Hill G L, Witney G B, Christie P M, Church J M
University Department of Surgery, Auckland Hospital, New Zealand.
Br J Surg. 1991 Jan;78(1):109-13. doi: 10.1002/bjs.1800780133.
To determine whether nutritional and metabolic factors affect the response to intravenous nutrition (IVN) 146 surgical patients were classified according to their protein and metabolic status using direct measurements of body protein and metabolic expenditure. The patients were grouped into four categories: category I, moderate to severe protein depletion without raised metabolic expenditure; category II, moderate to severe protein depletion with raised metabolic expenditure; category III, mild protein depletion without raised metabolic expenditure; and category IV, mild protein depletion with raised metabolic expenditure. After 2 weeks of IVN patients in category I gained a mean(s.e.m.) of 0.43(0.06) kg of body protein (P less than 0.001) and had significant rises in both plasma transferrin and prealbumin (P less than 0.05); patients in category II gained 0.30(0.11) kg of protein (P less than 0.005) and also had significant rises in transferrin and prealbumin (P less than 0.05). Patients in category III lost 0.24(0.11) kg protein (P less than 0.05) and had no changes in either transferrin or prealbumin and patients in category IV lost 0.51(0.13) kg of body protein (P less than 0.001) and although there was a significant rise in plasma prealbumin there was no significant change in plasma transferrin. When postoperative patients were examined separately, they did not differ significantly from preoperative patients except in category I, where their protein gain was only 0.19(0.10) kg, an amount not significantly different from that gained by patients in category II. In each of the four categories described, the changes in total body protein occurring with 2 weeks of IVN were determined by the relative effects of two competing processes; protein depletion and raised metabolic expenditure. With moderate to severe protein depletion (approximately 30 per cent depletion of body protein stores) there was a marked tendency to gain protein with IVN. When the patient had a raised metabolic expenditure or was postoperative this tendency of depleted patients to gain protein was still present but it was less. With only mild protein depletion (approximately 10 per cent depletion) increases in metabolic expenditure made it difficult, if not impossible, to prevent continuing protein loss in spite of aggressive nutritional support. The patient categories we have described determine the response to IVN and form the basis of a new clinical classification of surgical malnutrition.
为了确定营养和代谢因素是否会影响静脉营养（IVN）的效果，146名外科患者根据其蛋白质和代谢状况进行了分类，采用直接测量身体蛋白质和代谢消耗的方法。患者被分为四类：第一类，中度至重度蛋白质消耗且代谢消耗未增加；第二类，中度至重度蛋白质消耗且代谢消耗增加；第三类，轻度蛋白质消耗且代谢消耗未增加；第四类，轻度蛋白质消耗且代谢消耗增加。接受两周IVN治疗后，第一类患者平均（标准误）增加了0.43（0.06）千克身体蛋白质（P<0.001），血浆转铁蛋白和前白蛋白均显著升高（P<0.05）；第二类患者增加了0.30（0.11）千克蛋白质（P<0.005），转铁蛋白和前白蛋白也显著升高（P<0.05）。第三类患者减少了0.24（0.11）千克蛋白质（P<0.05），转铁蛋白和前白蛋白均无变化；第四类患者减少了0.51（0.13）千克身体蛋白质（P<0.001），虽然血浆前白蛋白显著升高，但血浆转铁蛋白无显著变化。当对术后患者单独检查时，除了第一类患者外，他们与术前患者没有显著差异，第一类患者的蛋白质增加量仅为0.19（0.10）千克，与第二类患者增加的量没有显著差异。在所描述的四类患者中，IVN两周内全身蛋白质的变化是由两个相互竞争的过程的相对影响决定的；蛋白质消耗和代谢消耗增加。当中度至重度蛋白质消耗（身体蛋白质储备约30%的消耗）时，IVN治疗有明显的蛋白质增加趋势。当患者代谢消耗增加或处于术后状态时，蛋白质消耗患者增加蛋白质的这种趋势仍然存在，但程度较轻。仅存在轻度蛋白质消耗（约10%的消耗）时，尽管给予积极的营养支持，代谢消耗的增加使得即使不是不可能，也很难防止持续的蛋白质流失。我们所描述的患者类别决定了对IVN的反应，并构成了手术营养不良新临床分类的基础。
