影响严重烧伤病人尽早肠内营养的主要因素

doi:10.16139/j.1007-9610.2023.05.09

摘要/Abstract

摘要：

目的：通过11年病人住院资料的回顾性队列研究，分析影响严重烧伤病人早期营养的主要因素和伤后72 h内是否实施肠内营养对治疗结局的影响，为严重烧伤病人肠内营养方案提供依据。方法：本回顾性研究对2009年1月到2020年12月间在烧伤后24 h内收治入院烧伤总面积>30%的烧伤成年病人资料进行分析。采用单因素和多元回归分析影响严重烧伤病人尽早实施肠内营养的主要原因，采用非参数Mann-Whitney U检验比较72 h内与72 h后给予实施肠内营养的主要影响因素及对28 d生存率、在院期间生存率等治疗结局的影响。结果：影响严重烧伤病人启动肠内营养时间的单因素分析结果为烧伤总面积、Ⅲ度烧伤面积及烧伤原因、是否有吸入性损伤（P<0.05）。将上述单因素纳入多元回归分析发现，影响病人尽早实施肠内营养的主要影响因素是Ⅲ度烧伤面积（P=0.017）及吸入性损伤(P=0.001)。进一步以烧伤后72 h内是否启动肠内营养作为研究目标分析发现，病人有吸入性损伤和Ⅲ度烧伤面积大是其主要原因。经数据匹配后的受伤情况及伤前情况一致条件下，烧伤后72 h内与72 h后实施肠内营养的病人在院期间生存率、28 d生存率、血培养阳性率等结局差异无统计学意义（P>0.05），但静脉导管培养阳性率较低(P=0.001)、烧伤后7 d内接受肠外营养治疗率较低(P=0.001)。结论：导致严重烧伤病人未能尽早实施肠内营养主要原因是Ⅲ度烧伤面积大及合并吸入性损伤。烧伤后72 h内接受肠内营养降低静脉导管培养阳性率及肠外营养的使用率，从而降低严重烧伤病人救治风险。

关键词: 大面积烧伤, 肠内营养, 肠外营养, 导管感染

Abstract:

Objective To analyze the main factors affecting early using enteral nutrition and the effect of enteral nutrition within 72 h after burning on outcomes by presenting a retrospective cohort study of 11 years of hospitalization data, to provide evidence for enteral nutrition regimens for severe burn patients. Methods A retrospective study analyzed adult extensive burn patients between January 2009 and December 2020. Patients enrolled in this study who admitted to the burn department within 24 h after burning and with a burned area of more than 30%. Univariate and multiple regression were used to analyze the main factors affecting early using enteral nutrition in patients with severe burn. Non parametric Mann-Whitney U test was used to compare the main influencing factors of enteral nutrition implementation within or after 72 h, as well as the impact on the treatment outcomes such as 28-day survival rate and in hospital survival rate. Results The univariate analysis found that total burn area, full-thickness burn area, burn type, and inhalation injury were the main factors of the time to initation of enteral nutrition in patients with severe burn (P<0.05). Incorporating the above single factors into multiple regression analysis, we found that the main factors affecting enteral nutrition using in patients with severe burn were full-thickness burn area (P=0.017) and inhalation injury (P=0.001). To analysis whether enteral nutrition was started within 72 h after burning, we found that inhalation injury and larger area of full-thickness burn area in patients was the main factors for initiating enteral nutrition. After matching injury situation with pre-injury situation, we found that using enteral nutrition within or after 72 h after injury were no significant differences in the survival rate, 28-day survival rate, and positive blood culture rate （P>0.05），but was associated with the lower incidence of bacteria positive in intravenous catheters (P=0.001) and the lower rate of parenteral nutrition treatment used within 7 d after burning (P=0.001). Conclusions The main factor for influencing early implement enteral nutrition in patients with severe burn were large area of full-thickness burn and inhalation injury. Enteral nutrition using within 72 h after burning reduces the incidence of catheter infection and the use of parenteral nutrition, thereby reducing the risk of treatment in patients with severe burn.

Key words: Extensive burn, Enternal nutrition, Parenteral nutrition, Catheter infection

中图分类号:

R459.3
R644

张寅, 窦懿, 张勤, 汪雯靓, 沈晓娴, 马珍珠, 吴蓓雯. 影响严重烧伤病人尽早肠内营养的主要因素[J]. 外科理论与实践, 2023, 28(05): 441-447.

ZHANG Yin, DOU Yi, ZHANG Qin, WANG Wenliang, SHEN Xiaoxian, MA Zhenzhu, WU Beiwen. Factors influencing early using enteral nutrition in severe burn patients[J]. Journal of Surgery Concepts & Practice, 2023, 28(05): 441-447.

