptake, carbon dioxide output, non-protein respiratory quotient, and heart rate all decreased, whereas oxygen pulse did not change significantly. Absolute REE showed a significant reduction 3 months postoperatively (2006.7 ± 376.4 kcal/day to 1763.3 ± 310.5 kcal/day), but no significant difference was found compared with REE relative to body weight (0.71 ± 0.15 kcal kg⁻¹h⁻¹ to 0.75 ± 0.12 kcal kg⁻¹ h⁻¹) or as percent of Harris-Benedict predicted REE (106.2 ± 21.0% to 103.3 ± 15.1%). Conclusion  In this study, bariatric surgery using the RYGBP technique (Capella) led to a significant decrease of body weight that decreased resting energy expenditure proportional to this weight loss, and to an increase in the utilization of fat as an energy substrate. It can be concluded that after 3 months, the Roux-en-Y gastric bypass surgery may provide significant metabolic benefits to morbidly obese women.     

Changes in Measured Resting Energy Expenditure after Roux-en-Y Gastric Bypass for Clinically Severe Obesity are Not Related to Bypass Limb-length

Background: Roux-en-Y gastric bypass (RYGB) for clinically severe obesity (CSO) results in a ‘paradoxical’ response of the measured resting energy expenditure (MREE) in which the MREE remains within the predicted range based upon the Harris-Benedict (HB) equation, despite a significant decrease in caloric intake to 500-1000 kcal/day. The mechanism for this response is unknown. A study was undertaken to determine whether the changes in MREE after RYGB are related to limb-length of the gastric bypass. Methods: A prospective clinical trial of varying limb-lengths based on body mass index (BMI) in patients having RYGB for CSO. The records of patients who underwent RYGB for CSO and had MREE measured at baseline, 6 months and 12 months postoperation were reviewed. MREE was performed using a Med Graphics? CCM system after an overnight fast or at least 4 hours after a light meal, and a 30 minute rest in a supine position in a neutral environment, on the same day of the week between the hours of 10a.m. and 4p.m. Patients were selected for RYGB in accordance with NIH recommendations. RYGB was performed in a standardized fashion with the Roux limb-length varied as follows: (A) BMI ≤ 51 kg/m² - 75 cm limb (n = 20); (B) BMI ≤ 51 kg/m² - 150 cm limb (n = 16); (C) BMI ≥ 51 kg/m² - 150 cm limb (n = 18); or (D) BMI ≥ 51 kg/m² - 250 cm limb (n = 6). Results: Data from 60 patients (nine male, 51 female; mean age 39 years; mean baseline BMI 51.5 ± 10 kg/m²; mean baseline weight 145 ± 32 kg) were analyzed. There were no significant differences in MREE or percentage HB-predicted energy expenditure between the groups. Conclusions: These data suggest that the observed changes in MREE following RYGB for CSO are not related to the limb-length of the bypass.     

Respiratory Muscle Dysfunction: A Multicausal Entity in the Critically Ill Patient Undergoing Mechanical Ventilation

Respiratory muscle dysfunction, particularly of the diaphragm, may play a key role in the pathophysiological mechanisms that lead to difficulty in weaning patients from mechanical ventilation. The limited mobility of critically ill patients, and of the diaphragm in particular when prolonged mechanical ventilation support is required, promotes the early onset of respiratory muscle dysfunction, but this can also be caused or exacerbated by other factors that are common in these patients, such as sepsis, malnutrition, advanced age, duration and type of ventilation, and use of certain medications, such as steroids and neuromuscular blocking agents. In this review we will study in depth this multicausal origin, in which a common mechanism is altered protein metabolism, according to the findings reported in various models. The understanding of this multicausality produced by the same pathophysiological mechanism could facilitate the management and monitoring of patients undergoing mechanical ventilation.     

