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中华损伤与修复杂志(电子版)

中华损伤与修复杂志(电子版) ›› 2024, Vol. 19 ›› Issue (01) : 24 -33. doi: 10.3877/cma.j.issn.1673-9450.2024.01.006

论著

应用床旁超声监测胃残余量指导重症烧伤患者早期肠内营养的临床价值
李鹏, 崔庆伟, 张盼, 唐浩, 庄梦梦, 孙晗, 孙媛, 李丹, 陈文娣, 毛学飞, 孙勇†()   
  1. 221004　徐州医科大学附属淮海医院　陆军第七十一集团军医院烧伤整形科
  • 收稿日期:2023-09-26 出版日期:2024-02-01
  • 通信作者: 孙勇
  • 基金资助:
    国家自然科学基金面上项目(81772082); 陆军第七十一集团军医院院内重点课题(YNZD－202202)

Value of bedside ultrasound monitoring of gastric residual volume in guiding early enteral nutrition in BICU patients

Peng Li, Qingwei Cui, Pan Zhang, Hao Tang, Mengmeng Zhuang, Han Sun, Yuan Sun, Dan Li, Wendi Chen, Xuefei Mao, Yong Sun†()   

  1. Department of Burns and Plastic Surgery, the 71st Group Army Hospital of Army, Affiliated Huaihai Hospital of Xuzhou Medical University, Xuzhou 221004, China
  • Received:2023-09-26 Published:2024-02-01
  • Corresponding author: Yong Sun
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引用本文：

李鹏, 崔庆伟, 张盼, 唐浩, 庄梦梦, 孙晗, 孙媛, 李丹, 陈文娣, 毛学飞, 孙勇. 应用床旁超声监测胃残余量指导重症烧伤患者早期肠内营养的临床价值[J]. 中华损伤与修复杂志(电子版), 2024, 19(01): 24-33.

Peng Li, Qingwei Cui, Pan Zhang, Hao Tang, Mengmeng Zhuang, Han Sun, Yuan Sun, Dan Li, Wendi Chen, Xuefei Mao, Yong Sun. Value of bedside ultrasound monitoring of gastric residual volume in guiding early enteral nutrition in BICU patients[J]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2024, 19(01): 24-33.

目的

探讨床旁超声监测胃残余量(GRV)指导重症烧伤患者早期肠内营养(EN)的应用效果。

方法

选取2022年1月至2023年6月徐州医科大学附属淮海医院烧伤整形科诊治的66例重症烧伤患者进行前瞻性随机对照研究。按烧伤严重程度分为重度烧伤患者(36例)与特重度烧伤患者(30例)。按照随机数字表法将重度烧伤患者分为观察组(予床旁超声监测GRV)与对照组(予注射器抽取胃内容物估测GRV)，每组18例；将特重度烧伤患者分为观察组(予床旁超声监测GRV)与对照组(予注射器抽取胃内容物估测GRV)，每组15例。分别于治疗1、3、5、7、14、21、28 d，对比4组患者治疗期间肠内营养摄入总能量、喂养不耐受发生率、血红蛋白(Hb)、总蛋白(TP)、白蛋白(ALB)、球蛋白(GLB)、前白蛋白(PA)、降钙素原(PCT)、C反应蛋白(CRP)、白细胞介素-6(IL-6)、尿素氮(BUN)、机械通气时间、喂养达标时间、BICU住院时间、脓毒症发生率。对数据行Fisher确切概率法、Mann-Whitmey U检验、独立样本t检验、重复测量方差分析。

结果

重度烧伤和特重度烧伤患者观察组的喂养不耐受发生率均低于对照组(P<0.05)。特重度烧伤患者在治疗7、28 d,观察组Hb高于对照组(P<0.05)。重度烧伤患者在治疗1～7 d，观察组TP高于对照组(P<0.05)。重度烧伤及特重度烧伤患者在治疗3～14 d，观察组ALB高于对照组(P<0.05)。重度烧伤患者在治疗5～21 d,观察组PA高于对照组(P<0.05)；特重度烧伤患者在治疗5～28 d，观察组PA高于对照组(P<0.05)。重度烧伤患者在治疗1～5 d、14 d，观察组PCT低于对照组(P<0.05)；特重度烧伤患者在治疗3～14 d，观察组PCT低于对照组(P<0.05)。特重度烧伤患者在治疗3、5 d，观察组IL-6低于对照组(P<0.05)。特重度烧伤患者观察组喂养达标时间短于对照组(P<0.05)。

