Schmitz J E
Infusionsther Klin Ernahr. 1984 Aug;11(4):205-18.
An adequate "individually tailored" infusion and nutritional therapy is one of the essential prerequisites for an optimal healing process - especially in ventilated, polytraumatized patients with reduced compensatory capacities. There are nevertheless practically no publications dealing with the effect of substrate application adjusted to the measured metabolic rate on the energy and protein metabolism of the critically ill. In order to clarify this situation a prospective study was carried out on a group of 40 polytraumatized, ventilated patients, who were randomized into four groups, each receiving different infusion and nutritional regimen. The O2-consumption, energy expenditure, nitrogen balance and substrate concentrations in plasma and urine were determined, and the urea production rate and substrate turnover of all patients calculated. In the groups given nutritional support carbohydrate application adjusted to O2-consumption - lead to blood glucose concentrations which were persistently high. However, median values did not exceed 10 mmol/l and insulin application was never necessary. Energy expenditure - calculated from O2-consumption - averaged about 3000 kcal/day and was clearly below values previously reported in the literature for patients comparable to those studied in this investigation. There was no difference in energy expenditure between the patients treated with various infusion regimen. In none of the groups the median plasma urea concentration did exceed reference range. Despite an apparent improvement in nitrogen retention rate - through an increased amino-acid intake and a balanced energy input - an increased urea production rate resulted. When a balanced delivery of energy-yielding substrates is given, 2 g amino-acids/kg/day seems to be the upper limit of nitrogen support in the critically ill. 3-methylhistidine excretion in urine was parallel to urea production rate, indicating that the amino-acid sparing effect of carbohydrates is mainly derived from amino-acid conservation in muscle. These results seem to indicate that even in the early posttraumatic period a substrate application, adjusted to the measured turnover is possible without leading to a disturbance in homeostasis.
适当的“个体化定制”输液和营养治疗是实现最佳愈合过程的基本前提条件之一，尤其是对于通气的、多发伤且代偿能力降低的患者。然而，实际上几乎没有出版物探讨根据测量的代谢率调整底物应用对危重症患者能量和蛋白质代谢的影响。为了阐明这种情况，对一组40例多发伤、通气的患者进行了一项前瞻性研究，这些患者被随机分为四组，每组接受不同的输液和营养方案。测定了氧消耗、能量消耗、氮平衡以及血浆和尿液中的底物浓度，并计算了所有患者的尿素生成率和底物周转率。在给予营养支持的组中，根据氧消耗调整碳水化合物的应用导致血糖浓度持续升高。然而，中位数未超过10 mmol/L，且从未需要应用胰岛素。根据氧消耗计算的能量消耗平均约为3000千卡/天，明显低于先前文献报道的与本研究中所研究患者类似的患者的值。接受不同输液方案治疗的患者之间能量消耗没有差异。在任何一组中，血浆尿素浓度中位数均未超过参考范围。尽管通过增加氨基酸摄入量和平衡能量输入，氮保留率明显提高，但尿素生成率却增加了。当给予产能量底物的平衡输送时，2克氨基酸/千克/天似乎是危重症患者氮支持的上限。尿中3-甲基组氨酸排泄与尿素生成率平行，表明碳水化合物的氨基酸节约作用主要源于肌肉中氨基酸的保存。这些结果似乎表明，即使在创伤后早期，根据测量的周转率调整底物应用也是可行的，而不会导致体内稳态的紊乱。
