DOI QR코드

DOI QR Code

초기 경장영양 공급 수준과 다발성 외상 중환자의 임상 경과와의 상관성 연구

Association of the initial level of enteral nutrition with clinical outcomes in severe and multiple trauma patients

  • 양수영 (이화여자대학교 임상보건융합대학원) ;
  • 정승연 (이화여자대학교 식품영양학과) ;
  • 이지현 (아주대학교병원 영양팀) ;
  • 권준식 (아주대학교병원 외과학교실 외상외과) ;
  • 김유리 (이화여자대학교 임상보건융합대학원)
  • Yang, Suyoung (Department of Clinical Nutrition, The Graduate School of Converging Clinical & Public Health, Ewha Womans University) ;
  • Jung, Seungyoun (Department of Nutritional Science and Food Management, Ewha Womans University) ;
  • Lee, Ji-hyun (Food Services & Clinical Nutrition Team, Ajou University Hospital) ;
  • Kwon, Junsik (Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine) ;
  • Kim, Yuri (Department of Clinical Nutrition, The Graduate School of Converging Clinical & Public Health, Ewha Womans University)
  • 투고 : 2021.11.26
  • 심사 : 2022.01.11
  • 발행 : 2022.02.28

초록

본 연구에서는 다발성 외상 중환자에게 있어 급성 단계에서의 이화학적 상태 및 경장영양 공급 수준이 임상적 예후에 미치는 영향을 알아보고자 하였다. 먼저 조사 대상자 302명의 특성을 분석한 결과, 남성의 비율이 높으며 다른 중환자실에 비해 연령이 낮게 나타났으며 과체중의 체격을 가지고 있었다. 입원 후 7일간의 경장영양 공급 수준에 따라 일반적 결과와 합병증 발생률, 영양 관련 생화학적 지표를 비교한 결과, 초기 경장영양이 가장 적극적으로 공급되었던 High EN 그룹에서 사망률, CRP에서 유의적으로 감소하였다. 질소 평형을 기준으로 이화상태가 양호한 그룹에서는 경장영양 공급 기간이 길수록 HAIs 발생률이 높았으나, 이화상태가 불량한 그룹에서는 적극적인 경장영양 공급에도 여러 합병증 발생이 증가하지 않았다. 생화학적 검사 결과에서는 그룹 간 유의적인 차이가 없었으며, 경장영양 공급 수준에 따른 사망률 감소 추세는 두 그룹 모두에서 유지되었다. 결론적으로, 본 연구에서는 사망률 감소, 염증 수치의 감소 등에서 초기 경장영양 공급 일수가 증가할수록 긍정적인 효과를 확인하였다. 단, 후향적 관찰연구라는 제한점을 미루어 보아 향후 연속적으로 이화상태를 모니터링 및 평가하며 기본 특성의 차이가 없는 그룹 간에서 경장영양 공급 수준을 차별화한 전향적 코호트 연구가 필요하겠다.

Purpose: This study is aimed to examine the association between initial enteral nutrition (EN) and the clinical prognosis among patients with severe and multiple traumatic injuries, and to investigate whether this association is modified by the patients' catabolic status. Methods: This was a retrospective study of 302 adult patients with severe and multiple traumatic injuries admitted between January 2017 and September 2020 at Ajou University hospital in Suwon, Korea. The initial nutritional support by EN and parenteral nutrition were monitored up to day 7 after admission. Patients were classified into "No", "Low", and "High" EN groups according to the level of initial EN. Multivariable-adjusted logistic regression and linear regression models were used to estimate the association of the initial EN levels at hospital admission with the risk of mortality, morbidities, and levels of nutrition-associated biochemical markers. Results: High EN support was associated with reduced mortality (odds ratio, 0.07; 95% confidence interval [CI], 0.02, 0.32) and lower levels of C-reactive protein (β, -0.22; 95% CI, -8.66, 1.48), but longer stay in the intensive care unit (β, 0.19; 95% CI, 1.82, 11.32). In analyses stratified by catabolic status, there were fewer incidences of hospital-acquired infections with increasing EN levels in the moderate or higher nitrogen balance group than in the mild nitrogen balance group. Conclusion: Our observation of the inverse association between levels of initial EN administration with mortality risk and inflammatory markers may indicate the possible benefits of active EN administration to the recovery process of severe and multiple trauma patients. Further studies are warranted on whether the catabolic status modifies the association between the initial EN and prognosis.

