From the Department of Surgery (A.E.S., P.B.) and Department of Medicine (L.Y.), Boston Medical Center, Boston University, Boston, Massachusetts; Department of Biostatistics (J.W.), Boston University School of Public Health, Boston, Massachusetts; Department of Pathology (J.K., D.G.R.), Boston Medical Center, Boston University, Boston, Massachusetts; Department of Surgery (E.L.), University of Minnesota Medical School, Minneapolis, Minnesota; and Department of Medicine (B.B.), Beth Israel Deaconess Medical Center, Boston, Massachusetts.
J Trauma Acute Care Surg. 2022 Feb 1;92(2):255-265. doi: 10.1097/TA.0000000000003453.
There is a lack of consensus regarding the optimal nutritional support for trauma patients. We hypothesize that early postinjury metabolic support focusing on adequate protein would modify the metabolic signature and alter the inflammatory environment for critically ill trauma patients.
We conducted a prospective randomized controlled pilot trial for adult patients admitted to the surgical intensive care unit following traumatic injury. Patients were randomized to receive early metabolic support (EMS) (peripheral amino acid infusions) or standard of care (enteral nutrition as soon as feasible). Routine laboratory assessments, nitrogen balance, cytokines, and metabolomic analyses were assessed at baseline and day 5 after intervention.
A total of 42 trauma patients were randomized into well-balanced groups with similar age (32 years), Injury Severity Score (25), and body mass index (27.4 kg/m2). Early metabolic support provided significantly more protein (1.43 g/kg vs. 0.35 g/kg; p < 0.0001) and more calories (12.6 kcal/kg vs. 7.5 g/kg; p = 0.0012) over the first 5 days as compared with the standard of care. Early metabolic support modified protein catabolism and synthesis as demonstrated by a larger median negative nitrogen balance (-16.3 g vs. -5.3 g; p = 0.03) and a unique metabolomic profile at day 5. The biochemical profile of patients who received EMS was defined by greater declines in circulating levels of stress hormone precursors and increased levels of amino acids. The inflammatory response following EMS resulted in a greater decrease in interleukin-1B (p = 0.02) and increase in soluble interleukin-6 receptor (p = 0.01) between baseline and day 5 as compared with the standard of care. The EMS group had a decreased length of stay (15 vs. 22 days) and decreased surgical intensive care unit length of stay (8 vs. 9 days); however, this disappeared after adjustment for Injury Severity Score in this small population.
Early metabolic support with amino acid is safe, modifies metabolism, and may downregulate the inflammatory state associated with significant trauma, warranting a larger trial to assess for improved outcomes.
Therapeutic/Care Management; Level II.
目前对于创伤患者的最佳营养支持仍缺乏共识。我们假设，早期以提供足够蛋白质为重点的损伤后代谢支持将改变危重症创伤患者的代谢特征并改变其炎症环境。
我们对因创伤而入住外科重症监护病房的成年患者进行了一项前瞻性随机对照试验。将患者随机分为早期代谢支持（EMS）（外周氨基酸输注）组或标准治疗（一旦可行即给予肠内营养）组。在干预后第 5 天进行常规实验室评估、氮平衡、细胞因子和代谢组学分析。
共有 42 例创伤患者被随机分为两组，两组年龄（32 岁）、损伤严重程度评分（25）和体重指数（27.4 kg/m2）均衡。与标准治疗相比，早期代谢支持在最初 5 天内提供了更多的蛋白质（1.43 g/kg 比 0.35 g/kg；p < 0.0001）和更多的热量（12.6 kcal/kg 比 7.5 g/kg；p = 0.0012）。早期代谢支持改变了蛋白质的分解和合成，表现为更大的中位负氮平衡（-16.3 g 比-5.3 g；p = 0.03）和第 5 天独特的代谢组学特征。接受 EMS 的患者的生化特征表现为循环应激激素前体水平下降更大，氨基酸水平升高。与标准治疗相比，EMS 后的炎症反应导致白细胞介素-1B（p = 0.02）下降更大和可溶性白细胞介素-6 受体（p = 0.01）升高。与标准治疗相比，EMS 组的住院时间（15 天比 22 天）和外科重症监护病房住院时间（8 天比 9 天）均缩短；然而，在对小样本中的损伤严重程度评分进行调整后，这种差异消失。
早期氨基酸代谢支持是安全的，可改变代谢，并可能下调与严重创伤相关的炎症状态，值得进行更大规模的试验以评估改善结局的效果。
治疗/护理管理；II 级。