结论

床旁超声监测重症烧伤患者GRV可以指导早期肠内营养治疗，有利于提高肠内营养总能量，降低喂养不耐受发生率，改善营养代谢状况，减轻机体炎性反应。

关键词: 床旁超声监测, 胃残余量, 重症烧伤, 早期肠内营养
Objective

To investigate the effect of bedside ultrasound monitoring gastric residual volume (GRV) on guiding early enteral nutrition (EN) in BICU patients.

Methods

Totally 66 BICU patients diagnosed and treated at Department of Burns and Plastic Surgery, Affiliated Huaihai Hospital of Xuzhou Medical University from January 2022 to June 2023 were enrolled into the prospective randomized contolled trial, including 36 severe burn patients and 30 extremely severe burn patients according to the severity of burn. According to the random number table method, the patients with severe burn were divided into observation group (with bedside ultrasound monitoring of GRV) and control group (with syringe extraction of gastric contents to estimate GRV), with 18 cases in each group. The patients with extremely severe burn were divided into observation group (with bedside ultrasound monitoring of GRV) and control group (with syringe extraction of gastric contents to estimate GRV), with 15 cases in each group. After 1, 3, 5, 7, 14, 21 and 28 days of treatment, total energy intake of enteral nutrition, incidence of feeding intolerance, hemoglobin (Hb), total protein (TP), albumin (ALB), globulin (GLB), prealbumin (PA), procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL-6), blood urea nitrogen (BUN), mechanical ventilation time, feeding compliance time, BICU hospitalization time and sepsis incidence were compared among 4 groups during treatment. Fisher exact probability test, Mann-Whitmey U test, independent sample t test and repeated analysis of measurement variance were used for data analysis.

Results

The incidence of feeding intolerance in the observation group was lower than that in the control group for both severe burn patients and extremely severe burn patients (P<0.05). In the treatment of 7 and 28 d, the Hb level of the observation group was higher than that of the control group in extemely severe burn patients (P<0.05). In the treatment of 1-7 days, the TP level of the observation group was higher than that of the control group in severe burn patients (P<0.05). In the treatment of 3-14 days, the ALB of the observation group was higher than that of the control group in both severe burn patients and extremely severe burn patients (P<0.05). In the treatment of 5-21 days, the PA level of the observation group was higher than that of the control group in severe burn patients (P<0.05). In the treatment of 5-28 days, the PA of the observation group was higher than that of the control group in extremely severe burn patients (P<0.05). In the treatment of 1-5 days and 14 d, the PCT of the observation group was lower than that of the control group in severe burn patients (P<0.05), while in the treatment of 3-14 days, the PCT of the observation group was lower than that of the control group in extremely severe burn patients (P<0.05). The IL-6 of the observation group was lower than that of the control group in 3 and 5 d of treatment in extremely severe burn patients (P<0.05). In extremely severe burn patients, the feeding compliance time of the observation group was shorter than those of the control group (P<0.05).

Conclusion

Bedside ultrasound monitoring of GRV in BICU patients can guide early EN therapy, which is beneficial to improving total enteral nutrition energy, reducing the incidence of feeding intolerance, improving nutritional metabolism, and reducing the body′s inflammatory response.