키워드

참고문헌

  1. Dick WF, Baskett PJ. Recommendations for uniform reporting of data following major trauma--the Utstein style. A report of a working party of the International Trauma Anaesthesia and Critical Care Society (ITACCS). Resuscitation 1999; 42(2): 81-100. https://doi.org/10.1016/S0300-9572(99)00102-1
  2. Roumen RM, Redl H, Schlag G, Zilow G, Sandtner W, Koller W, et al. Inflammatory mediators in relation to the development of multiple organ failure in patients after severe blunt trauma. Crit Care Med 1995; 23(3): 474-480. https://doi.org/10.1097/00003246-199503000-00010
  3. Dickerson RN, Pitts SL, Maish GO 3rd, Schroeppel TJ, Magnotti LJ, Croce MA, et al. A reappraisal of nitrogen requirements for patients with critical illness and trauma. J Trauma Acute Care Surg 2012; 73(3): 549-557. https://doi.org/10.1097/ta.0b013e318256de1b
  4. Rogobete AF, Grintescu IM, Bratu T, Bedreag OH, Papurica M, Crainiceanu ZP, et al. Assessment of metabolic and nutritional imbalance in mechanically ventilated multiple trauma patients: from molecular to clinical outcomes. Diagnostics (Basel) 2019; 9(4): 171. https://doi.org/10.3390/diagnostics9040171
  5. Butcher N, Balogh ZJ. The definition of polytrauma: the need for international consensus. Injury 2009; 40 Suppl 4: S12-S22. https://doi.org/10.1016/j.injury.2009.10.032
  6. Brattstrom O, Granath F, Rossi P, Oldner A. Early predictors of morbidity and mortality in trauma patients treated in the intensive care unit. Acta Anaesthesiol Scand 2010; 54(8): 1007-1017. https://doi.org/10.1111/j.1399-6576.2010.02266.x
  7. Rha MY, Kim EM, Cho YY, Seo JM, Choi HM. The outcome of nutrition support of surgery patients with hypermetabolic severity by total parenteral nutrition and enteral nutrition and biochemical data. Korean J Community Nutr 2006; 11(2): 289-297.
  8. Sun JK, Yuan ST, Mu XW, Zhang WH, Liu Y, Zou L, et al. Effects of early enteral nutrition on T helper lymphocytes of surgical septic patients: a retrospective observational study. Medicine (Baltimore) 2017; 96(32): e7702. https://doi.org/10.1097/MD.0000000000007702
  9. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JPEN J Parenter Enteral Nutr 2016; 40(2): 159-211. https://doi.org/10.1177/0148607115621863
  10. Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019; 38(1): 48-79. https://doi.org/10.1016/j.clnu.2018.08.037
  11. Zhou W, Shi B, Fan Y, Zhu J. Effect of early activity combined with early nutrition on acquired weakness in ICU patients. Medicine (Baltimore) 2020; 99(29): e21282. https://doi.org/10.1097/md.0000000000021282
  12. Chung CK, Whitney R, Thompson CM, Pham TN, Maier RV, O'Keefe GE. Experience with an enteralbased nutritional support regimen in critically ill trauma patients. J Am Coll Surg 2013; 217(6): 1108-1117. https://doi.org/10.1016/j.jamcollsurg.2013.08.006
  13. Wischmeyer PE, Hasselmann M, Kummerlen C, Kozar R, Kutsogiannis DJ, Karvellas CJ, et al. A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial. Crit Care 2017; 21(1): 142. https://doi.org/10.1186/s13054-017-1736-8
  14. Badjatia N, Monahan A, Carpenter A, Zimmerman J, Schmidt JM, Claassen J, et al. Inflammation, negative nitrogen balance, and outcome after aneurysmal subarachnoid hemorrhage. Neurology 2015; 84(7): 680-687. https://doi.org/10.1212/WNL.0000000000001259
  15. Nik A, Sheikh Andalibi MS, Ehsaei MR, Zarifian A, Ghayoor Karimiani E, Bahadoorkhan G. The efficacy of glasgow coma scale (GCS) score and acute physiology and chronic health evaluation (APACHE) II for predicting hospital mortality of ICU patients with acute traumatic brain injury. Bull Emerg Trauma 2018; 6(2): 141-145. https://doi.org/10.29252/beat-060208
  16. Yildirim Aydin F, Dulger D. The importance of the injury severity scores and revised trauma scores for moderate traumas: a state hospital experience. Ulus Travma Acil Cerrahi Derg 2020; 26(2): 242-246.
