Dissanaike Sharmila, Shelton Marilyn, Warner Keir, O'Keefe Grant E
Harborview Medical Center, 325 9th Ave, Seattle, WA 98104, USA.
Crit Care. 2007;11(5):R114. doi: 10.1186/cc6167.
Patients receiving total parenteral nutrition (TPN) are at high risk for bloodstream infections (BSI). The notion that intravenous calories and glucose lead to hyperglycemia, which in turn contributes to BSI risk, is widely held but is unproven. We therefore sought to determine the role that hyperglycemia and parenteral calories play in the development of BSI in hospitalized patients receiving TPN.
Two hundred consecutive patients initiated on TPN between June 2004 and August 2005 were prospectively studied. Information was collected on patient age, sex, admission diagnosis, baseline laboratory values, intensive care unit (ICU) status and indication for TPN. Patients in the ICU were managed with strict glycemic control, whereas control on the general ward was more liberal. The maximum blood glucose level over each 8-hour period was recorded, as were parenteral daily intake, enteral daily intake and total daily caloric intake. The primary outcome measure was the incidence of BSI. Additional endpoints were ICU length of stay, hospital length of stay and mortality.
A total of 78 patients (39%) developed at least one BSI, which were more common in ICU patients than in other hospitalized patients (60/122 patients versus 18/78 patients; P < 0.001). Maximum daily blood glucose concentrations were similar in patients with BSI and in patients without BSI (197 mg/dl versus 196 mg/dl, respectively). Patients with BSI received more calories parenterally than patients without BSI (36 kcal/kg/day versus 31 kcal/kg/day, P = 0.003). Increased maximum parenteral calories, increased average parenteral calories, and treatment in the ICU were strong risk factors for developing BSI. There was no difference in mortality between patients with and without BSI.
Increased parenteral caloric intake is an independent risk factor for BSI in patients receiving TPN. This association appears unrelated to hyperglycemia. Based upon our observations, we suggest that parenteral caloric intake be prescribed and adjusted judiciously with care taken to account for all intravenous caloric sources and to avoid even short periods of increased intake.
接受全胃肠外营养（TPN）的患者发生血流感染（BSI）的风险很高。静脉输注热量和葡萄糖会导致高血糖，进而增加BSI风险，这一观点被广泛认可，但尚未得到证实。因此，我们试图确定高血糖和胃肠外热量在接受TPN的住院患者发生BSI过程中所起的作用。
对2004年6月至2005年8月期间开始接受TPN的200例连续患者进行前瞻性研究。收集患者的年龄、性别、入院诊断、基线实验室值、重症监护病房（ICU）状态及TPN适应证等信息。ICU患者采用严格的血糖控制，而普通病房的控制则较为宽松。记录每8小时期间的最高血糖水平、胃肠外每日摄入量、肠内每日摄入量及每日总热量摄入量。主要结局指标为BSI的发生率。其他终点指标为ICU住院时间、住院时间及死亡率。
共有78例患者（39%）发生至少一次BSI，ICU患者比其他住院患者更常见（122例患者中有60例，78例患者中有18例；P<0.001）。发生BSI的患者与未发生BSI的患者的每日最高血糖浓度相似（分别为197mg/dl和196mg/dl）。发生BSI的患者胃肠外摄入的热量比未发生BSI的患者更多（36kcal/kg/天对31kcal/kg/天，P=0.003）。最高胃肠外热量增加、平均胃肠外热量增加及在ICU接受治疗是发生BSI的强烈危险因素。发生BSI与未发生BSI的患者死亡率无差异。
胃肠外热量摄入增加是接受TPN患者发生BSI的独立危险因素。这种关联似乎与高血糖无关。基于我们的观察结果，我们建议谨慎开具和调整胃肠外热量摄入处方，注意考虑所有静脉热量来源，避免即使是短时间的摄入量增加。
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