Key words: Bedside ultrasonic monitoring, Gastric residual volume, BICU patients, Early enteral nutrition
图1 胃窦单切面
图2 胃窦面积测量
表1 重度烧伤2组患者一般资料比较
组别 例数 性别(例) 年龄(岁，±s) 烧伤总面积[%，M(Q1，Q3)] Ⅲ度烧伤面积[%，M(Q1，Q3)] 烧伤指数[%，±s]
男 女
观察组 18 13 5 50.78±9.91 38.00 (32.00，40.00) 14.00(12.25, 16.00) 25.94±2.46
对照组 17 12 5 49.05±11.04 38.00(34.00，41.00) 14.00(13.00，16.00) 26.11±2.41
χ2值/t值/Z值   0.010 0.485 －0.030 －0.150 －0.210
P值   0.630 0.631 0.970 0.880 0.835
表2 特重度烧伤2组患者一般资料比较
组别 例数 性别(例) 年龄(岁，±s) 烧伤总面积[%，±s] Ⅲ度烧伤面积[%，M(Q1，Q3)] 烧伤指数[%，±s]
男 女
观察组 13 10 3 43.00±16.40 62.69±16.60 28.00(23.00, 32.00) 46.19±10.71
对照组 14 10 4 50.21±16.32 59.35±15.77 29.00(23.00, 34.00) 45.57±11.05
Fisher值/t值/Z值   0.10 －1.14 0.53 －0.63 0.15
P值   0.74 0.26 0.59 0.52 0.88
表3 重度烧伤2组患者肠内营养摄入总能量比较(kcal，±s)
组别 例数 1 d 3 d 5 d 7 d 14 d 21 d 28 d
观察组 18 361.67±7.07 474.44±44.35 922.22±73.21 951.11±74.90 1671.67±281.70 1983.33±73.88 2030.56±34.89
对照组 17 350.59±14.34 457.65±41.16 726.47±134.77 800.00±122.47 1588.24±182.63 1906.47±92.93 1987.65±33.45
t值   2.923 1.159 5.382 4.432 1.033 2.716 3.710
P值   0.006 0.255 <0.001 <0.001 0.309 0.010 0.001
表4 特重度烧伤2组患者肠内营养摄入总能量比较(kcal，±s)
组别 例数 1 d 3 d 5 d 7 d 14 d 21 d 28 d
观察组 13 359.23±2.77 480.77±36.62 896.15±77.62 961.54±50.64 1828.46±262.32 2066.15±64.36 2115.38±25.37
对照组 14 350.00±17.10 415.00±77.73 689.29±116.32 782.86±171.98 1550.00±253.32 1905.00±127.20 2064.29±50.19
t值   1.921 2.775 5.390 3.600 2.806 4.102 3.298
P值   0.066 0.010 <0.001 0.001 0.010 <0.001 0.003
表5 重度烧伤2组患者喂养不耐受发生率比较[例(%)]
组别 例数 腹胀 呕吐 腹泻 胃潴留 消化道出血 误吸 总发生率
观察组 18 1(5.56) 1(5.56) 0(0) 1(5.56) 0(0) 0(0) 3(16.67)
对照组 17 4(23.53) 2(11.76) 1(5.88) 4(23.53) 0(0) 0(0) 11(64.71)
P值               0.006
表6 特重度烧伤2组患者喂养不耐受发生率比较[例(%)]
组别 例数 腹胀 呕吐 腹泻 胃潴留 消化道出血 误吸 总发生率
观察组 13 1(7.69) 1(7.69) 0(0) 1(7.69) 0(0) 0(0) 3(23.08)
对照组 14 3(21.43) 1(7.14) 1(7.14) 4(28.57) 1(7.14) 1(7.14) 11(78.57)
P值               0.007
表7 重度烧伤2组患者治疗各时间点营养代谢指标比较
组别 例数 1 d 3 d 5 d 7 d 14 d 21 d 28 d
观察组 18              
Hb(g/L，±s)   130.94±12.38 121.44±6.74 112.33±6.16 108.61±7.24 114.06±7.49 120.72±7.16 128.56±5.29
TP(g/L，±s)   60.80±4.06 54.98±4.16 54.11±3.69 58.52±2.89 61.84±2.43 67.09±2.74 70.70±2.67
ALB(g/L，±s)   36.22±3.93 32.66±1.80 31.12±2.38 33.22±2.60 34.99±2.67 37.36±2.38 39.88±1.93
GLB(g/L，±s)   24.57±2.44 22.32±3.62 22.99±2.63 25.31±2.07 27.29±1.67 29.74±1.84 30.83±1.98