液体复苏对危重患者腹腔高压的影响

目的探讨液体复苏对危重患者腹腔高压（intra—abdominal hypertension,IAH）的影响。方法2010年3～8月,膀胱测压法监测危重患者腹腔内压,比较IAH组和非IAH组的每日液体平衡量及累积液体平衡总量。IAH组和非IAH组性别、年龄、急性生理和慢性健康评估Ⅱ（acute physiology and chronic health evaluation II,APACHEⅡ）评分、序贯器官衰竭评估（sequential organ failure assessment,SOFA）评分、机械通气时间、住ICU时间、住院存活例数均无显著差异。结果与非IAH组比较,IAH组住院第1、2、4天液体平衡量显著增加[中位数2780（690—5390）ml vs．2134（-275—5600）ml,Z=-3．107,P=0．002;1415（1000～3060）ml VS．890（-1200～3300）ml,Z=-4．045,P=0．000;350（～1250～2320）ml VS．180（-1250～1230）ml,Z=-2．189,P=0．029],2组在第3、5天液体平衡量无显著差异;IAH组的1～5日每日累积液体平衡量均显著增加[中位数2780（690～5390）mlVS．2134（-275—5600）ml,Z=-3．107,P=0．002;（4490±1149）ml VS．（3240±1724）ml,t=3．277,P=0．002;（5393±1490）mlVS．（4147±1916）ml,t=2．869,P=0．005;（5830±1913）mlVS．（4136±2176）ml,t=3．350,P=0．001;（5791±2533）mlVS．（4440±2411）ml,t=2．377,P=0．022]。结论大量液体复苏与IAH有关,对危重患者进行液体复苏的同时,早期监测危重患者腹内压,有利于早期发现IAH及腹腔间隔室综合征。     

腹腔内高压对危重患者器官功能的影响

目的 探讨腹腔内高压（intra-abdominal hypertension,IAH）对危重患者器官功能的影响.方法 2010年3-8月,膀胱测压法监测危重患者腹腔内压,以膀胱内压≥12 mm Hg为IAH,比较IAH组和非IAH组的肾功能、呼吸功能、血流动力学等器官功能.2组性别、年龄、急性生理和慢性健康评估Ⅱ（acute physiology and chronic health evaluation Ⅱ,APACHEⅡ）评分、序贯器官衰竭评估（sequential organ failure assessment,SOFA）评分、机械通气时间、住ICU时间、住院存活情况无显著差异.结果与非IAH组比较,IAH组发生多器官功能不全综合征的比例显著增加[40.0%（10/25） vs.14.3%（9/63）,χ2=6.991,P=0 008],肾功能不全的比例增多[32.0%（8/25） vs.11.1%（7/63）,χ2=5.523,P=0.019],急性呼吸窘迫综合征的比例、氧合指数（FiO2/PaO2）无显著差异,但气道平台压[（22.28±7.54）mm Hg vs.（13.87±3.93）mm Hg,t=6.851,P=0.000]和血管外肺水显著增加[（12.82±7.47）ml/kg vs.（7.00±2.38）ml/kg,t=2.400,P=0.032],肺顺应性显著下降[（34.20±6.98） ml/cm H2O vs.（39.16±9.82） ml/cm H2O,t=-2.302,P=0.024].与非IAH组比较,IAH组休克的比例显著增加[56.0%（14/25） vs.23.8%（15/63）,χ2=7 000,P=0.008],心指数、每搏变异度、心肌收缩力和肺血管通透性指数无显著差异,胸内血容量[（766.86±99.88） ml/m2 vs.（929.18±171.56） ml/m2,t=-2.257,P=0.038]和全心舒张末容积显著降低[（613.86±79.63） ml/m2 vs.（743.36±137.30） ml/m2,t=-0.251,P=0.039].结论 IAH影响危重患者器官功能,早期监测危重患者腹内压,有利于早期发现IAH.     

Pressure-controlled Ventilation Does Not Improve Gas Exchange in Morbidly Obese Patients Undergoing Abdominal Surgery

Background

Morbid obesity results in marked respiratory pathophysiologic changes that may lead to impaired intraoperative gas exchange. The decelerating inspiratory flow and constant inspiratory airway pressure resulting from pressure-controlled ventilation (PCV) may be more adapted to these changes and improve gas exchanges compared with volume-controlled ventilation (VCV).