  17. Bilgin S, Guclu-Gunduz A, Oruckaptan H, Kose N, Celik B. Gait and Glasgow Coma Scale scores can predict functional recovery in patients with traumatic brain injury. Neural Regen Res 2012; 7(25): 1978-1984. https://doi.org/10.3969/j.issn.1673-5374.2012.25.009
  18. Dickerson RN, Tidwell AC, Minard G, Croce MA, Brown RO. Predicting total urinary nitrogen excretion from urinary urea nitrogen excretion in multiple-trauma patients receiving specialized nutritional support. Nutrition 2005; 21(3): 332-338. https://doi.org/10.1016/j.nut.2004.07.005
  19. National Emergency Medical Center (KR). Emergency medical information intranet [Internet]. Seoul: National Emergency Medical Center; 2019 [cited 2021 Aug 21] Available from: https://www.e-gen.or.kr/nemc/statistics_annual_report.do?brdclscd=04.
  20. Li PF, Wang YL, Fang YL, Nan L, Zhou J, Zhang D. Effect of early enteral nutrition on outcomes of trauma patients requiring intensive care. Chin J Traumatol 2020; 23(3): 163-167. https://doi.org/10.1016/j.cjtee.2020.04.006
  21. Doig GS, Heighes PT, Simpson F, Sweetman EA. Early enteral nutrition reduces mortality in trauma patients requiring intensive care: a meta-analysis of randomised controlled trials. Injury 2011; 42(1): 50-56. https://doi.org/10.1016/j.injury.2010.06.008
  22. Shen Y, Cheng X, Ying M, Zhang W, Jiang X, Du K. Early low-energy versus high-energy enteral nutrition support in patients with traumatic intracerebral haemorrhage: protocol for a randomised controlled trial. BMJ Open 2017; 7(11): e019199. https://doi.org/10.1136/bmjopen-2017-019199
  23. Wilson JT. Assessing outcome in head injury trials. Curr Pharm Des 2001; 7(15): 1537-1552. https://doi.org/10.2174/1381612013397276
  24. Abunnaja S, Cuviello A, Sanchez JA. Enteral and parenteral nutrition in the perioperative period: state of the art. Nutrients 2013; 5(2): 608-623. https://doi.org/10.3390/nu5020608
  25. Allen K, Hoffman L. Enteral nutrition in the mechanically ventilated patient. Nutr Clin Pract 2019; 34(4): 540-557. https://doi.org/10.1002/ncp.10242
  26. Jiang Y, Hu B, Zhang S, Cai M, Chu X, Zheng D, et al. Effects of early enteral nutrition on the prognosis of patients with sepsis: secondary analysis of acute gastrointestinal injury study. Ann Palliat Med 2020; 9(6): 3793-3801. https://doi.org/10.21037/apm-20-1650
  27. Luo Y, Qian Y. Effect of combined parenteral and enteral nutrition for patients with a critical illness: a meta-analysis of randomized controlled trials. Medicine (Baltimore) 2020; 99(3): e18778. https://doi.org/10.1097/md.0000000000018778
  28. Wan G, Wang L, Zhang G, Zhang J, Lu Y, Li J, et al. Effects of probiotics combined with early enteral nutrition on endothelin-1 and C-reactive protein levels and prognosis in patients with severe traumatic brain injury. J Int Med Res 2020; 48(3): 300060519888112.
  29. Blass SC, Goost H, Burger C, Tolba RH, Stoffel-Wagner B, Stehle P, et al. Extracellular micronutrient levels and pro-/antioxidant status in trauma patients with wound healing disorders: results of a cross-sectional study. Nutr J 2013; 12(1): 157. https://doi.org/10.1186/1475-2891-12-157
  30. Hesselink L, Spijkerman R, van Wessem KJ, Koenderman L, Leenen LP, Huber-Lang M, et al. Neutrophil heterogeneity and its role in infectious complications after severe trauma. World J Emerg Surg 2019; 14(1): 24. https://doi.org/10.1186/s13017-019-0244-3
  31. Felicetti-Lordani CR, Eckert RG, Valerio NM, Lordani TV, Jorge AC, Duarte PA. Nitrogen balance in nutritional monitoring of critically Ill adult patients: a prospective observational study. J Med Surg Intensive Care Med 2017; 8(3): 59-64.
  32. Ostadrahimi A, Nagili B, Asghari-Jafarabadi M, Beigzali S, Zalouli H, Lak S. A proper enteral nutrition support improves sequential organ failure score and decreases length of stay in hospital in burned patients. Iran Red Crescent Med J 2016; 18(2): e21775. https://doi.org/10.5812/ircmj.21775
  33. Park BN, Kim EJ. Analysis of influence factors on ventilator-associated pneumonia in severe trauma patients. J Korean Acad Soc Home Care Nurs 2018; 25(3): 224-231.