PA(mg/L，±s)   268.64±25.64 232.84±21.62 224.74±26.04 244.50±21.51 271.94±16.33 291.79±22.33 306.97±19.62
BUN(mmol/L，±s)   3.54±0.99 3.66±0.95 4.02±0.88 4.09±0.66 4.21±0.64 4.01±0.79 4.03±0.50
对照组 17              
Hb(g/L，±s)   131.12±10.22 121.88±8.96 113.06±8.33 114.35±7.63 117.76±6.38 123.94±6.05 129.35±6.83
TP(g/L，±s)   57.31±3.79 49.70±4.61 50.63±3.14 53.65±3.07 61.18±2.79 66.02±1.70 70.76±2.23
ALB(g/L，±s)   34.14±3.07 28.251±3.15 26.77±2.62 27.94±2.15 32.95±2.03 36.74±1.38 39.71±1.67
GLB(g/L，±s)   23.17±2.43 21.48±2.78 23.86±1.90 25.72±2.18 28.23±1.73 29.29±1.30 31.06±1.43
PA(mg/L，±s)   262.31±32.73 218.18±23.78 196.06±22.56 198.19±12.24 231.02±11.88 274.03±16.66 311.62±18.21
BUN(mmol/L，±s)   4.04±0.81 4.25±0.78 4.09±0.66 4.35±0.32 4.27±0.57 4.17±0.73 3.98±0.24
表8 特重度烧伤2组患者治疗各时间点营养代谢指标比较
组别 例数 1d 3d 5d 7d 14d 21d 28d
观察组 13              
Hb(g/L，±s)   144.38±26.92 120.38±25.33 111.77±10.89 111.31±9.02 111.69±11.64 116.54±10.67 121.00±12.64
TP(g/L，±s)   48.79±8.33 47.23±4.53 57.78±5.45 60.24±5.35 59.31±5.15 62.80±4.67 63.08±4.17
ALB(g/L，±s)   29.56±8.40 29.41±3.40 35.86±4.89 37.21±3.52 34.78±2.68 35.38±3.06 35.37±3.49
GLB(g/L，±s)   19.23±4.04 17.82±3.15 21.93±3.05 23.04±5.11 24.54±3.33 27.42±4.01 27.72±2.84
PA(mg/L，±s)   254.92±33.64 223.08±25.73 268.53±16.09 266.91±17.45 298.72±28.07 301.98±42.75 301.25±29.79
BUN(mmol/L，±s)   4.87±1.54 4.97±1.41 4.75±1.77 6.63±2.27 5.46±1.60 4.94±1.08 3.87±0.84
对照组 14              
Hb(g/L，±s)   143.86±22.77 125.64±23.25 106.57±11.36 98.29±14.01 100.50±16.27 108.93±16.72 108.86±14.63
TP(g/L，±s)   53.27±3.97 48.35±4.69 52.12±7.74 52.17±6.29 54.32±6.66 59.85±6.74 61.78±7.53
ALB(g/L，±s)   30.97±2.88 26.15±4.40 29.46±4.67 31.11±3.99 30.76±3.25 30.76±3.25 34.87±4.27
GLB(mg/L，±s)   22.30±4.37 22.21±3.54 22.66±7.12 21.06±4.23 23.57±5.43 24.66±5.80 26.93±6.46
PA(mg/L，±s)   256.45±18.02 220.56±22.98 208.96±25.74 211.54±30.29 229.98±44.30 243.15±26.01 259.20±25.69
BUN(mmol/L，±s)   6.64±1.71 5.67±2.52 5.11±2.25 5.91±2.44 6.37±2.98 5.93±3.28 4.01±1.80
表9 重度烧伤2组患者治疗各时间点机体炎性因子指标比较
组别 例数 1 d 3 d 5 d 7 d 14 d 21 d 28 d
观察组 18              
WBC(×109/L，±s)   10.31±2.43 11.10±2.97 12.24±3.60 11.78±2.34 9.83±1.99 8.10±1.62 7.33±0.69
NE%(±s)   84.82±5.30 81.87±8.24 81.56±6.33 83.97±5.54 80.20±5.15 73.52±7.22 67.60±3.85
CRP(mg/L，±s)   61.45±11.00 78.19±39.51 71.91±26.18 63.06±19.63 49.48±24.31 28.22±4.70 12.27±6.19
