Kudsk K A, Croce M A, Fabian T C, Minard G, Tolley E A, Poret H A, Kuhl M R, Brown R O
Department of Surgery, Presley Memorial Trauma Center, University of Tennessee, Memphis.
Ann Surg. 1992 May;215(5):503-11; discussion 511-3. doi: 10.1097/00000658-199205000-00013.
To investigate the importance of route of nutrient administration on septic complications after blunt and penetrating trauma, 98 patients with an abdominal trauma index of at least 15 were randomized to either enteral or parenteral feeding within 24 hours of injury. Septic morbidity was defined as pneumonia, intra-abdominal abscess, empyema, line sepsis, or fasciitis with wound dehiscence. Patients were fed formulas with almost identical amounts of fat, carbohydrate, and protein. Two patients died early in the study. The enteral group sustained significantly fewer pneumonias (11.8% versus total parenteral nutrition 31.%, p less than 0.02), intra-abdominal abscess (1.9% versus total parenteral nutrition 13.3%, p less than 0.04), and line sepsis (1.9% versus total parenteral nutrition 13.3%, p less than 0.04), and sustained significantly fewer infections per patient (p less than 0.03), as well as significantly fewer infections per infected patient (p less than 0.05). Although there were no differences in infection rates in patients with injury severity score less than 20 or abdominal trauma index less than or equal to 24, there were significantly fewer infections in patients with an injury severity score greater than 20 (p less than 0.002) and abdominal trauma index greater than 24 (p less than 0.005). Enteral feeding produced significantly fewer infections in the penetrating group (p less than 0.05) and barely missed the statistical significance in the blunt-injured patients (p = 0.08). In the subpopulation of patients requiring more than 20 units of blood, sustaining an abdominal trauma index greater than 40 or requiring reoperation within 72 hours, there were significantly fewer infections per patient (p = 0.03) and significantly fewer infections per infected patient (p less than 0.01). There is a significantly lower incidence of septic morbidity in patients fed enterally after blunt and penetrating trauma, with most of the significant changes occurring in the more severely injured patients. The authors recommend that the surgeon obtain enteral access at the time of initial celiotomy to assure an opportunity for enteral delivery of nutrients, particularly in the most severely injured patients.
为研究营养支持途径对钝性和穿透性创伤后脓毒症并发症的重要性，将98例腹部创伤指数至少为15的患者在受伤后24小时内随机分为肠内营养组或肠外营养组。脓毒症发病率定义为肺炎、腹腔内脓肿、脓胸、导管败血症或伴有伤口裂开的筋膜炎。给予患者脂肪、碳水化合物和蛋白质含量几乎相同的配方饮食。研究早期有2例患者死亡。肠内营养组发生肺炎的患者明显较少（11.8% 对比全肠外营养组的31%，p<0.02），腹腔内脓肿较少（1.9% 对比全肠外营养组的13.3%，p<0.04），导管败血症较少（1.9% 对比全肠外营养组的13.3%，p<0.04），且每位患者发生感染的次数明显较少（p<0.03），每位感染患者的感染次数也明显较少（p<0.05）。尽管损伤严重程度评分小于20或腹部创伤指数小于或等于24的患者感染率无差异，但损伤严重程度评分大于20（p<0.002）和腹部创伤指数大于24（p<0.005）的患者感染明显较少。肠内营养在穿透伤组产生的感染明显较少（p<0.05），在钝性伤患者中勉强未达到统计学显著性（p = 0.08）。在需要超过20单位血液、腹部创伤指数大于40或在72小时内需要再次手术的患者亚组中，每位患者的感染明显较少（p = 0.03），每位感染患者的感染明显较少（p<0.01）。钝性和穿透性创伤后接受肠内营养的患者脓毒症发病率明显较低，大多数显著变化发生在伤势较重的患者中。作者建议外科医生在初次剖腹术时建立肠内营养通道，以确保有机会进行肠内营养支持，尤其是在伤势最严重的患者中。