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参考文献 24

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Variables	Assignment method
Age	≤60=1，>60=0
Gender	male=1，female=0
Burn type	flame=1， other type=0
Total body surface area	30%-50% =1, >50%=0
Full-thickness burned area	≤20%=1， >20%=0
Inhalation injury	with inhalation injury=1, without inhalation injury=0

Item	Group	n	Start time of EN（d）	Z/χ² value	P value
Age(years)	≤60	438	4（3,5）	Z=-1.730	0.084
Age(years)	>60	84	3（3,5）	Z=-1.730	0.084
Gender	Male	405	4（3,5）	Z=-0.045	0.964
Gender	Female	117	4（3,5）	Z=-0.045	0.964
Burn type	Flame	403	4（3,5）	Z=-3.579	<0.001
Burn type	Other type	119	3（2,5）	Z=-3.579	<0.001
Total body surface area	30%-50%	243	3（3,4）	Z=-6.399	0.000
Total body surface area	>50%	279	4（3，6）	Z=-6.399	0.000
Full-thickness burn area	≤20%	260	3（3,4）	Z=-6.428	<0.001
Full-thickness burn area	>20%	262	4（3，6）	Z=-6.428	<0.001
Inhalation injury	Yes	192	5（4，6）	χ²=49.320	0.000
Inhalation injury	No	330	3（3,4）	χ²=49.320	0.000

Variable	B	Std Error	Beta	t value	P value
Constant	2.968	0.521		5.696	0.000
Inhalation injury	0.853	0.258	0.161	3.306	0.001
Full-thickness burn area	0.563	0.234	0.110	2.404	0.017

Item Gruop		Start EN within 72 h (n=215)	Start EN after 72 h (n=307)	Z/χ²value	P value
Age (year)		47(33,57)	46（36,55）	Z=-0.477	0.633
Gender [n(%)]	Male	168（78.1）	237（77.2）	χ²=0.064	0.800
Gender [n(%)]	Female	47（21.9）	70（22.8）	χ²=0.064	0.800
Burn type [n(%)]	Flame	154（71.6）	249（81.1）	χ²=6.456	0.011
Burn type [n(%)]	Other type	61（28.4）	58（18.9）	χ²=6.456	0.011
Total body surface area （%）		43 (35,60)	60（42,78）	Z=-6.578	0.000
Full-thickness burn area （%）		12（0,30）	30（10,50）	Z=-6.578	0.000
Inhalation [n(%)]	Yes	41（19.1）	151（49.2）	χ²=49.320	0.000
Inhalation [n(%)]	No	174（80.9）	156（50.8）	χ²=49.320	0.000

Item	Gruop	Start EN within 72 h(n=215)	Start EN after 72 h(n=307)	Z/χ²value	P value
Length of hospital stay（d）		31（23,42）	38（27,57）	Z=-4.206	0.000
28 d survival [n(%)]	survival	211（98.1）	288（93.8）	χ²=4.644	0.031
	death	4（1.9）	19（6.2）	χ²=4.644	0.031
Overall survival [n(%)]	survival	209（97.2）	275（89.6）	χ²=10.914	0.001
	death	6（2.8）	32（10.4）	χ²=10.914	0.001
blood culture [n(%)]	positive	13（6.1）	47（15.3）	χ²=10.665	0.001
blood culture [n(%)]	negative	202（93.9）	260（84.7）	χ²=10.665	0.001
21 d blood culture [n(%)]	positive	7（3.3）	31（10.1）	χ²=9.769	0.003
21 d blood culture [n(%)]	negative	208（96.7）	276（89.9）	χ²=9.769	0.003
Time to first positive blood culture（d）		17（11,29）	14（9,27）	Z=-0.727	0.467
Sputum culture [n(%)]	positive	21（9.8）	56（18.2）	χ²=7.220	0.007
	negative	194（90.2）	251（81.8）	χ²=7.220	0.007
14 d sputum culture [n(%)]	positive	13（6.1）	42（13.7）	χ²=7.818	0.005
14 d sputum culture [n(%)]	negative	202（93.9）	265（86.3）	χ²=7.818	0.005
Time to first positive sputum culture（d）		12（9,16）	9（5,15）	Z=-1.238	0.216
Intravenous catheter [n(%)]	positive	9（4.2）	45（14.7）	χ²=14.951	0.000
Intravenous catheter [n(%)]	negative	206（95.8）	262（85.3）	χ²=14.951	0.000
Time to first positive intravenous catheter culture（d）		15（8,24）	12（10,21）	Z=-0.105	0.917
EN tolerance [n(%)]	intolerance	16（7.4）	33（10.8）	χ²=1.626	0.202
EN tolerance [n(%)]	tolerance	199（92.6）	274（89.3）	χ²=1.626	0.202
PN usage [n(%)]	use	59（27.4）	175（57.0）	χ²=44.678	0.001
PN usage [n(%)]	unused	156（72.6）	132（43.0）	χ²=44.678	0.001
Start time for PN（d）		5（3,9）	5（4,8）	Z=-0.858	0.391