Methods

Forty morbidly obese patients scheduled for gastric bypass were included in this study. Total intravenous anesthesia was given using the target-controlled infusion technique. During the first intraoperative hour, VCV was used and the tidal volume was adjusted to keep end-tidal PCO₂ around 35 mmHg. After 1 h, patients were randomly allocated to 30-min VCV followed by 30-min PCV or the opposite sequence using a Siemens® Servo 300. FiO₂ was 0.6. During PCV, airway pressure was adjusted to provide the same tidal volume as during VCV. Arterial blood was sampled for gas analysis every 15 min. Ventilatory parameters were also recorded.

Results

Peak inspiratory airway pressures were significantly lower during PCV than during VCV (P? <?0.0001). The other ventilatory parameters were similar during the two periods of ventilation. PaO₂ and PaCO₂ were not significantly different during PCV and VCV.

Conclusion

PCV does not improve gas exchange in morbidly obese patients undergoing gastric bypass compared to VCV.

     

机械通气患者并发消化道出血的危险因素分析

目的探讨机械通气患者并发消化道出血的危险因素。方法回顾2007年1月~2009年12月在我院ICU住院的91例机械通气（≥48 h）并发消化道出血的临床资料,配对选取91例同期住院的性别相同、年龄差距不超过2岁的机械通气但无消化道出血的患者作为对照组。结果机械通气患者消化道出血的发生率为12.4%（91/736）,logistic回归分析显示镇静不充分（OR=3.728,95%CI=1.377~10.093）、血小板减少（OR=2.269,95%CI=0.876~5.588）、休克（OR=2.25,95%CI=1.109~4.959）为机械通气患者发生消化道出血的三项独立危险因素。根据出血程度将消化道出血分为轻度出血（显性出血）67例（73.4%）,重度出血（临床严重出血）24例（26.6%）。轻度出血组镇静不充分比例明显高于对照组（22.4%vs.6.6%,P=0.004）,病死率与对照组无显著差异（P=0.264）。重度出血组APACHⅡ评分高于对照组[（20.5±7.5）分vs.（17.5±5.4）分,P=0.024],肾功能衰竭（45.8%vs.11.0%,P=0.000）、休克（45.8%vs.15.4%,P=0.003）、血小板减少（33.3%vs.8.8%,P=0.005）等发生比例均明显高于对照组,病死率明显增高（58.3%vs.7.7%,P=0.000）。结论镇静不充分,血小板减少,休克为机械通气患者发生消化道出血的三项独立危险因素,其中镇静不充分在轻度出血中较为突出。重度出血与肾功能衰竭、休克、血小板减少有关,为病情笃重的标志,预后差,死亡风险明显增高。     

The Effects of Fat Distribution on Resting Energy Expenditure in Premenopausal Morbidly Obese Females

Background: upper body, or abdominal, distribution of body fat is associated with a number of metabolic and hormonal aberrations that could influence resting energy expenditure REE. The purpose of our study was to examine the effects of fat distribution on REE of 96 morbidly obese premenopausal females. Methods: the study population consisted of three groups of study subjects, 32 with lower body fat distribution (LBD) and waist-to-hip circumference ratios WHR < 0.80, 20 with intermediate (INT) fat distribution and WHR between 0.80 and 0.85 and 34 females with upper body distribution of fat (UBD) and WHR > 0.85. Indices measured included: (1) REE; (2) maximal oxygen consumption during an exercise tolerance test (VO_2max); (3) basal respiratory quotient (RQ); (4) fasting blood glucose; and (5) serum cholesterol and triglycerides. Results: we found that morbidly obese women who store fat abdominally (WHR > 0.80) have significantly (p < 0.01) higher REE (kcal per h per BSA) than those with lower body obesity. Levels of triglyceride and glucose of the UBD group were also higher than those of the LBD subjects, i.e. 35% and 23%, respectively. VO_2max and RQ were similar between the study groups, suggesting that the elevated REE of the patients with abdominal adiposity were likely not the result of their greater muscle mass or differences in substrate utilization. Conclusion: fat distribution affects REE in morbidly obese premenopausal females, and further research is needed to identify the various entities regulating REE in the morbidly obese.