Rhee Peter, Hadjizacharia Pantelis, Trankiem Christine, Chan Linda, Salim Ali, Brown Carlos, Green Donald, Inaba Kenji, Law Jenifer, Demetriades Demetrios
Trauma Division, University of Arizona, Phoenix, Arizona, USA.
J Trauma. 2007 Dec;63(6):1215-22. doi: 10.1097/TA.0b013e31815b83e9.
Total parenteral nutrition (TPN) is associated with known costs, including the use of invasive procedures, which may be necessary to optimize care. Our purpose was to document TPN use in trauma patients over time as well as concurrent changes in TPN-associated complications.
Retrospective analysis of all consecutive trauma patients admitted to the surgical intensive care unit during a period of 6 years from a Level I trauma center. Comparative cohorts and the matched case-control approaches were used to analyze the difference in outcomes between patients with and without TPN during hospitalization. Logistic regression model was used to compare the outcomes of the two groups of patients adjusting for significant risk factors. The McNemar's test was used to assess the differences in outcomes between the cases and their matched controls.
There were 2,964 patients admitted to the surgical intensive care unit during the 6-year period and 464 patients received TPN during their hospital course. TPN use decreased significantly from 26% in the year 2000 to 3% in 2005 (p < 0.0001). Excluding those who died in the first 72 hours, the mortality rate was significantly lower (5.4% no TPN vs. 10.2% TPN, p = 0.001) in patients who were managed without TPN. Complication rates (wound infection, dehiscence, line sepsis, bacteremia, sepsis, pneumonia, renal failure, acute respiratory distress syndrome, multiple organ dysfunction syndrome, deep venous thrombosis, pulmonary embolism) were significantly higher in patients that were managed with TPN. Multivariate analysis adjusting for abbreviated injury score, injury severity score, mechanism, admission year, dialysis, ventilator use, hollow viscous injury, and solid organ injury found that TPN use was still an independent risk factor for increased complications but not death. The matched case-control approach confirmed this finding. TPN use was also associated with increase intensive care unit and hospital length of stay.
The rate of TPN use has declined significantly from 26% to 3% during the 6-year period. The change in practice of minimizing TPN was concurrent with decreased complications and less hospital resource utilization without negatively impacting mortality.
全胃肠外营养（TPN）存在已知的成本，包括使用侵入性操作，而这些操作对于优化治疗可能是必要的。我们的目的是记录创伤患者随时间推移的TPN使用情况以及TPN相关并发症的同期变化。
对一家一级创伤中心6年内收治入外科重症监护病房的所有连续创伤患者进行回顾性分析。采用比较队列和匹配病例对照方法分析住院期间接受TPN和未接受TPN患者的结局差异。使用逻辑回归模型比较两组患者的结局，并对显著风险因素进行校正。采用McNemar检验评估病例与其匹配对照之间的结局差异。
6年期间有2964例患者收治入外科重症监护病房，其中464例患者在住院期间接受了TPN。TPN的使用从2000年的26%显著下降至2005年的3%（p < 0.0001）。排除在最初72小时内死亡的患者后，未接受TPN治疗的患者死亡率显著更低（未接受TPN者为5.4%，接受TPN者为10.2%，p = 0.001）。接受TPN治疗的患者并发症发生率（伤口感染、裂开、导管败血症、菌血症、败血症、肺炎、肾衰竭、急性呼吸窘迫综合征、多器官功能障碍综合征、深静脉血栓形成、肺栓塞）显著更高。在对简明损伤评分、损伤严重程度评分、损伤机制、入院年份、透析、呼吸机使用、中空脏器损伤和实体器官损伤进行校正的多变量分析中发现，使用TPN仍然是并发症增加的独立危险因素，但不是死亡的独立危险因素。匹配病例对照方法证实了这一发现。使用TPN还与重症监护病房和住院时间延长相关。
在6年期间，TPN的使用率从26%显著下降至3%。尽量减少TPN使用的实践变化与并发症减少和医院资源利用减少同时出现，且未对死亡率产生负面影响。