PCT(ng/mL，±s)   0.89±0.15 1.22±0.26 0.65±0.17 0.56±0.15 0.19±0.02 0.12±0.02 0.07±0.02
IL-6[ng/L，M(Q1，Q3)]   0.130(0.020，0.210) 0.090(0.010，0.100) 0.060(0.040，0.090) 0.030(0.020，0.060) 0.028(0.011，0.080) 0.015(0.008，0.032) 0.008(0.003，0.012)
对照组 17              
WBC(×109/L，±s)   11.23±1.73 12.45±2.83 13.44±3.87 11.34±0.91 10.37±1.67 8.32±1.82 7.26±0.93
NE%(±s)   86.61±5.04 83.61±5.14 83.26±3.68 84.33±5.68 79.62±5.87 73.78±5.75 63.85±5.52
CRP(mg/L，±s)   63.94±12.31 83.23±41.16 77.45±26.07 68.52±18.92 50.73±26.88 28.03±5.01 12.54±6.58
PCT(ng/mL，±s)   1.49±0.20 1.74±0.53 1.38±0.25 0.81±0.17 0.36±0.08 0.17±0.03 0.09±0.02
IL-6[ng/L，M(Q1，Q3)]   0.140(0.030，0.220) 0.070(0.030，0.090) 0.070(0.040，0.090) 0.050(0.030，0.090) 0.038(0.016，0.080) 0.020(0.012，0.370) 0.007(0.004，0.012)
表10 特重度烧伤2组患者治疗各时间点机体炎性因子指标比较
组别 例数 1d 3d 5d 7d 14d 21d 28d
观察组 13              
WBC(×109/L，±s)   15.26±6.52 8.61±5.29 9.18±6.94 11.85±5.78 11.15±5.78 8.93±3.29 7.16±2.13
NE%(±s)   84.79±9.96 78.58±8.35 78.37±6.28 84.88±8.03 80.38±4.60 71.45±11.76 64.11±8.30
CRP(mg/L，±s)   112.34±25.54 103.78±20.17 100.08±56.49 92.36±14.75 56.95±13.70 29.10±7.78 21.60±5.40
PCT(ng/mL，±s)   2.19±0.69 4.25±1.02 1.23±0.38 0.54±0.10 0.16±0.02 0.14±0.03 0.08±0.02
IL-6[ng/L，±s]   0.610±0.300 0.14±0.050 0.080±0.010 0.045±0.010 0.045±0.0100 0.018±0.040 0.014±0.006
对照组 14              
WBC(×109/L，±s)   18.12±8.14 10.04±4.99 7.64±3.43 8.74±4.82 11.21±5.82 8.45±1.85 8.16±1.70
NE%(±s)   87.00±3.42 78.09±13.24 76.66±9.41 78.13±5.91 82.19±5.75 71.24±8.45 66.24±6.52
CRP(mg/L，±s)   94.62±16.76 94.27±13.49 121.34±32.85 94.46±17.90 67.87±15.50 47.69±9.42 23.26±7.04
PCT(ng/mL，±s)   2.67±0.92 6.89±4.11 4.28±1.25 2.37±0.41 0.42±0.11 0.17±0.05 0.09±0.02
IL-6[ng/L，±s]   0.790±0.300 0.600±0.160 0.370±0.100 0.110±0.040 0.046±0.010 0.023±0.005 0.007±0.001
表11 重度烧伤2组患者住院相关指标比较
组别 例数 机械通气时间[d，M(Q1，Q3)] BICU住院时间(d，±s) 喂养达标时间(d，±s) 脓毒症发生率[例(%)]
观察组 18 0(0，5.75) 13.16±3.55 7.11±1.13 1(5.56)
对照组 17 0(0，6.00) 13.29±3.68 7.05±1.43 1(5.88)
Fisher值/t值/Z值   －0.09 －0.10 0.12 0.001
P值   0.93 0.92 0.78 0.96
表12 特重度烧伤2组患者住院相关指标比较
组别 例数 机械通气时间(d，±s) BICU住院时间(d，±s) 喂养达标时间(d，±s) 脓毒症发生率[例(%)]
观察组 13 3.84±4.18 20.07±11.72 7.38±1.70 2(15.38)
对照组 14 6.00±5.43 24.28±12.44 8.64±1.23 5(35.71)
Fisher值/t值/Z值   －1.14 －0.90 2.21 1.45
P值   0.26 0.37 0.03 0.23
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